原位肝移植术后胆漏的诊断和治疗

目的　探讨原位肝移植 (orthotopiclivertransplantation ,OLT)术后胆漏的诊断和治疗方法。方法　回顾性分析 12例患者OLT术后胆漏的诊断和治疗。 12例中男 9例 ,女 3例 ,平均年龄 (45±10 )岁。 3例行经典式OLT ,9例行背驮式OLT。胆管重建方式均为胆总管端端吻合术 ,其中 9例放置“T”形管引流。诊断主要依据临床表现及胆管造影。胆漏平均诊断时间为 (8± 6 )d。 7例经非手术治疗 ,包括保持腹腔引流通畅、重置引流管、鼻胆管引流、B型超声引导穿刺抽吸引流及抗炎治疗 ;5例经手术治疗 ,包括胆总管 空肠吻合术、“T”形管重置术或吻合口修补术。结果　 10例治愈 ,2例死于严重全身感染。结论　OLT术后胆漏的诊断主要依据临床表现及胆管造影。高龄患者或合并有胆道缺血者预后差。     

同种原位肝移植术的胆管重建及其术后并发症的防治

目的探讨同种原位肝移植(OLT)的胆管重建方式及其术后并发症的防治。方法回顾性分析1999年2月至2003年1月间103例终末期肝病患者施行OLT胆管重建及术后并发症的防治情况。103例患者中,75例采用经典式原位肝移植伴体外静脉转流、17例采用经典式原位肝移植不伴转流、11例采用背驮式原位肝移植。胆道重建过程中有94例行胆管端端吻合,9例行胆肠吻合。胆管端端吻合的患者中,62例带T管引流,32例不带T管,但11例经受者胆囊管置入小橡胶管引流。术后胆管并发症的诊断主要依据临床表现、B型超声波、磁共振胰胆管成像或逆行胰胆管造影检查。所有患者均随访1年以上。结果103例OLT患者术后胆管并发症发生率为7.8%(8/103)。62例带T管引流的患者中,6例(9.6%)发生胆管并发症,其中4例术后发生胆漏,2例拔除T管后发生局限性腹膜炎;32例不带T管引流的患者中,1例(3.1%)发生胆管狭窄。9例胆肠吻合中,1例(11.1%)术后发生胆漏。7例胆漏患者,2例经再次手术引流,其余继续保持引流胆漏自愈。不带T管引流的患者中的胆管狭窄为吻合口狭窄,经内镜取出异物、球囊扩张与安放内支架后治愈。1例患者因胆漏导致肝动脉吻合口假性动脉瘤及腹腔大出血,经介入法明确诊断并行栓塞治疗后治愈。患者中无胆管并发症而引起的死亡。结论胆管吻合口的胆漏与狭窄是OLT术后最常见的胆管并发症。良好的胆管血供与胆管吻合技术是防止胆管并发症发生的关键。及时的内镜检查与放射学技术是诊断和治疗胆管并发症的有效手段。     

肝移植术变异胆管胆漏的预防与处理

目的 探讨肝移植术中变异肝管胆漏的预防及治疗.方法 回顾性分析我院3例肝移植术后发生变异肝管胆漏的诊断及预防、治疗方法.3例供肝切取均采用肝肾联合切取的方法,胆管重建方式为胆总管端端吻合.结果 1例右后叶副肝管汇入胆囊管患者在胆管吻合后发现肝门处胆囊管残端胆汁漏出,立即拆除原胆管吻合口,成型后一期吻合,术后痊愈.1例Luschka胆管漏患者术后胆漏经过充分引流漏口自行闭合痊愈,但最后终因肝内外感染而于术后7个月再次肝移植.另一例右后叶副肝管汇入胆总管患者,术中遗漏断端导致术后胆漏.该患者因严重并发症行二次肝移植.结论 了解肝内外胆管的解剖和常见变异形式,供肝修整时仔细辨认肝门组织,提高对存在副肝管及迷走胆管变异的警惕性,对预防肝移植术后胆管断端胆漏的发生非常重要.     

