完整结肠系膜切除在中间入路右半结肠癌D3根治术中的临床应用

目的 探讨完整结肠系膜切除在中间入路右半结肠癌D3根治术中临床应用的可行性和有效性.方法 回顾性分析2010年2月至2012年6月我院胃肠肿瘤外科完整结肠系膜右半结肠癌D3根治术患者42例的临床病理资料,其中开腹手术20例,腹腔镜手术22例.结果 42例患者平均手术时间(146.43±30.73)min(90～240min),术中平均出血量(152.86±38.97)ml(100～300ml),术后平均住院时间(11.5±2.45)d(6～16d),无严重并发症,无住院期间死亡病例.中位淋巴结清扫数17.5枚(12～50枚),淋巴结阳性率11.43%,中位随访时间19个月(1～28个月),肿瘤复发率为2.38%.结论 完整结肠系膜切除在中间入路右半结肠癌D3根治术中的临床应用具有可行性和有效性.     

全结肠系膜切除术在腹腔镜与开腹右半结肠癌根治术中应用的对比研究

目的:探讨完整全结肠系膜切除(C M E)在腹腔镜右半结肠癌根治术中应用的可行性。方法:统计2010年3月—2014年1月67例在C M E概念下腹腔镜组(35例)与开腹组(32例)右半结肠癌根治术的临床疗效并进行比较分析。结果:两组手术顺利,排除中转开腹患者。腹腔镜手术组与开腹手术组:平均手术时间分别为(128.0±5.4)m in、(125.5±6.6)m in;平均术中出血量分别为(77.8±13.9)m L、(77.1±15.4)m L;平均检出淋巴结分别为15.9枚/例、16.0枚/例;术后平均排气时间分别为(2.9±0.9)d、(2.8±0.9)d;平均住院日分别为(9.6±1.0)d、(13.6±1.3)d;术后并发症率分别为18.8%(6/32)、20.0%(7/35)。结论:全结肠系膜切除治疗右半结肠癌是安全有效的,可以达到系膜和淋巴组织切除的最大化。腹腔镜与开腹手术相比疗效无明显差别。     

回盲部腹、背侧联合入路法行腹腔镜右半结肠癌根治术安全性与可行性的临床分析

目的:探讨联合回盲部腹、背侧入路法行腹腔镜全结肠系膜切除右半结肠癌根治术的安全性与可行性。方法:回顾分析2016年1月至2017年6月为56例右半结肠癌患者行回盲部腹、背侧联合入路法腹腔镜全结肠系膜切除右半结肠根治术的临床资料。结果:56例均顺利完成手术,无一例中转开腹。手术时间平均(163.8±42.5)min,术中出血量平均(113.3±21.3)mL,术后首次排气时间平均(58.3±13.6)h,恢复流质饮食时间平均(68.5±19.6)h,术后平均住院(12.1±3.0)d,术后发生吻合口漏1例,淋巴瘘2例,吻合口出血1例,均保守治疗后痊愈,无围手术期死亡病例。术后病理结果:均为腺癌,清扫淋巴结数量(18.1±5.9)枚,肿瘤分期:Ⅰ期8例、Ⅱ_A期19例、Ⅱ_B期11例、Ⅲ_A期12例、Ⅲ_B期6例。术后随访6～24个月,复发转移3例,死亡1例。结论:采用回盲部腹、背侧联合入路法行腹腔镜全结肠系膜切除右半结肠癌根治术是安全、可行的,术中更易进入右侧Toldt间隙,对血管解剖更安全,更利于初学者。     

右半结肠癌手术中完整结肠系膜切除的技巧

探讨右半结肠癌行完整结肠系膜切除的手术技巧。回顾性分析2010年8月—2012年9月45例行传统右半结肠癌根治术患者(传统组)和2012年12月—2014年10月53例行完整结肠系膜切除的右半结肠癌患者(CME组),CME组采用对侧站位剥离筋膜,以胰颈部与肠系膜上动静脉交点为中心立体式清除结肠三站淋巴结;比较两组手术时间、术中出血量、淋巴结清除数目、术后排气时间、术后住院时间、腹腔引流量及术后并发症的差异。CME组淋巴结清除总数(20.46±6.08)枚和阳性淋巴数4(2,7)枚,明显多于传统组的(17.06±4.40)枚、2(1,4)枚,手术时间(206.35±33.08)min、术中出血量(151.92±72.06)mL、术后排气时间3(2,4)d、腹腔引流量(157.9±25.7)mL,明显少于传统组的(224.91±18.57)min、(237.27±94.90)mL、4(2,6)d、(278.7±47.2)mL,差异均有统计学意义(P0.05)。CME组与传统组在术后住院时间及术后并发症等方面比较差异无统计学意义(P0.05)。完整结肠系膜切除可提高右半结肠癌淋巴结清除数量、缩短手术时间、减少术中出血量,促进患者术后恢复;对侧站位及立体式淋巴结清除方式能提高手术效率,增加手术安全及效果。     

腹腔镜辅助右半结肠切除术21例报告

目的探讨腹腔镜辅助右半结肠切除术治疗右侧结肠癌的安全性与疗效。方法应用腹腔镜技术,按开腹手术的原则行右半结肠切除术21例,所有肠系膜分离、肠系膜血管的处理和淋巴结清扫均在腹腔镜下完成,肠段的切除和吻合通过腹部小切口在体外完成。结果21例均成功完成手术,无中转开腹。手术时间136~248min,平均153.6min。结肠癌切除标本上下切缘长度分别(10.8±3.6)cm和(10.2±3.5)cm,清扫淋巴结数目(9.7±4.9)枚。1例术后切口感染,3个月后再次清创愈合。17例术后随访3~36个月,平均19个月。2例分别于术后8、20个月发生肝转移。无切口和穿刺口种植转移发生。结论腹腔镜辅助右半结肠切除术是安全可行的,按肿瘤根治原则可以达到开腹手术同样的疗效。     

