Denver管腹腔静脉分流术治疗肝硬化难治性腹水的临床评价

目的评价Denver管腹腔静脉分流术(PVS)治疗肝硬化难治性腹水的效果.方法选择10例肝硬化难治性腹水病人置Denver管行腹腔颈内静脉分流术.手术前后观察病人的体重、尿量、腹围、生化指标和凝血指标以及生活质量的改变.结果术后所有病人体重较术前平均降低2.7kg(P＜0.01),腹围平均减少11.7cm(P＜0.01),尿量平均增加1053.8ml/d(P＜0.01),肌酐和尿素氮水平均有改善(P＜0.05),但白蛋白、谷丙转氨酶和凝血酶原时间无明显变化.术后生活质量明显改善.术后并发症包括堵管(2例)、发烧(2例)、腹膜炎(2例)、心衰(1例)和上消化道出血(2例).所有病人均有生化的DIC指标异常,但没有临床DIC表现,经处理后均缓解.结论肝硬化难治性腹水行Denver管PVS后能明显增加尿量、降低体重、减小腹围和提高生活质量,虽然可有许多并发症发生,但是经积极处理后可以缓解,不少可积极预防.相信随临床经验的不断积累,其在肝硬化难治性腹水治疗中会起相当重要作用.     

经皮集束电极射频毁损治疗肝脏恶性肿瘤67例

我院于 1999年 6月～ 2 0 0 3年 1月采用经皮射频毁损治疗法 (PRFA)治疗肝癌 67例 ,取得较好疗效。对象与方法1.对象 :肝癌患者 67例 ,年龄 3 5～ 83岁 ,平均年龄 5 4岁 ,男性 49例 ,女性 18例。原发性肝癌 5 9例 ,转移性肝癌 8例。伴肝硬化者 42例 (62 .7% ) ,肝功能Child分级A级 3 9例、B级2 8例 ,无C级病例。均无肝性脑病病史。少量腹水 9例(13 .4% )。67例患者共有 85个结节 ,平均 1.2 7个 ,其中 1个结节者 5 4例 ,2个结节者 8例 ,3个结节者 5例。结节直径 1.1cm～ 15 .5cm ,其中结节直径 <3cm 2 6个 ,结节直径 3～ 5cm2 4个 ,结节…     

肝硬化病人顽固性腹水的腹腔—颈静脉分流术治疗

1974年,LeVeen 等介绍了一种腹腔-静脉引流腹水的新方法。本文报道用 LeVeen 氏法治疗的最初18例病人的结果。顽固性腹水患者18例(男13,女5)平均年龄50(32～72)岁,其中酒精性肝硬化16例,慢活肝和慢性 Budd-Chiari 氏综合征各1例。按 Child 氏标准分类,11例属 B 组,7例属 C 组。18例中有12例出现肾功能衰竭的生化指标,所有腹水均为无菌性。方法在肋缘下作一小切口后放入 LeVeen 氏活瓣导管,经皮下由颈内静脉插入(深约8～12cm),用单股丝线固定于静脉壁,术后即试验活瓣的性能,     

Denver管腹腔静脉分流术的并发症及其处理

目的：分析Denver管腹腔静脉分流术（PVS）临床运用的并发症及其处理的效果。方法：回顾性分析20例行PVS术后患者的近远期并发症的类型和发生率，统计各项处理措施的效果和术后患者生存率。结果：共有29例次9类（12种）并发症发生，近期（＜1月）19例次，中远期（＞1月）10例次，1年堵管率为5％。共有13例（65％）患者出现并发症，9例（45％）为近期并发症，9例（65％）为中远期并发症，有4种并发症导致了随后患者的死亡。肝硬化难治性腹水者术后1年生存率为24％，生存期小于半年的主要影响因素是高龄和Child C级。与PVS术直接相关的死亡原因是败血症、上消化道出血和DIC。结论：Denver管PVS术后半数以上患者出现并发症，经积极处理后大多数近期并发症可以缓解，不少可积极预防，中远期并发症缓解率极低，部分可能原因是随访指导不够和不能及时治疗。只要合理选择患者，术前积极准备，改善置管技术，术后积极预防并发症，加强随访和及时治疗并发症，PVS在肝硬化难治性腹水及癌性腹水治疗中仍可发挥一定作用。     

