国产机器人手术系统在甲状腺癌手术中应用的安全性与疗效

背景与目的 机器人手术系统在甲状腺手术中的应用有效推动了甲状腺微创外科的发展,目前应用最多是达芬奇机器人外科手术系统,但其高昂的设备成本限制了机器人甲状腺手术的开展。因此,本研究探讨国产机器人手术系统在甲状腺癌手术中应用的安全性和有效性,以期为临床开展提供参考。 方法 回顾性分析2023年5月—2023年10月中国人民解放军联勤保障部队第九六〇医院甲状腺乳腺外科211例行甲状腺切除术的甲状腺乳头状癌患者临床资料,其中42例行图迈 ^?腔镜手术机器人手术（国产机器人组）,169例行达芬奇机器人手术（达芬奇机器人组）,采用倾向评分匹配（PSM）平衡两组患者基线资料后,比较两组患者的手术与术后相关指标。 结果 所有患者手术均顺利完成,两组均未中转开放手术。PSM前,两组间性别差异有统计学意义（ P<0.05）。按1∶1进行PSM后,两组各纳入41例患者,两组的基线资料差异均无统计学意义（均 P>0.05）。与达芬奇机器人组比较,国产机器人组平均总手术时间、助手准备时间、术者手术时间明显延长（193.68 min vs. 138.85 min, P=0.00;43.32 min vs.37.9 min, P=0.00;150.37 min vs. 100.95 min, P=0.00）,淋巴结清扫数量减少（10.41枚 vs. 8.32枚, P=0.03）。两组患者的淋巴结阳性数量、术后引流量、术后引流时间、术后住院时间、术后并发症、疼痛评分、美容效果满意度及主刀医师评价的差异均无统计学意义（ P>0.05）。 结论 国产机器人手术系统在有选择性甲状腺癌患者的治疗中安全有效,给患者提供了新的选择。     

老年腹股沟疝手术方式选择及安全性分析

背景与目的 腹股沟疝是外科常见疾病,其中老年患者是接受腹股沟疝修补术的主要群体。然而,对于老年腹股沟疝患者选择何种手术方式目前尚无定论。局麻Lichtenstein术难度低、效果好、术后愈合较快,在临床中运用广泛。腹腔镜下腹股沟疝无张力修补术因其视野开阔、可发现对侧隐匿疝、可同时处理双侧疝等优势而被越来越多外科医生接受和推荐。本文主要对接受局麻开放疝修补术或全麻腔镜疝修补术的老年患者临床数据进行分析,以期为临床提供一定参考。方法 通过电话随访和病历系统搜集资料,回顾性分析东南大学附属中大医院2019年1月—2021年12月期间130例行腹股沟疝修补手术老年患者（>60岁）的临床资料,其中开放Lichtenstein术67例（开放组）,腔镜疝修补术63例（腹腔镜组）。比较两组患者的基线资料及手术相关指标。结果 基线资料分析结果显示,开放组患者平均年龄大于腹腔镜组（78.94岁vs. 71.83岁）,术前麻醉风险比例、各种合并症比例以及双侧疝发病率均高于腹腔镜组（均P<0.05）;其余基线指标在两组间差异无统计学意义（均P>0.05）。手术相关指标分析结果显示,腹腔镜组术后住院时间较开放组缩短（1.51 d vs. 2.16 d）、术后1 d疼痛评分低于开放组（2.70 vs. 3.58）（均P<0.05）;两组间术后各并发症（切口感染、血肿、血清肿、神经感觉异常、尿潴留）发生率、1年复发率、长期疼痛（>3个月）等指标差异均无统计学意义（均P>0.05）。结论 在老年患者中,疝侧、麻醉风险分级、术前合并症均是临床医师选择手术方式时需要评估的内容。经过充分的术前评估后,选择行腔镜手术是安全的。     

