胃癌根治术相关胰瘘预防及处理

胰瘘是胃癌根治术术后主要并发症之一,严重时可导致病人死亡。胃癌根治术术后发生胰瘘与术中胰腺损伤密切相关。因此,外科医师应熟悉其发生的危险因素,重在预防。一旦发生术后胰瘘,应分期施治,采取合理、及时的治疗措施,争取早期治愈。     

腹腔镜辅助胃癌D2根治术后并发症及其危险因素分析

目的:探讨腹腔镜辅助胃癌D2根治术后并发症的相关影响因素,进一步预防术后并发症的发生。方法:回顾分析2013年1月至2016年1月为441例患者行腹腔镜辅助胃癌D2根治术的临床资料,观察总结术后并发症发生情况,并对其可能的危险因素进行评估分析。结果:本组441例患者中术后46例发生并发症,发生率为10.4%,其中吻合口瘘14例,吻合口出血5例,吻合口狭窄3例,十二指肠残端瘘2例,胰瘘1例,腹腔出血3例,下肢深静脉血栓1例,淋巴瘘2例,肠梗阻3例,腹腔感染3例,切口感染5例,胃瘫2例,肺部感染2例。单因素分析结果显示,高龄、肥胖、手术方式、术前合并疾病情况、手术时间、术中失血量是腹腔镜辅助胃癌D2根治术后并发症发生的相关因素(P<0.05)。多因素分析结果显示,影响腹腔镜胃癌D2根治术后并发症发生的独立危险因素为高龄、肥胖、术前合并疾病、手术时间(P<0.05)。与无并发症的患者相比,发生并发症的患者术后住院时间较长,且住院花费增加(P<0.05)。结论:高龄、肥胖、术前合并疾病情况、手术时间是腹腔镜辅助胃癌根治术后并发症发生的危险因素,腹腔镜辅助胃癌根治术后并发症中吻合口瘘较常见。     

腹腔镜胃癌根治术并发症及其预防

坚持手术的安全性和肿瘤的根治性是腹腔镜胃癌根治术的第一准则。在腹腔镜胃癌根治术不断规范、推广和普及的当今,重视手术的安全性,降低并发症的发生率,避免严重手术并发症的发牛,是胃肠外科医师们所追寻的目标。腹腔镜胃癌根治术常见的腹部并发症包括腹腔内出血、吻合口瘘、吻合口狭窄、脏器损伤、胰漏等。本文主要探讨腹岁腔镜胃癌根治术常见腹部并发症的原因及其预防。     

腹腔镜胃癌根治术围手术期使用生长抑素对减轻胰腺损伤的影响

目的:比较术前使用与术后使用生长抑素与对减轻腹腔镜胃癌根治术所致胰腺损伤的疗效差异。方法:50例拟行腹腔镜胃癌根治术的患者随机均分为观察组(术前12~24 h开始使用生长抑素,术中及术后维持)或对照组(术后使用生长抑素),5例患者中途退出研究,最终观察组纳入22例,对照组23例。比较两组相关临床指标。结果:两组一般资料及术前感染、营养指标差异均无统计学意义(均P0.05)。与对照组比较,观察组术后第1天腹腔引流量明显低于对照组(P=0.016),但术后总引流量两组无明统计学差异(P0.05);两组间围手术期血清淀粉酶浓度、腹腔引流液淀粉酶含量、术后感染与营养指标、引流管拔除时间、胃肠动力恢复与并发症情况均无统计学差异(均P0.05)。结论:术前、术后使用生长抑素比较,在减轻腹腔镜胃癌根治术所致胰腺损伤方面无明显差异。     

胰十二指肠切除术后胰瘘预防的研究进展

目的总结胰十二指肠切除术后胰瘘的预防方法。方法通过检索近年来国内外关于胰十二指肠切除术后胰瘘预防方法的相关文献并做一综述。结果胰瘘是胰十二指肠切除术后常见并发症之一,其主要由于术前持续高黄疸,术中吻合方式的选择,术后早期大量胰液的分泌,胰蛋白酶原被碱性肠液激活,从而消化附近的组织造成胰瘘,胰液流入腹腔而消化腹腔组织,造成严重并发症,甚至死亡。通过药物、术前减黄、术中吻合方式的选择等方面的预防,术后胰瘘的发生率有所下降。结论胰十二指肠切除术后胰瘘的预防是一个综合过程,需贯穿整个围手术期。     

腹腔镜胃癌根治术后胰瘘发生率及其影响因素

目的 探讨腹腔镜胃癌根治术后胰瘘的发生率及其影响因素.方法 回顾性分析上海交通大学医学院附属瑞金医院普通外科2018年1月至2020年11月完成的290例腹腔镜胃癌根治术病人的各级胰瘘发生率,对病人一般临床病理信息和术中、术后资料进行统计,分析胰瘘发生的影响因素.结果 腹腔镜胃癌根治术后,胰瘘总发生率为22.8％(66...     

开放、腹腔镜及机器人辅助行胰十二指肠切除术后胰瘘特点及对策

微创手术的发展为胰腺外科手术指明了新的发展方向,然而其术后并发症尤其是胰瘘的发生仍严重影响病人的术后恢复。腹腔镜及机器人手术系统为减少胰十二指肠切除术术后胰瘘发生提供了新的研究领域。根据现有经验,机器人手术并不能明显降低术后胰瘘发生率,但在微创化和精确化方面明显优于开放和腹腔镜手术。     

胰外瘘的诊治

胰瘘（pancreatic fistula,PF）是胰腺外科的严重并发症之一。引起胰瘘的病因主要有急、慢性胰腺炎、胰腺外伤、胰腺手术（如胰腺切除术、引流及活检术等）及胰周脏器的手术,这些原因均可使胰管破裂,致胰液渗出,从而导致出现一系列的症候群。     

胰腺完全性横断伤的诊断与治疗：附23例报告

作者总结３０多年以来，收治胰腺完全性横断伤共２３例，均经急诊手术治疗并证实。术前有１８例误诊为腹部其他脏器损伤，仅有５例术前拟诊为胰腺损伤。２３例中２２例治愈，１例因并发胰腺脓肿，于术后４９天死于败血症。作者认为：术后应用生长抑素，可减少术后胰瘘、胰腺炎、胰腺坏死等并发症的发生。     

胃癌根治术后胰瘘预防与治疗

根治性手术是胃癌的主要治疗方法。胰瘘是胃癌根治术后的主要并发症之一,处理不及时可能危及病人生命。胃癌根治术后胰瘘的发生主要与手术方式、器械操作、胰腺和病人全身的基本情况密切相关。胃肠外科医生应该熟悉胰瘘发生的危险因素并加以关注,加强预防。胰瘘的治疗应根据分期而定,及早治疗,从而改善预后。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.