CT在腔内外联合断流术中的应用价值

食管胃底静脉丛是门脉系统中一个重要的侧支循环，门脉高压症时，食管曲张静脉破裂出血是其最严重的并发症，也是导致死亡的主要原因。其中，经内镜食管曲张静脉套扎术（Endoscopic varices ligation，EVL）、非选择性贲门周围血管离断术（Hassab’s procedure）以及腔内外联合断流术（EVL＋Hassab’s procedure）是治疗食管静脉曲张，     

贲门周围血管离断术治疗食管静脉曲张破裂急性出血

目的 总结贲门周围经血管离断术治疗食管静脉曲张破裂包性出血的经验。方法 对47例急诊施行贲门周围血管离断术患者的临床资料进行回顾性分析。结果 急诊手术止血率100%,术后死亡2例（4.3%),并发症率8.6%,均经非手术疗法治愈。45例均获随访（0.5-13年）,再出血3例（6.7%）,死亡6例（13.3%)（其中肝癌2例,食管癌,肝衰,多发骨髓瘤,营养不良各1例）。食管胃底静脉曲张消失者26例,好转者9例。结论 贲门周围血管断苛刻治疗胃底食道静脉曲张破裂急性出血只要正确掌握适应证,抓住手术时机。断流彻底,不论近期或者远期疗效都是满意的。     

贲门周围血管离断术后上消化道再出血10例报告

贲门周围血管离断术是治疗门静脉高压症伴食管胃底静脉曲张出血的主要方法之一。贲门周围血管离断术止血效果好，操作简单。但其并发症较多，应引起重视。断流术后再出血率达10％，是当今外科治疗面临的难题。发生术后再出血除了与病人全身情况差、肝功能低下有关外，还与术者的操作熟练程度及手术时机的选择有关。我们自1996年1月-2008年6月对150例门静脉高压症食管静脉曲张破裂出血病人施行贲门周围血管离断术，     

贲门周围血管离断加经腹食管横断吻合术治疗门静脉高压症的疗效评价

目的探讨贲门周围血管离断加经腹食管横断吻合术治疗门静脉高压症的疗效。方法对1997年6月至2002年6月在我科行贲门周围血管离断加经腹食管横断吻合术治疗的48例门静脉高压症患者的临床资料进行回顾性分析。结果94%的患者得到了随访,平均随访时间为39个月。术后静脉曲张消失率为93%,食道曲张静脉再出血率2%,患者存活率为93%,手术死亡2例。术后门静脉系统血栓形成发生率为8%,膈下积液发生率为6%,吻合口漏发生率为8%,吻合口狭窄发生率为6%。结论贲门周围血管离断加经腹食管横断术是治疗门静脉高压症的一种有效术式。     

门脉高压症上消化道大出血急诊手术治疗体会

目的探讨门脉高压症食管胃底静脉曲张破裂出血急诊手术时机和疗效。方法2002年1月~2007年4月48例肝硬化门脉高压症上消化道大出血患者行急诊选择性贲门周围血管离断,其中18例加行改良Sugiura术。结果45例获随访,平均18(3~24)个月,无术后死亡,无吻合口瘘和肝性脑病,无术后再出血的发生。结论选择性贲门周围血管离断和条件允许情况下的改良Sugiura术能有效地治疗门脉高压症食管胃底静脉曲张破裂出血,降低术后再出血率和并发症发生率。     

贲门周围血管离断术加内镜下曲张静脉套扎术治疗门静脉高压症

１９９３年以来,我院应用贲门周围血管离断术加内镜下曲张静脉套扎术治疗门静脉高压症６６例。结果：术后食管胃底静脉曲张消失率９５．５％（６３／６６）,无手术死亡,无严重并发症,远期再出血率为４．７％（３／６４）,无肝性脑病发生,三年生存率达９０．２％。我们认为此种联合断流术可降低术后再出血率,且不增加手术复杂性及手术创伤,适应证与单独应用贲门周围血管离断术同样广泛。     