腋窝入路与侧方入路腔镜保留乳头乳晕乳腺癌根治切除加假体植入乳房重建术的疗效比较

背景与目的 近年来,腔镜保留乳头乳晕乳腺癌根治切除（NSM）加假体植入乳房重建术的开展逐渐增多。腔镜手术的入路多种多样,目前主要是腋窝入路与侧方入路,然而目前对两种入路手术效果的比较研究仍少有报道,因此,本研究对腋窝入路与侧方入路行腔镜NSM加假体重建手术的疗效进行比较,以期为临床选择合适的腔镜手术入路提供参考。方法 回顾性收集中国人民解放军陆军军医大学第一附属医院乳腺甲状腺外科2016年1月—2022年10月152例行腔镜NSM加假体植入乳房重建术乳腺癌患者临床资料。按手术入路分为腋窝入路组（78例）与侧方入路组（74例）,比较两组患者的相关临床指标。结果 两组患者的基线资料差异无统计学意义（均P>0.05）。侧方入路组手术时间短于腋窝入路组（211.50 min vs. 250.00 min,P<0.001）,引流量少于腋窝入路组（300.50 mL vs. 504.50 mL,P<0.001）,腋窝入路组行胸肌前假体植入比例明显高于侧方入路组（24.4% vs. 6.8%,P=0.003）,两组术中出血量、术后引流时间差异无统计学意义（均P>0.05）。两组患者术后血肿、感染、积液、乳头乳晕或皮瓣坏死、包膜挛缩发生率差异均无统计学意义（均P>0.05）。术后随访6个月结果显示,两组患者乳房外形、生活质量情况及术后满意度（腋窝入路：91.0% vs. 侧方入路：91.9%）差异均无统计学意义（均P>0.05）。两组在远处转移、局部复发、总生存率差异均无统计学意义（均P>0.05）。结论 经腋窝入路和侧方入路NSM加假体植入乳房重建的两种入路方式均安全有效,美学效果无差异。腋窝入路适合进行胸肌前假体植入,侧方入路操作简便,手术时间短,利于保留胸肌筋膜,可进行免补片的胸肌后假体植入。     

腹腔镜胆总管一期缝合与内镜取石治疗继发性胆总管结石的临床疗效比较

背景与目的 腹腔镜胆总管探查术与内镜下取石术在治疗继发性胆总管结石方面仍存在争议,但文献报道多倾向于腹腔镜胆总管探查术一期缝合术联合胆囊切除术的单阶段治疗策略。因此,本研究比较腹腔镜胆总管一期缝合与内镜取石治疗继发性胆总管结石的临床疗效。方法 回顾性分析2019年1月—2020年2月天津市南开医院肝胆胰第二外科治疗的183例继发性胆总管结石患者临床资料,其中,60例行腹腔镜胆总管探查术+胆总管一期缝合+胆囊切除术（一期缝合组）,123例行内镜逆行胰胆管造影术/内窥镜括约肌切开术+腹腔镜胆囊切除术（内镜取石组）。采用倾向性评分匹配（PSM）方法对两组病例进行1∶1匹配,共59对匹配成功,比较匹配后两组患者手术疗效、术后并发症、住院时间等指标,并分析术后住院时间及术后相关并发症的影响因素。结果 PSM前,两组患者性别差异有统计学意义（P=0.007）,经PSM后两组基线数据差异均无统计学意义（均P>0.05）。内镜取石组术后总体并发症发生率高于一期缝合组（P<0.05）,主要原因是前者较高的术后高淀粉酶血症发生率（20.3% vs. 0）,其他并发症发生率两组间差异均无统计学意义（均P>0.05）;一期缝合组术后住院时间明显短于内镜取石组,住院费用也明显低于内镜取石组（均P<0.05）。高龄（OR=0.396,95% CI=0.182~0.864,P=0.020）、高淀粉血症（OR=0.057,95% CI=0.007~0.468,P=0.008）、内镜取石术（OR=0.084,95% CI=0.040~0.179,P=0.000）是术后住院时间延长的危险因素;手术方式是术后高淀粉酶血症的影响因素（P<0.05）。两组患者获至少1年随访,均无发生结石复发及胆道狭窄。结论 腹腔镜胆总管一期缝合治疗继发性胆总管结石相较内镜取石住院时间更短、费用更低,且不破坏Oddi括约肌正常生理结构。     

