双通道植管联合胆道镜保胆取石治疗高龄结石性胆囊炎

目的：评价B超引导下胆囊穿刺双通道植管联合胆道镜保胆取石治疗高龄高危急性结石性胆囊炎患者的疗效。 方法：回顾性分析2012年1月—2013年12月收治的35例80岁以上急性结石性胆囊炎患者的临床资料。 结果：35例患者均行超声引导下胆囊穿刺双通道植管胆囊冲洗、减压、持续引流,6~8周后,行胆道镜经窦道保胆取石。所有患者超声引导穿刺植管均一次性成功,1例发生穿刺后出血,经对症处理止血成功;1例因植管窦道形成不佳改行胆囊切除术,余34例均成功保胆取石（34/35）;随访4~24个月,结石复发1例（1/34）。 结论：双通道胆囊穿刺植管联合胆道镜保胆取石治疗高龄高危胆囊结石方法简单、疗效可靠,具有推广价值。

     

超声引导下双通道置管联合胆道镜保胆取石术治疗高龄急性结石性胆囊炎

目的 探讨超声引导下双通道置管联合胆道镜保胆取石术治疗高龄急性结石性胆囊炎患者的疗效.方法 回顾性分析2012年1月至2013年12月成都军区总医院收治的35例高龄(≥80岁)胆囊结石患者的临床资料,先在B超引导下行经皮胆囊双通道穿刺置管引流,后期联合胆道镜保胆取石术.术后长期口服消炎利胆药物,降低结石复发.采用电话和门诊随访,随访时间截至2014年6月30日.结果 35例患者B超引导下胆囊穿刺置管均一次性成功,1例发生穿刺后出血,经对症治疗止血成功;因置管窦道形成不佳改行胆囊切除术1例;余34例均成功取石;随访4～24个月,结石复发1例.结论 双通道胆囊穿刺置管联合胆道镜保胆取石治疗高龄急性结石性胆囊炎,该手术方式方法简单、疗效可靠,具有推广价值.     

介入超声联合胆道镜双通道“一步法”治疗高龄急性结石性胆囊炎的疗效观察

目的 探讨介入超声联合胆道镜双通道“一步法”治疗高龄高危急性结石性胆囊炎的临床可行性。方法 回顾性分析2016年6月至2018年7月于西部战区总医院就诊并接受该技术治疗的54例患者临床资料。结果 54例患者均成功完成双通道置管（超声引导下经皮经肝胆囊穿刺,同期行胆道镜取石）。其中50例患者取石成功,成功率为93%;并发症方面,1例出血,1例术后超声复查疑似胆漏。50例患者随访3～12个月,1例结石复发。结论 超声引导下经皮经肝胆囊穿刺同期胆道镜取石这种双通道“一步法”治疗高龄高危急性结石性胆囊炎安全有效,具有临床可行性。     

胆囊穿刺双置管引流联合胆道镜治疗高危结石性胆囊炎临床效果观察

目的:探讨超声引导下经皮胆囊穿刺双管引流联合胆道镜在高危结石性胆囊炎患者中的应用效果及对血清肿瘤坏死因子-α(TNF-α)、瘦素水平的影响。方法:选取收治的高危结石性胆囊炎患者110例,随机数字表法分为对照组(n=55)和观察组(n=55)。对照组采用传统开腹手术治疗,观察组采用超声引导下经皮胆囊穿刺双管引流联合胆道镜治疗,采用酶联免疫吸附试验测定两组治疗前、后血清TNF-α、瘦素水平,比较两组临床疗效及对血清TNF-α、瘦素水平的影响。结果:两组术前血清TNF-α、瘦素水平比较差异无统计学意义(P0.05);观察组出院前血清TNF-α为(41.2±5.5)ng/L、瘦素为(4.5±1.2)ng/L,均低于对照组[分别为(58.6±7.2)ng/L、(6.9±1.4)ng/L,P0.05];观察组术后并发症发生率为3.6%,对照组为10.9%,二者比较差异有统计学意义(P0.05)。结论:超声引导下经皮胆囊穿刺双置管引流联合胆道镜治疗高危结石性胆囊炎患者疗效确切,同时能降低血清TNF-α、瘦素水平。     

膀胱造瘘穿刺针结合气囊导尿管在经皮胆囊造瘘术中的应用

目的：探讨膀胱穿刺针结合气囊导尿管在高危急性胆囊炎患者中胆囊造瘘的价值。 方法：回顾性分析2001—2010 年收治的42 例高危急性胆囊炎患者临床资料。42 例不能进行急诊 胆囊切除术的高危急性胆囊炎患者在超声引导下应用气囊导尿管经皮穿刺胆囊造瘘术,在胆囊内 放置直径为16 F 气囊导尿管引流胆汁和结石,观察胆囊造瘘前后患者临床症状、体征及白细胞计 数的变化情况。 结果：42 例患者在超声引导下应用膀胱穿刺针和气囊导尿管经皮胆囊造瘘均获得成功。所有患者 术后1~2 d 临床症状、体征缓解。6 例患者获得终末性治疗,4 例术后择期行胆囊切除术,5 例胆 囊小结石通过窦道行胆道镜取石,27 例胆囊结石直径超过窦道直径患者行气压弹道碎石并结合胆 道镜取石。 结论：超声引导下应用气囊导尿管经皮胆囊造瘘术是一种操作简单、安全有效的胆囊造瘘方法, 对于高危的急性胆囊炎患者能缓解症状,且为后续的治疗提供良好的取石通道。     