腹水浓缩回输治疗肝癌合并顽固性腹水47例

目的观察腹水浓缩腹腔回输治疗肝癌合并顽固性腹水的并发症与疗效。方法对47例肝癌合并顽固性腹水患者进行73次腹水超滤浓缩,经腹腔回输体内。结果腹水回输相关事件8次,占10.9%(8/73);轻中度并发症7例,占9.5%(7/73);严重并发症6例次,占8.2%(6/73);治疗后腹围(92.8±4.5)cm与治疗前(98.7±7.3)cm比较,明显下降(P<0.05),治疗后每日尿量(1880.5±201.6)mL与治疗前(986.8±158.5)mL比较,明显增加(P<0.05);腹胀明显缓解且血压无明显下降。首次腹水回输后3～5d内死亡5例,15d、1个月病死率分别为23.9%、41.3%;3个月、1年病死率分别为78.2%、93.4%。结论腹水浓缩回输对肝癌合并顽固性腹水减轻症状有一定疗效,但不能改善患者预后。     

综合疗法加腹水超滤浓缩回输治疗顽固性腹水疗效观察

1999年 6月以来 ,我科应用腹水超滤浓缩回输治疗顽固性腹水患者 5 1例 ,效果良好 ,现报告如下。1　资料与方法1 .1　临床资料　本文患者 96例 ,随机分成两组 ,治疗组 5 1例、男 3 5例、女 1 6例 ,年龄 2 5～ 79岁、平均41 .5 6± 1 1 .81岁 ;腹水病因为肝硬化失代偿期 40例 ,肾     

Wingspan支架置入术治疗症状性大脑中动脉狭窄临床观察

目的 观察Wingspan支架置入术治疗症状性大脑中动脉狭窄的近期临床疗效及并发症.方法 46例症状性大脑中动脉狭窄患者,采用经血管内Gateway球囊扩张成功后,再行Wingspan支架置入术,分析大脑中动脉M1段不同形态、Mori分型、狭窄程度手术疗效及并发症发生情况.结果 46例手术均获成功,平均管腔狭窄率从术前84.7％±6.9％降至术后21.2％±14.4％（P＜0.05）;术中出现并发症者3例,术后出现并发症者9例,M1段形态为S型、Mori C型及极重度狭窄患者的手术并发症发生率高,近期疗效差.结论 Wingspan支架置入治疗症状性大脑中动脉狭窄有较好的安全性和近期临床疗效.     

腹水浓缩回输治疗肝硬变顽固性腹水

目的:探讨肝硬变顽固性腹水的治疗及影响疗效的因素。方法:用HAUF-B型腹水超滤机及PSU-I型聚砜中空纤维超滤器,对236例肝炎肝硬变顽固性腹水患者,进行自体腹水浓缩回输治疗。结果:治疗后腹围平均减少9.2±3.8cm,清除腹水量3787±1426ml,尿量平均增加582.4±108.5ml/24h,总有效率为68.6％。结论:自体腹水浓缩回输是治疗肝炎肝硬变顽固性腹水的有效方法。     

腹腔置管治疗顽固性腹水对血浆RAAS的影响

目的 探讨中心静脉导管腹腔置入术治疗顽固性腹水对肾素-血管紧张素Ⅱ-醛固酮系统(RAAS)的影响.方法 21例肝硬化顽固性腹水患者,经皮穿刺导丝引导法置入中心静脉导管,通过该导管隔日大量引流一次腹水,同时联合内科综合治疗,检测腹水引流前后肾素、血管紧张素Ⅱ和醛固酮水平及体重、腹围、尿量和肾功能.结果 所有患者感腹胀、纳差、呼吸困难症状均完全缓解或者部分缓解;置管治疗能迅速减少腹围,显效33.3%,总有效率达71.4%;治疗后腹围及体重显著低于治疗前,而肾功能有所恢复;并且血浆肾素、血管紧张素Ⅱ和醛固酮水平显著减低(P＜0.05);引流不畅3例(占14.3%),穿刺点腹水渗漏2例(占9.5%),无其他严重并发症.结论 中心静脉导管腹腔置入术联合内科综合治疗是肝硬化顽固性腹水的有效治疗方法,能迅速消除腹水,抑制RAAS系统活性,并发症少,安全可靠.     

腹水回输治疗肝硬化腹水32例

我们在综合治疗晚期血吸虫病肝硬化腹水病人中,对顽固性腹水病人采用腹水回输的方法,取得了较好的效果,现报告如下。1　一般资料顽固性肝硬化腹水32例,其中男19例,女13例,年龄34～69岁,平均55岁。均为晚期血吸虫病人。其中,合并乙肝、伴有肝炎后肝硬化者14例。2例并发肝癌。有上消化道出血史或/和行脾切除手术者4例。就诊时均为中、高度腹水,腹围86～108cm,平均96cm。病程3月～20年,多为反复发作、多次治疗的老患者,对常规利尿剂已不敏感。肝功能多有不同程度损害,白蛋白明显偏低,白/球比例倒置。有明显腹胀、纳差、尿少、水肿等。2　方法2.…     

