高龄胆道疾病89例外科治疗经验

目的　探讨高龄 (70岁以上 )胆道疾病的外科治疗方法。方法　回顾性分析了我院 13年来手术治疗 70岁以上高龄胆道疾病 89例的经验。急诊手术 4 7例 (5 2 .8% ) ,择期手术 4 2例 (47.2 % )。结果　治愈 80例 (89.9% ) ,死亡 5例 (5 .6 % ) ,未愈出院 4例 (4.5 % )。术后发生并发症 35例 (39.3% )。结论　择期手术应进行全面细致的体检 ,积极治疗合并病 ,选择好合适的手术时机。急诊应边抢救边检查 ,术中进行监测 ,手术应简单实用有效。术后全面监测生命体征变化 ,发现问题及时处理 ,预防并发症发生     

高龄胆道疾病235例治疗的临床经验

目的　总结高龄胆道疾病患者的治疗经验。方法　对近 2年来我科收治的 6 0岁以上因胆道疾病入院的急、择期手术患者的临床资料进行了回顾性分析。结果　本组 2 35例中行急诊手术 78例 (33 .2 % ) ,择期手术 16 7例(71.1% ) ;合并各种内科疾病者 14 7例 ,占 6 2 .6 % ,其中以心血管疾病最多 ,71例 (48.3 % ) ,其次为呼吸系统疾病 ,5 4例(36 .7% ) ;术后并发症发生率为 2 3 .0 % (5 4/2 35 ) ,在并发症中以肺部感染发生率最高 ,占 42 .6 % (2 3/5 4) ,其次为泌尿道感染 ,占 33 .3 % (18/5 4) ,再其次为切口感染 ,占 2 9.6 % (16 /5 4) ;全组术后近期死亡 7例 ,占 3 .0 % ,其中死于肝、肾功能衰竭 4例 ,呼吸衰竭 2例 ,心衰 1例。结论　高龄胆道疾病患者合并疾病多 ,手术风险性增加 ,术后并发症发生率较高 ,因此应加强围手术期的监护与处理 ,确保患者平安度过手术期。     

老年胆道外科疾病手术适应证与时机问题

目的 研究胆道疾病手术适应证和手术时机，减少术后并发症，降低死亡率。方法 160例60岁以上老年胆道疾病患者全部行外科手术治疗．择期手术87例(54．37%)；急诊手术73例(45.63%)。术前伴随一种并存病88．75%(三种以上并存病20．63%)。结果 术后并发症32．75%，死亡率6．25％．6例ACST术后死于MODF．4例胆道肿瘤衰竭死亡。结论 掌握手术的适应证和手术时机．处理并存病，争取择期手术．避免急诊手术盲目性是外科治疗老年胆道疾病，减少并发症，降低死亡率的关键。     

胆道良性疾病老年患者的治疗分析

目的探讨老年胆道良性疾病的治疗方式选择。方法回顾性分析了1999年5月-2005年4月218例60岁以上老年人胆道良性疾病的治疗情况，分为手术组和非手术组，分析了疾病种类分布、合并症类型、治疗方式选择和治疗结果。结果75．2％的患者存在不同类型的合并症。206例行手术治疗，其中急诊95例，手术并发症33例。总死亡率2．29％。结论针对老年患者并存病多和术后并发症多的特点，强化围手术期处理是提高手术成功率，降低并发症和病死率的关键。     

肠外营养在高龄胆道疾病患者围手术期的临床意义

目的 总结肠外营养在高龄胆道疾病患者围手术期的治疗经验。方法 选择35例营养状况较差的高龄胆道疾病患者围手术期进行肠外营养，与32例高龄术前营养状况良好、围手术期常规补液的患者进行对比，分析肠外营养支持和常规补液的临床效果及生化变化。结果 肠外营养组自我恢复能力较好，体重、血浆蛋白在术后变化较小，胃肠功能恢复较快，并发症少；常规补液组体重、血浆蛋白术后改变明显，并发症多。结论 围手术期肠外营养支持对高龄胆道疾病患者术后恢复起明显的促进作用，降低了并发症的发生。     

