老年胃癌患者手术安全性分析

目的分析老年胃癌患者手术安全性。方法回顾性分析我院2004年1月至2005年12月期间收治的92例70岁以上老年胃癌患者的临床病理特性、手术及预后。结果老年胃癌以分化型腺癌为主(70.65%);病理分期以中晚期为主(89.6%);术前营养条件差、合并症多,术后并发症发生率高;总手术切除率占97.8%,住院病死率4.3%。结论围手术期加强对各重要脏器功能监测和合并症的治疗,选择个体化的手术方式,老年人行胃癌根治性手术是安全可行的。     

重视老年胃癌患者的围手术期处理(附370例报告)

目的 总结老年胃癌的临床特点及围手术期处理经验。方法 回顾性分析我院1990年1月至2003年1月间共收治的370例老年胃癌患者的临床资料。结果 370例老年胃癌中290例（78．4％）伴有高血压、心脏病、糖尿病等老年常见病；术后发生并发症110例次，死亡16例；手术前有共存病者术后并发症的发生率（34．5％）明显高于无共存病者（12．5％），P〈0．01。结论 加强围手术期处理是降低老年胃癌患者并发症和死亡率的关键。     

70岁以上老年人胆石症外科手术治疗体会

目的 探讨老年人胆石症的临床特点、手术适应证、手术治疗方法及围术期处理。方法 回顾217例70岁以上老年胆石症患者，针对合并症、手术方式、手术时机、治疗效果等进行综合分析。结果本组70岁以上手术患者217例，并发症65例（30．6％），死亡1例（0．5％），疗效满意。结论 掌握手术的适应证和手术时机、处理合并症、争取择期手术及避免急诊手术盲目性是外科治疗老年胆道疾病、减少并发症、降低死亡率的关键。     

淋巴结外软组织阳性胃癌预后相关分析

目的探讨淋巴结外软组织阳性（EM）与胃癌各种临床病理因素的相关性以及其对胃癌预后的影响。方法2001年1—12月间，天津医科大学附属肿瘤医院手术治疗和经病理确诊、且随访资料完整的胃癌患者共计276例。回顾性分析这组病例的临床资料，确定EM的相关因素及与胃癌预后的关系。结果本组276例手术标本中有58例（21．0％）EM。无EM者和有EM的胃癌患者2、3、5年生存率分别为71．2％、55．4％、45．1％和24．1％、15．5％、8．0％（P=0．000）；EM与胃癌病理分类（r=0．163，P=0．008）、浸润深度（r=0．215，P=0．003）、淋巴结转移（r=0．368，P=0．000）、远处转移（r=0．375，P=0．000）、TNM分期（r=0．441，P=0．000）、肿瘤最大径相关（r=0．167，P=0．007）（P〈0．05）；多因素分析显示，EM为胃癌独立预后因素之一。结论EM与多种胃癌临床病理因素相关，是胃癌独立预后因素。     

2335例胃癌外科治疗的临床分析

目的探讨胃癌外科治疗的临床疗效和影响预后的因素。方法应用我院建立的胃癌数据库资料，回顾性分析解放军总医院1996年1月至2005年12月2335例胃癌外科手术患者的临床病理因素及治疗措施对预后的影响。结果全组男性患者占81．0％，女性19．0％；男女之比4．3：1．0。50岁以下患者占22．8％，50岁以上者占77.2％。早期胃癌275例，占11．8％；其余88．2％均为进展期胃癌。72．8％的患者肿瘤直径超过4cm，69．6％的患者其肿瘤呈低分化。1690例（72．4％）患者进行了根治性切除手术，其余为姑息性切除或探查；术后予以综合治疗者1538例（65．9％）。全组总的1、3、5年生存率分别为71．9％、45．3％和40．1％。经单因素和多因素分析显示，影响胃癌生存的独立预后因素分别是手术方式（P〈0．01）、TNM分期（P〈0．01）和综合治疗（P〈0．01）。结论手术根治程度、肿瘤TNM分期和综合治疗是影响胃癌患者预后重要因素，早期手术和根治性手术是治愈胃癌最有效的手段。     

胃癌同时性肝转移的临床病理分析和外科治疗效果评价

目的分析影响胃癌同时性肝转移的临床病理因素，探讨胃癌肝转移的治疗方法。方法回顾性分析1994年8月至2004年2月间收治的44例胃癌同时性肝转移患者的病例资料，并与同期收治的无转移的576例胃癌病例资料进行比较，分析影响同时性肝转移的临床病理因素。对胃癌肝转移根治性切除、姑息性切除和探查性手术的生存状况进行分析比较。结果单因素分析显示，腹水、盆结节、腹膜侵犯、浆膜浸润、淋巴结转移、周围脏器受累以及肿瘤Borrmarm分型、浸润深度都与胃癌肝转移有关（P〈0．01）；Logistic回归分析发现，腹膜侵犯（P=0．003）、浆膜浸润（P=0．000）、淋巴结转移（P=0．081）是影响胃癌肝转移最重要的因素。本组胃癌肝转移患者行根治性切除16例（36．4％），姑息性切除15例（34．1），探察性手术13例（29．5％）；中位生存期分别为19．5、11．0和6．2个月：3组比较差异有统计学意义（P〈0．05）。结论胃癌肝转移是胃癌的晚期事件；根治性切除胃癌原发病灶和肝转移灶，仍然可以明显提高患者的生存率。     

