1例蓝色橡皮疱痣综合征内镜下治疗的护理配合

对1例蓝色橡皮疱痣综合征患者,采取内镜下曲张静脉套扎、硬化治疗及黏膜剥离术治疗,配合术前耐心细致的心理护理、术中对不同治疗方法的准确配合及术后休息、饮食及用药护理,食管、胃及结肠共11处病变均治疗成功。提示蓝色橡皮疱痣综合征内镜下治疗安全性高、并发症少,科学、有效的护理配合是治疗成功的保障。     

腹腔镜联合内镜治疗2例蓝色橡皮大疱痣综合征的护理

对2例蓝色橡皮疱痣综合征患者采取腹腔镜及内镜联合治疗,手术过程顺利,患者术后生命体征稳定,康复出院。提出术前耐心细致的心理护理、用药指导、充分的肠道准备以及术后严密的病情观察、对症处理与基础护理是其护理要点。     

小儿肠道血管瘤3例临床分析

本研究收集3例小儿肠道血管瘤患者的临床资料, 生长方式为小肠单发包块型、小肠结肠多发型、直肠肛管弥漫型, 分别接受手术治疗、手术联合内镜治疗、介入治疗, 取得良好效果。小儿肠道血管瘤表现多样, 应采取个体化治疗。     

胶囊内镜在小肠疾病诊断中的价值

目的探讨胶囊内镜对小肠疾病的诊断价值。方法2002年9月至2007年3月间对155例患者所进行的159例次胶囊内镜检查进行回顾性研究。记录胶囊内镜在胃和小肠的平均运行时间,评价患者的耐受性、胶囊内镜完成检查情况及胶囊内镜下病变的检出情况等。结果155例患者中,不明原因的消化道出血97例,腹痛42例,腹部不适6例,腹泻4例,体检6例。93．1％的患者（148／159）完成了全小肠摄影。所有患者在检查过程中未诉特殊不适。胶囊内镜胃内平均停留时间为65．5（1～335）min,小肠平均停留时间为282．2（45～524）min。胶囊内镜病变检出率为78．6％（125／159）。胶囊内镜发现血管病变43．4％（69／159）,小肠炎性病变28．3％（45／159）,黏膜下结节10．1％（16／159）,小肠憩室8．2％（13／159）,小肠肿物5．7％（9／159）以及小肠息肉、小肠异物、小肠寄生虫等。不明原因消化道出血病变检出率为89．7％（87／97）,腹痛查因病变检出率为73．8％（31／42）。结论胶囊内镜检查安全性较高,患者容易接受。胶囊内镜对小肠疾病、尤其消化道不明原因出血者具有重要的诊断价值。     

黑斑息肉综合征的外科治疗(附8例报告)

目的总结黑斑息肉综合征的外科治疗经验。方法回顾性分析我院1986～2002年期间收治的8例黑斑息肉综合征患者的临床资料。结果8例中行部分小肠切除(其余段小肠多处切开，切除息肉)5例；胃大部切除术2例；右半结肠切除术1例。本组1例肠套叠致肠坏死急诊行肠切除，术后2年，因小肠息肉引起肠套叠致肠坏死，再次手术切除坏死肠段；1例术后内镜随访中发现直肠息肉，给予内镜下电灼切除；其余6例未见复发。结论黑斑息肉综合征手术主要是针对胃肠道息肉的治疗，解除临床症状；并注意把握手术时机，严格遵循手术适应证，并加强术后的随访。     

