肝门胆管切开整形、肝门空肠吻合术治疗Ⅰ型胆道闭锁

目的 了解肝门胆管切开整形、肝门空肠吻合术治疗Ⅰ型胆道闭锁的疗效。方法 1992-2001年本院对4例Ⅰ型胆道闭锁患儿行肝门胆管切开整形、肝门空肠吻合术,对临床资料（病史、体征、肝脏功能、B超、术中胆道造影、组织学检查等）进行回顾性分析,并对患儿的症状、体征、肝脏功能及肝胆系统B超进行长期随访。结果 4例患儿的临床表现均为阻塞性黄疸,B超示胆囊及胆管囊肿均小于同龄胆总管囊肿组,术中胆道造影确立诊断同并发现肝门部肝管和左右肝管狭窄,肝脏组织学改变与Ⅲ型胆道闭锁者相似,术后患儿全部成活,无近期并发症发生,黄疸于术后30-74d,完全消退,术后远期随访患儿生长发育正常,无黄疸,肝功能恢复正常。结论 Ⅰ型胆道闭锁常伴有肝管及肝内胆管异常,肝门胆管切开整形,肝门空肠吻合术治疗该畸形可取得满意的疗效。     

Ⅲ型胆道闭锁Kasai术联合矩形瓣成形术与常规Kasai术临床对比研究

目的 探讨Ⅲ型胆道闭锁(肝门部胆管闭锁)肝门空肠吻合术(Kasai术)联合矩形瓣成形术与常规Kasai术的效果.方法 前瞻性纳入郑州大学附属儿童医院2013-04—2015-04间行Kasai术的Ⅲ型胆道闭锁患儿,按照是否联合矩形瓣成形术分为矩形瓣组和非矩形瓣组.比较2组患儿的基线资料、术后1个月肝功能改善效果,统计术...     

肝内胆管结石伴肝门部血管变异的手术处理

目的 研究肝内胆管结石伴肝门部血管变异的手术处理方法。方法 回顾性分析57例肝内胆管结石伴肝门部血管变异行胆道手术病人的临床资料。结果 57例中，行单纯胆道手术13例，异位血管切断，结扎术14例，胆管血流交叉换位术22例，肝内胆管空肠吻合术8例。本组未发生严重术后并发症和围手术期死亡。51例（89．6％），获得随访，随访时间4－15（平均9．6）年。疗效优良率84．3％（43／51）。7例有胆道残余结石，其中5例表现为间歇性右上腹隐痛不适，另2例因反复发作胆管炎需再次手术。1例术后1．5年死于门静脉高压症所致的食道胃底曲张静脉破裂大出血。结论 采用合适的手术方式治疗肝内胆管结石伴肝门部血管变异，既能完成复杂胆道手术，又能避免肝脏缺血性损害。     

恶性梗阻性黄疸病人经圆韧带途径肝内胆管空肠吻合术

目的　评价经圆韧带途径行Ⅲ段胆管空肠吻合术姑息性治疗不能切除的恶性梗阻性黄疸病人的临床效果。方法　对 1999年 1月至 2 0 0 2年 12月间 5例不能切除的肝门部恶性梗阻性黄疸病人实施经圆韧带途径显露Ⅲ段肝内胆管 ,并与空肠行Roux en Y式吻合术。对术后血清胆红素和碱性磷酸酶进行动态检测 ,并就病人住院时间、术后生活质量、生存时间进行观察。结果　 5例病人实施肝内胆管空肠吻合术后血清胆红素逐渐降低至正常范围 ,2例病人临终前可维持无黄疸状态。术后 1例并发胆漏 ,1例住院期间因胃肠道恶性梗阻恶病质死亡 ,其他病人均存活超过 13个月 ,最长达 2 3个月。本组 5例术后均无胆管炎和复发性胆道梗阻。结论　经圆韧带途径肝内胆管空肠吻合术是恶性梗阻性黄疸病人姑息治疗的有效术式 ,损伤小 ,方法简便 ,减黄效果确切 ,病人生存质量提高     

Kasai肝门空肠吻合术在医源性高位胆管损伤手术中的应用

目的总结Kasai术(肝门空肠吻合术)治疗医源性高位胆管损伤的临床价值。方法回顾性分析1994年3月～2006年1月18例因医源性高位胆管损伤而采用Kasai肝门空肠吻合加胆管外引流术的临床资料。结果术后随访15例,平均时间3.5年(3个月～11年),优良率为86.7%(13/15)。差2例,分别于术后1年和拔管后2年内多次胆道感染。结论Kasai肝门空肠吻合加胆管外引流术是治疗医源性高位复杂胆管损伤的简单而有效的方法。     

肝内胆管结石术后并发症的对比分析

目的　对比分析肝内胆管结石术式的选择对术后并发症发生的影响。方法　选择同期采用保留胆总管下端和不保留胆总管下端的两种手术方式各 2 5例 ,分析其术后并发症发生的原因 ,以及保留胆总管下端oddi括约肌的意义。结果　保留组中术后胆道残石、胆道蛔虫、轻度胆管炎各 1例 ,随访 1～ 3年出现轻度胆管炎 1例 ,胆道残石 1例。不保留组中术后胆道残石 3例 ,9例有返流性胆管炎的症状 ,2例分别随访 2～ 5年 ,发现有胆道残石 ,1例术后 3个月死于消化道大出血。结论　对肝内胆管结石 ,术中应尽可能去除病灶 ,取尽结石 ,选择肝门部胆管与胆总管间置空肠袢吻合术 ,可减少或避免返流性胆管炎的发生 ,简化了胆道残石的处理。     

