腹腔镜胆囊切除术并发症的发生原因及预防对策

目的 探讨腹腔镜胆囊切除术并发症的发生原因及其预防对策。方法 采用腹腔镜胆囊切除术治疗426例。结果 成功419例，中转开腹7例，平均手术时间46．5分钟，切口感染2例，胆总管残余结石4例，胆漏2例，无胆管损伤和术后大出血等严重并发症。结论 合理选择病例、规范的手术操作、果断及时地中转开腹，可有效地防止腹腔镜胆囊切除术发生严重的并发症。     

腹腔镜胆囊次全切除术92例临床分析

目的探讨腹腔镜胆囊次全切除术的适应证、手术方法、临床效果和并发症。方法回顾性分析腹腔镜胆囊切除术遇困难时行腹腔镜胆囊次全切除术92例患者的临床资料。急性化脓性胆囊炎46例多伴胆囊颈部结石嵌顿,由于炎症重、张力高、胆囊壁水肿增厚,腹腔镜顺行或顺逆行相结合次全切除胆囊;萎缩性胆囊结石29例及充填性胆囊9例腹腔镜逆行或顺逆行相结合次全切除胆囊;肝内胆管结石并发肝硬化7例和横位胆囊1例均腹腔镜顺逆行相结合次全切除胆囊。结果 92例腹腔镜胆囊次全切除术病例无1例中转开腹,手术时间30～120min,平均60min;住院天数3～10d,平均5d;术后无胆汁漏、出血、黄疸等并发症。随访2～5年患者无不适感觉。结论腹腔镜胆囊次全切除术与腹腔镜胆囊切除术相比疗效相似,均具有出血少、术后恢复快、住院时间短、痛苦少、并发症低等优点,故在复杂情况下行腹腔镜胆囊次全切除术,有利于降低手术难度及风险,减少中转开腹率,缩短手术时间,减少术后并发症,切实可行。     

肝硬化患者腹腔镜胆囊切除术的体会(附46例报告)

目的探讨在合并肝硬化的胆囊结石病例中腹腔镜胆囊切除术的应用价值。方法对46例肝硬化胆囊切除手术患者的临床资料进行回顾性分析。结果46例完成腹腔镜胆囊切除手术,,手术时间18～95min,平均34.2min。术中出血20～350mL,平均45.3mL。术后无出血、胆漏等并发症,住院3～9d,平均4.2d。结论术中出血的处理是肝硬化胆囊切除成功的关键点。腹腔镜胆囊切除术对ChildA和B级肝硬化胆囊结石患者是安全的,对ChildC级患者应审慎选择。     

经脐单孔腹腔镜胆囊切除术18例分析

目的探讨经脐单孔腹腔镜胆囊切除术的可行性和临床应用前景。方法回顾性分析2009-10-2011-01徐州市第六人民医院普外科完成18例经脐单孔腹腔镜胆囊切除术患者的手术时间、出血量、并发症及术后恢复情况等。结果共完成15例经脐单孔腹腔镜胆囊切除术,3例经脐单孔腹腔镜胆囊切除因操作困难中转为常规腹腔镜胆囊切除术。手术时间为46～130(68±25)min。术中无明显出血。术后未发生胆漏、腹腔感染、切口感染等并发症。术后平均3～4 d出院。结论经脐单孔腹腔镜胆囊切除术可实现腹壁无瘢痕化,减少切口感染概率,但操作难度较大,可以在慎重选择病例的基础上开展。     

腹腔镜胆囊切除术治疗胆囊颈部结石

目的：总结腹腔镜胆囊切除术治疗胆囊颈部结石的方法和经验。方法：回顾分析50例腹腔镜胆囊切除术治疗胆囊颈部结石病例和同期50例非颈部结石腹腔镜胆囊切除术病例的临床资料。结果：所有病例均腹腔镜操作成功,无中转开腹,无并发症发生,胆囊颈部结石腹腔镜胆囊切除术的病例的手术方法、手术时间和术后住院时间较非颈部结胆囊石胆囊腹腔镜胆囊切除术的病例明显不同。结论：腹腔镜胆囊切除术治疗胆囊颈部结石安全、有效。术前充分准备,操作熟练、经验丰富的医师能够成功运用腹腔镜胆囊切除术治疗胆囊颈部结石。     