胸乳入路腔镜手术治疗甲状腺良性肿瘤的临床应用

背景与目的 传统开放甲状腺手术会在颈前部留下瘢痕,严重影响颈部美观,尤其对于年轻女性且有瘢痕体质的患者,会造成较大的心理创伤。腔镜甲状腺手术可经过乳晕、腋窝或胸乳等入路进行病灶的切除,具有隐形疤痕的作用,但有部分观点认为腔镜甲状腺手术因为要建立皮下通道及手术空间,其创伤更大。因此,本研究通过对比行经胸乳入路腔镜手术与传统开放手术治疗的甲状腺良性肿瘤患者的临床指标,进一步评价腔镜甲状腺手术安全性与可行性。方法 回顾性分析2018年1月—2021年1月江苏省扬州市中医院外科手术治疗106例甲状腺良性肿瘤患者的临床资料,其中52例采取经胸乳入路腔镜甲状腺切除术（腔镜组）,54例采取传统开放手术（开放组）。比较两组患者的手术时间、术中出血量、术后引流量、住院时间、切口美容效果满意度、视觉模拟评分（VAS）及术后并发症发生情况。结果 腔镜组手术时间长于开放组［（115.3±22.7）min vs.（87.5±26.4）min,P=0.037］;术中出血量、引流量均少于开放组［（22.3±6.4）mL vs.（45.2±7.1）mL,P=0.009;（25.6±6.5）mL vs.（49.5±12.7）mL,P=0.011］;腔镜组住院时间短于开放组［（4.52±0.31）d vs.（7.81±0.86）d,P=0.027］;腔镜组切口满意度评分高于开放组［（9.33±1.40）分 vs.（3.41±1.24）分,P=0.033］;腔镜组VAS评分低于开放组［（1.77±0.34）分 vs.（4.52±0.55）分,P=0.024］;腔镜组总术后并发症发生率低于开放组（6.2% vs. 18.4%,P=0.018）。结论 与开放甲状腺手术比较,经胸乳入路腔镜甲状腺手术切口小、疼痛轻、出血少、恢复快、并发症发生率低,美容效果显著,值得临床进一步推广应用。     

胚系BRCA突变年轻乳腺癌术式选择对预后影响的Meta分析

背景与目的 携带胚系BReast CAncer基因（gBRCA）突变的年轻乳腺癌患者同时具有年轻与基因突变带来的双重风险。目前对于gBRCA突变早期乳腺癌患者是否可行保乳治疗目前尚无一致结论。本研究通过Meta分析探讨不同手术方式对gBRCA突变的年轻乳腺癌患者预后的影响，以及该影响是否有人种差异。方法 检索多个国外数据库，收集比较gBRCA突变早期乳腺癌患者行保乳手术与全乳切除术预后差异的临床研究，对无复发生存（RFS）、无转移生存（MFS）、乳腺癌特异性生存（BCSS）、总生存（OS）等指标进行Meta分析。结果 最终纳入6篇研究（中国2篇，欧美4篇），共2 140例gBRCA突变患者，中位年龄38~47岁。Meta分析结果显示，总体人群中，gBRCA突变患者行保乳手术较全乳切除术复发风险增高（RFS：HR=1.91，95% CI=1.03~3.54，P<0.05），但两种术式的MFS、BCSS、OS差异均无统计学意义（均P>0.05）；中国人群中，gBRCA突变患者行保乳手术较全乳切除术复发风险增高（RFS：HR=1.63，95% CI=1.10~2.41，P<0.05），两种术式的其余指标差异均无统计学意义（均P>0.05），欧美人群中，两种术式的上述指标差异均无统计学意义（均P>0.05）。结论 对于欧美人群，保乳手术不是gBRCA突变早期年轻乳腺癌术后预后的风险因素；但在中国人群中，gBRCA突变早期年轻乳腺癌患者行保乳手术可能具有更高的复发风险，需在术式选择的医疗决策时充分告知。     