微小切口肝门空肠Roux-en-Y吻合术治疗Ⅲ型胆道闭锁

目的探讨微小切口肝门空肠Roux-en-Y吻合术的可行性和疗效。方法 2008年3月～2010年6月腹腔镜下胆道造影或探查术确诊Ⅲ型胆道闭锁82例,行微小切口肝门空肠Roux-en-Y吻合术。上腹横切口,4把S拉钩分别在上下左右对拉,暴露肝门,游离切除胆囊,彻底游离切除肝门纤维块,行肝门空肠吻合。结果 82例均完成微小切口肝门空肠Roux-en-Y吻合手术。手术切口长度平均4.2 cm（4～4.5 cm）;开腹手术操作时间平均71.8 min（55～90 min）;平均出血量8.3 ml（5～20 ml）,无术中输血者。均未放置腹腔引流。术后24～48 h拔除胃管,48～72 h进食。无围手术期死亡病例。术后第2天消化道出血1例,术后切口裂开2例。82例随访6～18个月,平均10.5月,术后4周获得胆汁引流率（直接胆红素降至正常水平或较术前下降超过60%）占69.5%（57/82）,术后胆管炎发作3次以上占29.3%（24/82）。结论微小切口肝门空肠Roux-en-Y吻合术治疗胆道闭锁,可以不将肝脏拖出腹腔外进行吻合,避免对患儿循环系统的严重影响,同时直视下肝门空肠吻合可以保证吻合确切在门静脉后方,手术安全可靠。     

先天性胆管囊状扩张症的手术治疗

目的　探讨先天性胆管囊状扩张症的最佳手术方式。方法　回顾分析我院 1980～2 0 0 2年 76例经手术治疗的先天性胆管囊状扩张症的临床诊疗资料。结果　本组 76例中 ,13例行囊肿空肠Roux en Y吻合术 ;3例行囊肿十二指肠吻合术 ;7例行囊肿外引流术 ;1例行憩室型总胆管囊肿切除T管引流术 ;5 5例行囊肿切除、总肝管空肠Roux en Y吻合术 (占手术病例的 72 4 % ) ;2例Ⅳa型囊肿行肝左外叶切除加总胆管囊肿切除、总肝管空肠Roux en Y吻合术 ,1例Ⅴ型囊肿行肝左外叶切除、总胆管切除、肝门胆管空肠Roux en Y吻合术。 16例囊肿内引流术、7例囊肿外引流术和5 5例囊肿切除总肝管空肠Roux en Y吻合术的术后并发症发生率分别为 5 6 3%、2 8 6 %和 3 6 % ,经统计学分析差异有显著性 (P <0 0 1)。结论　手术是先天性胆管囊状扩张症惟一有效的治疗方法。外引流术可用于全身状态极差而不能耐受较复杂手术的病人 ,待全身状况改善后应及时行二次手术 ;对于较为复杂的Ⅳa型和Ⅴ型病变 ,应选择合适的病例行肝叶切除术或肝移植术 ;总胆管囊肿切除、肝管空肠Roux en Y吻合术是Ⅰ型先天性胆管囊状扩张症的一种较为合理的手术方式。     

原位肝移植治疗先天性胆道闭锁(文献综述)

1959年前,先天性胆道闭锁为不治之症,一般于出生后12～24个月由于胆管炎、肝功能衰竭或出血而死亡。1959年,Kasai创用了肝门空肠Roux-en-Y吻合术治疗本病。后来又有人采用皮肤空肠造口或双桶空肠造口对Kasai氏术进行改良,使术后胆管炎发病率降低。但Kasai氏术的成功率仅为20～50%,一般为30%。而Kasai氏术失败者,90%患儿将在5岁内死亡,从而推动了开展肝移植治疗本病。手术适应证及手术时机在小儿肝移植中,胆道闭锁是最主要的手术适应证。Brolsch等报告8例中,3例系胆道闭锁。Asc-her等报告30例中,8例为肝外胆道闭锁,男性2例,女6例,年龄为8～19个月,体重5.4～10公斤。8例移植前均施行过Kasai氏手术,其中1次手术者     

肝门部胆管空肠盆式吻合治疗肝内胆管结石

目的　探讨肝门部胆管空肠盆式吻合治疗肝内胆管结石的疗效。方法　回顾性分析31例肝内胆管多发性结石采用肝门部胆管空肠盆式吻合的治疗经过。结果　本组无手术死亡。有2 9例平均随访 4 .2年 ,其中 ,症状完全消失 2 5例 ,偶有胆管炎发作者 4例。术后残石共 6例 ,均勿须再手术治疗。结论　肝门部胆管空肠盆式吻合术治疗肝内胆管多发结石易于纠正肝胆管狭窄 ,取石彻底 ,术后胆汁引流通畅 ,远期效果满意。     

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.     

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.