腹腔镜阑尾切除133例分析

目的:总结腹腔镜阑尾切除术(LA)的经验并探讨手术适应证。方法:总结分析LA133例的临床资料。结果:133例中急性单纯性阑尾炎12例,急性化脓性阑尾炎91例,其中急性阑尾炎合并卵巢囊肿1例,黄体破裂出血1例,急性盆腔炎2例,回肠内异物致肠穿孔1例。急性坏疽性阑尾炎15例,坏疽穿孔并急性弥漫性腹膜炎13例,慢性阑尾炎2例,其中合并结石性胆囊炎1例。中转剖腹1例,平均住院时间为4.1d。无切口感染、肠粘连、肠梗阻等并发症发生。结论:行LA时妥善处理阑尾系膜及残端,掌握阑尾移出腹腔的方法,可避免戳孔感染,减少肠粘连、肠梗阻的发生。尤其适合于肥胖、小儿、老年人、育龄妇女及诊断未明的腹膜炎患者,可作为阑尾切除的首选方法。     

腹腔镜阑尾切除术1261例报告

目的 :总结腹腔镜阑尾切除术的经验。方法 :回顾分析行腹腔镜阑尾切除术 12 6 1例的临床资料。结果 :12 6 1例中 ,12 4 9例在腹腔镜下完成阑尾切除术 ,2例行阑尾周围脓肿引流术 ,10例为阑尾根部穿孔或腹膜后阑尾中转剖腹手术。 1例术后出血而再手术 ,戳孔感染 4例 ,无因肠瘘、肠粘连、肠梗阻而再手术者。结论 :腹腔镜阑尾切除术要正确处理系膜并将阑尾移出腹腔 ,可降低切口感染、肠粘连、肠梗阻的发生率 ,此术式尤其适用于肥胖 ,小儿及化脓坏疽性阑尾炎患者     

腹腔镜下阑尾切除术153例临床分析

目的总结腹腔镜阑尾切除术(laparoscopic appendectomy,LA)的应用经验。方法回顾性分析我院2009年5月至2010年8月期间153例行LA手术患者的临床资料。结果 153例中男74例,女79例;年龄8~76岁,平均32.5岁。其中慢性阑尾炎7例,急性单纯性阑尾炎41例,急性化脓性阑尾炎81例,急性坏疽穿孔性阑尾炎24例。149例在腹腔镜下顺利完成手术,4例因阑尾周围组织水肿及粘连明显、镜下解剖不清而中转开腹。手术时间30~90 min,平均51 min。住院时间3~8 d,平均5 d。发生脐部戳孔感染5例。随访1~12个月(平均5个月),无术后出血、腹腔脓肿及粘连性肠梗阻发生。结论 LA创伤小,疤痕小,恢复快,住院时间短,并发症少,安全性高。     

腹腔镜阑尾切除术的适应证探讨

目的:探讨腹腔镜阑尾切除术的适应证。方法:回顾分析2006年6月至2008年6月为165例患者行腹腔镜阑尾切除术的临床资料。结果:术后34例(20.6%)发生并发症,其中穿刺孔感染5例(14.7%),穿刺孔血肿2例(5.9%),穿刺孔硬结7例(20.6%),腹腔出血2例(5.9%),腹腔感染(肠间隙积液)8例(23.5%),腹腔脓肿6例(17.6%),粘连性肠梗阻4例(11.8%),无死亡病例。化脓性阑尾炎、穿孔性阑尾炎、阑尾周围脓肿与急性单纯性阑尾炎相比,穿刺孔感染、腹腔感染、腹腔炎性包块、炎性肠梗阻发生率高(P0.05)。结论:阑尾病理损害程度越重,术后并发症发生率越高。腹腔镜阑尾切除术的适应证包括单纯性阑尾炎、化脓性阑尾炎早期、慢性阑尾炎、肥胖及老年性阑尾炎。术前不能确诊的阑尾炎或弥漫性腹膜炎患者可行腹腔镜探查,以免误诊、漏诊。     

腹腔镜阑尾切除术80例体会

目的 探讨腹腔镜阑尾切除术（laparoscopic appendectomy,LA）的常见手术技巧.方法回顾分析我院近3年来80例阑尾炎患者行LA的临床资料.结果 76例在腹腔镜下顺利完成手术,4例中转开腹,其中阑尾周围脓肿1例,特殊位置阑尾1例,阑尾根部坏疽穿孔1例,系膜血管回缩引起大出血1例,手术时间35～130min,住院时间3～9d,1例戳孔感染经对症处理后痊愈,无术后出血、肠粘连等并发症发生.结论耐心、细致、熟练的腹腔镜外科技术是保证各种阑尾炎一期切除、减少并发症的关键.     