充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术临床效果分析

背景与目的 传统的充气式经腋窝胸锁乳突肌前缘入路全腔镜甲状腺手术,由于受胸锁乳突肌的阻挡,暴露甲状腺不充分,为操作带来一定的难度。为此,笔者近年来将该手术改良为充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术。本研究比较该改良术式与传统术式的应用效果,以期为临床提供借鉴。方法 选取2020年1月—2023年6月于河北省沧州市人民医院甲状腺头颈外科进行充气式经腋窝入路腔镜甲状腺手术患者78例为研究对象,其中39例行充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术（改良入路组）,另39例行充气式经腋窝胸锁乳突肌前缘入路全腔镜甲状腺手术（传统入路组）。比较两组患者手术和术后恢复情况、术后1、3 d的视觉模拟评分法（VAS）、并发症发生情况及术后满意度。结果 两组手术时间差异无统计学意义（P>0.05）,但改良入路组的术中出血量、术后1 d引流量、术后拔管时间、颈部恢复活动时间及术后住院时间均优于传统入路组（均P<0.05）。改良入路组术后1、3 d的VAS评分均明显低于传统入路组（均P<0.05）。改良入路组并发症发生率5.13%,传统入路组12.82%,差异无统计学意义（P>0.05）。改良入路组总满意度明显高于传统入路组（89.74% vs. 66.67%,P<0.05）。结论 充气式经腋窝胸锁乳突肌肌间入路全腔镜甲状腺手术操作相对更容易,可以改善手术状况,患者术后恢复更快,术后疼痛感低,并发症较少,患者术后满意程度也更高,值得在临床推广应用。     

经口腔前庭入路机器人甲状腺切除术中使用吲哚菁绿荧光显影技术的安全性与效果分析

背景与目的 目前,机器人甲状腺手术中采用吲哚菁绿（ICG）荧光显影技术识别与保护甲状旁腺的相关报道相对较少,因此,其临床实用性仍需进一步研究。本研究通过比较在经口腔前庭入路机器人甲状腺切除术（TORTVA）使用与不使用ICG荧光显影技术病例资料的对比分析,探讨TORTVA术中应用ICG荧光显影技术的安全性与有效性。方法 回顾性收集2018年12月—2021年11月行TORTVA患者的病历资料,经筛选后纳入80例患者,其中45例术中采用ICG荧光显影技术（ICG组）,35例未使用ICG荧光显影技术（对照组）,采用1∶1最邻近匹配法进行倾向性评分匹配（PSM）消除两组间混淆偏差后,比较两组患者术中、术后相关指标。结果 PSM后,两组各纳入24例患者,两组间基线资料均衡可比。ICG组与对照组的术中出血量差异无统计学意义（P=0.910）,但ICG组的平均手术时间明显短于对照组（223 min vs. 251 min,P=0.032）。两组术中淋巴结清扫数目、阳性淋巴结数目及淋巴结阳性率差异均无统计学意义（均P>0.05）。两组患者总住院时间与术后住院时间差异无统计学意义（均P>0.05）。两组间术后甲状旁腺素与血清钙水平差异均无统计学意义（均P>0.05）。ICG组3例（12.5%）、对照组6例（25.0%）出现并发症,两组间并发症发生率的差异无统计学意义（P=0.461）;两组均无术中甲状旁腺自体移植患者,均无永久性喉返神经损伤和甲状旁腺功能减退发生。结论 TORTVA术中利用ICG荧光显影技术不会增加术后并发症的风险,具有可靠的安全性;TORTVA术中利用ICG荧光显影技术可以更清楚地显示甲状旁腺,显著缩短手术时间,具有一定的有效性。     