腹腔镜胆囊大部分切除术在复杂胆囊手术中的应用

【目的】总结腹腔镜下胆囊大部分切除在复杂胆囊切除术中应用的经验。【方法】回顾分析本院2002年1月至2005年9月施行的36例腹腔镜胆囊大分部切除术的病例,对手术方法、手术疗效及并发症进行分析。【结果】36例均在腹腔镜下行胆囊大部分切除,无中转开腹、无术后出血及肝外胆管损伤,手术时间为(56±16.5)min,开始下床活动时间(13±4.3)h,开始进食时间(23±8.5)h,住院时间(5±1.5)d,术后胆漏1例,经保守治疗治愈。随访7~28个月,未见与手术有关的并发症。【结论】在复杂胆囊手术中,腹腔镜胆囊大部分切除术可简化手术,降低手术风险,可收到胆囊造瘘与标准胆囊切除相结合的疗效。     

改良经脐单孔腹腔镜胆囊切除术

目的 探讨改良经脐单孔腹腔镜胆囊切除术的可行性及临床应用.方法 对17例胆囊病变患者采用史赛克迷尔钳加弹道碎石杆辅助下行经脐单孔腹腔镜胆囊切除术.结果 16例经脐单操作孔腹腔镜胆囊切除术取得成功,手术时间30～90 min,平均42 min,1例因术中解剖困难改传统腹腔镜完成手术,所有病例无手术并发症发生.结论 经脐单操作孔腹腔镜胆囊切除术是一种安全可行的术式,有美容性好、创伤小的优点.     

腹腔镜胆囊切除术187例临床疗效分析

目的 评价腹腔镜胆囊切除术在胆囊切除中的应用特点.方法 回顾性分析2003年10月～2009年10月该院收治的370例胆囊疾病病例,187例采用腹腔镜胆囊切除术治疗,183例采用传统胆囊切除术,比较两种不同手术方式的治愈率、住院时间及术后并发症情况.结果 两种不同手术方式成功率均达100%.腹腔镜手术较传统胆囊切除术有巨大优势,腹腔镜手术术后恢复快,平均住院时间为8.2 d,明显短于传统手术组(P<0.05);传统胆囊切除术组术后合并胆管损伤、胆痿、肺部损伤等并发症的发生率30.6%(56例),远远高于腹腔镜组5.9%(P<0.05).结论 腹腔镜胆囊切除术方便实用,恢复快,术后并发症少,适合进一步推广.     

二孔与三孔法腹腔镜胆囊切除术的对比分析

目的 探讨二孔法腹腔镜胆囊切除术的临床应用及意义.方法 采用二孔法完成腹腔镜胆囊切除术116例.与三孔法182例进行临床效果对比分析.结果 116例顺利完成二孔法手术,手术时间20～55 min,平均33 min.二孔法5例改为三孔(归入二孔法)或四孔法,均未发生并发症.随访87例,时间6～12个月,平均9个月,无腹痛、黄疸发生.结论 选择合适的病例,二孔法腹腔镜胆囊切除术是安全可行的.     

高原腹腔镜下胆囊切除的体会

目的 探讨高原腹腔镜下胆囊切除的特点和手术技巧.方法 分析我院从2007年4月～12月开展腹腔镜下胆囊切除术188例的临床资料.结果 完成腹腔镜下胆囊切除术186例,中转开腹2例,无腹腔镜下胆囊造瘘、胆囊大部分切除,无胆道、胃肠道损伤及其他并发症.结果 高原腹腔镜下胆囊切除术有其特点,关键是术者的经验和手术技巧.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.