后腹腔镜肾部分切除术在治疗肾肿瘤的临床应用

目的探讨后腹腔镜保留肾单位的肾部分切除术治疗肾肿瘤的临床应用价值。方法 11例患者施行后腹腔镜保留肾单位的肾部分切除术的临床资料,其中男8例,女3例,年龄平均51.2岁,肿瘤直径3～4cm回顾性分析。结果所有手术均获成功,手术时间70～120min,血管阻断时间20～40min,术中失血100～300ml,术后无出血、尿漏等并发症。术后病理9例肾脏透明细胞癌(T1N0M0),2例肾血管平滑肌脂肪瘤,随访3～15个月无局部复发。结论后腹腔镜下保留肾单位的肾部分切除术治疗早期肾脏肿瘤,安全、有效,兼有创伤小,康复快等优点,近期疗效满意,远期疗效有待进一步观察。     

肾血管平滑肌脂肪瘤32例诊治分析

目的 提高肾血管平滑肌脂肪瘤的诊断符合率和治疗效果.方法 回顾性分析32例患者临床资料.结果 根据肿瘤的大小和病变程度,24例行肾错构瘤剜除术,5例行肾部分切除术,3例行肾切除术.结论 B超和CT为诊断肾血管平滑肌脂肪瘤的首选方法,治疗应以外科手术为主.肿瘤直径〈4 cm的患者多无临床症状,可临床随访 肿瘤直径〉4 cm的患者应积极行手术治疗,以保留肾单位的手术为首选.     

腹腔镜肾部分切除术(附15例报告)

目的 评价腹腔镜肾部分切除术治疗肾脏肿痛的临床效果。方法 2004年1月至2005年4月采用腹腔镜经腹腔或后腹腔途径对15例肾肿瘤患者行肾部分切除术。男11例，女4例。平均年龄52岁（29～70岁）。局限性肾透明细胞癌12例，平均肿瘤直径3．0cm（2．0～4，0cm）；肾血管平滑肌脂肪瘤3例，平均肿瘤直径4．5cm（3．5～6．0cm）。观察手术时间、术中出血量、住院天数、并发症及手术效果。结果 15例手术顺利。平均手术时间120min（80～150min），术中平均出血量150ml（100～220ml），无输血、中转开放手术病例。术后无并发症，平均住院时间8d（7～9d）。随访2～16个月肿瘤无复发。结论 腹腔镜肾部分切除术安全有效，但需长期随访以确定其远期疗效。     

腹腔镜保留肾脏肾肿瘤切除术

目的:探讨腹腔镜保留肾脏手术治疗肾肿瘤的临床应用价值。方法:为21例患者施行腹腔镜保留肾脏肾肿瘤切除术,其中13例经后腹腔途径,8例经腹腔途径,肿瘤直径2.5～4.0cm。术后病理为15例肾脏透明细胞癌(T1N0M0),6例肾血管平滑肌脂肪瘤。结果:21例手术均获成功,手术时间80～130min,血管阻断时间10～35min,术中失血100～400ml,术后无出血、尿漏等重要并发症发生。术后短期随访所有透明细胞癌病例5～22个月无局部复发。结论:腹腔镜保留肾脏肾肿瘤切除术治疗早期肾脏肿瘤(直径≤4cm)安全有效,患者损伤小,康复快,值得临床推广应用。     

肾血管平滑肌脂肪瘤的诊断与治疗(附72例报告)

目的　探讨肾血管平滑肌脂肪瘤的诊治方法。　方法　总结分析 72例肾血管平滑肌脂肪瘤患者的临床资料。统计学方法采用 χ2 检验。　结果　 13例 (18.1% )术前误诊。诊断正确率B超为 73.6 % (5 3/ 72 ) ,CT为 81.9% (5 9/ 72 ) ,两者同时误诊者 10例 (13.9% )。直径 <4cm的肿瘤误诊率高于≥ 4cm者 ,P <0 .0 5。治疗以保留肾单位的手术为主 ,术前选择性动脉栓塞及术中暂时阻断肾动脉可显著减少出血。　结论　应提高对肾血管平滑肌脂肪瘤的术前诊断水平 ,采取各种措施保留肾单位。     

