甲状腺手术中超声刀应用与喉返神经保护

目的:探讨开放性甲状腺疾病手术中超声刀的应用与喉返神经保护.方法:回顾性分析187例开放性甲状腺良性疾病手术患者的临床资料,据治疗方式分为超声刀组和传统电刀组,比较两组手术时间、术中出血量、术后引流量、术后住时间及声嘶等并发症发生率.结果:超声刀组手术时间、术中出血量均显著少传统电刀组(P<0.05),术后并发症发生率降低(P<0.05),术后住时间及术后引流量两组间无明显差异(P>0.05).结论:开放性甲状腺手术中,合理使用超声刀及有限度显露喉返神经可以缩短手术时间,减少术中出血,减少术后并发症发生率.     

超声刀行开放性甲状腺手术与传统手术的对比分析

回顾性分析2009年10月-2011年10月用超声刀行开放性甲状腺手术96例（超声刀组）与同期传统手术87例（传统组）患者的临床资料,比较2组切口长度、手术时间、术中出血量、术后引流量及术后并发症情况.超声刀组的手术时间、术中出血量、切口长度、术后引流量均显著少于传统组（P＜0.01）,2组术后并发症差异无统计学意义（P＞0.05）.超声刀在开放性甲状腺手术中能显著缩短切口长度及手术时间、减少术中出血量及术后引流量,且不增加并发症,值得推广.     

超声刀在小切口甲状腺手术中的应用研究

探讨超声刀在小切口甲状腺手术中的应用价值。以2014年3月—2015年6月在我院接受甲状腺手术的患者为观察对象。根据其手术方式分为传统手术组(30例)和超声刀组(50例)。比较两组患者切口长度、术中出血量、术后引流量、麻醉时间、手术时间、住院时间、住院费用及术后并发症发生率的差异。与传统手术组比较,超声刀组切口长度、麻醉时间、手术时间、术后住院时间更短,术中出血量、术后引流量少(P0.05);但两组住院费用差异无统计学意义(P0.05)。超声刀组甲状腺功能降低、喉返神经损伤和喉上神经损伤发生率明显低于传统手术组(P0.05),两组甲状旁腺损伤发生率差异无统计学意义(P0.05)。超声刀应用于小切口甲状腺手术可取得较好效果,具有临床应用价值。     

甲状腺切除手术中应用钳式超声刀和传统电刀的效果比较

目的比较甲状腺切除手术中应用钳式超声刀和传统电刀的效果。方法前瞻性收集笔者所在医院于2016年2月至2017年1月期间收治的160例接受开放性甲状腺手术患者的临床资料,随机分为钳式电刀组和传统电刀组,各80例。比较2组患者的手术效果指标、术后并发症发生情况和术后切口数字疼痛分级法(NRS)评分。结果在手术效果指标方面,钳式超声刀组患者的手术时间、术中出血量、术后引流量、术后引流时间、手术切口长度和住院时间均短于或低于传统电刀组,差异均有统计学意义(P0.05);在术后并发症方面,钳式超声刀组患者的声音嘶哑、伤口出血和甲状旁腺功能减退发生率,以及总并发症发生率均低于传统电刀组(P0.05),但2组患者的低钙血症、伤口感染和暂时性喉返神经麻痹发生率比较差异均无统计学意义(P0.05);在术后切口NRS评分方面,重复测量资料的方差分析结果表明,各时点钳式超声刀组患者的NRS评分均低于传统电刀组(P0.05)。结论开放性甲状腺手术中使用钳式超声刀可有效提高手术效果,减轻术后的疼痛,降低并发症的发生率。     

双极电凝镊在开放性甲状腺手术中的临床应用

目的探讨双极电凝镊在开放甲状腺手术中应用的安全性和可行性,并总结相应的手术技巧。方法对南京大学医学院附属鼓楼医院2011年10月至2014年10月期间347例分别应用双极电凝镊和超声刀开展的开放性甲状腺手术患者的临床资料进行回顾性分析。结果 2组病例在手术时间、术中出血量、术后引流量和术后住院时间上的差异均无统计学意义(P0.05);并发症方面,超声刀组的暂时性喉返神经麻痹及暂时性的甲状旁腺功能不足的发生率明显高于双极电凝镊组(P0.05),而在气道压迫、永久性喉返神经和甲状旁腺损伤及喉上神经麻痹发生率方面2组间的差异无统计学意义(P0.05)。结论用双极电凝镊行开放甲状腺手术是安全可行的,紧贴甲状腺被膜边凝边切并配合清楚直视下的精细分离是减少并发症的关键。     

超声刀在开放性甲状腺手术中的应用

目的探讨超声刀在开放性甲状腺手术中的可行性及优越性。方法2008年2月至今收治232例甲状腺疾病患者,依据术前B超报告甲状腺大小随机分为154例用超声刀行甲状腺手术为超声刀组,78例传统甲状腺手术为对照组。比较两组的手术切口长度、手术时间、术中出血量、术后引流量及并发症情况。结果与传统手术组相比,超声刀组手术切口长度、手术时间和术中出血量明显减少（P〈0．05）,两组术后引流量及并发症差异无显著性（P）〉0．05）。结论应用超声刀进行开放性甲状腺手术安全可靠,优于传统方法甲状腺手术,但不能盲目使用超声刀,要与丝线结扎手术方法相结合。     