以锁骨上窝特殊脂肪组织为标记指引无充气腋窝入路腔镜甲状腺手术的临床效果（附视频）

背景与目的 目前，无充气腋窝入路腔镜下甲状腺手术（GUA-ET）逐渐被广泛采用，但建腔因其分离皮瓣时存在损伤重要血管和神经的可能性而一直是该手术的重难点。笔者中心近年发现位于锁骨上窝的脂肪团（笔者将其命名为freedom脂肪，简称F脂肪）在GUA-ET手术中有示踪颈外静脉及属支、锁骨上神经和皮下神经分支的作用。因此，本文探讨以F脂肪为指引标记在GUA-ET手术中的临床应用价值。方法 回顾分析2022年5月—2022年12月在湖南省人民医院乳甲外科二病区接受GUA-ET手术的177例甲状腺乳头状癌患者的临床数据。其中，93例术中采用F脂肪作为指引标记（观察组），84例术中未采用F脂肪指引标记（对照组），比较两组患者的初始建腔时间、建腔出血例数、中转开放以及皮肤烧灼伤等并发症的发生率。结果 两组患者的性别与年龄差异均无统计学意义（均P>0.05）。观察组患者GUA-ET手术初始建腔时间明显少于对照组［（12.84±2.218）min vs.（30.49±5.871）min，P<0.05］；观察组建腔过程中出血4例（4.3%），对照组6例（7.1%），差异无统计学意义（P>0.05）；观察组未发生术中出血转开放及皮肤烧灼伤等并发症，对照组发生术中出血转开放与皮肤烧灼伤各1例，但差异均无统计学意义（均P>0.05）。结论 以F脂肪为标记指引GUA-ET手术可避免因保护颈外静脉及其属支等结构而进行的分离与暴露，从而有效缩短初始建腔时间，并可能减少并发症的发生，建议临床推广应用。     

腹腔镜下腹壁疝腹膜外补片修补术与腹腔内补片修补术比较的多中心回顾性研究

背景与目的 腹壁疝修补术是最常见的外科手术之一,全球每年有200万例左右的腹壁疝患者接受手术治疗。与开放手术相比,腹腔镜下腹壁疝修补术优势明显。然而腹腔镜下腹腔内补片修补术（IPOM）与腹腔镜下腹膜外补片修补术（ESR）这两种腔镜术式的优缺点及疗效如何,尚无大样本的临床研究证实。因此,本研究通过比较ESR与IPOM两种手术方式治疗腹壁疝的近远期疗效,为临床提供循证参考。方法 回顾性分析2017年1月1日—2022年12月31日湖南省11家医疗机构收治的157例行腹腔镜腹壁疝修补术患者的临床资料,其中124例行ESR（ESR组）,33例行IPOM（IPOM组）,对比分析两组病例的临床特点、手术方式和术后近远期效果。结果 全组无中转开腹病例或围术期死亡病例。两组病例的年龄、性别、BMI、类型差异均无统计学意义（均P>0.05）。两组病例疝环横径、手术时间、术中出血量、疝环闭合概率差异均无统计学意义（均P>0.05）。网片固定方式ESR组以自固定和缝线固定为主（91.1%）,而IPOM组以钉枪固定为主（69.7%）,差异有统计学意义（P<0.05）。ESR组的术后疼痛评分明显低于IPOM组（2.4±0.8 vs. 2.8±1.0,P<0.05）,住院费用明显低于IPOM组（21 001元vs. 38 437元,P<0.05）。两组的术后住院时间和近期并发症发生率差异无统计学意义（均P>0.05）。中位随访10.3个月,ESR组无复发病例,IPOM组2例复发（6.1%）,差异有统计学意义（P<0.05）。结论 ESR是湖南地区腹腔镜下腹壁疝修补的主流术式之一。由于固定方式和网片选择的不同,ESR较之IPOM而言,术后疼痛更轻微、费用更低、复发率更低,且并不明显增加手术时间和术后近期并发症。     

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.