胆管囊腺肿瘤的诊断与治疗

胆管囊腺肿瘤(BCTs)是一种较少见的肝脏囊性肿瘤,占肝脏全部囊性病变的比例≤5％.BCTs好发于中老年女性,术前缺乏特异性诊断指标,主要依赖影像学诊断,影像学相对特征表现为多房性伴乳头状突起及分隔的囊性肿瘤.其误诊误治率极高,尤其需与肝囊肿相鉴别.BCTs疑似患者应首选完整的根治性切除,手术切除范围包括囊性肿瘤在内的部分正常肝组织.根治性切除术后BCTs患者总体预后较好,但仍有一定的复发率,需规范化随访检查,一旦发现肿瘤复发,及时行再手术仍可获得较好疗效.     

肝脏良性肿瘤的外科治疗策略

随着影像学诊断技术提高和应用增加,肝脏良性肿瘤检出率逐年升高.主要包括血管瘤、局灶性结节性增生、肝腺瘤等实质肿瘤及单纯肝囊肿、多发性肝囊肿、多囊肝及囊腺瘤等囊性病变.但相对于肝癌来说,肝脏良性肿瘤比较少见,大约占肝脏原发肿瘤的5%～10%.正因如此,临床医生对其认识程度远远不够,如何获得正确诊断和及时恰当治疗,也日益受到临床肝脏外科医师的重视.     

肝囊性淋巴管瘤2例报告并国内文献回顾

目的:探讨肝囊性淋巴管瘤的临床特点和诊治方法,以提高诊断率及治疗效果。方法:回顾性分析广东医科大学附属医院收治的2例成人肝囊性淋巴管瘤患者临床资料及诊疗过程,并检索、复习中文期刊数据库中肝囊性淋巴管瘤的文献。结果:笔者收治的2例患者,均为女性,入院诊断分别为肝囊性占位和肝囊肿;患者完善相关检查后行肝切除术,术后病理诊断肝囊性淋巴管瘤;患者术后随访均无复发,治疗满意。检索1984—2017年期间国内共报道6例患者,其中男4例,女2例;入院诊断肝囊淋巴管瘤2例(2/6);其他均误诊(4/6),6例患者均行手术切除后明确诊断,术后患者恢复满意。结论:肝囊性淋巴管瘤为临床罕见的肝脏良性疾病。临床症状、体征及影像学表现无特异性,临床易误诊为肝囊肿及其他囊性疾病;MRl有助于鉴别诊断;有明确症状、体征或不能排除恶性的患者应结合个体情况制定治疗方案,病理检查是明确诊断的唯一方法。     

肝脏囊性病变的影像学表现

目的总结不同病因的肝脏囊性病变的超声、CT和(或)MRI影像学征象,以提高肝脏囊性病变的诊断正确率。方法复习国内外关于不同类型肝脏囊性病变的影像学研究的文献,以病因为线索,总结其超声、CT和(或)MRI平扫及增强特点。结果肝脏囊性病变种类较多,其影像学表现多样且征象间存在重叠,不典型病例的诊断及鉴别诊断困难。(1)对于单纯性肝囊肿,影像学检查呈水样回声、密度及信号的圆形或类圆形囊性肿块,边界清晰,囊内无分隔,对比增强无强化。超声和MRI诊断的敏感性和特异性均较高,CT诊断价值不及这二者。(2)胆管错构瘤和Caroli病均表现为多发、广泛分布于全肝的单纯囊性小病变,多数无强化,与胆管是否相通是鉴别的关键征象。(3)相比肝内胆管囊腺瘤,壁结节强化多见于囊腺癌,准确诊断肝内胆管囊腺瘤应结合典型超声、CT及MRI表现。(4)囊性肝转移瘤表现为肝实质内或肝周多发以囊性为主的肿瘤,CT是其诊断的主要方法,其密度低于肝实质,增强扫描病变外周环形强化;行MRI检查可与单纯性肝囊肿鉴别。(5)囊性肝细胞癌表现为多房囊实性肿瘤,门静脉内如果出现癌栓可提高本病诊断准确性。(6)未分化胚胎肉瘤的CT平扫为边界清楚的囊状低密度肿块,边缘可有钙化,增强扫描肿块内软组织成分持续强化;MRI平扫肿块内部信号无特异性,肿块周边呈缓慢渐进性强化。(7)肝脓肿的不同形成时期有其特征性表现,不难诊断,但对于症状不典型时与肝内胆管细胞癌易误诊;(8)对肝囊型包虫病主要选超声检查,影像学检查的意义在于判断包虫囊的活性,而肝泡型棘球蚴病的主要诊断方法是CT,MRI检查可于术前评估病变与胆管和血管的解剖关系及判断有无侵犯,MRCP有重要诊断价值。结论腹部超声检查可作为肝脏囊性病变检查的首选方法,CT和MRI可作为有效的补充方法,合理选择多种影像学技术进行综合分析是关键,根据肝脏囊性病变的数目、形态以及是否有实性成分是诊断和鉴别诊断的重要征象。     

