经内窥镜化学性胆囊切除术31例

作者对化学性胆囊切除术中某些关键技术作了较大的改进，首先采用了经内窥镜途径胆囊造瘘，微波闭塞胆囊管，硬化剂加压灌注等操失技术，并使胆囊造瘘，经瘘管取石，闭塞胆囊管和胆囊感化四个步骤一期完成，本组共治疗３１例患者（５例中转开腹）。随访２￣１２个月（平均７．６个月），２５例胆囊腔完全纤维化闭塞，仅１例术后胆囊区仍有２ｃｍ×３ｃｍ的囊腔。所有患者均无并发症。结果表明：该方法在临床上切实可行，疗效满意，明     

Mirizzi综合征合并胃瘘二例

例１：女性，７４岁。黄染伴食欲不振、消瘦７０天。既往有上腹不适“胃病”史。腹部无阳性体征查见。Ｂ超及ＥＲＣＰ示“慢性胆囊炎、胆囊及肝内外胆管结石”。钡餐不能排除“胃窦癌”。手术探查：大网膜包裹肝下区，分离后见幽门前区胃壁与胆囊底部融合成块，钝性分开见胆囊胃瘘直径１．２ｃｍ，未见癌肿表现；胆囊壁厚０．５ｃｍ，经瘘口切开胆囊取出４ｃｍ×３ｃｍ结石后，发现胆囊颈与肝总管间有直径２ｃｍ。内瘘，经该瘘口取出泥沙样结石３ｇ，查胆总管下端通畅，行胆囊大部切除并清除胆囊残余粘膜后，经该瘘口置入Ｆ２０＃Ｔ管，修补…     

胆囊造瘘后内镜下胆囊黏膜电凝消除术

目的探讨胆囊造瘘后经内镜电凝消除胆囊黏膜的可行性。方法20例胆囊造瘘术后病人在硬膜外麻醉或基础加局部麻醉下行电切镜检查和治疗。通过胆囊造瘘窦道插入Storz前列腺电切镜，分别用滚球和滚桶电极电凝消除胆囊黏膜，电凝功率60～70w，滚桶移动速度10～15mm／s，使胆囊内壁呈均匀棕灰色。结果内镜下操作时间25～55min，平均35min。术后1个月胆囊腔完全闭合者12例，3个月完全闭合者5例，另3例未闭合者形成潴留性囊肿。结论用电切镜电极消除胆囊黏膜是胆囊造瘘后胆囊硬化闭塞的可行方法，可避免再次胆囊切除术。     

经胆囊管探查胆总管应用价值的探讨

目的 探讨经胆囊管探查胆总管的适应征、方法和应用价值。方法 距胆总管０．５～１ｃｍ切断胆囊管，除去胆囊，血管钳提起管腔边缘，插入弯成弧形的探条探查胆总管。如探条受阻，以探条为引导，触摸探条尖端附近，有助于鉴别结石、肿瘤或炎性狭窄。结果 ５１例胆囊结石，探查３６例，阳性７例（１９．４％），其中有探查指征６例，阳性４例（６６．６）；无探查指征３０例，阳性３例（１０％）。结论 经胆囊管探查胆总管无创、便捷，能准确发现胆总管病变，凡胆囊管径〉０．３ｃｍ者，应采用该法探查。     

腹腔镜治疗胆囊内瘘7例报告

目的总结腹腔镜手术诊治胆囊内瘘的经验。方法回顾分析2002年1月～2005年12月我院2113例腹腔镜胆囊切除术中遇到的7例（0．3％）胆囊内瘘的诊治经过。结果7例均系术中确诊，其中胆囊十二指肠瘘5例，胆囊横结肠瘘和胆囊胃瘘各1例。6例在腔镜下完成胆囊切除和瘘口关闭，平均手术时间130min（50～180min），术中无意外出血和损伤，术后恢复顺利；1例胆囊十二指肠瘘中转开腹。随访6个月～4年（平均22，6个月），无手术相关并发症发生。结论对于Lc中遇到的胆囊内瘘，可以酌情选择镜下完成手术，同样安全可靠。腔镜下瘘管的处理可以采用：夹闭或套扎、缝合、造疼和内镜切割吻合器切断闭合．     

腹腔镜胆囊切除术少见并发症(附2例报告)

