腹腔镜胰十二指肠切除术后胃排空延迟原因分析及处理

目的 探讨腹腔镜胰十二指肠切除术（LPD）后胃排空延迟（DGE）发生原因及处理要点。方法 回顾性分析2017年3月至2021年11月山东第一医科大学附属省立医院器官移植肝胆外二科832例行LPD病人临床资料,根据是否发生DGE分为DGE组和无DGE组,比较两组病人临床特征,logistic回归分析DGE发生的危险因素,评估不同处理方式的效果。结果 共有194例（23.3%）术后发生DGE。与无DGE组比较,DGE组术前低白蛋白血症病例多,手术时间长,术中出血量多,行改进前胃空肠吻合和术中输血例数多,术后并发症发生率高,其中Clavien-Dindo分级≥Ⅲa级并发症,胆漏,B、C级胰瘘和腹腔感染发生率高于无DGE组。多因素logistic回归分析发现术前低白蛋白血症、术中输血和腹腔感染是任意级别DGE发生的独立危险因素;其中术中输血、胰瘘、胆漏和腹腔感染是B、C级DGE发生的独立危险因素。B、C级DGE 62例,48例存在腹腔感染合并吻合口漏,其中42例接受腹腔穿刺引流,6例持续内冲洗负压引流,均取得良好治疗效果。结论 DGE多继发于术后吻合口漏及腹腔感染,术前纠正低白蛋白血症、合理的...     

改良Child术式预防胰十二指肠切除术后并发症的应用研究

目的探讨一种改良Child消化道重建方式(捆绑式胰腺-空肠吻合及胰肠Roux-en-Y式吻合的胰十二指肠切除术,未置胰管支撑引流)与传统的Child术式在预防胰十二指肠切除术后并发症及术后远期生存率等方面的研究。方法回顾性分析2009年1月-2013年3月间我院施行标准胰十二指肠切除术111例患者的临床资料。其中65例患者采用改良的Child术式,46例采用传统的Child术式。结果改良组和传统组术后发生并发症分别为25例和20例(38.5%和43.5%,P=0.135),其中改良组在胰瘘(P=0.024)和胃排空障碍(P=0.029)的发生率明显低于传统组,差异有统计学意义,而两组患者在胆瘘、腹腔感染、腹腔出血、肺内感染、围手术期死亡、上消化道出血等发生率比较方面无明显差异。术后生存曲线显示,改良组生存率比传统组高(P=0.038)。结论改良Child消化道重建方法能够显著降低胰十二指肠切除术后胰瘘和胃排空障碍的发生率,改善生存质量,延长生存时间,但对其他并发症的影响与传统的Child术式相比并无显著差异。     

保留幽门胰十二指肠切除术后发生胃排空延迟的影响因素分析

目的 探讨保留幽门胰十二指肠切除术（PPPD）后胃排空延迟（DGE）的影响因素及预防措施。方法 回顾性分析2000年1月至2006年7月42例PPPD与同期104例标准胰十二指肠切除（SPD）围手术期并发症,对可能影响PPPD术后发生DGE的原因进行分析。结果 PPPD与SPD手术时问、失血量相当,PPPD组术后胰瘘明显少于SPD组,两组术后死亡率差异无统计学意义。PPPD组DGE发生率为35．7％,显著高于SPD组的18．3％（P=0．024）。与手术时间〈6h者相比,手术时间〉6h者DGE发生率明显增加（17．2％对76．9％,P〈0．05）。结肠后十二指肠空肠吻合术后DGE的发生率显著高于结肠前十二指肠空肠吻合者（50％对20％,P=0．043）。多因素分析显示,术后胰瘘、胆瘘等腹腔并发症并非导致DGE的危险因素,预防性使用生长抑素也无预防DGE的效果。结论 PPPD术后DGE是其最常见的并发症,缩短手术时间、采取结肠前十二指肠空肠吻合可有效降低其发生率,目前尚无确切药物预防方法。     

腹腔镜辅助胰十二指肠切除术14例分析

目的探讨腹腔镜辅助胰十二指肠切除术的可行性及疗效。方法回顾性分析自2015年3月~2015年12月安徽医科大学附属省立医院胆胰外科收治并行腹腔镜辅助胰十二指肠切除术患者的围手术期的临床资料,分析手术疗效及术后并发症及预后。结果自2015年3月~2015年12月安徽医科大学附属省立医院共收治并完成14例腹腔镜辅助胰十二指肠切除术,其中男性5例,女性9例,年龄40~74岁,平均年龄60.14±9.85岁,其中手术平均时间为568.71±107.75min,手术术中平均出血量为614.2±443.5ml,术后胰瘘发生率为28.5%,其中A级胰瘘为3例(21.4%);B级胰瘘1例(7.1%),未出现C级胰瘘患者,术后DGE发生率为21.4%,其中A级胃排空延迟1例(7.1%),B级胃排空延迟1例(7.1%),C级胃排空延迟1例(7.1%),总并发症发生率为42.8%。结论与传统的开腹PD相比,LPD具有术后恢复时间较快,手术安全、可行,值得临床推广。     

胰十二指肠切除术后围手术期腹腔或消化道出血的诊治

目的 探讨胰十二指肠切除术后围手术期腹腔或消化道出血的原因及防治.方法 回顾性研究1998年1月至2008年4月共263例行胰十二指肠切除术患者的临床资料,分析其中合并有围手术期腹腔或消化道出血患者术后出血的影响因素.结果 263例胰十二指肠切除术患者中,围手术期死亡13例(4.94% ),并发术后腹腔或消化道出血23例(8.75% ),并发术后围手术期出血患者中,死亡8例(8/23,34.8% ).统计学分析显示,胰瘘、肿瘤直径、Child分级、是否钩突切除为影响术后围手术期出血的相关因素.多因素Logistic回归分析表明,肿瘤直径、Child分期及是否发生胰瘘为影响出血的独立危险因素.结论 术中仔细止血是预防术后围手术期出血的重要因素;胰瘘是引发术后出血的重要原因;使用生长抑素类药物对预防及控制出血未见明显效果.     