劈离式肝移植术后胆管并发症

目的 探讨体外劈离式肝移植术后胆管并发症的危险因素及其防治措施.方法 2006年6月至2010年9月,我院共施行劈离式肝移植术33例,其中1例于术后10 d死亡,予以排除.其余32例患者中男性18例,女性14例,平均年龄33.4岁(6个月～65岁).胆管重建方式胆管端端吻合20例,胆肠吻合12例.胆管并发症的诊断依靠T管造影、经皮经肝胆管造影(PTC)、经内镜逆行胆胰管造影、磁共振胰胆管造影(MRCP)等方法.胆管并发症定义为存在需要外科、介入、内镜等方法治疗的胆漏或胆管狭窄.结果 受者中位随访时间13.5个月(3～54个月).32例患者中11例患者发生12次胆管并发症(37.5％),其中肝断面胆漏3例(9.3％),胆管吻合口漏4例(12.5％),左肝管残端漏1例(3.1％),胆管吻合口狭窄1例(3.1％),缺血性胆管狭窄3例(9.3％).8例发生胆漏的受者中6例经手术或穿刺放置引流后痊愈,2例因腹腔内感染死亡.单因素分析表明,移植物类型、胆管重建方式等均不是肝断面胆漏的危险因素.结论 与全肝移植和活体肝移植相比,劈离式肝移植术后胆管并发症尤其是胆漏更为常见.进一步防治胆管并发症是改善劈离式肝移植预后的重要因素.     

肝移植胆系并发症的防治

目的 探讨原位肝移植胆系并发症的预防及治疗。方法 回顾性分析1999年2月至2002年12月完成的95例次原位肝移植。门静脉、下腔静脉转流下原位肝移植12例,背驮式肝移植78例,活体部分肝移植5例。胆道重建：胆管对端吻合91例,放置胆道外引流55例,36例未放置胆道引流。胆管空肠Roux-en-Y吻合4例。胆管吻合及胆肠吻合应用5旬或6-0 Vicryl缝线或PDS缝线间断或连续缝合。术后以血清学检查、超声、胆道造影等手段随访。结果 共发生胆系并发症7例,发生率7．3％。2例术后7、10d吻合口胆漏,致胆汁性腹膜炎,再次手术引流。1例术后1个月胆管吻合口狭窄,内窥镜下支架内支撑治愈。2例拔除T管时胆漏,1例保守治愈,1例腹腔镜下缝合窦道、腹腔引流治愈。1例术后5个月因胆管消融、胆管炎死亡。1例术后10d因肝动脉血栓形成继发胆管坏死后死亡。74例随访1-42个月(平均11．4个月),胆道造影及(或)超声检查未见肝内外胆管狭窄,无胆泥、胆石形成,血清学检查提示肝功能状态良好。结论供肝切取时保护胆管黏膜及肝外胆管动脉供给,实现精细胆管黏膜对黏膜无张力对端吻合是预防胆系并发症的关键。内窥镜下狭窄段胆管扩张、内支撑是治疗肝移植肝外胆管狭窄的有效手段。     

肝移植术后胆道并发症的预防与处理

回顾性研究20例原位肝移植的临床资料，并结合相关文献探讨原位肝移植术后胆道并发症的发生原因及防治措施。20 例患者中术后发生胆道并发症3例(15%) 。1例为术后1周内T管致胆管梗阻；1 例为术后3个月拔除T 管后胆漏，均经及时介入、置管引流而愈；1例为术后4个月弥漫性肝内外胆管狭窄经再次肝移植治愈。提示胆道并发症与留置T管、吻合等技术因素有关，而再灌注损伤、缺血性损伤是引起肝移植术后远期胆道并发症的重要原因。改进手术技术，缩短供肝缺血时间和确保供肝胆管系统的血供可减少胆道并发症的发生。     