Arterial-Venous Shunting in Liver Cirrhosis

Controversial data exist in the literature aboutthe presence and clinical relevance of hepaticarterial-venous shunting. An interesting opportunity forreconsidering the problem has been provided by the use, in the study of liver function, ofD-sorbitol, a substance whose first-pass hepaticextraction is very high in normal subjects, while beingdirectly related to circulatory alterations in livercirrhosis. Because of this property, the systemicbioavailability of D-sorbitol during hepatic arterialinfusion can be assumed to reflect arterial-venousshunting. Thirteen biopsy-proven cirrhotic patients(ages 35- 66 years), who required diagnostic arterialcatheterization, entered the study. Patients werestudied on two subsequent days, in which a sterilepyrogen-free solution (1.5%) of D-sorbitol wasadministered by direct low-rate infusion (15 mg/min for 20min) into the hepatic artery and the systemiccirculation, respectively. Urine samples werespontaneously collected for 8-hr periods before andduring/after each infusion. The hepatic arterialbioavailability of D-sorbitol was calculated as theratio between the net cumulative urinary outputs ofD-sorbitol after infusions into the hepatic artery andthe systemic vein. Observed values confirm the existence andthe large variability (0-88.7%) of hepaticarterial-venous shunting in cirrhoticpatients.     

Chronic Thromboembolic Pulmonary Hypertension Following Ventriculo-Atrial Shunting

Summary: Multiple pulmonary emboli and pulmonary hypertension occurred in a 49-year-old man four years after insertion of a ventriculoatrial shunt. Although this complication is a common finding at post-mortem in children with ventriculo-atrial shunts the frequency with which it occurs in adults is unknown. Routine electrocardiography and lung scanning is necessary for early diagnosis and treatment as symptoms are often insidious and the prognosis in established thromboembolic pulmonary hypertension is poor.     

Chronic Thromboembolic Pulmonary Hypertension Following Ventriculo-Atrial Shunting

Summary: Multiple pulmonary emboli and pulmonary hypertension occurred in a 49-year-old man four years after insertion of a ventriculoatrial shunt. Although this complication is a common finding at post-mortem in children with ventriculo-atrial shunts the frequency with which it occurs in adults is unknown. Routine electrocardiography and lung scanning is necessary for early diagnosis and treatment as symptoms are often insidious and the prognosis in established thromboembolic pulmonary hypertension is poor.     

Diastolic Left-to-Right Shunting in Uncomplicated Ventricular Septal Defect

The systolic left-to-right shunt in patients with uncomplicated ventricular septal defect is associated with a classic loud murmur, and is well described. The additional diastolic left-to-right shunt, always silent, is less well recognized. Left-to-right diastolic shunt flow is directly related to the defect size, to the diastolic pressure gradient between the left and right ventricle, and to the duration of diastole. The purpose of this study was to evaluate by Doppler echocardiography the duration, magnitude, and flow velocity characteristics of the diastolic left-to-right shunt. There were 30 adult patients with uncomplicated ventricular septal defects studied by color, pulsed, and continuous wave Doppler echocardiography. In each patient, the uncomplicated ventricular septal defect was visualized by two-dimensional echocardiography and/or Doppler echocardiography, and the systolic and diastolic left-to-right shunt flow was identified by Doppler echocardiography. Accurate Doppler flow velocity peaks twice, in beginning and again at end diastole. The mean diastolic flow velocity was 0.5–1.5 msec (average 0.83 ± .22 msec). This flow velocity was markedly lower than the mean systolic shunt flow velocity (2.4–5.3 msec, average 3.8 ± .7 msec). The Doppler flow velocity integral was 0.17–0.64 m (average 0.36 ± 0.14), markedly smaller than the systolic flow velocity integral (0.8–1.8 m, average 1.3 ± 0.3). The diastolic left-to-right shunt flow was 12–41% (average 21 ± 8) of total (systolic and diastolic) shunt flow. In conclusion: Diastolic left-to-right shunts can be identified in all patients with uncomplicated ventricular septal defects, and analyzed in the majority of patients. A significant degree of the left to right shunting in uncomplicated ventricular septal defects occur during diastole.     

