胃食管结合部常见良性疾病的腹腔镜治疗

目的探讨腹腔镜手术治疗胃食管结合部常见良性疾病（胃食管反流病和贲门失弛缓症）的可行性和临床应用价值。方法2001年6月～2009年6月,对283例胃食管反流病（GERD组）实施腹腔镜胃底折叠术,其中Nissen胃底折叠术127例,Toupet胃底折叠术55例,Dor胃底折叠术101例;对33例贲门失弛缓症（贲门失弛缓症组）实施腹腔镜Heller肌切开联合Dor胃底折叠术。结果全组无中转开腹,手术时间60～125min,平均78min;术中出血量40～120ml,平均66ml;术后住院时间3～21d,平均4.2d。术后临床症状均得到缓解,无严重并发症及死亡病例。术后3个月复查胃镜、上消化道造影、食管测压和24hpH检测均恢复正常。GERD组272例随访3个月～8年,平均3.5年,对手术结果满意率95.6%（260/272）,21例有进固体食物时轻度哽噎感,6例反酸症状复发,使用抑酸药物可控制。贲门失弛缓症组33例随访3个月～4年,平均2.1年,均可正常进食,无吞咽困难或反酸表现。结论腹腔镜手术治疗胃食管结合部良性病变具有独特优势,充分体现微创手术创伤小、恢复快、安全可行、疗效可靠的优点。     

胃食管反流病的腹腔镜外科治疗

目的:探讨腹腔镜手术治疗胃食管反流病的临床效果.方法:回顾性分析2008年1月—2011年9月对33例胃食管反流病患者行腹腔镜食管裂孔疝修补和胃底折叠术的临床资料.腹腔镜单纯胃底折叠术5例(Toupet式),腹腔镜食管裂孔疝修补加胃底折叠术25例(Nissen式3例,Toupet式22例),腹腔镜单纯食管裂孔疝修补术3例.结果:全组患者手术均获成功,手术时间90～185 min.术后平均住院6d.无中转开腹及死亡病例,无术后严重并发症.术后随访1～24个月,32例临床症状完全消失,1例明显好转.结论:对于胃食管反流性疾病,腹腔镜食管裂孔疝修补和胃底折叠术是一种微创、安全、有效的治疗方法.     

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目的观察腹腔镜胃底折叠抗反流手术联合胃袖状切除术对动物模型的可行性和安全性。方法 2013年12月至2014年5月在柯惠上海临床培训中心及奥林巴斯上海实验室对8只小猪行腹腔镜下保留部分胃底的胃袖状切除术联合食管裂孔疝修补术及不同类型胃底折叠术(包括Nissen、Toupet、Dor胃底折叠术)。记录术中情况、手术步骤、技术难点及注意事项等。结果成功完成小猪腹腔镜胃袖状切除术和食管裂孔疝缝合修补术8次,不同类型胃底折叠术24次,即Nissen胃底折叠术、Toupet胃底折叠及Dor胃底前折叠术各8次。无一例中转开腹,所有实验动物均在手术中生命体征保持平稳,平均手术时间为(120.2±13.7)min,出血量为5~80(35.8±11.1)m L。术中1只发生肝损伤出血,其余均未发生脏器损伤及吻合口漏。手术时间随着训练次数明显缩短。结论腹腔镜胃底折叠抗反流手术联合胃袖状切除术对小猪动物模型安全可行,可为临床医师提供极佳训练机会,有助于缩短学习曲线,可能成为治疗肥胖合并胃食管反流病或食管裂孔疝的新型抗反流手术方法。     

腹腔镜胃底折叠术治疗胃食管反流病

目的探讨腹腔镜胃底折叠术治疗胃食管反流病的临床效果。方法2008年1月-2011年11月对40例胃食管反流病行腹腔镜胃底折叠术。腹腔镜单纯胃底折叠术7例（Toupt式）,腹腔镜食管裂孔疝修补加胃底折叠术33例（Nissen式5例,Toupet式28例）。结果手术均获成功,无中转开腹及死亡病例,无术后严重并发症。手术时间75～215min,平均112min;术中出血量10-350ml,平均52ml;术后住院5—10d,平均7d。40例术后随访1—24个月,平均16个月,34例临床症状完全消失,6例症状明显好转。结论腹腔镜胃底折叠术治疗胃食管反流病疗效满意。     

腹腔镜抗反流手术猪动物训练模型的建立

目的 分享建立用猪作腹腔镜抗反流手术动物训练模型的经验.方法 对6头小猪全身麻醉下进行腹腔镜下食管裂孔疝修补术,Nissen胃底折叠术,Toupet胃底折叠术,Dor胃底折叠术.记录术中并发症的发生情况、手术步骤、手术重点、技术难点,注意事项等.结果 成功完成腹腔镜食管裂孔疝修补术6次,Nissen胃底折叠术6次,Toupet胃底折叠术6次,Dor胃底折叠术6次.均未出现严重术中并发症.手术时间随着训练次数明显缩短.结论 腹腔镜抗反流手术猪动物训练模型的建立是可行的,手术具有可逆性、可重复操作性等特点,可以为外科医生提供极佳训练机会,明显缩短掌握手术技术时间.     

