脾肾分流加让奇断流联合术治疗门静脉高压症的远期疗效

评价门静脉高压症采用脾肾分流加门奇断流联合术治疗门静脉高压症的长期效果。方法 回顾性总结了１９例采用脾肾分流加门奇断流联合治疗门静脉高压症１４０例,并通过手术前后采色彩色多普勒显像,数字减影血管造影和术中测ＦＰＰ观察门静脉系血流动力学变化。     

贲门周围血管离断加肠腔静脉侧侧分流术治疗门静脉高压症

目的防止肝硬变门静脉高压症患者术后再出血,保持门静脉向肝血供,降低肝性脑病发生率。方法对３７例门静脉高压症患者施行了联合断流加肠腔静脉分流手术,即贲门周围血管离断后,肠系膜上静脉与下腔静脉采用直接侧侧吻合。结果本组手术成功率１００％。术后自由门静脉压（ＦＰＰ）３１６±０５８ｋＰａ,较术前３９１±０６４ｋＰａ明显降低,差异有极显著性意义（Ｐ＜００１）。术后随访５～２２个月,所有患者肝功能均有不同程度恢复,其中１２例肝功能Ⅲ级的患者,有５例恢复到Ⅰ级、７例恢复到Ⅱ级、无１例发生肝性脑病及再出血。腹水消失率１００％,食管胃底静脉曲张改善消失率８２９％。结论断流分流联合应用,既能保持一定的门静脉压力及门静脉肝脏血供,又能疏通门静脉系统的高血流状态,是一种较理想的治疗门静脉高压症的手术方法     

脾肾分流加门奇断流术治疗门静脉高压症的远期疗效

报告脾肾分流加门奇断流术治疗门静脉高压症１４０例的长期疗效。术后近期无１例再出血,再出血率为８．３％,术后肝性脑病为５．０％。５、１０和１５年生存率分别为８３．３％、６４．５％和５４．５％。通过前瞻性临床随访和手术前后门脉血流动力学对比研究证实：本联合术发挥了优势互补作用,既保留了分流术和断流术二者的优点,又克服了二者的缺点。作者认为本联合术是治疗门静脉高压症合理、实用而可取的一种术式。     

门静脉高压症手术前后血流动力学改变及临床意义

采用彩色多普勒血流显像（ＣＤＦＩ）．对门静脉高压症手术前后门静脉血流动力学进行观测和对比分析。结果表明：（１）肝硬变门静脉高压症的门、脾静脉内径和血流量显著扩张和增加，和正常人比较差异有显著性（Ｐ＜０．０１）．门静脉血流量增加与脾静脉血流量增加呈正相关；（２）断流术后．门静脉内径变窄和血流量明显减少，与对照组比较差异有显著性（Ｐ＜０．０１）；（３）断流加脾肾分流联合术后，门静脉内径变窄明显大于断流术，但两术式后门静脉血流量减少差异无显著性、结果认为．断流术和断流加脾肾分流联合术均为治疗肝硬变门静脉高压症较合理的术式。     

脾次全切除腹膜后移位加断流术治疗门静脉高压症的临床研究

目的探讨提高肝硬变门静脉高压症疗效的新术式。方法采用脾次全切除腹膜后移位加断流术治疗肝硬变门静脉高压症患者３６例,以３６例行贲门周围血管离断术的患者为对照,进行对比研究。术后随访３个月～５５年,平均２６个月。结果（１）研究组患者食管静脉曲张消失者约１１５％,好转６１５％,无变化２６９％;而对照组好转５００％,无变化４５８％,加重４２％,研究组疗效显著优于对照组（Ｐ＜００５）;（２）研究组脾亢消失;（３）术后２年内研究组免疫指标（ＩｇＭ,Ｃ３）与对照组相比升高有显著性意义（Ｐ＜００５）;（４）血管数字减影显示,余脾与腹膜后组织建立了丰富的侧支循环,使门静脉血向腹膜后分流。结论本术式兼有断流术和分流术的优点,门静脉高压症手术可保留部分脾脏。     

选择性远端脾腔静脉分流术治疗门静脉高压症

目的探讨远端脾腔静脉分流术治疗门静脉高压症的远期疗效。方法用远端脾静脉腔静脉直接吻合分流,并行脾胰断流和胃小弯侧门静脉奇静脉断流。结果分流术后,自由门静脉压平均下降０５３ｋＰａ,并仍维持在３２９±０４４ｋＰａ较高水平;再出血率７５８％;腹水发生率２７３０％;无明显肝性脑病发生;手术病死率７５８％;５年生存率７０４５％。结论远端脾腔静脉分流术是一种较理想的选择性分流术式。     

