肝脏功能与外科临床的联系(2)

胆红素代谢胆红素是血红素破坏的终末产物,几乎全部由胆汁排泄。肝细胞疾患或肝外胆道梗阻时,即有胆红素积聚于血液和组织中,约75%的胆红素来自衰老的红细胞。胆红素在循环血中与白蛋白结合,这样即能保护组织不会遭受到胆红素的毒性损害。肝脏通过载体介导的转运系统迅速清除血浆中的胆红素。在肝细胞内,胆红素与Y和Z蛋白结合进行转运,最后与葡萄糖醛酸结合经胆汁排泄。结合型胆红素与白蛋白形成共价键称为delta胆红素,其意义仍有待进一步研究。胆红素代谢紊乱可导致非结合高胆红素血症,见于新生儿高胆红素血症,Crigler鄄NajjarⅠ型(常发…     

肝脏功能与外科临床的联系(1)

肝脏在人体一系列特殊功能中起着关键性的作用。其可协助发现并能改变内脏循环和体循环血中的异常成分,以保持内环境的稳定;能够调节能量的贮存和多种物质的合成及分解代谢过程,包括胆红素、碳水化合物、脂类和蛋白质的代谢等。肝脏通过生成胆汁和肠肝循环影响消化功能,可制造、分布、贮存多种矿物质和维生素;另外还能合成、分泌前体凝血因子、铜蓝蛋白、转铁蛋白、结合蛋白和白蛋白;代谢和处理废料、药物和毒素;在免疫功能方面也起着关键性作用,如能过滤来自肠道的病原体等。本文主要介绍肝脏的有关生物学和实用的基本知识,以期达到加强了…     

Creation of an Online Wiki Improves Post-Operative Surgical Protocol Adherence in Arthroplasty Patients

Background

Perioperative care pathways are tools used in high-volume clinical settings to standardize care, reduce variability, and improve outcomes. However, the mechanism by which the information is transmitted to other caregivers is often inconsistent and error-prone. At our institution, we developed an online, user-editable (“wiki”) database to communicate post-operative protocols. The purpose of this study is to evaluate the hypothesis that implementation of the wiki would improve protocol adherence and reduce unintentional deviations inpatient care.

Loss of Anergic B Cells in Prediabetic and New-Onset Type 1 Diabetic Patients

Although dogma predicts that under normal circumstances, potentially offensive autoreactive cells are silenced by mechanisms of immune tolerance, islet antigen–reactive B lymphocytes are known to play a crucial role in the development of autoimmunity in type 1 diabetes (T1D). Thus, participation of these cells in T1D may reflect escape from silencing mechanisms. Consistent with this concept, we found that in healthy subjects, high-affinity insulin-binding B cells occur exclusively in the anergic naive IgD⁺, IgM⁻ B-cell (B_ND) compartment. Antigen receptors expressed by these cells are polyreactive and have N-region additions, Vh usage, and charged complementarity-determining region 3 consistent with autoreactivity. Consistent with a potential early role in autoimmunity, these high-affinity insulin-binding B cells are absent from the anergic compartment of some first-degree relatives and all prediabetic and new-onset (<1 year) T1D patients tested, but return to normal levels in individuals diabetic for >1 year. Interestingly, these changes were correlated by transient loss of the entire B_ND compartment. These findings suggest that environmental events such as infection or injury may, by disrupting B-cell anergy, dispose individuals toward autoimmunity, the precise nature of which is specified by genetic risk factors, such as HLA alleles.     

Effect of Surgical Stress on Immune Function in Patients with Urologic Cancer

Background: To determine the immunosuppressive effect of surgery for urologic cancers, multiple variables of immune function were measured serially before and after operation in patients with urologic cancer.
Methods: Peripheral blood was obtained before operation and at postoperative day 7 and 14 from 20 patients with bladder cancer, renal pelvic, or ureteral cancer, or renal cell carcinoma.
Results: In patients with bladder cancer who were undergoing radical cystectomy with use of intestine for urinary diversion, the serum level of immunosuppressive acidic protein (IAP) increased, and serum levels of immunoglobulin (Ig)A, IgG, and IgM decreased after operation. In contrast, the number of CD25+ lymphocytes significantly increased. Transurethral resection of bladder cancer also resulted in an increase in serum IAP level, however, the number of CD4+ and human leukocyte-associated HLA-DR+ lymphocytes increased. In patients with renal pelvic or ureteral cancer undergoing nephroureterectomy with cuff, the level of serum IAP increased and serum IgG level decreased after operation. By contrast, the number of CD3+ lymphocytes increased. In patients with renal cell carcinoma, radical nephrectomy led to a significant increase in the number of CD8+ lymphocytes.
Conclusions: These findings suggest that surgical stress in patients with urologic cancer may result in both suppression and stimulation of host immunity.     