经皮经肝胆囊穿刺引流术在高危急性胆囊炎患者中的应用

急性胆囊炎是普通外科的常见急腹症,其发病率随年龄的增长而增加,常需要急诊行手术治疗.然而高龄且合并严重内科疾病(如心脑血管疾病、糖尿病、肺功能不全)者,急诊手术有较高的中转开腹率、术后并发症率及死亡率[1].我院将CT引导下经皮经肝胆囊穿刺引流(percutaneoustranshepatic gallbladder drainage,PTGBD)技术应用于高危急性胆囊炎患者的治疗,现报道如下.     

80岁以上高龄结直肠癌患者的术后并发症相关因素分析

目的分析80岁以上高龄结直肠癌术后并发症发生的相关因素,探讨围手术期的治疗。方法回顾性分析湖州市中心医院2008月12月至2018年12月期间收治并行手术治疗的90例80岁以上高龄结直肠癌患者的临床资料。结果择期手术79例(88%),急诊手术11例(12%);平均手术时间145.7分钟,平均获取淋巴结16.8枚,手术中平均出血量65ml。共35例(39%)出现术后并发症,其中5例患者因心肌梗死、肠瘘伴腹腔感染、呼衰、肺部感染或心衰死亡。高龄结直肠肿瘤患者术后发生并发症与有无合并肿瘤梗阻、基础疾病类型及手术方式有关(均P0.05)。结论 80岁以上高龄结直肠癌患者尽管术后并发症发生率较高,但经充分术前评估、积极治疗基础疾病以及术后处理,能够很好耐受手术。     

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目的 探讨高龄胆道疾病的治疗方式选择。方法 对1994年5月至2000年4月，外科收治的80岁以上胆道病人152例，分别行手术与非手术治疗，分析病人的疾病种类分布，并存病类型，治疗方式的选择和治疗结果。结果 76.3%的病人存在有不同类型的并存病，95例行手术治疗，其中84例为急诊手术，手术并发症发生率38%，总病死率5.26%，手术治疗死亡3例。结论 年龄不是高龄胆道病人的手术禁忌，做好围手术期的处理及合理选用手术方式是治疗的关键。     

85岁以上结直肠癌患者术后并发症的危险因素分析

目的探讨85岁以上高龄结直肠癌患者发生术后并发症的危险因素。方法回顾性分析84例85岁以上结直肠癌患者的临床资料,所有患者均采取手术治疗,探讨患者临床病理资料与术后并发症发生与否的关系。结果单因素分析结果显示,基础疾病状态、手术类型、手术时间、切除范围与术后并发症发生与否有关(均P0.05)。进一步行多因素Logistic回归分析结果显示,合并基础疾病、开腹手术、手术时间4 h、联合器官切除和扩大切除均为85岁以上结直肠癌患者发生术后并发症的独立危险因素(均P0.05)。结论合并基础疾病、开腹手术、手术时间4 h、联合器官切除和扩大切除均为85岁以上结直肠癌患者发生术后并发症的独立危险因素,临床中应重视对85岁以上结直肠癌患者术后并发症的预防干预。     

合并内科疾病的80岁以上高龄患者股骨粗隆间骨折的围手术期处理

目的探讨合并内科疾病的80岁以上高龄股骨粗隆间骨折的围手术期治疗特点。方法回顾性分析经手术治疗的合并内科疾病的股骨粗隆间骨折患者的资料,包括合并症的类型、术前准备、手术方法、术后处理等。结果实验组中行手术治疗的85例患者均顺利进行手术．术后出现单一并发症23例,其中中枢神经系统异常和肺部感染高发。合并2种以上并发症有8例,其中1例死于肺部感染并发多脏器功能衰竭。84．7％获得随访,优良率72｜2％。对照组中适合手术但未行手术的42例患者中出现并发症35例,死亡3例,78．5％获得随访,优良率42．4％。结论围手术期的全身状况评估、充分的术前准备,合理的麻醉和手术方式的选择以及术后处理和早期功能锻炼是获得成功的关键。     

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.     

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.     

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.