重症急性胰腺炎术后并发结肠瘘治疗的经验总结

目的 探讨重症急性胰腺炎(severe acute pancreatitis,SAP)术后并发结肠瘘的原因和诊治经验.方法 统计2008年1月至2014年12月我院收治的SAP术后并发结肠瘘的病人相关情况,了解其发生原因、危险因素、常见部位、发生时间,并针对诊断、治疗方法进行总结分析.结果 125例经手术治疗的SAP病人共11例发生结肠瘘(8.8％),6例经应用抗生素、全肠外营养、充分确切引流等非手术治疗后治愈,4例经手术治愈,1例因并发多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)死亡.结论 SAP术后并发结肠瘘与多因素有关,通过积极的非手术治疗措施多可治愈,少数病例需采取手术方式解决.     

重症急性胰腺炎术后并发十二指肠瘘

目的　探讨重症急性胰腺炎 (SAP)术后并发十二指肠瘘的原因及防治方法。方法　对 2 2例SAP术后并发十二指肠瘘患者的临床资料进行回顾性分析。结果　 184例手术治疗的SAP发生十二指肠瘘 2 2例 ,15例出现在术后 2周。 18例非手术治疗自行愈合 ,4例再次手术治愈。结论　SAP早期手术、胰周感染、手术时引流管放置不当或时间过长与十二肠瘘发生有关。保持瘘口周围引流通畅 ,积极控制胰周感染 ,抑制胃肠道分泌 ,加强营养支持 ,多数十二指肠瘘可自行愈合     

重症急性胰腺炎并发肠瘘的诊断和治疗

目的探讨重症急性胰腺炎(SAP)术后并发肠瘘的诊断和治疗。方法对2000年7月至2007年7月手术治疗的107例SAP进行回顾性分析,并对可能导致肠瘘发生的危险因素及其诊断治疗进行总结。结果治疗的SAP发生肠瘘21例,其中结肠瘘17例,十二指肠瘘4例,均出现在术后两周内,有胰腺感染的较无感染的发生率高(P<0.05);早期手术较后期手术发生率高(P<0.05);蝶形引流术较经后上腰引流术发生率高(P<0.05)。结论SAP术后的肠瘘与胰外炎性浸润,手术创伤以及手术时机的选择和手术方式有关。肠瘘的治疗应充分考虑原发病的状况,并根据肠瘘的位置、局部炎症的情况,早期通过加强营养支持,保持瘘口周围引流通畅,多数肠瘘可自行愈合,后期少数不愈合肠瘘可考虑手术治疗。     

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目的探讨肠内营养治疗对克罗恩病并发管状外瘘的临床效果。方法回顾性分析2007年5月至2011年12月南京军区南京总医院普通外科收治的克罗恩病并发管状外瘘43例病人,应用半要素肠内营养治疗3个月的临床资料。记录经肠内营养治疗后肠瘘是否愈合、愈合时间,以及治疗前后的炎症指标C反应蛋白(CRP)、血沉(ESR)、血小板(Plt),营养指标体重、身体质量指数(BMI)、血红蛋白(Hb)、白蛋白、前白蛋白、总蛋白等指标,以观察肠内营养对克罗恩病并发肠外瘘的治疗效果。病人肠瘘愈合后随访时间至少半年。结果 43例病人经过肠内营养治疗后,27例病人肠瘘得到愈合,平均愈合时间为(32.6±9.2)d。经治疗后所有病人的克罗恩病炎症指标血沉、CRP、Plt计数均较治疗前显著改善(P<0.05),愈合组、未愈组炎症指标改善均有显著意义(P<0.05),但两组间差异无统计学意义(P>0.05)。治疗后的营养指标如体重、BMI、Hb、白蛋白、前白蛋白、总蛋白均较治疗前显著改善(P<0.05),其中愈合组白蛋白、前白蛋白的改善情况明显优于未愈组(P<0.05)。结论克罗恩病并发管状外瘘的病人应用肠内营养治疗后,可诱导克罗恩病缓解,减轻病人的炎症反应,改善营养状态,使部分病人的肠外瘘达到临床愈合,避免了再次手术对病人的打击。     

86例老年大肠癌并肠梗阻外科治疗体会

目的:探讨老年大肠癌病人合并肠梗阻的外科治疗的方法。方法:回顾性分析收治的86例老年大肠癌合并肠梗阻病人的外科治疗资料。结果:86例病人,Ⅰ期右伴结肠切除27例,均Ⅰ期吻合,并发肠瘘1例,Ⅰ期左半结肠切除49例,Ⅰ期吻合8例,并发肠瘘2例,单纯性肠造瘘Ⅱ期手术肠切除5例,肿瘤无法切除行肠造瘘或捷径手术5例。围手术期死亡率8.14％(7／86)。结论:外科手术是老年大肠癌合并肠梗阻病人的主要治疗方法,年龄的大小不是手术的禁忌症,早期诊断、早期治疗、术前、术后合理处理并存病、选择适当的术式是提高疗效的关键。     

