预防性造口在低位直肠癌手术中的应用分析

目的探讨预防性造口在低位直肠癌手术中的应用价值。方法采用病例对照研究,将湖南省攸县人民医院普外科2011年1月~2013年4月期间共46例低位直肠癌患者分为两组:26例行预防性回肠造口(A组),其中23例为回肠双腔造口,3例为回肠单腔造口,术后3月回纳造口;20例未行预防性造口(B组)。对比其术后吻合口漏、肠梗阻、切口感染等并发症发生率。结果 46例患者中共发生7例吻合口漏,其中A组2例(7.7%),B组5例(25%),且死亡1例,两组比较无显著性差异(P0.05);切口感染率A组6例(23.1%),B组5例(25%),两组比较无明显差异(P0.05);肠梗阻发生率A组1例(3.8%),B组3例(15%),两组比较无显著性差异(P0.05)。结论预防性造口可有效降低低位直肠癌术后吻合口漏发生率。对存在2个以上危险因素,尤其是超低位直肠癌(距肛缘低于5cm)推荐行预防性造口术。     

预防性回肠造口在腹腔镜超低位直肠癌保肛术中的应用

为评价预防性回肠造口在腹腔镜超低位直肠癌保肛术中应用的安全性和有效性,回顾性分析113例腹腔镜超低位直肠癌保肛并行预防性回肠造口患者的临床资料。结果显示,113例患者均行根治性手术,并预防性末段回肠双腔造口,术后3月造瘘口还纳。术后并发症:吻合口漏4例,肠梗阻9例,造瘘口旁疝1例,切口感染3例。随访3~24月,吻合口处肿瘤复发1例。结果表明,预防性回肠造口在腹腔镜超低位直肠癌保肛术中的应用安全、有效,显著降低术后吻合口瘘发生率。     

弧形切割吻合器在低位直肠癌保肛手术中的应用

目的 总结弧形切割吻合器在低位直肠癌保肛术中的应用.方法 将121例低位直肠癌患者随机分成两组,分别应用弧形切割吻合器(A组,60例)和TLH30直线切割闭合器(B组,61例)闭合直肠远端行保肛手术,比较两组保肛率、吻合口瘘、吻合口出血、切口感染及术后排便次数.结果 两组吻合口瘘、吻合口出血、术后排便次数比较,差异无统计学意义(P＞0.05);而A组保肛率(98.3%)高于B组(68.9%)、切El感染率(4.0%)明显低于B组(9.5%)(均P＜0.05).结论 应用弧形切割吻合器行低位直肠癌保肛手术是安全可靠的,而且能明显增加保肛率,减少切口感染率.     

经肛粪便导流技术预防中低位直肠癌术后吻合口漏的回顾性临床研究

目的评估经肛粪便导流技术预防中低位直肠癌术后吻合口漏的有效性、安全性及可行性。方法回顾性收集2014–2019年期间在我院完成的中低位直肠癌手术患者,按采用预防吻合口漏方式分为经肛粪便导流组(粪便导流组)和末端回肠预防性造口组(回肠造口组),比较2组患者术后吻合口漏发生率及漏后处置方式及转归。结果共纳入患者231例,其中粪便导流组84例,回肠造口组147例,2组患者性别、年龄、术前合并症等基线资料比较差异无统计学意义(P0.050)。2组患者手术时间、术中失血量、切口感染、术后肠梗阻、总住院费用、死亡情况、吻合口漏(总体、各分级、处理方式及结局)比较差异均无统计学意义(P0.050)。虽然粪便导流组的住院时间(除外漏病例)明显长于回肠造口组(P0.001),但2组患者总住院时间和排除死亡病例后的住院时间比较差异无统计学意义(P0.050),且粪便导流组的吻合口漏愈合后吻合口狭窄发生率低于回肠造口组(P=0.029)。结论经肛粪便导流技术在预防中低位直肠癌保肛手术吻合口漏的发生的安全、有效、可行的。     

腹腔镜低位直肠癌根治术预防性造口与无预防性造口临床对比研究

目的 比较腹腔镜下低位直肠癌根治术无预防性造口与预防性造口的临床资料及术后并发症的发生情况,探讨不行预防性造口的临床意义.方法 回顾70例实施手术治疗的低位直肠癌患者的临床资料,根据手术方式分为无预防性造口组(28例)和预防性造口组(42例),采用SPSS19.0统计软件比较两组患者术后并发症发生情况.结果 预防性造口组和非预防性造口组术中手术时间、出血量、术后进食时间差异无统计学意义;预防性造口组术后留院时间明显延长(P＜0.05);预防性造口组术后并发吻合口瘘2例,吻合口出血1例,肠梗阻2例,切口并发症2例,吻合口狭窄8例,造瘘口并发症7例,大便失禁1例,便频、便急2例,并发症发病率59.5％;非预防性造口组术后吻合口瘘1例,吻合口出血1例,肠梗阻1例,切口并发症1例,大便失禁1例,便频、便急1例,并发症发病率21.4％;预防性造口术后总体并发症发病率较非预防性造口高(P＜0.05),但吻合口瘘发病率差异无统计学意义(P＞0.05).结论 腹腔镜低位直肠癌根治术无适应证行预防性造口不能降低术后并发症的发生.     

