胰十二指肠切除术后腹内并发症和手术死亡的影响因素分析

目的探讨胰十二指肠切除术（PD）后胰瘘等腹内并发症发生和手术死亡的相关危险因素,为临床有效减少其并发症发生和手术死亡提供理论依据。方法回顾性分析2003年6月至2011年11月期间上海交通大学医学院附属第三人民医院施行标准PD术的78例患者的临床资料,分析手术并发症、胰瘘及手术死亡的影响因素。结果术后发生并发症29例,其中胰瘘13例;手术死亡6例。单因素分析结果显示,影响胰瘘和术后并发症发生的因素有胰腺质地、胰管直径、术前胆道引流、胰管内置支撑管及应用生长抑素（P〈0．05）;未发现与手术死亡相关的因素。多因素分析结果显示,胰管内未置支撑管（OR=1．867,P=0．000）、胰腺质地软（OR=1．356,P=0．046）和胰管直径小于3mm（OR=2．874,P=0．015）者的胰瘘发生率更高;胰管内未置支撑管（OR=1．672,P=0．030）、胰腺质地软（OR=1.946,P=0．042）和胰管直径小于3mm（OR=1．782,P=0．002）者的手术并发症发生率更高;未发现与手术死亡相关的独立危险因素。结论术中胰管内是否置支撑引流管、胰腺质地和胰管直径是PD术后胰瘘和手术并发症发生的影响因素,行PD术应认真考虑这些因素并采取必要措施。     

胰十二指肠切除术后胰瘘的危险因素分析

目的 探讨胰十二指肠切除术后胰瘘发生的危险因素.方法 回顾性分析2005年1月至2013年5月上海交通大学医学院附属瑞金医院收治的310例施行胰十二指肠切除术患者的临床资料,并对围手术期可能与胰瘘有关的临床病理因素进行分析.单因素分析采用Pearson x2检验,多因素分析采用非条件Logistic回归模型.结果 310例患者中134例术后发生并发症,其中胰瘘发生率为33.23％（103/310）,胰瘘患者中合并其他并发症者40例.单因素分析结果显示：术前Hb、术前TBil、胰管直径及术后Alb 4个因素是胰十二指肠切除术后胰瘘发生的危险因素（x2=4.543,6.087,6.265,5.311,P＜0.05）.多因素分析结果显示：术前TBil ≥34.2 μmol/L、胰管直径＜3 mm及术后Alb＜ 28 g/L是胰十二指肠切除术后胰瘘发生的独立危险因素（OR=1.806,1.936,1.780;95％可信区间：1.107 ～2.948,1.170 ～3.206,1.002～3.165,P＜0.05）.结论 术前显性黄疸（TBil≥34.2 μmol/L）,胰管直径过小（＜3 mm）和术后营养情况不良（Alb ＜28 g/L）预示着胰十二指肠切除术后较高的胰瘘发生率.     

胰腺术后胰瘘发生相关危险因素分析（附303例胰腺手术报告）

目的 探讨影响病人胰腺手术后胰瘘发生率的危险因素。方法 回顾性分析2012年2月至2015年1月中国医科大学附属第一医院收治的303例行胰腺手术病人资料,其中术后发生胰瘘50例。对影响术后胰瘘发生的相关因素进行单因素分析及Logistics回归分析。结果 单因素分析结果显示,影响术后胰瘘发生的因素包括性别、病理类型、胰管扩张、手术时间、术中出血量、术前血红蛋白、术前血清总胆红素、术后血清总胆红素（P<0.05）。非条件Logistic回归分析结果显示,影响术后胰瘘发生的独立危险因素为：性别（OR=12.001,95%CI 3.049~47.230,P<0.05）、病理类型（OR=1.605,95%CI 1.108~2.324,P<0.05）、胰管扩张（OR=1.177,95%CI 0.188~0.468,P<0.05）、手术时间（OR=1.641,95%CI=1.173~2.339,P<0.05）、术中出血量（OR=1.096,95%CI 1.094~1.099,P<0.05）、术前血红蛋白（OR=0.888,95%CI 0.823~0.921,P<0.05）、术前血清总胆红素（OR=1.359,95%CI 1.335~1.381,P=0.010）、术后血清总胆红素（OR=1.030,95%CI 1.064~1.004,P<0.05）。结论 男性、手术前后血清胆红素浓度高、壶腹部癌或十二指肠癌是胰瘘发生的独立危险因素,而胰管扩张则可减少胰腺手术后胰瘘的发生。     