１　临床病例例１　患者,女,５２岁。８个月前因胆囊结石在院外行腹腔镜胆囊切除术（ＬＣ）。据患者自述,手术历时约２小时,术中取出３０多粒小结石（直径０．５ｃｍ左右）,胆囊壁有多处破裂,经术后置管引流创口愈合良好,但感右上腹胀痛,经抗炎等对症治疗１周症状稍有缓解后出院。６个月前,右上腹胀痛逐渐加重,并发现剑下穿刺孔附近有一包块,Ｂ超检查提示右上腹有一５．２ｃｍ×４．８ｃｍ的囊性包块,继而自溃流脓,经反复冲洗换药,伤口一直不愈而形成窦道。故于４个月前在另一医院行剑下窦道切除,术中在窦道底部取出数粒沙粒…     

经皮胆囊微造瘘联合肾镜治疗老年急性结石性胆囊炎研究(附62报告)

目的探讨经皮胆囊微造瘘联合肾镜治疗高危老年急性结石性胆囊炎的临床体会。方法回顾分析62例高危老年急性结石性胆囊炎患者临床资料,评估经皮胆囊微造瘘联合肾镜治疗结石性胆囊炎的技术价值。结果 62例高危老年急性胆囊炎患者行"经皮胆囊造瘘联合经皮肾镜治疗",72 h内症状有明显缓解。并发症:3例切口感染,2例因胆囊活检显示癌变再次入院治疗,余60例全部带管出院,或转内科治疗原发内科疾患。术后3、6、12个月随访未发生胆囊炎再发。结论经皮胆囊微造瘘联合肾镜治疗高危老年急性结石性胆囊炎是一种安全、有效的方法,具有重要临床应用价值。     

经皮穿刺造瘘置管引流77例应用体会

经皮穿刺造瘘置管引流７７例应用体会安徽省肥西县三河医院（２３１２２１）高泽玉李琳作者于１９８７年５月至１９９７年５月采用经皮穿刺造瘘置管引流７７例，收到满意效果。在Ｂ超定位引导下经皮穿刺造瘘置管引流治疗肝脓肿３２例，膈下脓肿１例，肝外阻塞性黄疸２例，...     

人工血管移植动-静脉造瘘术的临床应用

目的 报道采用人工血管移植进行动－静脉造瘘术的临床应用效果。方法 １９９５年１０月～１９９８年８月,对２３例肾功能衰竭患者选择了膨体泡沫聚四氟乙烯（ＰＴＦＥ）人工血管进行前臂的动－静脉造瘘术。人工血管的直径为６ｍｍ,长４０ｃｍ。用Ｇｏｒｅ皮下隧道器分两次做皮下隧道,将人工血管一端从肘部切口引至腕侧切口后再引回肘部切口,形成Ｕ形袢管。用肝素盐水２０ｍｌ灌入血管腔内,人工血管两端分别与肘浅静脉及肘动脉     

恶性输尿管梗阻的腔内微创治疗(附85例报告)

目的探讨盆腔肿瘤或盆腔转移性肿瘤及放疗等引起的恶性输尿管梗阻的腔内微创治疗方法和效果。方法2004年1月-2007年1月收治恶性输尿管梗阻病人85例,采用腔内泌尿外科微创治疗,其中72例经尿道膀胱镜下（25例）或输尿管镜下（47例）留置双J管,单侧42例,双侧30例,13例经皮肾穿刺微造瘘顺行放置2根双J管。结果所有病例均获随访,平均9（6-24）个月。术后下腹不适15例,排尿时腰部胀痛22例,肉眼血尿3例,均自行缓解。腹平片未发现双J管移位。术后3个月更换双J管时,未发现导管周围结石形成。71例患者留置双J管后引流通畅,尿量明显增加,肾功能复查,肌酐5-7 d恢复正常或接近正常,B超示置管侧肾积水减轻。14例患者术后B超示肾积水无明显改变,肾功能改善不明显,改行经皮肾穿刺微造瘘术后肾功能恢复正常。8例术后9-15月再发梗阻,经皮肾穿刺微造瘘术后肾功能恢复正常。结论恶性输尿管梗阻的腔内治疗创伤小,疗效确切,可以为患者解除痛苦,提高生活质量。     

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.