老年患者开胸术后心肺并发症发生原因分析

目的 探讨老年重症患者开胸手术后心肺并发症的发生原因和预防措施。方法 对2001年7月至2003年12月收治的58例年龄〉65岁、术前有重要器官合并症和行大手术的开胸手术患者（实验组）进行围术期呼吸、循环监测，观察术后并发症发生情况，并与同期收治的56例（65岁开胸手术患者（对照组）进行比较。结果 实验组患者术前合并心血管和呼吸系统疾病的比率显著高于对照组，肺功能指标均较对照组差（P〈0．05）。实验组死亡4例，术后并发症、功能性并发症发生率显著高于对照组[58．6％（34／58）vs．17．9％（10／56），P=0.000；51．7％（30／58）vs．12．5％（7／56），P=0.000]，呼吸系统并发症发生率明显较对照组高。logistic回归分析显示，术前呼吸系统合并症（OR=5．4）和肥胖（OR=4．9）是术后呼吸系统并发症发生的独立预测因素。结论 术前合并呼吸系统、心血管疾病是老年患者术后易发生呼吸、心血管系统功能性并发症的主要原因。呼吸系统并发症是老年重症患者开胸手术后主要的死亡原因。术前呼吸系统合并症、肥胖是术后发生呼吸系统并发症的主要危险因素。心血管并发症主要表现为阵发性室上性心动过速，术前有心血管合并症是术后发生心血管并发症的危险因素。密切监护老年患者的呼吸循环指标及液体出入平衡变化有助于及早发现呼吸循环异常，提高老年患者开胸手术的疗效。     

老年人胃癌49例手术治疗分析

目的 探讨老年人胃癌围手术期处理的有关问题及适当的手术治疗方式。方法 回顾性分析1993－1998年我院收治70岁以上老年人胃癌53例，其中施行手术49例的临床资料和手术疗效。结果 老年人胃癌起病隐匿，症状多无特异性。术前多数合并有其它疾病；手术证实多数为中晚期胃癌，癌肿多见于幽门窦（77．5％）、大于5cm并累及胃浆膜层（81．6％）。病理检查多为分化型腺癌（73．4％）。49例中30例行胃 切除术，切除率为61．2％；其中根治性切除8例（17％），姑息性切除22例（45％）。其它手术19例（胃－空肠吻合术13例，手术探查取活检6例）。围手术期死亡率2．7％。手术后并发症27例（55％）。根治性切除术后5年生存率2．5％，姑息性切除术后五年生存率为零。结论 老年人胃癌有其特殊性，其围手术期处理至关重要，手术根治性切除率低。手术方式应根据病情而定，对早期或中期胃癌争取行D2以内的胃癌根治术。术前充分准备，提高病人手术耐受能力，手术时间以不超过2h为好，术毕常规残留或空肠造瘘，以期减少术后并发症。术后加强管理，并辅以腹腔灌注化疗，对提高病人生活质量，延长生存期有明显帮助。     

老年腹部手术患者129例合并症的围术期处理分析

目的探讨老年腹部手术患者合并症的围术期处理。方法回顾分析2003年1月～2007年12月我院收治的129例60岁以上腹部手术患者有合并症的围术期临床资料。结果治愈126例，死亡3例，死亡率2．4％。其中并存呼吸系统疾病58例（46．6％），心血管疾病48例（37．3％），糖尿病32例（24．8％），肝肾功能异常20例（15．5％），贫血、低蛋白血症24例（18．6％）。术后并发伤口感染11例，伤口裂开3例，肺部感染5例，肠瘘3例，心功能不全2例。结论年龄不是腹部手术患者的手术禁忌证，做好合并症的围术期处理，可极大地提高手术成功率，降低手术死亡率和并发症发生率。     

胃癌128例临床病理分析

目的 探讨胃癌的临床及病理特点。方法回顾性分析我院2002年1月～2004年12月行手术治疗，并经病理确诊的128例胃癌患者的临床资料。结果 本组患者男性多于女性（3．4：1），40岁以上中老年占86．7％。临床症状主要为：中上腹疼痛86例（67．2％），消瘦66例（51．6％）和贫血58例（45．3％）。128例中胃体及胃底部癌71例（55．5％）；Bor-rmannⅡ型和Ⅲ型分别为41例（32．O％）和52例（40．6％）。56．3％（72例）组织病理学为腺癌；76．6％（98例）TNM分期为Ⅲ期和Ⅳ期；120例肿瘤可切除，属根治性切除101例（78．9％）。结论 本组资料显示中老年胃癌发病率高，且中晚期病变多．根治性切除率仅为60％。因此，必须进一步提高对胃癌的认识，尽可能做到早诊断、早治疗，这是提高疗效及患者生存率的关键。     

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.