胰十二指肠切除术后胰瘘的危险因素分析

目的分析胰十二指肠切除术后胰瘘的危险因素,探讨黏膜-黏膜胰肠吻合减少术后胰瘘的可能性。方法回顾性研究我院2000年1月至2004年4月间85例胰十二指肠切除术病例,分析影响胰瘘的术前及术中危险因素,比较不同胰肠吻合方式对胰瘘的影响。结果术后胰瘘总发生率16.5%(14/85),其中黏膜-黏膜组3.57%(1/28),传统套入组22.8%(13/57)。统计学分析显示,胰肠吻合方式、胰管直径及残余胰腺质地为影响胰瘘发生的显著因素;多因素Logistic回归分析表明,胰管直径和胰腺质地为影响胰瘘发生的独立危险因素,P值分别为0.013和0.009,相对危险度(OR)分别为5.276和8.538。结论胰肠吻合方式、胰管直径和胰腺质地是影响胰十二指肠切除术后胰瘘的危险因素,对胰管扩张者(≥3mm)行黏膜-黏膜吻合可显著降低术后胰瘘的发生率,是一种安全可靠的胰肠吻合方法。     

端侧胰管空肠黏膜-黏膜吻合术后胰瘘的危险因素分析

目的 分析胰十二指肠切除术中应用端侧胰管空肠黏膜-黏膜吻合法术后胰瘘的危险因素.方法 回顾性分析我院1994年1月至2008年1月问101例胰十二指肠切除术病例,分析影响胰瘘的术前及术中危险因素. 结果本组胰瘘发生率为9.9%(10/101),单变量分析结果表明术前黄疸程度(χ2=5.814,P=0.016)、黄疸持续时间(χ2=4.17,P=0.041)、胰腺质地(χ2=5.286,P=0.021)、胰管直径(χ2=4.165,P=0.041)、手术失血量(χ2=5.273,P=0.022)是胰瘘发生的危险因素,多因素Logistic回归分析结果表明,胰腺质地(OR=13.355,P=0.023)、术前黄疸程度(OR=12.126,P=0.006)、手术失血量(OR=5.92,P=0.032)是胰瘘发生的独立危险因素.Logistic回归预测方程:P=1/[<1+e-(-6.378+2.592胰腺质地+2.495术前黄疽程度+1.778手术失血量)],此方程预测发生胰瘘的正确性为92.1%.结论 胰腺质地、术前黄疸程度、手术失血最是端侧胰管空肠黏膜-黏膜吻合法术后胰瘘发生的独立危险因素,手术技术提高,减少术中失血量,可降低胰瘘的发生率.     

胰十二指肠切除术后外科相关并发症的分析与处理

目的 探讨胰十二指肠切除术后外科相关并发症发生的原因与处理措施.方法 回顾性研究1995年1月至2010年4月共412例行胰十二指肠切除术患者的临床资料,男性232例,女性180例,分析其术后并发症发生的影响因素与治疗方法.结果 本组中共有153例患者出现并发症214例次,总发生率为37.1%.术后30 d内死亡19例,总病死率4.6%.统计学分析显示,胰腺钩突全切除与否(P=0.022)、胰肠吻合方式(P=0.005)、胰管直径(P=0.007)及残余胰腺质地(P=0.000)与胰瘘的发生具有相关性;未进行胰腺钩突全切除(P=0.002)、术中失血量≥600ml(P=0.000)及合并胰瘘者(P=0.000)术后出血发生率显著增高;保留幽门的胰十二指肠切除术组术后胃排空障碍的发生率显著高于传统胰十二指肠切除术组(P=0.000).多因素Logistic回归分析表明,胰管直径及胰腺质地是影响胰瘘发生的独立危险因素;未进行胰腺钩突全切除、术中失血量≥600ml及胰瘘为影响术后出血的独立危险因素;联合血管切除或腹膜后淋巴清扫的患者与未行血管切除或腹膜后淋巴清扫的患者相比,并发症发生率的差异无统计学意义(P＜0.05).结论 合并慢性胰腺炎及胰管扩张的患者可行胰肠端侧黏膜对黏膜吻合,而端端或端侧套入式吻合更适于胰管不扩张或胰腺质软者;完整切除钩突、术中仔细止血是预防术后出血的重要因素;胰瘘是并发术后出血的重要原因之一.联合肠系膜上静脉或门静脉切除及腹膜后淋巴结清扫不会增加术后并发症的发生率.     