断流术对门静脉高压症患者肝脏血流动力学及肝功能的影响

目的观察断流术对门静脉高压症肝血流动力学改变及肝功能的影响。方法应用超声多普勒分别检测２５例门静脉高压症患者手术前后门静脉血流量（ＰＶＦ）、肝动脉血流量（ＨＡＦ），采用水柱法测量自由门静脉压力（ＦＰＰ）的变化，应用吲哚氰绿１５分钟潴留率（Ｒ１５ＩＣＧ）分别估测患者手术前后的肝功能。结果ＰＶＦ由术前的（１３２３±３８８）ｍｌ／ｍｉｎ减少至术后的（８９５±２６２）ｍｌ／ｍｉｎ（Ｐ＜００１）；ＨＡＦ由术前的（３７０±７０）ｍｌ／ｍｉｎ增加至术后的（４８５±１２３）ｍｌ／ｍｉｎ（Ｐ＜００１）；ＦＰＰ由术前的（２８±４）ｍｍＨｇ降至术后的（２５±４）ｍｍＨｇ（Ｐ＜００５）；Ｒ１５ＩＣＧ由术前的（１９±７）％变至术后的（２１±７）％（Ｐ＞００５）。结论断流术后门静脉血流量虽然减少，但是肝动脉血流量增加及术后门体分流的减少均利于术后硬变肝脏的功能维护。     

脾肾静脉分流联合断流术与单纯断流术远期疗效比较

目的评价近端脾肾静脉分流加门奇断流联合手术和单纯门奇断流术的远期临床疗效。方法回顾性总结近10年采用脾肾静脉分流加门奇断流联合手术和单纯门奇断流术治疗门静脉高压症384例,从术后再出血、脑病、肝功能衰竭发生率三方面总结临床疗效;于术前1周和术后2周应用核磁共振血管造影测量门静脉、脾静脉和肠系膜上静脉的直径、流速和流量,并于术中动态测量门静脉压力。结果联合手术组术后再出血率明显低于断流组,而肝功能和脑病发生率两组差异无统计学意义。联合手术组手术前后门静脉血流量下降差异有统计学意义。联合手术组和断流组门静脉血流量减少差异无统计学意义,但是自由门静脉压的下降差异有统计学意义。结论联合手术可结合断流和分流手术的优点,明显降低出血率,而且不增加脑病和肝衰竭发生率,应成为治疗门静脉高压症合并出血的首选术式。     

贲门及近端胃壁内外双重断流术治疗门静脉高压症出血

目的探索有效治疗门静脉高压症胃底曲张静脉破裂出血的手术方法。方法采用贲门周围血管离断术（壁外断流）加贲门环周粘膜下血管缝扎和近端胃（胃左动脉平面以上）中点环周缝扎粘膜下血管（壁内断流）。结果本组接受贲门及近端胃壁内外双重断流术４９例,其中单行贲门周围血管离断术（壁外断流）２１例。断流后自由门静脉压分别为（３３±０５）ｍｍＨｇ和（２１０±０１５）ｍｍＨｇ,两者比较Ｐ＜００１;术后随访３月至８年,双断流组无再出血发生,单断流组３例发生再出血,１例出血死亡。结论贲门及近端胃壁内外双重断流术治疗门静脉高压症胃底曲张静脉破裂出血比贲门周围血管离断术更为合理、彻底和有效     

脾肾静脉分流联合断流术的临床疗效及对门静脉系统血流动力学的影响

目的 评价近端脾肾静脉分流加门奇断流联合手术和门奇断流术的临床疗效及对门静脉系统血流动力学的影响。方法 回顾性总结近8年采用脾肾分流加门奇断流联合手术和门奇断流术治疗门静脉高压症245例，于术前一周和术后2周应用核磁共振血管造影测量门静脉、脾静脉和肠系膜上静脉的直径，流速和流量，并于术中动态测量门静脉压力。结果 联合手术组术后较术前门静脉血流量下降，肠系膜上静脉流量增加，差异有统计学意义（P〈0．05），门静脉直径和自由门静脉压下降差异有统计学意义（P〈0．01）。联合手术组与断流组相比，门静脉血流量的减少差异没有统计学意义，而自由门静脉压的下降差异有统计学意义（P〈0．01）。联合手术组术后再出血率明显低于断流组，而肝功能和脑病发生率两组间差异无统计学意义。结论 联合手术可结合断流和分流手术的优点，既明显降低出血率又不增加脑病发生，应成为治疗门静脉高压症合并出血的首选术式。     

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.     

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.     

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.     

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.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

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.