术前经新辅助治疗的中低位直肠癌患者吻合口漏的预防和治疗

目的 探讨中低位直肠癌新辅助治疗后吻合口漏的预防和治疗.方法 回顾性分析2004年8月至2007年7月间50例低位直肠癌采用新辅助治疗保肛术后,吻合口漏的发生及治疗情况.结果 50例患者接受FOLFOX方案联合放疗的新辅助治疗后接受保肛手术.行预防性回肠末段造口的19例患者未发生吻合口漏,31例未行预防性回肠末段造口术中有4例术后发生吻合口漏,其中2例合并直肠阴道瘘,均经保守治疗治愈.结论 FOLFOX方案联合放疗的新辅助治疗,可提高中低位直肠癌手术的保肛率,保肛术后行回肠末段预防性造口,对吻合口漏的发生有预防作用.     

低位直肠癌保肛中预防性造口的临床应用分析

目的探讨预防性造口在低位直肠癌保肛术中的临床应用价值。方法分析2010年3月至2013年10月期间收治的37例低位直肠癌保肛术患者的临床资料,两组患者术前均经病理检查确诊,癌灶下缘距肛缘小于7 cm。将患者分成预防性造口组(19例)、未施行预防性造口组(18例),应用SPSS17.0对相关数据进行处理。手术时间、术中出血、首次排气排便时间、首次进食时间、住院时间等计量资料比较用t检验;术后并发症、再手术率发生率等资料用χ~2检验,P0.05差异具有统计学意义。结果预防性造口组术后首次排气、排便时间为(2.8±0.6)d,未施行预防性造口组为(4.1±0.5)d,差异有统计学意义(t=1.92,P0.05);术后首次进食时间分别为(3.8±1.2)和(5.6±1.8)d;术后平均住院时间分别为(8±2)d和(12±2)d,差异均有统计学意义(t=2.34,t=2.68,P0.05)。术后总并发症预防性造口组为1/19(5.3%),未施行预防性造口组为4/18(22.2%),两组术后总的并发症发生率差异有统计学意义(χ~2=4.75,P0.05)。预防性造口组发生1例(5.3%)吻合口漏,经反复腹腔冲洗引流等保守治疗后痊愈;未造口组发生3例(16.7%)吻合口漏,其中2例经保守治疗后愈合,1例发展为弥漫性腹膜炎接受再手术;经检验,两组吻合口漏发生率有显著统计学差异。两组术后均无因吻合口漏而死亡的病例。结论预防性造口能显著降低吻合口漏的发生率,同时也能降低与吻合口吻合口漏相关的再手术率。对吻合口高度较低及具有高危因素的患者,建议常规施行预防性造口。     

低位直肠癌保肛手术60例治疗体会

目的探讨直肠全系膜切除联合双器械吻合在低位直肠癌保肛术中应用效果及其实用性和安全性。方法回顾性分析2010年1月至2013年12月我院60例用全直肠系膜切除加双吻合器行保肛根治手术的临床资料。结果 60例均保肛成功,无手术死亡病例(其中32例行预防性造瘘术)。术后共发生并发症8例(13.3%),吻合口漏2例(3.3%),均为未行预防性造瘘术患者。所有并发症经保守治疗后均治愈。术后一年内局部复发3例(5%)。结论全直肠系膜切除联合双器械吻合行低位直肠癌保肛术不仅提高了保肛率且降低了局部复发率,是一种安全有效的手术方式。     

选择性预防末端回肠造瘘在腹腔镜低位直肠癌保肛手术中的应用价值

目的:探讨选择性预防末端回肠造瘘在腹腔镜低位直肠癌保肛术中对降低吻合口漏发生率的临床价值。方法:回顾分析为109例患者行腹腔镜低位直肠癌保肛手术的临床资料,其中40例行预防性末端回肠造瘘术,69例未行末端回肠造瘘术,对比两组患者术后情况。结果:造瘘组术后无一例发生吻合漏,术后肛门排气时间平均(1.3±0.4)d,术后进食时间平均(1.8±0.4)d,术后盆腔引流管拔除时间平均(6.2±1.5)d,术后平均住院(8.0±1.5)d,治疗费用平均(3.2±0.3)万元。未造瘘组患者术后9例(13.0%)发生吻合口漏,术后肛门排气时间平均(5.1±0.6)d,术后进食时间平均(5.7±0.3)d,术后盆腔引流管拔除时间平均(8.3±3.8)d,术后平均住院(14.2±3.6)d;治疗费用平均(4.3±0.8)万元。两组术后观察指标差异均有统计学意义。结论:低位直肠癌保肛术中选择性预防末端回肠造瘘可有效降低吻合口漏的发生率,尤其高龄、全身情况较差等不利于低位吻合的患者。但术者应进行个体化选择,同时严格遵循无瘤原则、合理选择病例、精细操作可使更多的低位直肠癌患者获得保留肛门的机会。     

低位三管引流防治直肠癌保肛术后吻合口漏220例

目的研究低位三管引流预防直肠癌保肛术后吻合口漏的效果。方法 2006年1月至2010年12月共220例直肠癌患者进行保肛术（治疗组）,术中经肛门放置双管引流,经肛旁于骶前腔内放置双套引流管。选取2001年1月至2005年12月间205例经左下腹壁于盆腔放置引流管的患者作对照组。对照两组患者术后切口感染率及吻合口漏率进行对比分析。结果切口感染、吻合口漏发生率：治疗组分别为8.18%（18/220）、2.27%（5/220）;对照组分别为7.80%（16/205）、8.78%（18/205）。两组切口感染发生率差异无统计学意义（P〉0.05）,吻合口漏发生率治疗组显著低于对照组（P〈0.05）。结论低位三管引流可显著降低低位直肠癌保肛术后吻合口漏的发生。     

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.     

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.