肠外瘘－重症胰腺炎的严重并发症

作者自１９８３年以来１０年间共收治重症胰腺炎并发肠瘘或肠、胰、胆、胃多发瘘患者２４例，占同期治疗肠瘘患者的３．６％，年龄为２７～６６岁，平均年龄４９．７岁。其中急性胰腺炎由胆道病引起者１０例，饮酒后诱发者３例，无明显原因者１１例，全组患者均经两次以上手术。消化道瘘的发生率依次为结肠、小肠、十二指肠、胰、胆、胃。本组单发瘘治愈率６８％，多发瘘治愈率为６２％，总治愈率６７％。手术治愈占５４％。有效地控制感染是预防胰腺炎后肠瘘的关键，ＴＰＮ可进一步减少胃肠液分泌，促进瘘口愈合。肠瘘手术应选择在瘘不能自愈，胰腺炎完全消退，感染已被控制，患者情况允许时进行。     

重症急性胰腺炎相关性消化道瘘的发生与预防探讨

目的：探讨重症急性胰腺炎（SAP）相关性消化道瘘的发生与预防。 方法：回顾2000年1月—2012年1月收治的23例SAP并发消化道瘘患者的临床资料,分析SAP相关性消化道瘘的发生部位、发生时间,患者胰腺病变范围特点和并发消化道瘘与引流管置入情况。 结果：全组23例患者中结肠瘘11例（47.8%）,十二指肠瘘7例（30.4%）,小肠瘘4例（17.4%）,胃瘘1例（4.3%）;消化道瘘多发生在SAP术后1~2周内;患者腺病变累及范围大,常累及胰头、十二指肠、结肠等;16例患者的消化道瘘与引流管放置有关。 结论：SAP并发消化道瘘不仅与解剖因素、胰外炎症侵犯、手术创伤等相关,而且与SAP自然病程相关,预防消化道瘘还需从SAP的整体治疗来考虑。     

非手术治疗重症急性胰腺炎并发十二指肠内瘘：附6 例报告

目的：探讨非手术重症急性胰腺炎(SAP) 并发十二指肠瘘的原因及防治方法。 方法：对6例非手术治疗SAP并发十二指肠瘘患者的临床资料进行回顾性分析。 结果：6例非手术SAP患者在SAP发生后5~8周并发胰腺假性囊肿十二指肠瘘，均行B超引导下胰腺假性囊肿穿刺引流和内科保守治疗，十二指肠瘘在发生后3~5周治愈。 结论：非手术SAP并发十二指肠瘘与SAP并发胰腺假性囊肿感染有关，其形成的瘘口较小，治疗上可行保守治疗保持胰腺假性囊肿引流通畅，无需手术治疗。     

造口袋内置多侧孔引流管用于肠外瘘负压冲洗引流

目的 防止肠瘘液外渗刺激周围组织,促进瘘口愈合.方法 自制多侧孔引流管置于尿路造口袋内,用于16例高排量肠外瘘患者持续负压冲洗引流.结果 负压冲洗引流15～58 d,13例瘘口愈合,1例手术修复,1例瘘口缩小,1例放弃治疗.结论 多侧孔引流管的应用有效防止了肠瘘液外漏对局部皮肤造成的损害,有利于促进瘘口愈合.     

胰头癌患者经保留幽门胰十二指肠切除术后吻合口瘘合并感染的诊治:附12例报告

目的通过分析胰头癌患者经保留幽门胰十二指肠切除(PPPD)术后吻合口瘘合并感染病例的临床资料,总结和提高诊治经验。方法 2014年2月至2016年8月四川省宣汉县人民医院收治胰头癌患者经PPPD术后发生胰瘘合并感染12例,采用保守治疗,包括禁饮禁食、静脉营养支持、水电解质平衡管理,持续冲洗引流和胃肠减压,原窦道置入双腔引流管,同时加强还原性谷胱甘肽+甲氧苄啶等药物治疗。结果 2例保守治疗失败,中转手术治疗。所有患者均痊愈,未见脓毒症、腹腔感染、皮肤感染,出现2例胃排空障碍;瘘道愈合时间(39.4±5.4)d;治疗72 h后患者血淀粉酶(AMY)、尿胰蛋白酶激活肽(TAP)、C反应蛋白(CRP)水平均低于治疗前,差异有统计学意义(t=24.651、18.092、4.135,均P0.01)。结论胰头癌患者经PPPD术后若发生吻合口瘘合并感染,需加强引流管理、控制感染,采取持续胃肠减压,联合肠外肠内营养支持、应用还原性谷胱甘肽等药物;当出现胰瘘或严重肠瘘应尽早发现和明确诊断,采取综合治疗,必要时手术,以治愈胰肠吻合口瘘。     

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.