腹腔镜胃底折叠抗反流术联合胃袖状切除术动物实验研究

目的 观察腹腔镜胃底折叠抗反流手术联合胃袖状切除术对动物模型的可行性和安全性。方法 2013年12月至2014年5月在柯惠上海临床培训中心及奥林巴斯上海实验室对8只小猪行腹腔镜下保留部分胃底的胃袖状切除术联合食管裂孔疝修补术及不同类型胃底折叠术（包括Nissen、Toupet、Dor胃底折叠术）。记录术中情况、手术步骤、技术难点及注意事项等。结果 成功完成小猪腹腔镜胃袖状切除术和食管裂孔疝缝合修补术8次,不同类型胃底折叠术24次,即Nissen胃底折叠术、Toupet胃底折叠及Dor胃底前折叠术各8次。无一例中转开腹,所有实验动物均在手术中生命体征保持平稳,平均手术时间为（120.2±13.7）min,出血量为5~80（35.8±11.1）mL。术中1只发生肝损伤出血,其余均未发生脏器损伤及吻合口漏。手术时间随着训练次数明显缩短。
结论 腹腔镜胃底折叠抗反流手术联合胃袖状切除术对小猪动物模型安全可行,可为临床医师提供极佳训练机会,有助于缩短学习曲线,可能成为治疗肥胖合并胃食管反流病或食管裂孔疝的新型抗反流手术方法。     

经脐单孔腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的临床体会

目的：总结经脐单切口腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的经验,提高腹腔镜临床应用的水平。方法：2010年3月—2011年10月分别对3例贲门失迟缓症进行单切口腹腔镜食管Heller肌切开、Dor胃底折叠术,对4例食管裂孔疝患者进行单切口腹腔镜食管裂孔疝修补、Nissen胃底折叠术。结果：7例手术均顺利完成。手术时间115～180 min;出血量50～110 mL;住院时间5～7 d。所有患者均无术后出血、食管漏、发热感染等并发症。患者术后脐部切口愈合良好,美容效果明显。结论：对于有经验的腹腔镜外科医生,单切口腹腔镜手术治疗贲门失弛缓症及食管裂孔疝是安全可行的,并具有极佳的美容效果。     

食管肌层切开术联合胃底折叠术治疗食管运动功能障碍性疾病的远期疗效

目的 比较食管肌层切开术加不同胃底折叠术式治疗贲门失弛缓症或弥漫性食管痉挛的远期效果.方法 1978年1月至1998年10月,共64例贲门失弛缓症或弥漫性食管痉挛患者经左胸行Heller手术+抗反流手术.其中21例加行Nissen全胃底折叠术(Nissen组),43例加行BelseyⅣ式部分胃底折叠术(Belsey组).患者于手术前后行影像学、食管核素排空、食管压力测定和内窥镜检查及24 h pH值监测.结果 全组无手术死亡及严重并发症.术后6年随访,Nissen组吞咽困难(P=0.025)及核素潴留(P=0.044)的发生率高于Belsey组.两种术式均可降低食管下括约肌的压力梯度.Nissen组术后食管直径较术前增加(P=0.012),而Belsey组增加不明显(P=0.695).两组烧心与反酸症状均少见.Nissen组有8例患者、Belsey组有1例患者因复发性吞咽困难需行二次手术(P＜0.01).结论 在治疗贲门失弛缓症或弥漫性食管痉挛患者时,加行全胃底折叠术可能并不适宜,而部分胃底折叠术可以提供满意的抗反流效果,且不会显著影响食管排空功能.     

免气腹辅助3D腹腔镜改良Heller肌切开联合Dor胃底折叠治疗贲门失弛缓症

目的探讨免气腹辅助3D腹腔镜改良Heller肌切开联合Dor胃底折叠治疗贲门失弛缓症的临床价值。方法 2013年7月~2015年11月对32例贲门失弛缓症行免气腹辅助3D腹腔镜下贲门食管肌层切开,联合Dor胃底折叠术(前部180°胃底折叠缝合术)。结果 32例均成功完成免气腹腹腔镜手术,手术时间(71.6±36.8)min,术中出血量(23.6±18.4)ml,住院时间(8.2±2.6)d,无食管漏等并发症及死亡。32例术后随访6~34个月,平均15.3月,Eckardt评分Ⅰ级20例(62.5%),Ⅱ级9例(28.1%),Ⅲ级3例(9.4%);手术有效29例(90.6%),失败3例(9.4%)。23例术后6个月复查食管吞钡造影,食管最大横径(31.1±5.2)mm,较术前(45.3±8.0)mm明显改善(t=11.064,P=0.000)。结论免气腹辅助3D腹腔镜改良Heller联合Dor胃底折叠术治疗贲门失弛缓症疗效满意。     

经腹Heller手术治疗贲门失弛缓症的远期疗效(附112例报告)

目的 评价经腹Heller手术治疗贲门失弛缓症的远期疗效。方法 回顾分析1973年6月至2003年6月，112例经腹Heller手术治疗贲门失弛缓症病例资料。其中行单纯Heller手术19例，Heller附加抗反流术式93例（Lortat-Jacob术式60例，Toupet术式20例，Dor术式13例）。结果 96例获得随访资料，随访1～10年。效果优良者79例，改善者14例，无效3例。17例发生反流性食管炎，单纯Heller手术组术后反流发生率明显高于Heller附加抗反流术（P〈0．05）；胃壁肌层切开长度大于2cm组术后反流发生率高于长度小于2cm组（P〈0．05）。结论 经腹Heller手术治疗贲门失弛缓症远期疗效满意；Heller手术不加抗反流术以及胃壁肌层切开长度大于2cm者术后易发生反流性食管炎。     

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.     

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.     

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.