肝移植术后胆道并发症的防治

目的：探讨肝移植术后胆道并发症的防治。方法：对7例终末期肝病（包括3例原发性肝癌）患者行原位肝移植，供肝除1例仅经门静脉灌注外，其余均经动脉及门静脉双重灌注。胆道重建采用胆道端端吻合6例，胆肠吻合1例。结果：3例出现胆道并发症，术后2w，发现1例T管周围胆漏，经放开T管后治愈；术后12d，1例出现胆漏，再次手术发现胆管从吻合口穿出，第2次术后腹腔感染一度控制，术后49d再次高热，术后52d死亡，尸检发现胆管坏死，胆漏，1例术后3d发生胆漏,昆充分引流治愈，术后4个月发现有胆泥，经口服溶石药等治疗，症状消失。结论：对供者动脉充分灌注，胆道充分冲洗，尽量减少对供者胆管血供的损害是预防胆道并发症的关键，而术后胆道并发症多经非手术或微创手术治愈。     

肝移植术后近、远期胆道并发症的诊断和外科处理

目的探讨原位肝移植术后胆道并发症的诊断和外科处理。方法总结2002年～2004年在我院接受原位肝移植手术的100例患者的临床资料,分析肝移植术后胆道并发症的诊断和外科处理。结果手术成功率为95%,随访率达100%,平均随访时间为(326±18.2)个月(24～51个月)。发生胆道并发症10例(10%),其中T管拔除后胆漏1例、肝断面胆漏2例、胆管狭窄2例、胆道吻合口梗阻2例和胆泥淤积或结石3例,经相应处理后,除1例行再移植外,余均获得满意的疗效。结论胆道并发症是肝移植术后常见并发症之一,经妥善处理后并不影响移植患者的长期生存。     

降低肝移植术后手术技术相关胆道并发症的体会

目的 探讨肝移植的手术技巧，以降低手术相关胆道并发症。方法 对89例终末期肝病患者施行腔静脉成形的改良背驮式原位肝移植，供肝肝总动脉与受者肝总动脉端端吻合，供肝肝总管或胆总管与受者胆总管端端吻合，未置T管。术后定期进行影像学检查，了解移植肝是否出现胆道并发症。结果 1例术后5个月发生肝门分叉处胆管狭窄，经球囊扩张后效果不佳，再次手术行胆管狭窄成形术后治愈；其余患者未发生胆漏、吻合口狭窄、胆泥或胆道结石、肝门部胆管狭窄、胆管炎、胆汁瘤、粘液囊肿及十二指肠乳头功能异常等胆道并发症。结论 注重供肝的灌洗和修整，提高肝动脉吻合和胆道重建技巧，可有效避免或减少技术性胆道并发症的发生。     

活体肝移植的胆道重建技术及并发症分析

目的 探讨活体肝移植的胆道重建方法及并发症防治措施.方法 回顾性分析77例活体肝移植临床资料,其中74例行右半肝移植(带肝中静脉29例,不带肝中静脉45例),左半肝带肝中静脉1例,左外叶切取2例.胆道重建采用胆肠吻合或供肝肝管与受体肝管端端吻合.结果 供肝断面1个胆管开口为54例,多个胆管开口为23例;胆肠吻合2例,胆管端端吻合75例,63例留置T管;术后总体胆道并发症发生率为36.4%(28/77),其中胆漏为10.4%(8/77),胆道狭窄为26.0%(20/77).供肝单支胆道以及单个吻合口术后胆道狭窄的发生率明显低于多支胆道及多个吻合口(P<0.05).8例胆漏病人经过B超指引穿刺引流全部治愈,20例吻合口狭窄病人经T管窦道放置支撑管或通过ERCP进行扩张,肝功能全部或部分好转.结论 活体肝移植供肝切取术中注意对断面胆管血供的保护以及尽可能获得单一的肝管开口可有效减少术后胆道并发症的发生;内镜和放射介入技术是治疗胆道并发症的有效手段.     

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.