Complement and Neutrophil Function Changes After Liver Resection in Humans

Background  

Complement activation contributes to the regulation of liver regeneration after liver resection (LR) in mice.     

Functional Hepatic Flow Can Predict the Hepatic Reserve Function in Surgical Cirrhotic Patients

Aim: To evaluate hepatic reserve function by monitoring functional hepatic flow in cirrhotic patients admitted for surgical treatments. Methods: Thirty-seven biopsy-proved cirrhotic patients with portal hypertension and 10 healthy volunteers entered the study. Eleven were Child-Pugh class A, 18 class B, and 8 class C. Eight patients undergone Transjugular intrahepatic portosystemic shunt (TIPS), 10 were submitted to the combination of TIPS and portal-azygous disconnection, 10 were treated with surgical portal-azygous disconnection, and 9 were treated with the combination of portal-azygous disconnection and spleno-renal shunt. The functional hepatic flow (FHF) and total hepatic flow (THF) were determined by means of modified hepatic clearance of D-sorbitol combined with duplex Doppler color sonography. Portal pressure was measured directly by portal vein catheterization. Results: Portal blood flow, hepatic artery flow, and THF significantly increased in cirrhotic patients compared to the controls, while FHF was significantly reduced. Both portal pressure and FHF decreased in cirrhotic patients submitted to TIPS, the combination of TIPS and portal-azygous disconnection, or the combination of portal-azygous disconnection and spleno-renal shunt (p <.05). FHF decreased significantly in patients treated with TIPS compared to other patients (p <.01). The portal pressure decreased in patients treated with portal-azygous disconnection while FHF maintained no changes (p >.05). Conclusions: Monitor of FHF in cirrhotic patients is valuable to predict different hepatic reserve function in patients receiving different surgical operations.     

Effects of Probenecid on Renal Function in Surgical Patients Anesthetized with Low-flow Sevoflurane

Background: Dehydrofluorination of sevoflurane by carbon dioxide absorbents in anesthesia machines produces compound A, which is nephrotoxic in rats. Several clinical studies indicate that prolonged low-flow sevoflurane anesthesia is associated with an increased urinary excretion of biochemical markers, such as protein. Probenecid, a competitive inhibitor of organic anion transport, diminishes compound A nephrotoxicity in rats. The purpose of the present study was to examine the effects of low- and high-flow sevoflurane anesthesia on urinary excretion of biochemical markers in humans and to examine the effects of probenecid on urinary excretion of these markers.

Methods: Elective surgical patients (n = 64) were assigned to four groups (n = 16 each): low-flow sevoflurane plus probenecid (LSP), low-flow sevoflurane (LS), high-flow sevoflurane plus probenecid (HSP), and high-flow sevoflurane (HS). Probenecid (2.0 g) was administered orally 2 h before the induction of anesthesia in both the LSP and HSP groups. Nothing was administered orally 2 h before the induction of anesthesia in either the LS or HS groups. All patients underwent prolonged low-flow (1 l/min) or high-flow (6 l/min) sevoflurane anesthesia. Urinary excretion of protein, albumin, [beta]2-microglobulin, glucose, and N-acetyl-[beta]-d-glucosaminidase was measured for up to 7 days postoperatively.

Results: Sevoflurane doses were similar in all four groups. There were no differences in blood urea nitrogen, creatinine, or creatinine clearance among the four groups after anesthesia. Average values for urinary excretion of protein, [beta]2-microglobulin, and N-acetyl-[beta]-d-glucosaminidase in the LS group were significantly higher than those in the other groups (LSP, HSP, HS;P < 0.05). There was no significant difference between the LS and LSP groups in average values for urinary excretion of albumin and glucose, although there were significant differences between the LS and both high-flow sevoflurane groups (HSP, HS).     