486例胃肠道间质瘤的外科治疗

目的 根据不同部位胃肠道间质瘤(GIST)的临床特点,总结其外科手术治疗方式.方法 回顾性分析2003年1月至2012年12月北京协和医学院经过手术治疗的486例GIST患者的临床资料.原发GIST 461例,继发GIST 25例.对患者临床特征、手术方式进行分析.计数资料以百分比表示,采用x2检验.结果 本组461例原发GIST患者中,6例食管间质瘤患者均行食管部分切除术;234例胃间质瘤患者中,行胃部分切除术183例、近端胃+贲门切除术23例、远端胃切除术23例、全胃切除术2例、剖腹探查3例;51例十二指肠间质瘤患者中,行十二指肠局部切除术34例、胰十二指肠切除术9例、保留幽门胰十二指肠切除5例、姑息性手术3例;116例小肠间质瘤患者中,行小肠部分切除110例、姑息性手术6例;29例直肠间质瘤患者中,行经骶经肛门括约肌直肠肿瘤切除术13例、经肛门直肠肿瘤切除术12例、经腹会阴联合切除术4例;25例其他部位的原发GIST患者均行开腹手术.25例继发GIST患者中,肝转移患者行肝段切除10例、肝活组织检查1例;腹盆腔肿瘤切除6例;小肠或结肠部分切除5例,乙状结肠切除1例;脾切除及颅内肿瘤切除各1例.461例原发GIST患者中,联合原发部位以外脏器切除占12.58％(58/461),其中联合胆囊切除比例最高,占34.5％(20/58).最易出现联合脏器切除的GIST依次为十二指肠间质瘤、胃间质瘤、小肠间质瘤.腹腔镜手术占总手术的20.39％(94/461),其中近5年腹腔镜手术占总手术的28.52％ (77/270),与前5年的8.90％(17/191)比较,差异有统计学意义(x2=36.67,P＜0.05).结论 根据不同部位GIST的临床特点,采用包括微创手术在内的不同手术方式,完整切除肿瘤是主要目标.     

消化道出血

消化道出血可引起一时循环障碍和/或明显贫血,出血多见部位为食管、胃、十二指肠和结肠、直肠。近年纤维内镜检查附有彩图记录已普及,只要执行“内镜为先”方针,不难较早得出诊断。多数医院纤维内镜检查归属内科,普遍存在的问题是取材太小,部位太少,对可疑黏膜未行染色后取材。此外,圈套取材后引起的出血,未用电凝止血,以致无经验。空肠和回肠部位出血相对少见,这些都是反复胃十二指肠和结直肠内镜检查未发现出血部位的病例。熟练掌握小肠镜检需要有一个学习阶段,且空肠和回肠两端只能检查50cm左右,仍存在有小肠盲区。胶囊样内镜虽已在少数…     

少见原因所致上消化道出血1例报告

患者，女，58岁，因反复解黑便1年半人院，伴乏力纳差，无呕吐及腹痛，无畏寒、发热，无黄疸等。既往史无特殊。查体：生命体征平稳，慢性病容，贫血貌，腹平坦，无包块扪及，移浊(-)。消化道X线钡餐未见异常；肠镜检查示回肠末端肠腔内可见鲜红色液体，全结肠未见异常；选择性肠系膜动脉造影未发现活动性出血征象；核素扫描示：在相当于降结肠的部位可见肠管影像，相当于降结肠下段的部位见一核素浓聚增高区；胶囊内镜示：小肠活动性出血，小肠血管发育不良，小肠血管瘤。遂行剖腹探查术。     

胃肠道间质瘤23例诊治体会

胃肠道间质瘤(gastrointestinal tumors,GIST)是消化道最常见的间叶源性肿瘤.我院2005年1月至2011年1月共诊治23例GIST患者,现报告如下. 临床资料 1.一般资料:23例均经病理确诊为GIST的患者,男12例,女11例,发病年龄34～76岁,中位年龄55岁.肿瘤的发生部位:胃15例,小肠6例,结直肠2例.首发症状:消化道出血13例(62%),腹部包块4例(17%),腹痛、腹胀3例(13%),另有3例(13%)是在体检或是在行其他手术中发现.辅助检查:23例均行CT检查,均能发现病灶,内镜检查确诊2例.术后病理检查肿瘤直径3～15cm,,均为梭形细胞.23例经免疫组织化学检查:CD117阳性率为87%(20/23),CD34阳性率70%(16/23),两者均阳性率43%(10/23).清扫31枚淋巴结均未发现淋巴结转移.     

体位干预在胶囊内镜检查中的应用

目的探讨体位干预在胶囊内镜检查中的应用效果。方法选取行胶囊内镜检查的患者70例,随机分为观察组和对照组各35例,对照组按照常规方法进行检查,采取端坐位吞服胶囊内镜;观察组采用体位干预的方法,以仰卧位吞服胶囊内镜后,逐渐抬高患者上半身,延长胶囊内镜在食管内的运行时间,通过更换不同的卧位方向,充分利用重力对胶囊内镜的影响,使其在胃内的拍摄更全面。结果两组胶囊内镜在食管、胃及小肠各部位摄片率比较,差异有统计学意义(均P<0.01),但对小肠摄片质量无影响。结论采取体位干预的方法,可以使胶囊内镜在保证小肠疾病检出质量的同时,提高对食管及胃的观察效果。     

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.     

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.     

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.     

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.     

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.