Patient Selection and Survival after Peritoneovenous Shunting for Nonmalignant Ascites

Patient selection and survival after peritoneovenous shunting for nonmalignant ascites was assessed in 30 patients undergoing 44 peritoneovenous shunting procedures over a 5-year period. Indications for peritoneovenous shunting included refractory ascites alone, refractory ascites complicated by hepatorenal syndrome, and nonrefractory but recurrent ascites. Fifty-six percent of shunting procedures were complicated by shunt malfunction and an additional 13% ended in shunt removal or ligation. Serious perioperative morbidity occurred in 47% of patients. Mean duration of shunt function was significantly less (p less than 0.05) in the patients with hepatorenal syndrome (15 +/- 5 days) compared to the patients with refractory ascites alone (45 +/- 13 days), or the patients with nonrefractory ascites (64 +/- 34 days). Mean survival was 265 +/- 87 days. Survival of patients with nonrefractory ascites (767 +/- 214 days) was significantly longer (p less than 0.05) than that seen in patients with hepatorenal syndrome (28 +/- 5 days) or in patients with refractory ascites alone (256 +/- 148 days). Combined inhospital mortality was 30%. It was significantly greater (p less than 0.05) in patients with hepatorenal syndrome (70%) than in patients with refractory ascites alone (14%) or in patients with nonrefractory ascites (0%). We conclude that patient selection significantly influences survival after peritoneovenous shunting and may account for the varying results reported by other groups.     

Carotid Endarterectomy with Contralateral Carotid Occlusion: Is Shunting Necessary?

Background Controversy exists about the effect of contralateral carotid stenosis on the perioperative risks of carotid endarterectomy (CEA). Despite increased perioperative risk, the long-term outcome is improved in patients who undergo ipsilateral CEA with significant contralateral carotid stenosis. Traditionally, this involved shunting the ipsilateral carotid artery during the procedure. It was believed that this minimized the risk for cerebral ischemia. We believe selective shunting can be employed while still avoiding cerebral ischemia. This requires a reliable method of monitoring for ischemia. Intraoperative EEG monitoring has been proven to be a reliable method for monitoring for ischemic changes during a case.Methods A standard operative technique involving continuous EEG monitoring was used. We reviewed the records of carotid endarterectomies in the past 3 years. We present a series of 8 cases of CEA with contralateral occlusion in which shunting was selective based on EEG.Results Of eight patients, seven (87.5%) tolerated the procedure without EEG changes and thus did not requiring intraluminal shunting. There were no long-term complications in our series of patients.Conclusion We found that intraluminal carotid shunting during CEA with contralateral occlusion is not mandatory but neuroprotection methods need to be added to the operative procedure to ensure safety.     

Combined Interatrial and Intrapulmonary Shunting in Orthodeoxia Detected by Transesophageal Echocardiography

Contrast transesophageal echocardiography was found useful in diagnosing combined interatrial and intrapulmonary right-to-left shunts in a patient presenting with orthodeoxia. This was done by separately examining the pulmonary veins and the interatrial septum during intravenous normal saline injections.     

Cardiac Tamponade as a Sequela to Ventriculoatrial Shunting for Congenital Hydrocephalus

Cardiac tamponade is a life-threatening condition that demands prompt diagnosis and emergency intervention to prevent the sequelae of persistent low cardiac output, cardiopulmonary failure, and death. Cardiac tamponade due to pericardial collection of cerebrospinal fluid is a rare but recognized sequela associated with ventriculoatrial shunts used in the management of congenital hydrocephalus.Herein, we describe the treatment of an 8-month-old infant with multiple congenital anomalies who presented with cardiac tamponade. This condition was caused by cardiac perforation by the distal tip of a ventriculoatrial shunt catheter. Timely pericardiostomy and repair of the cardiac perforation through a left anterior thoracotomy resulted in an uneventful recovery.Key words: Cardiac tamponade/diagnosis/etiology/surgery, cerebrospinal fluid shunts/adverse effects, hydrocephalus/surgery, thoracotomy, left anterior, pericardial effusion/diagnosis/etiology/surgery, pericardiostomyCardiac tamponade is a hemodynamically significant cardiac compression caused by the accumulation of pericardial contents that evoke and defeat compensatory mechanisms.¹ Up to one quarter of cases of pericardial effusions are eventually complicated by cardiac tamponade,² which is usually associated with a crisis of diminishing venous return and impaired diastolic ventricular filling. If unresolved, cardiac tamponade leads to low cardiac output, cardiac arrest, and death.Pericardial effusions can be caused by a variety of conditions, such as malignancies, tuberculosis, bacterial and viral infections, and idiopathic causes; they can also occur after cardiac surgery and chest and upper abdominal trauma.^3–5 Symptomatic effusions after intravenous device insertion have been described.^6,7 These consist mainly of bloody intrapericardial collections due to catheter-tip perforation of the right atrium or right ventricle. Herein, we describe an unusual case of cardiac tamponade due to a massive cerebrospinal-fluid pericardial effusion after ventriculoatrial shunt insertion in an infant who had multiple cardiovascular, neurologic, and vertebral anomalies.