贲门周围血管离断术治疗门静脉高压症50例临床分析

目的总结贲门周围血管离断术的治疗经验。方法回顾性分析我院1994年1月．2002年10月贲门周围血管离断术患者50例。结果术后大部分患者静脉曲张有不同程度改善，脾功能亢进表现消除，住院期间死亡4例，术后近期再出血率为6.0％。结论贲门周围血管离断术对防治门静脉高压食管胃底静脉曲张出血占有重要地位，肝功能A级或B级者，择期手术的病死率低，并发症少；对肝功能C级患者应谨慎选择，不提倡对急性大出血患者行急诊贲门周围血管离断术。     

食管胃底静脉曲张破裂出血内镜治疗失败后再手术

目的 比较内镜治疗后贲门周围血管离断术与未经内镜治疗患者贲门周围血管离断术治疗食管胃底曲张静脉破裂出血的疗效.方法 2005年6月至2010年6月期间共完成贲门周围血管离断术230例,其中肝炎后肝硬化202例,酒精性肝硬化28例.A组16例,为内镜治疗(套扎、栓塞)后再行贲门周围血管离断术;B组214例,直接行贲门周围血管离断术.结果 A组平均手术时间为(198±59)min,平均出血(750±120)ml,术后平均住院(11±2)d;B组平均手术时间为(120±26)min,平均出血(250±43)ml,术后平均住院(7±1)d.两组的平均手术时间、术中出血量、术后住院时间之间相比差异有统计学意义(均P＜0.05).230例患者中获得随访212例,随访率为92.2％,术后平均随访2.5年(1～6年),死亡率为4.2％,再出血率为5.7％.结论 内镜治疗后食管胃底周围组织纤维化、质硬,明显增加手术难度,手术时间、术中失血量较单纯贲门周围血管离断术明显增加,故对于适合行手术治疗的门静脉高压症患者应首选贲门周围血管离断术.     

门静脉高压症三种断流手术方式及其疗效的探讨

目的评价因门静脉高压症行断流手术的方式及其疗效。方法对2000年1月至2015年1月十堰市太和医院肝胆胰外科诊疗中心收治的因门静脉高压症接受断流手术治疗的389病人进行随访,其中根据肝功能Child-Pugh分级A级345例、B级44例。据手术方法分三组:脾切除加贲门周围血管离断组157例;脾切除加食管下段吻合器横断吻合组139例;脾切除加食管下段联合胃近端切除组93例。结果 389例病人中无手术死亡和近期再出血。术后发生并发症31例,占8.0%。术后随访389例,随访12～52个月。术后1～3年内,行钡餐和胃镜检查,断流手术后再发静脉曲张的发生率为4.9%(19/389)。其中行脾切除加贲门周围血管离断术的157例,有15例(9.6%)表现为中重度曲张;行脾切除加食管下段吻合器横断吻合组139例中仅有4例(2.9%)表现为轻度静脉曲张;行脾切除加食管下段联合胃近端切除组93例均无再发静脉曲张。结论三种断流手术中接受脾切除+食管下段联合胃近端切除术的病人均未再发静脉曲张,具有良好的疗效。     

门静脉高压症断流手术方式及其疗效的探讨

目的 评价门静脉高压症断流手术方式及其疗效。方法 对l996年1月--2002年1月我科收治的167例门静脉高压症接受断流手术治疗的患者进行随访，其中肝功能Child A级46例、B级115例和C级6例。结果 本组无手术死亡和近期再出血。术后发生并发症37例，占22％。其中术后胃出血l9例，9例需手术止血。随访132例，平均随访32个月。术后行钡餐和胃镜检查，断流手术后再发静脉曲张的发生率为20％(26／132)。其中接受单纯贲门周围血管离断术的50例，有22例表现为中重度曲张；贲门周围血管离断 食管横断术56例中仅有4例表现为轻度静脉曲张；食管下段 胃近端切除者26例均无再发静脉曲张。结论 断流手术采用单纯贲门周围血管离断术者效果较差，而接受食管下段 胃近端切除术的患者均未再发静脉曲张，提示该术式具有良好的疗效。     

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.     

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.     

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.