改良套入式胰肠端端吻合对胰十二指肠切除术后胰瘘的影响

目的 探讨改良套入式胰肠端端吻合对胰十二指肠切除术后胰瘘的影响.方法 回顾性分析2001年1月至2011年1月山东省肿瘤医院施行396例胰十二指肠切除术患者的临床资料.根据吻合方式分为2组:改良组235例,经典组161例.两组患者均由同一术者带领的医疗小组完成手术,消化道重建以Child吻合为基本术式.改良组采用改良套入式胰肠端端吻合,经典组采用经典套入式胰肠端端吻合,两组患者在术中及术后的处理均相同.比较两组患者术中出血量、手术时间、术后胰瘘和住院时间.计量资料采用t检验,计数资料采用x2检验,胰瘘的分析采用Fisher确切概率法.结果 改良组和经典组患者术中平均出血量、平均手术时间、平均住院时间分别为(383 ±56)ml、(7.2±1.0)h、(21 ±3)d和(381±39)ml、(7.0±0.5)h、(22 ±5)d,两组比较,差异无统计学意义(t=0.388,1.680,± 1.835,P＞0.05).396例患者均无手术死亡发生,胰瘘总发生率为7.6％(30/396).改良组患者术后无一例胰瘘发生,经典组患者术后发生胰瘘30例(胰肠吻合口瘘4例、单纯性胰瘘26例),两组比较,差异有统计学意义(P＜0.05).经典组中发生胰瘘的患者通过保持引流通畅、使用生长抑素及胃肠外营养等保守治疗后痊愈.结论 改良套入式胰肠端端吻合能显著降低胰十二指肠切除术后胰瘘的发生率.     

改良Child消化道重建-彭氏捆绑式胰肠吻合术临床应用探讨

胰十二指肠切除术手术范围大、危险高、并发症多、操作复杂,其并发症会影响术后患者的恢复与预后,也是患者术后死亡的主要原因.因此,成功地预防胰瘘、胆瘘等近期及远期并发症是胰十二指肠切除术后延长患者生存期和提高生活质量的关键所在.我科自2003年1月至2008年1月共施行胰十二指肠切除术67例,其中采用改良Child消化道重建-彭氏捆绑式胰肠吻合术52例,现报道如下.     

胰十二指肠切除术后出血的原因及防治

目的 探讨胰十二指肠切除术后出血的原因、诊断及防治方法.方法 回顾性分析1995年1月至2008年12月142例胰十二指肠切除术的临床资料.结果 142例胰十二指肠切除共发生术后出血20例,发生率14.1%.20例出血病例中,腹腔出血7例,消化道出血14例,1例兼有腹腔出血和消化道出血.在7例腹腔出血中,早期和晚期出血分别有3例和4例;14例消化道出血中,早期出血3例,晚期出血11例.20例患者中7例死亡,死亡率为35%.单因素分析显示术中出血量、术中输血量、术后感染和胰瘘为术后出血的相关因素,多因素分析显示术后感染(OR=6.918)和术后胰瘘(OR=3.948)为独立危险因素.结论 胰十二指肠切除术后出血的发生率和死亡率仍较高.术中严密止血,术后预防胰瘘、感染及应激性溃疡是减少术后出血的关键,应根据出血的部位、时间和严重程度采取相应的止血措施.     

胆胰双支撑引流对预防胰十二指肠切除术后胰瘘的作用

目的探讨应用胆胰双支撑引流在胰十二指肠切除术后预防胰瘘的价值。方法胰十二指肠切除术31例,采用Child方式重建消化道,胰管内置入硅胶管引入肠腔,于胆肠吻合口上方的肝总管另行戳孔置入T管引流入空肠。结果31例中发生并发症5例(16.1%),其中胰瘘1例(3.2%),无死亡病例。结论在胰十二指肠切除术中应用双支撑引流,有利于降低术后胰瘘发生率,值得推广应用。     

胰十二指肠切除术后胰瘘危险因素分析

目的:探讨影响胰十二指肠切除术后胰瘘的危险因素,从而进一步指导临床治疗。方法:回顾性分析1986年1月—2010年12月收治的1 025例行胰十二指肠切除术患者的临床资料,采用独立样本t检验、χ2检验进行统计学比较,应用Logistic回归模型进行多因素分析。结果:术后A级胰瘘108例(10.5%),B级56例(5.5%),C级36例(3.5%)。单因素分析表明,胰管内径(P=0.012)、手术失血量(P=0.035)及胰肠吻合方式(P=0.001)是胰十二指肠切除术患者术后胰瘘的危险因素;多因素回归分析显示胰管直径(P=0.030)是有统计学意义的独立相关因素。结论:胰管直径是影响胰十二指肠切除术后胰瘘的独立相关因素,而手术出血量及胰肠吻合方式可能也与术后胰瘘的发生有一定关系。     

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.