腹腔镜小儿阑尾切除术31例临床分析

目的总结腹腔镜阑尾切除术(laparoscopic appendectomy,LA)治疗小儿阑尾炎的疗效。方法采用LA治疗小儿急性阑尾炎31例。结果均顺利完成LA,无腹腔内出血,无肠管、输尿管等副损伤,无中转开腹,术后无粘连性肠梗阻、腹盆腔脓肿及手术切口感染等并发症发生。结论 LA治疗小儿急性阑尾炎具有安全、微创、并发症少及恢复快的优点,值得推广。     

腹腔镜阑尾切除术并发症探讨与分析

目的探讨腹腔镜阑尾切除术(LA)的并发症原因、预防与治疗。方法对648例阑尾炎患者行LA治疗,回顾分析患者的临床资料。结果术后发生并发症122例,发生率18.83%,包括穿刺孔及腹腔内出血、感染和炎性肠梗阻。化脓性、坏疽性阑尾炎、阑尾周围脓肿与慢性阑尾炎、急性单纯性阑尾炎相比并发症发生率明显增高,差异有统计学意义(P0.05)。结论阑尾病变程度与LA术后并发症发生率呈正相关。术前正确评估阑尾炎病变程度,严格掌握适应证,术中规范技术操作,适时中转开腹是预防LA并发症的关键。术后及早发现和综合治疗LA术后并发症效果良好。     

腹腔镜二孔法与三孔法阑尾切除术的对比研究

目的探讨腹腔镜二孔法与三孔法阑尾切除术的临床应用指征。方法回顾性分析腹腔镜阑尾切除术(Laparoscopic Appendectomy，LA)的临床资料，比较二孔法与三孔法LA的手术时间、戳孔感染率。本组206例完成LA术，其中三孔法148例(9例由二孔法中转)、二孔法58例。结果平均手术时间二孔法显著短于三孔法(P=0．000)。急性单纯性阑尾炎和慢性阑尾炎LA术后戳孔均无感染，急性化脓性阑尾炎戳孔感染率二孔法与三孔法无显著性差异(P=1．000)，急性坏疽性阑尾炎戳孔感染率二孔法显著高于三孔法(P=0．039)。结论LA二孔法具有更加微创、美容的特点，可作为单纯性、化脓性及慢性阑尾炎的首选术式．但对于坏疽性阑尾炎则宜选择三孔法。     

开腹与腹腔镜阑尾切除术治疗急性阑尾炎的疗效对比

目的:探讨开腹阑尾切除术(open appendectomy,OA)与腹腔镜阑尾切除术(laparoscopic appendectomy,LA)治疗急性阑尾炎的临床疗效。方法:选择2009年2月至2012年11月收治的197例急性阑尾炎患儿,其中91例行LA(观察组),106例行OA(对照组),对比分析两组患儿手术时间、术后肛门排气时间、住院时间、切口感染、腹腔脓肿及肠梗阻情况。结果:观察组单纯性阑尾炎及化脓性阑尾炎患儿术后肛门排气时间、住院时间均明显短于对照组(P<0.05),但手术时间明显长于对照组(P<0.05)。观察组坏疽穿孔阑尾炎患儿术后肛门排气时间明显短于对照组(P<0.05),手术时间长于对照组(P<0.05),观察组切口感染、腹腔脓肿及肠梗阻发生率明显低于对照组(P<0.05)。结论:单纯性与化脓性阑尾炎患儿行LA可明显缩短住院时间与肛门排气时间;对于坏疽穿孔性阑尾炎患儿,LA可明显缩短肛门排气时间,降低切口感染、腹腔脓肿发生率。临床应合理选择术式。     

腹腔镜阑尾切除术的常见难点与手术技巧

目的:探讨腹腔镜阑尾切除术(laparoscopic appendectomy,LA)的常见难点和手术技巧。方法:回顾分析我院近3年为220例阑尾炎患者行LA的临床资料。结果:216例在腹腔镜下顺利完成手术,4例中转开腹,阑尾取出困难62例,特殊位置阑尾18例,阑尾根部坏疽穿孔13例,阑尾周围重度粘连19例,阑尾显露困难12例,系膜出血7例,手术时间35~130min,住院时间3~9d,1例戳孔感染经对症处理后痊愈,无术后出血、肠粘连等并发症发生。结论:耐心、细致、熟练的腹腔镜外科技术是保证各种阑尾炎一期切除、减少并发症的关键。     

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.     

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.     

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.     