腔镜辅助下巨大甲状腺肿物手术中喉返神经监测的临床效果分析

目的探讨喉返神经监测在腔镜辅助下巨大甲状腺肿物手术中的应用效果。方法回顾性分析2013年1月至2015年6月期间在腔镜辅助下治疗的158例巨大甲状腺肿物患者的临床资料,其中喉返神经监测79例(喉返神经监测组),喉返神经未监测79例(喉返神经未监测组)。对比分析2组在手术时间、术中出血量、术后引流量、术后住院时间、术后暂时性及永久性喉返神经损伤发生情况之间的差异。结果 158例患者均顺利完成腔镜辅助颈部小切口甲状腺手术。与喉返神经未监测组比较,喉返神经监测组的手术时间(min)明显缩短(76.2±23.4比89.2±29.8,P0.05),术中出血量(m L)和术后引流量(m L)均明显减少(术中出血量:16.3±13.6比20.6±10.7,P0.05;术后引流量:20.7±9.6比25.5±9.1,P0.05),但2组的术后住院时间(d)比较差异无统计学意义(3.2±1.3比3.3±1.9,P0.05)。术后随访8周,喉返神经监测组暂时性神经损伤发生率明显低于喉返神经未监测组〔5.6%(5/90)比21.8%(17/78),P0.05〕,但永久性神经损伤发生率在2组间比较差异无统计学意义〔0(0/90)比1.3%(1/78),P0.05〕。结论腔镜辅助巨大甲状腺结节手术中应用喉返神经监测技术可有效减少神经损伤发生率,缩短手术时间。     

超声刀FOCUS在开放性甲状腺手术中的应用

目的探讨超声刀FOCUS在开放性甲状腺手术中的应用价值。方法回顾性分析2011年1月至2011年9月完成的甲状腺手术187例的临床资料,其中利用超声刀FOCUS对甲状腺腺体及血管进行切割、止血的有102例(超声刀组),采用电刀、以及传统结扎、缝合手术的病例有85例(传统组)。观察两组的手术出血量、手术时间、术后引流量及术后并发症。结果超声刀组与电刀组比较,手术出血量为(13.2±4.5)ml VS(22.8±7.3)ml,切除甲状腺手术时间为(26.8±5.2)min VS(38.2±6.1)min,手术切口长度为(38.4±7.5)mm VS(52.8±9.5)mm,均有统计学意义(P<0.05),术后引流量的比较无统计学意义(P>0.05),分别为(40.7±6.4)ml VS(35.3±5.6)ml,术后并发症声嘶、低钙麻木的发生率,分别为3.9%(4/102)VS 3.5%(3/85)和6.9%(7/105)VS 7.1%(6/85),两组比较均无统计学差异(P>0.05)。结论在开放性甲状腺手术中应用超声刀FOCUS能明显减少术中出血量以及缩短手术时间,超声刀在甲状腺手术中具有较好的临床应用价值。     

超声刀FOCUS在开放甲状腺手术中的应用

目的比较超声刀FOCUS与传统手术方法在开放甲状腺手术中应用的特点。方法收集我科自2010年7月至2011年12月接受开放甲状腺手术的患者共计126例,随机分为两组,超声刀组66例,使用超声刀FOCUS进行手术;传统手术组60例,采用高频电刀结合缝扎止血。两组均由同一手术组医生进行手术。分别比较两组的手术时间、术中出血量、术后引流量、切口大小、住院时间和手术并发症发生率(喉返神经损伤、喉上神经损伤、甲状旁腺功能低下)。结果超声刀组在手术时间、术中出血量、术后引流量、切口大小、住院时间方面均短于或少于传统手术组,差异有统计学意义(P<0.05)。两组中均有1例甲状旁腺损伤,而喉上神经损伤、喉返神经损伤各1例仅见于传统手术组。两组间的手术并发症发生率差异无统计学意义(P>0.05)。结论使用超声刀行开放甲状腺手术要优于传统手术方法,可尽量兼顾美容的优点,符合现代微创外科理念,值得应用和推广。     

超声刀在开放小切口甲状腺切除术中的应用及对术后创伤应激反应、血钙水平与喉返神经损伤的影响

目的探讨超声刀在开放小切口甲状腺切除术中应用疗效,并观察术后患者创伤应激反应、血清钙离子水平及喉返神经(RLN)损伤情况。方法以我院进行甲状腺切除术患者80例为研究对象,根据患者则术式不同分为观察组与对照组,对照组(40例)予以传统甲状腺切除术,观察组(40例)予以超声刀小切口甲状腺切除术。比较两组手术时间、术中出血量、术后引流量等手术情况,并检测两组术前、术后3 d白细胞计数(WBC)、C反应蛋白(CRP)、降钙素原(procalcition,PCT)等术后创伤应激水平,监测喉返神经损伤程度及血钙变化情况。结果观察组手术时间、术中出血量及术后引流量等手术情况均明显优于对照组,差异均显著(P0.05);两组WBC、CRP、PCT等创伤应激指标较术前均显著升高,且对照组上升幅度均明显高于观察组,差异显著(P0.05);对照组低血钙发生率42.5%,明显高于观察组20.0%,组间差异显著(P0.05);对照组暂时性RLNI 17.5%,明显高于观察组5.0%。结论超声刀在开放性小切口甲状腺切除术中可有效降低术后创伤应激反应,减少钙代谢紊乱及喉返神经损伤,且手术时间短、出血量少,手术效果显著。     

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.