高龄低肺功能食管、贲门癌患者的外科治疗

目的探讨高龄低肺功能食管、贲门癌患者的外科手术治疗、手术方式的选择及围手术期的合理处理。方法回顾性分析1990年1月~2003年12月44例70岁以上低肺功能食管、贲门癌患者的手术切除方式、围手术期处理及术后呼吸机的应用。结果术后19例行呼吸机辅助呼吸,围手术期死亡3例,其中2例死于呼吸衰竭,1例吻合口瘘患者死于胸腔感染,全身衰竭。结论由于手术技术的改进、术后呼吸机的应用及围手术期的正确处理,高龄低肺功能食管、贲门癌患者的手术适应证可相对扩大。     

Neutrophil Gelatinase-Associated Lipocalin Is a New and Sensitive Marker of Kidney Function in Chronic Kidney Disease Patients and Renal Allograft Recipients

Background/aims

Few biomarkers exist to monitor chronic kidney disease (CKD). Neutrophil gelatinase-associated lipocalin (NGAL), a member of lipocalin family, has recently been proven useful to quantitate CKD. The aim of the study was to assess whether NGAL could represent a novel, sensitive marker of kidney function in adult patients with CKD and in kidney transplant recipients.

Methods

We studied possible relations between serum NGAL, creatinine, and estimated glomerular filtration rate (eGFR) in 80 nondiabetic patients with CKD stages 2 to 4; 80 nondiabetic kidney transplant recipients on a calcineurin inhibitor mycophenolate mofetil, or azathioprine as well as prednisone and in healthy volunteers (n = 32, mean age 50 years).

Results

Serum NGAL and creatinine values were significantly higher and eGFR significantly lower in kidney allograft recipients and patients with CKD compared with controls. NGAL rose gradually, reaching the higher value in stage 4 CKD. In univariate analysis serum NGAL was related to serum creatinine, hemoglobin, hematocrit, leukocyte count, and eGFR. Predictors of serum NGAL were creatinine and eGFR among patients with CKD. On univariate analysis serum NGAL was related to serum creatinine, urea, hemoglobin, hematocrit, white blood cell count, calcineurin concentration, eGFR, and albumin in kidney transplant recipients. On multiple regression analysis, predictors of NGAL were creatinine, calcineurin concentration, and high-sensitivity C-reactive protein. In healthy volunteers, serum NGAL correlated with age, serum creatinine, eGFR, and leukocyte count.

Conclusion

NGAL should be investigated as a potential early, sensitive marker of kidney impairment/injury, which might provide an additional accurate measure of kidney impairment in CKD and among transplant recipients, particularly at advanced stages.     

Hand-Assisted Laparoscopic Living-Donor Nephrectomy Versus Open Surgery: Evaluation of Surgical Trauma and Late Graft Function in 82 Patients

Objective

We evaluated and quantified surgical trauma and late graft function in cases of hand-assisted laparoscopic living-donor nephrectomy (HALLDN) versus open living-donor nephrectom (OLDN).

Methods

This study is a retrospective nonrandomized single-center analysis. Between 1995 and January 2008, 82 patients with end-stage renal disease received kidney transplantations from living donors. Open living-donor nephrectomy was performed in 37 donors, and 45 underwent laparoscopic hand-assisted nephrectomy. Demographic data and perioperative and postoperative data, such as markers of acute phase (C-reactive protein; serum amyloid A) and biochemical markers of glomerular filtration (serum creatinine, serum cystatin C), were compared at serial time points.

Results

The mean operative times for HALLDN and OLDN were 165 min and 195 min, respectively. The average warm ischemia time was 45 seconds for laparoscopy and 87 seconds for open surgery. The evaluation of acute phase markers demonstrated a minimally invasiven nature of laparoscopy, with same late graft function compared with open surgery.

Conclusion

When the surgery was performed by experienced surgeons, hand-assisted living- donor nephrectomy showed shorter operative and warm ischemia times than open surgery, offering at least the same functional results and decreasing surgical complications compared with a completely laparoscopic technique.     