胰十二指肠切除术后胰瘘发生影响因素及处理

胰瘘是胰十二指肠切除术后最常见的并发症,严重影响手术疗效和病人预后。认识并了解胰瘘发生的相关危险因素有助于防治胰瘘。目前,影响胰瘘发生的较确切的因素主要有：胰腺质地、胰管直径、原发病的病理类型以及术者的个人经验等。尽管消化道重建的具体吻合方式被认为是影响胰瘘的危险因素,但目前的研究表明各种吻合方式的胰瘘发生率差异并无统计学意义;而多数研究均认为术者的经验和技术水平是术后胰瘘的重要影响因素。因此,吻合质量较吻合方式更重要。选择合适及熟练的方式进行确切吻合才是减少胰瘘发生的有效途径。     

胰十二指肠切除术后胰瘘危险因素的荟萃分析

目的运用荟萃分析评估胰十二指肠切除术后胰瘘的相关危险因素,以指导临床诊治。方法使用Rev Man5.2对2005年1月至2014年9月间国内发表的关于胰十二指肠切除术后胰瘘的危险因素分析的12篇文献进行Meta分析。结果性别、年龄、糖尿病、冠心病、高血压、手术时间、术前总胆红素以及术后是否使用生长抑素与术后胰瘘的发生无统计学意义(P0.05);而术前白蛋白低于30 g/L(OR=0.52,95%CI:0.33~0.80,P0.01)、胰腺质地柔软(OR=0.20,95%CI:0.14~0.29,P0.01)、胰管直径小于3 mm(OR=0.26,95%CI:0.17~0.42,P0.01)、胰管未放置支撑管(OR=0.52,95%CI:0.31~0.88,P0.05)以及胰肠套入式吻合(OR=0.60,95%CI:0.38~0.95,P0.05)与术后胰瘘的发生关系密切。结论胰十二指肠切除术后胰瘘与患者性别、年龄、糖尿病、冠心病、高血压、手术时间、术前总胆红素以及术后是否使用生长抑素;而术前低蛋白血症、质软的胰腺质地、细小的胰管、胰管支撑管是否放置以及胰肠吻合方式的选择等因素影响着术后胰瘘的发生。     

胰肠吻合手术方式的选择

正胰十二指肠切除术(pancreaticoduodenectomy,PD)术后并发症发生率高达50%左右,死亡率约5%,其中最常见最严重的是胰瘘(postoperative pancreatic fistula,POPF),其发生率20%左右[1-4]。PD术后发生胰瘘的相关因素包括:患者因素(如年龄、BMI、营养状况),胰腺因素(肿瘤类型、胰腺质地、胰管大小),吻合方式和术者经验等因素,其中胰管大     

胰肠吻合方式和保留幽门对胰瘘发生的影响

目的探讨胰肠吻合方式和保留幽门对胰十二指肠切除术后胰瘘发生的影响。方法回顾性分析我院1994年1月至2007年5月间142例胰十二指肠切除术患者临床资料，探讨胰瘘发生的危险因素，比较胰肠黏膜对黏膜胰管空肠端-侧吻合、胰腺空肠端-端套入式吻合及保留幽门与否对胰瘘发生率的影响。结果术后胰瘘总发生率22％（32／142），其中黏膜对黏膜吻合组21％（29／132），传统胰腺空肠端-端套入组33．33％（3／9）。结论胰肠吻合方式、保留幽门与否对胰瘘发生率无显著性的影响。     

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.