肝囊性肿瘤

肝囊性肿瘤（囊腺瘤与囊腺癌）虽发病率很低,但该病变与多房性或复杂型胆管囊肿、非典型性血管瘤、出血性囊肿、错构瘤的鉴别诊断较困难。囊腺瘤与囊腺癌的术前鉴别诊断也是临床诊断的难点,CT与MRI常无法将两者鉴别。笔者就肝囊性肿瘤的诊断和鉴别诊断进行一综述。     

肝脏外科良性占位性病变治疗的变革

随着影像学技术的提高，以及人们对肝脏外科疾病认识的不断深入，肝脏外科良性占位性病变包括肝海绵状血管瘤、肝囊肿、肝脓肿、肝包虫囊肿及肝炎性假瘤等的治疗理念和方法均在不断的发生变化。从以往多需手术治疗逐步过渡到采用其他治疗方法也能获得满意的疗效。     

实质性肝脏良性肿瘤的诊断与治疗

肝脏良性肿瘤包括实质性病变如肝血管瘤、局灶性结节性增生、肝腺瘤等以及囊性病变如肝囊肿、多囊肝、囊腺瘤等.前者有时难以与肝脏恶性肿瘤相鉴别,是否需手术治疗常存在争议,本文就最常见的几种实质性肝脏良性肿瘤的诊治加以讨论.     

胰腺囊性肿瘤诊治进展

目的：探讨胰腺囊性肿瘤的影像学特点和诊治方法,方法：参考目前关于胰腺囊性肿瘤的最新研究成果。结果：探讨了胰腺囊性肿瘤与胰腺假性囊肿的鉴别诊断,分别就浆液性囊性肿瘤（SCN）、粘液性囊性肿瘤(MCN)、导管内乳头状瘤(IPMN)和实性假乳头状瘤（SPN）的影像学特点和治疗方法进行了讨论,并且就内镜超声（EUS）、内镜超声引导下穿刺抽吸活检（EUS-FNA）以及囊液分析的诊断价值进行了深入探讨。结论：结论：尽管囊性病变有典型的影像学表现,但单一的影像检查的准确性还是有限的,CT、MR应与EUS相辅相成,而且还可行囊肿穿刺,分析囊液的成分,对于诊断不明确的病例,可以通过动态的影像检查来观察。     

颌骨囊性肿瘤治疗方法的临床探讨

目的:对引起颌骨囊性破坏的疾病进行临床统计分析,并对常见的颌骨囊性破坏的疾病诊断及治疗方案进行分析总结.方法:对我院1999～2010年住院患者中发生颌骨破坏的89例囊性肿瘤疾病进行回顾性研究,对不同疾患引起颌骨破坏的临床表现进行鉴别诊断,对各种引起颌骨破坏的囊性肿瘤疾病的治疗方案进行分析总结.结果:颌骨囊肿和成釉细胞瘤为引起颌骨破坏的最常见疾病,占颌骨破坏性疾病的近80％.对于普通的颌骨囊肿多采用单纯刮治术;而对于范围较大具有浸润性特征的成釉细胞瘤、角化囊肿;年纪较轻患者(小于13岁),采用开窗术,再行刮治术.结论:临床上各种颌面部疾病引起的囊性肿瘤临床表现不同,应进行仔细的鉴别诊断,防止误诊,而相应的颌骨治疗方案应基于该疾病的性质而定.     

局限性肝紫癜病三例并文献复习

目的 探讨肝紫癜病的病因、发病机制、诊断、鉴别诊断及治疗.方法 结合3例肝紫癜病病人的临床资料进行文献复习.结果 肝紫癜病影像学上需肝血管瘤、肝脓肿、肝转移瘤等进行鉴别,临床诊断有一定困难,亦无特殊治疗.结论 肝紫癜病是一种罕见的肝脏疾病,可累及其他器官,对有破裂出血危险的病人要手术切除,弥漫性病变要进行肝移植手术.     

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.