腹腔镜右半结肠全结肠系膜切除根治术效果观察

目的探讨腹腔镜右半结肠全结肠系膜切除根治术的效果。方法选取2014-12—2016-11间在濮阳市油田总医院接受腹腔镜右半结肠全结肠系膜切除根治术的50例结肠癌患者,回顾性分析其临床资料。结果 50例患者手术均获成功,无中转开腹。手术时间(175±23)min,术中出血量(80±25)m L,淋巴结获取量(20±5)枚,手术标本质量分级(West分级)均在C级以上,术后排气时间(4.5±1.3)min,住院时间(8.2±1.6)d。术后出现肺部感染4例,腹腔淋巴漏2例,切口感染2例,均经保守治疗痊愈。结论 D3根治术是治疗右半结肠癌必须遵循的原则,全结肠系膜切除理念的提出使结肠癌手术治疗更加规范。D3淋巴结清扫及右半全结肠系膜切除更符合肿瘤根治原则。     

腹腔镜下完整结肠系膜切除在左半结肠癌根治术中的应用

目的探讨腹腔镜下完整结肠系膜切除(complete mesocolic excision,CME)在左半结肠癌手术中的应用。方法回顾性分析2010年8月至2014年9月间42例行腹腔镜下 CME 治疗左半结肠癌病人的临床资料。结果本组所有病人手术均获成功,手术时间平均为(112.2±25.3) min,术中出血量平均为(54.4±21.6)ml;手术切除肠管的长度平均为(24.1±5.7)cm,清扫淋巴结数量平均为(18.5±6.2)枚;术后肛门首次排气平均时间为(3.3 ± 1.4)d,平均住院时间为(12.7±3.5)d,术后并发症发生4例,发生率为9.52%,其中切口感染 2例,肺部感染1例,吻合口出血1例,均经保守治疗后恢复。结论腹腔镜下左半结肠癌 CME 手术是安全可行的。     

联合中间入路腹腔镜辅助右半结肠癌根治术

目的探讨联合中间入路行腹腔镜辅助右半结肠癌根治术的可行性。方法回顾性分析2015年1月～2016年12月30例联合中间入路腹腔镜辅助右半结肠癌完整结肠系膜切除(complete mesocolic excision,CME)手术资料。先头侧入路,游离胰头、十二指肠,显露胃网膜右静脉,再沿该静脉向下游离出外科静脉干及其属支,显露肠系膜上静脉;再从尾侧解剖进入Toldt间隙,显露十二指肠,与头侧游离区汇合;最后从中间入路解剖出肠系膜上静脉各属支。结果 30例手术均顺利完成,无中转开腹,无术中并发症。手术时间109～156(137. 6±13. 9) min,术中出血量28～85(56. 8±15. 7) ml。术后并发症5例(16. 7%),其中粘连性肠梗阻2例,肺部感染2例,切口感染1例。术后随访24～36(27. 0±2. 2)月,无复发转移及吻合口狭窄。结论联合中间入路腹腔镜辅助CME手术相对易于掌握,安全可行。     

完全3D腹腔镜以血管为导向中间入路右半结肠癌根治术的临床体会

目的:探讨完全3D腹腔镜下采用以血管为导向的中间入路行右半结肠癌根治术的安全性。方法:回顾2018年12月至2019年12月施行的38例完全3D腹腔镜下以血管为导向的中间入路右半结肠癌根治术的临床资料。由中间入路解剖出肠系膜上静脉各属支,根部结扎离断,由内向外、自下而上分离右侧Toldt间隙及横结肠后间隙,切开胰颈部横结肠系膜前叶,离断横结肠,再由上向下、由内到外完整切除右半结肠系膜,最后采用腔内直线切割闭合器行回结肠侧侧吻合。结果:38例均顺利完成完全3D腹腔镜下右半结肠癌根治术,完整切除右半结肠系膜,根部结扎血管,彻底清扫淋巴结,无术中并发症发生。手术时间平均(140.7±11.4)min,术中出血量19(13.75,30)mL。术后发生并发症5例,包括吻合口漏1例,肺部感染3例,取标本切口感染1例。术后随访6～18个月,平均(10.0±3.1)个月,无吻合口狭窄,2例复发,其中1例出现腹膜转移。结论:完全腹腔镜下采用以血管为导向的中间入路行右半结肠癌根治术安全、可行。     

腹腔镜辅助右半结肠切除术16例临床分析

为探讨腹腔镜辅助右半结肠切除术的安全性和疗效,对16例行腹腔镜辅助右半结肠癌切除手术患者的临床资料进行回顾性分析。结果显示,顺利完成腹腔镜辅助右半结肠癌根治术14例,中转开腹2例,中转率为12．5％。无死亡病例。平均手术时间为（175±15）min,平均术中出血量为（120±9）ml,平均结肠癌切除标本上下切缘长度分别为（10．8±0．8）cm和（10．2±0．7）cm,平均清除淋巴结（16．1±1．2）枚,平均术后住院时间为（10±1）d。1例术后第3天肺部感染,1例切口感染。14例完成腹腔镜手术患者随访6～20个月,1例发生肝转移。结果表明,腹腔镜辅助右半结肠切除术安全性好,可达到与开腹手术同样的根治效果。     

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.