Free p‐Cresol Alters Neutrophil Function in Dogs

To achieve a clearer understanding of the mechanisms responsible for neutrophil dysfunction recently described in dogs with chronic renal failure (CRF), the plasma concentrations of free p‐cresol in healthy dogs (n = 20) and those with CRF (n = 20) were compared. The degree of correlation was determined between plasma levels of p‐cresol and markers of oxidative stress and function of neutrophils in these dogs. The effect of this compound on oxidative metabolism and apoptosis was assessed in neutrophils isolated from 16 healthy dogs incubated in RPMI 1640 supplemented with p‐cresol (0.405 mg/L) and compared with medium supplemented with uremic plasma (50%). To achieve this, the plasma concentration of p‐cresol was quantified by liquid phase high‐performance liquid chromatography. The neutrophil oxidative metabolism was determined using the probes hydroethidine and 2′,7′‐dichlorofluorescein diacetate and apoptosis was measured using Annexin V‐PE by capillary flow cytometry. Compared with the healthy dogs, uremic dogs presented higher concentrations of free p‐cresol, greater oxidative stress, and neutrophils primed for accelerated apoptosis. The free p‐cresol induced in neutrophils from healthy dogs increased apoptosis and decreased reactive oxygen species production. We conclude that the health status presented during uremia concomitant with the increase in plasma free p‐cresol can contribute to the presence of immunosuppression in dogs with CRF.     

Neutrophil Priming by Cytokines in Patients With Obstructive Jaundice

Patients with obstructive jaundice frequently suffer postoperative complications. We have investigated the relationship of obstructive jaundice to the neutrophil oxidase response and the “priming” of the response by the cytokines TNFα, interleukin-1 (IL-1), IL-6, and IL-8. On stimulation with f-met-leuphe (fmlp), the respiratory burst in neutrophils from jaundiced patients was greatly increased compared with controls (p < 0.01), jaundiced patients having the highest respiratory burst levels were those with the poorest prognosis. Neutrophils from controls were primed by all the cytokines tested, whereas “jaundiced” cells were primed only by IL-1, and not by TNFα, IL-6, or IL-8, which in fact produced slight inhibition. We conclude that neutrophils from obstructive jaundiced patients have raised oxidative responses which may be due to “pre-priming” in vivo by cytokines, such as IL-6, IL-8, or TNFα. This exaggeration of the oxidative response in circulating neutrophils may contribute to the peri-operate complications of patients with obstructive jaundice.     

New Surgical Concepts: Nasal Tip Function

Since the birth of plastic surgery, rhinoplasty has been an outstanding chapter. Facial balance has been endeavoured with two parameters: size and shape. Now, however, the criterion for harmony has involved two more parameters: position and function. Position is related to other facial elements, such as, upper maxilla, upper lip, forehead, and frontonasal sulcus. Function is important because nasal superficial musculoaponeurotic system (SMAS) muscles are important for Nasal tip movement. To understand this better, we must analyze the nasal SMAS, which consists of primary or intrinsic and secondary or extrinsic muscles. When the extrinsics contract, they allow function of the intrinsics. They are the ala nasalis dilator, the ala nasalis elevator, the tranversus, and the tip depressor. Obvious hypertrophies of the dilator and the elevator has been observed in young athletes. Our method combines conventional, new, and modern aspects. It is conventional because the alar cartilages have been completely freed by intercartilaginous and marginal approaches, and the upper or lower border trimmed according to the case. It is more important to measure how much cartilage is left, than how much is removed. The new aspect is consideration of nasal SMAS to treat short noses that display a tendency to descend with laughter, and the modern aspect is the evaluation of dynamic surgical results, apart from the static.     

Computerized Surgical Databases: Introduction to Design and Function

There has been an enormous increase in the variety and volume of information encountered in surgical practice, either as measurable clinical variables or laboratory research data over the last three decades. Despite its form and origin, this information remains the basis of both daily clinical decision making and analytical research. Inferences drawn from past experience will modify an individual's approach to disease and treatment. However, when the demands of information processing cannot be met, mischief begins and quality of care declines. Modern computers offer an extraordinarily powerful method of processing the large volumes of medical data that are acquired, and provide techniques for analysis that would have been impossible, and often inconceivable, without computers. The applications of computer technology to surgical data management range from such simple and repetitive tasks as practice administration and accounting to elegant statistical and image analysis.

This paper outlines the utility of computerized data management in clinical surgery and surgical research, and describes techniques for designing and implementing a customized surgical database system.