断流术治疗门静脉高压症的疗效分析

目的总结采用断流术治疗门静脉高压症的经验并分析其疗效.方法1994年1月至2004年12月间采用断流术治疗177例门静脉高压症患者,其中170例为肝炎后肝硬化,7例为酒精性肝硬化.择期手术132例,预防性手术25例,急诊手术20例.结果本组止血率为95%,总手术死亡率为4.5%.主要死亡原因为消化道大出血、肝功能衰竭及腹腔内出血.平均随访时间3.6年,5年或5年以上存活率为90%,5年再出血率为5.1%,术后脑病发生率为5.1%.结论断流术对门静脉高压症曲张静脉出血疗效满意,即时止血率高,再出血率、肝性脑病等并发症较少,特别是脾切除、贲门周围血管离断术是首选,但应做到完全彻底的断流.     

改良Sugiura术治疗门静脉高压症的疗效评价

目的评价改良Sugiura手术治疗门静脉高压症的疗效。方法回顾对85例门静脉高压症患者行改良Sugiura手术的情况。结果本组技术成功率100%,1例术后2周因肝功能衰竭死亡,吻合口漏1例。随访时间6个月至10年,平均4.1年。随访期间再出血1例,无吻合口狭窄发生,所有患者食管下段静脉曲张消失或明显好转,肝性脑病发生率2.35%。结论本术式治疗门静脉高压症围手术期死亡率和再出血率低,并发症少,值得推广。     

限制性分流与断流联合术治疗门静脉高压症

目的探讨限制性分流与断流联合手术治疗门静脉高压症的效果。方法对39例门静脉高压症患者行断流加肠腔静脉限制性分流术的临床疗效进行回顾性分析。结果患者术后自由门静脉压力水平下降8cm H2O，且皆保持门静脉的向肝血流，术后随访6～24个月，39例患者有18例肝功能有不同程度恢复，1例在围手术期有短暂的肝性脑病发作，38例患者腹水消失，食管胃底静脉曲张消失好转率82．1％，无再出血发生。结论断流限制性分流联合应用，既能保持一定的门静脉压力及门静脉肝脏血供，又能防止上消化道出血，降低肝性脑病发生率，是治疗门静脉高压症的较为理想的手术方法。     

门静脉高压症三种术式治疗远期疗效分析

目的探讨门静脉高压症断流术、分流术和联合手术后远期并发症的原因及防治措施。方法对128例门静脉高压症术后出现远期并发症31例患者临床资料进行回顾性分析。结果远期并发症4种,再出血15例,肝癌2例,肝性脑病7例,门静脉高压性胃黏膜病变7例。31例中行保守治疗17例,再手术8例,死亡6例。结论根据医院条件及术者能力严格掌握手术适应证,加强术后随访,及时正确地治疗并发症,是降低远期并发症和死亡率的关键。     

贲门周围血管离断术的远期疗效及评价

总结贲门周围血管离断术治疗门静脉高压症曲张静脉出血的效果。门静脉高压症４０３例，行预防性手术１０７例，择期手术２５４例，急诊手术４２例；平均随访５．８年。急诊手术止血率９５．２％，术后５年再出血率６．３％，１０年再出血率１３．４％；肝性脑病的发生率分别为２．６％（５年）和４．０％（１０年）；５年生存率９４．０％，１０年生存率７０．６％。贲门周围血管离断术对曲张静脉出血疗效满意，即时止血率高，并发症少，术后再出血率、肝性脑病发生率较低，术后长期生存率高，是治疗门静脉高压症曲张静脉破裂出血的重要的手术方法。     

门静脉高压症术后近期并发症的分析

目的探讨门静脉高压症患者术后近期并发症发生的相关因素，为预防术后并发症的发生提供理论依据。方法对近40年来各类门静脉高压症手术病例进行回顾性分析。结果在8240例患者中，术后1个月内并发症发生率为19．66％，病死率为15．31％。主要死亡原因为MDOS、腹腔内大出血、肝肾综合征、复发上消化道出血等。结论门静脉高压症手术近期是否发生并发症与产生门静脉高压症的病因、是否有过腹水、手术时机与术式的选择、肝功能级别(Child分级)等因素有关。     

外科治疗门静脉高压症术后再出血70例分析

目的 探讨门静脉高压症术后再出血外科治疗手术方式的选择和疗效。方法 回顾性分析郑州大学第一附属医院普通外科1987年1月至2007年12月收治的70例门静脉高压症术后再出血的临床资料。 结果 急诊手术5例,择期手术65例。行肠系膜上静脉-下腔静脉人工血管架桥术（MCS） 37例,断流术26例,肠系膜下静脉-下腔静脉分流术（IMCS）7例,手术死亡6例。随访52例,随访时间6个月至7年。死亡5例,其中2例死于原发性肝癌,1例死于肝衰竭、肝性脑病,2例死于上消化道再出血。 结论 对门静脉高压症术后再出血病人应首先采用积极的非手术治疗,控制出血后择期手术。积极非手术治疗无效者,应急诊手术治疗。MCS、断流术和IMCS是较理想的术式。     

肝硬化门静脉高压症食管胃底曲张静脉破裂出血医院内死亡原因分析

摘要：目的:探讨肝硬化门静脉高压症食管胃底曲张静脉破裂出血患者住院期间的死亡原因。方法:对近 3年收治的186例患者及在住院期内死亡的24例患者的临床资料进行回顾性分析。结果:186中择期手术130例，3例（2.31 %）因术后肝衰竭或其他并发症死亡；急诊手术28例，术后因肝衰竭或其他并发症死亡5例（17.86 %）；未行手术治疗28例，16例死亡，其中12例死于出血无法控制。结论:大出血非手术治疗无法控制而又未及时手术是导致肝硬化门静脉高压症食管胃底曲张静脉破裂出血患者最重要的医院内死亡原因，对此类患者及时采取急诊手术对降低门静脉高压症大出血患者的病死率具有重要意义。     

门静脉高压症经腹吻合器行Sugiura术的临床疗效观察

目的探讨门静脉高压症经腹吻合器行Sugiura术的临床疗效。方法回顾性分析我院2003年6月-2007年6月对47例门静脉高压症病人行经腹吻合器行Sugiura术的临床资料。结果本组无手术死亡病例。术后发生吻合口瘘1例、吻合口狭窄2例、门静脉血栓形成2例，均经早期治疗顺利出院。本组有40例获得随访，平均随访25个月，无再出血和肝性脑病发生。结论经腹吻合器行Sugiura术治疗门静脉高压症具有断流彻底、止血确切、术后并发症少等优点，而且操作并不复杂，值得推广。     

保留食道旁静脉选择性断流术治疗门静脉高压症临床分析

目的探讨选择性贲门周围血管离断术治疗门静脉高压症的临床效果。方法回顾分析2004年1月～2010年3月收治90例经选择性贲门周围血管离断术治疗肝硬化合并门静脉高压症病人的临床资料。结果术后FPP平均下降6±7 cmH2O;并发症发生率为22.2%。肝功能Child C级血胆固醇<3.0 mmol/L时术后并发症发生率有统计学意义(P<0.05);手术死亡率3.1%,主要死亡原因为上消化道再出血并发肝性脑病、多器官功能衰竭。获得随访1年、3年及5年再出血率分别为3.3%、5.6%及4.8%。结论选择性断流术合理地保留了机体的自发性分流,既保证入肝血量又降低门静脉压力,是一种较理想的断流术式。注重围手术期处理,肝功能较差、反复出血的患者尤应重视。     

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.