腹腔镜下保留肾单位手术止血经验介绍

目的 探讨腹腔镜下保留肾单位手术止血方法及临床效果.方法应用超声刀、双极电凝切除肾肿瘤,止血纱布块填压、生物黏合剂喷洒及肾实质创面缝合的方法对30例肾肿瘤患者行腹腔镜下保留肾单位手术,其中经腹腔途径4例.男22例,女8例.平均年龄50岁.局限性肾癌20例,肿瘤平均直径2.5(1.5～4.0)cm;肾血管平滑肌脂肪瘤10例,肿瘤平均直径2.4(1.0～4.0)cm.观察手术时间、术中术后出血量、术后住院天数、并发症及手术疗效.结果 30例均完成腹腔镜下保留肾单位手术,20例未阻断肾蒂.平均手术时间169min,平均出血量100 ml,1例术中输血200 ml,另1例术后第3天发生继发性出血,腹膜后血肿,输血800 ml.未发生其他并发症.术后平均住院9 d.30例术后1个月肾功能均正常.19例肾癌患者随访1～26个月,平均9个月,肿瘤无复发. 结论 腹腔镜下保留肾单位手术时,应用超声刀、双极电凝切除肿瘤,止血纱布块填压、生物黏合剂喷洒及肾实质创面缝合法止血效果确实可靠.     

腹腔镜下肾部分切除术治疗中央型肾肿瘤12例报告

目的 探讨中央型肾肿瘤腹腔镜肾部分切除术的经验. 方法 2004年1月至2007年5月,对12例中央型肾肿瘤(肾细胞癌10例、肾血管平滑肌脂肪瘤2例)施行腹腔镜下肾部分切除术.结果 12例手术均顺利完成,经腹腔途径5例,腹膜后腔途径7例,手术时间120～240 min,平均172 min,肾动脉阻断时间25～61 min,平均32 min.术中出血量100～300 ml,均未输血.术中结扎三级血管者9例,需缝合集合系统者7例.病理报告:肾细胞癌10例,切缘均阴性;肾血管平滑肌脂肪瘤2例.结论 中央型肾肿瘤行腹腔镜肾部分切除术安全有效,三级血管的分离结扎和腔内实时超声可能有助于此项术式的开展.     

肾血管平滑肌脂肪瘤18例报告

目的 探讨肾血管平滑肌脂肪瘤的诊断及治疗。方法 回顾性分析近10年来收治的肾血管平滑肌脂肪瘤18例的临床资料。结果 18例术前行B超检查．16例行CT检查。手术治疗16例．其中行肾切除术2例．肿瘤剜除术14例，术后均病理检查证实；定期随访2例．随访2～5年，无肿瘤恶变及复发。结论 对肾血管平滑肌脂肪瘤直径大于4cm．可手术治疗；对肿瘤直径小于4cm，可观察。     

高选择肾动脉阻断腹腔镜肾脏部分切除术治疗中央型肾肿瘤

目的:探讨中央型肾肿瘤腹腔镜肾部分切除术的手术技巧及结果。方法 :2006年6月～2011年6月,我院对8例中央型肾肿瘤施行腹腔镜下肾部分切除术。术中通过仔细游离肾蒂血管,选择性阻断或结扎滋养肿瘤的三级血管,以减少正常肾单位的热缺血时间和术中的出血。结果:8例手术均顺利完成,手术时间为150～300min,平均220min,肾血管阻断时间22～45min,平均33min。肿瘤大小为2.0～6.0cm,平均为2.8cm。需集合系统修补6例(75%)。术中出血量100～400ml,平均为130ml,均未输血。病理报告:肾透明细胞癌6例(75%),肾血管平滑肌脂肪瘤2例,术中及术后切缘均阴性。术后随访3～46个月,平均22.3个月,未见肿瘤局部复发或远处转移。结论:腹腔镜肾部分切除术治疗中央型肾肿瘤安全有效,选择性阻断或结扎滋养肿瘤的肾动脉三级分支可以有效减少正常肾单位的热缺血时间和出血,有利于该术式的开展。     

介入超声在腹腔镜下保留肾单位手术中的应用

目的 探讨介入超声辅助后腹腔镜下保留肾单位手术治疗肾肿瘤的方法与疗效.方法 肾肿瘤患者20例.男11例,女9例.年龄33～73岁,平均53岁.肾癌12例,肿瘤平均直径2.9(1.4～4.6)cm,临床分期均为T1 N0M0;肾血管平滑肌脂肪瘤7例,肿瘤平均直径4.5(1.8～8.0)cm;肾嗜酸细胞瘤1例,直径3.1 cm.行后腹腔镜下保留肾单位手术,术中以腹腔镜超声探头定位肿瘤,观察肿瘤血流及其周围是否存有小的肿瘤病灶.记录手术时间、肾动脉阻断时间及手术疗效.结果20例手术均顺利完成,无中转开放手术.平均手术时间115(85～270)min,平均肾动脉阻断时间28(22～50)min.12例肾癌患者平均随访16(4～30)个月,肿瘤无复发.结论 介入超声有助于腹腔镜下保留肾单位手术中肿瘤定位、判断血管阻断是否完全及彻底切除肿瘤.     

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.