序贯式双通道胆囊穿刺造瘘联合胆道镜微创保胆取石

目的:探讨超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石术治疗高龄高危急性结石性胆囊炎患者的疗效.方法:回顾性分析2012年1月-2013年4月接受双通道胆囊穿刺造瘘联合胆道镜保胆取石术治疗的30例高龄高危急性结石性胆囊炎患者的临床资料.结果:30例患者均穿刺置管成功,1例发生出血,向腔内注入立止血,夹闭弓引流管后出血停止,带管时间为14d至2个月,平均时间为30 d.4～8周后,28例患者成功行胆道镜取石,1例患者因窦道未形成行开腹胆囊切除术,1例患者因16F猪尾型外导管滑脱行腹腔镜胆囊切除术.28例患者获随访3～19个月,B超检查1例(3.6％)复发.结论:超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石是治疗高龄高危胆囊结石患者可靠、有效的方法.     

PTGD联合小切口胆道镜取石治疗高龄、高危急性梗阻性结石性胆囊炎

目的探讨B超引导下经皮经肝胆囊穿刺引流(PTGD)联合二期小切口胆道镜取石术治疗高龄、高危急性梗阻性结石性胆囊炎患者的疗效。方法回顾性分析2009年1月至2013年12月期间接受PTGD联合小切口胆道镜取石治疗的124例高龄、高危急性梗阻性结石性胆囊炎患者的临床资料。结果 124例均穿刺置管成功,置管引流后3~5 d出院。除2例引流管脱出;其余122例6~8周后行右上腹小切口胆囊切开胆道镜取石术,其中91例取净结石后一期缝合胆本+更换PTGD管,31例行胆囊切除。继发胆总管结石6例,其中4行经胆囊管胆道镜取石,2例行经胆囊管残端胆道镜取石。手术顺利,未发生胆管损伤、胆漏等重大并发症或死亡。结论 PTGD联合二期小切口胆道镜取石治疗高龄、高危急性梗阻性结石性胆囊炎,符合损伤控制理念,是一项有效、简便、微创的方法。     

超声引导下经皮经肝胆囊造瘘治疗老年急性重症胆囊炎

目的探讨超声引导下经皮经肝胆囊穿刺置管引流（percutaneous transhepatic gallb ladder catheterizing drainage,PTGCD）治疗老年急性重症胆囊炎的临床疗效。方法18例有急诊胆囊切除禁忌的老年急性重症胆囊炎患者,在超声引导下行PTGCD。其中,结石性胆囊炎14例,非结石性胆囊炎4例。结果均一次性置管成功,未出现并发症;14例结石性胆囊炎患者中,11例择期行胆囊切除术,3例不能耐受手术患者无症状长期置管。4例非结石性胆囊炎患者于引流后3~4周行胆道造影示无梗阻后拔管康复。结论超声引导下PTGCD治疗老年急性重症胆囊炎是一种简单、安全而有效的方法。     

介入超声联合纤维胆道镜治疗肝胆管结石合并急性梗阻性胆管炎

目的：探讨改良超声引导经皮经肝胆管穿刺置管联合纤维胆道镜治疗肝胆管结石合并急性梗阻性胆管炎患的效果。 方法：回顾性分析2013年6月―2014年6月接受改良超声引导经皮经肝胆管穿刺置管联合纤维胆道镜治疗肝胆管结石合并急性梗阻性胆管炎的10例患者的临床资料。 结果：10例患者均穿刺置管成功,置管后2~3 h疼痛症状缓解,24~48 h体温恢复正常,疼痛、寒战症状消失。带管时间为40 d至2个月,平均时间为50 d。置管6~8周后,10例患者成功行经窦道胆道镜取石及狭窄胆管扩张,结石取净率100%。1例患者在穿刺置管10 min后,引流管持续引流出暗红色血性胆汁,向腔内注入立止血夹闭引流管后出血停止。10例患者均未出现漏胆、损伤周围脏器等严重并发症。 结论：改良超声引导经皮经肝胆管穿刺置管联合纤维胆道镜是治疗肝胆管结石合并急性梗阻性胆管炎可靠、有效的方法,值得推广应用。

     

腹腔镜联合胆道镜胆总管切开取石一期缝合术56例疗效观察

2003年1月～2011年4月,选择非急性发作的慢性结石性胆囊炎继发胆总管结石且无黄疸患者56例,行腹腔镜联合胆道镜胆总管切开取石一期缝合术,均获成功。并发胆漏3例（5%）,其中2例引流2、4 d愈合,1例引流不畅,彩超引导下重新穿刺置管引流后愈合。随访6～12个月,未见结石残留及胆管狭窄,肝功能正常。     

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.     

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.     

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.     

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.     

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.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.