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.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

Background: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known.
Methods: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (millilitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion.
Results: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r²=0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0–4 u). However, 32% of such patients required allogeneic blood.
Conclusions: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

缺氧对肾小管上皮细胞分泌外泌体的影响

目的    观察缺氧对肾小管上皮细胞分泌外泌体的影响,探讨外泌体在缺氧致肾脏损伤中的作用及机制。 方法    （1）常氧（21% O₂）及缺氧（1% O₂）分别处理大鼠肾小管上皮细胞（NRK-52E）48 h,收集细胞上清液并使用高速梯度离心法分离外泌体。采用透射电镜、纳米示踪分析、Western印迹、蛋白浓度定量鉴定并比较两组外泌体的基本特性。（2）在共培养实验中,以不同浓度（1、10、50、100、300 mg/L）的常氧外泌体、缺氧外泌体分别干预脂多糖（LPS）诱导的大鼠原代腹腔巨噬细胞,使用实时荧光定量PCR与酶联免疫吸附试验（ELISA）法分别检测巨噬细胞白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）、诱导型氮氧化物合酶（iNOS）水平;使用Western印迹法检测巨噬细胞磷酸化（p）STAT/STAT及细胞因子信号传导抑制蛋白1（SOCS1）的蛋白表达;最后,使用实时荧光定量PCR法检测常氧外泌体与缺氧外泌体中炎性反应相关微RNA（microRNA,miR）的表达差异。 结果    （1）离心得到的囊泡具有外泌体典型的结构,粒径小于150 nm,表达外泌体标志蛋白CD63,说明分离得到外泌体。缺氧对肾小管上皮细胞分泌的外泌体形态、粒径分布比例无明显影响,但提高了外泌体的分泌量。（2）缺氧外泌体相比于常氧外泌体促进了LPS诱导的M1型巨噬细胞IL-6、TNF-α、iNOS 的表达和分泌（均P＜0.01）,同时提高STAT的磷酸化水平并减少SOCS1的蛋白表达（均P＜0.01）;对炎性反应相关microRNA检测发现缺氧外泌体中miR-155、miR-27a表达量较常氧外泌体明显升高（P＜0.05）。 结论    缺氧可改变外泌体的生物学功能,表现为协同促进LPS诱导的M1型巨噬细胞的表型转化,这可能是慢性肾脏病微炎性反应状态持续的原因之一。     

In Vitro Function and Durability Assessment of a Novel Polyurethane Heart Valve Prosthesis

Abstract While flexible-leaflet, central-flow prosthetic heart valves promise relief from anticoagulation therapy, they continue to be restricted by inadequate durability. In consequence, a novel trileaflet valve, made entirely from polyurethane, has been developed. A batch of 6 consecutively manufactured polyurethane valves was subjected to hydrodynamic function and accelerated fatigue testing. Computerized data acquisition and control systems have been introduced to improve valve testing methodologies. In terms of hydrodynamic function, the polyurethane valve demonstrates transvalvular pressure gradients similar to those for a bioprosthetic valve (Carpentier-Edwards) and levels of retrograde flow significantly less than those for either the bioprosthetic valve or a bileaflet mechanical valve (St Jude Medical). The equivalent of 10 years of cycling without failure has been exceeded by all 6 polyurethane valves in accelerated fatigue tests with 2 valves remaining intact after 674 million cycles (equivalent to approximately 17 years) in continuing tests. Highspeed photography revealed considerable differences in leaflet motion between valves cycled at accelerated and physiological rates.     

Negative pressure ventilation vs. spontaneous assisted ventilation during rigid bronchoscopy: A controlled randomised trial

Background: Ventilation during interventional rigid bronchoscopy (IRB) under general anaesthesia (jet ventilation, positive pressure ventilation and spontaneous assisted ventilation) may offer some difficulties. This study compares the effectiveness during IRB of intermittent negative pressure ventilation (INPV) and spontaneous assisted ventilation (SAV). Methods: Thirty-eight patients submitted to IRB were randomised into two groups: SAV or INPV. All patients received a total intravenous anaesthesia; INPV patients were paralysed. Pre-and intra-operative arterial blood gases and O₂ flow through a rigid bronchoscope were assessed. The endoscopist applying a subjective score evaluated the operating conditions. Results: Patients of the INPV group, as compared to the SAV group, required a lower dosage of fentanyl (2.6 ± 1.8 (μg · kg^?1· h^?1 vs. 6.6 ± 4.8 μg · kg^?1· h^?1), a lower O₂ supply (3.3 ± 2.8 1/min vs. 11.6 ± 3.4 1/min), a shorter recovery time (5.4 ± 2.9 min vs. 9.8 ± 7.1 min) and no manually assisted ventilation (0 ± 0 vs. 1 ± 1.1 nd?/procedure). Intraoperative PaCO₂ was higher in the SAV (8.1 ± 1.3 kPa) than in the INPV group (5.0 ± 1.6 kPa) and intraoperative pH differed in the two groups (7.26 ± 0.05, SAV vs. 7.47 ± 0.08, INPV). Operating conditions, as assessed by a subjective score, were considered better with INPV than with SAV (4.9 vs. 4.3). Conclusions: As compared to SAV, INPV in paralysed patients during IRB reduces administration of opioids, shortens recovery time, prevents respiratory acidosis, excludes the need for manually assisted ventilation, reduces 02 need and affords optimal surgical conditions. INPV appears a safe, non-invasive and effective ventilatory management during IRB.