十二指肠间质瘤10例临床分析

目的探讨十二指肠间质瘤(GIST)的诊断与治疗方法,分析影响预后的因素。方法收集2013-06—2018-02间昆山市中医院收治的10例十二指肠GIST患者的临床资料,进行回顾性分析。结果所有患者均经病理检查确诊,1例因高龄未行手术治疗,其余9例均进行择期手术。其中行十二指肠肿瘤局部切除5例,十二指肠部分切除术2例,胰十二指肠切除术2例。术后3例患者口服伊马替尼(格列卫)治疗。术后均恢复顺利,随访至今未复发。结论十二指肠GIST的预后取决于肿瘤直径、核分裂象及肿瘤是否破裂。服用伊马替尼靶向治疗,以减少术后复发率、延长生存期。     

十二指肠间质瘤16例临床分析

目的 探讨十二指肠间质瘤的诊断和治疗.方法 回顾性分析了16例十二指肠间质瘤治疗的临床资料.结果 十二指肠间质瘤发病部位主要集中在降部和水平部;出血是最常见的临床症状,其次为上腹部疼痛不适,内镜和CT为最常用的辅助检查手段,16例中行胰十二指肠切除2例,十二指肠节段切除9例,肿瘤局部切除5例,术后随访6～42个月,1例复发并出现肝脏转移存活22个月,其余均未发现复发.结论 根据十二指肠间质瘤大小和确切位置应采取不同的手术方式,大部分患者可通过十二指肠节段切除或局部切除达到根治目的,对于病理分级呈高度危险患者术后应给予伊马替尼辅助治疗.     

胃肠道间质瘤肝转移的诊断和治疗

目的 探讨胃肠道间质瘤(gastrointestinal stromal tumor,GIST)肝转移的诊断和治疗.方法 回顾性分析1993年12月至2007年5月收治的16例GIST肝转移患者的临床资料.结果 14例行根治性切除术,2例行姑息性切除术.3例根治性切除术及2例姑息性切除术患者术后服用伊马替尼治疗.术后随访时间3～161个月,14例根治性切除患者中共8例复发、转移.其中7例肝转移,3例采用肝动脉栓塞治疗,1例服用伊马替尼,2例手术切除,1例未治疗;1例腹壁转移,行手术切除.本组16例患者1、3年生存率分别为92%和74%.结论 GIST肝转移术后复发率高,手术治疗GIST肝转移及术后复发、转移效果较好,联合服用伊马替尼可进一步提高患者生存率.     

十二指肠间质瘤39例临床分析

目的 探讨十二指肠间质瘤的临床表现及外科治疗经验.方法 回顾性分析中国医科大学附属第一医院1992年1月至2010年12月收治的39例十二指肠间质瘤的临床资料.结果 本组十二指肠间质瘤的最常见症状为上消化道出血,占46％(18/39).增强CT是有效的诊断方法,准确率为69％(22/32),十二指肠镜检查的准确率为83％ (15/18).发病部位以十二指肠降部多见,占69％(27/39).39例均行手术治疗,R0切除34例,其中十二指肠部分切除术16例,胰十二指肠切除术12例,十二指肠节段切除术及胃大部切除术各3例,另有转流或探查手术5例.围手术期死亡1例,有9例出现术后并发症,均行非手术治疗治愈.R0切除术后患者1、3、5年生存率分别为90％、72％、41％.结论 腹部增强CT和十二指肠镜检查是诊断十二指肠间质瘤的有效方法.根据十二指肠间质瘤的大小和位置采取不同的手术方式以达到R0切除,而十二指肠部分切除术应该是首选术式.对于中、高危险度的患者,术后应给予伊马替尼辅助治疗.     

十二指肠间质瘤29例诊治分析

目的 总结十二指肠间质瘤的诊断和外科治疗经验.方法 回顾性分析1999年5月至2013年3月我院诊治的29例十二指肠间质瘤病例资料.结果 29例患者主要临床表现为黑便、中上腹不适或腹痛.术前诊断主要依据影像学和内镜检查,但活检准确率低.内镜超声引导下细针穿刺活检有助于明确诊断.29例患者均完整切除肿瘤.其中13例行胰十二指肠切除;11例行肿瘤局部切除;5例行十二指肠节段切除.术后7例服用伊马替尼.术后随访2～118个月,平均48.2个月.26例患者存活至今.其中23例无复发或转移征象;4例出现肝脏转移;2例肿瘤复发.核分裂相≥5/50高倍视野(HPF)为术后复发转移的高危因素.结论 十二指肠间质瘤首选手术切除,根据肿瘤大小和位置选择合理的手术方式.早期诊断和完整切除肿瘤对改善预后至关重要.肿瘤破裂或高危患者术后应给予口服伊马替尼辅助治疗.     

217例胃间质瘤的临床特点与诊治

目的 探讨胃间质瘤的临床特点、诊断与治疗方法.方法 对笔者所在医院2007年10月至2011年7月期间收治的217例胃间质瘤患者的临床资料进行回顾性分析.结果 胃间质瘤患者的临床表现主要有腹痛、上腹胀、血便、腹部包块等.术中见肿瘤位于贲门部、胃底、胃体及幽门部分别为24例(11.0％)、103例(47.5％)、59例(27.2％)和31例(14.3％).所有患者的肿瘤均于内镜下剥除或行手术切除,术后经病理及免疫组化检查确诊.属极低危险度、低危险度、中危险度及高危险度患者分别为56例(25.8％)、67例(30.9％)、41例(18.9％)和53例(24.4％).术后140例患者获得随访,随访时间为7～52个月,平均35个月.获得随访的35例高危险度患者中,服用伊马替尼者19例,2例进展;未服用者16例,9例进展,服用伊马替尼者病情进展的比例较低(x2=8.426,P=0.004).在11例病情进展患者中,局部复发4例、复发合并腹腔多处转移1例、肱骨转移1例、肝转移合并腹腔转移1例、肝转移4例.结论 胃间质瘤缺乏特异性临床表现,手术完整切除肿瘤是主要的治疗手段,伊马替尼可改善高危险度患者的预后.     

Treatment of 22 cases of duodenal gastrointestinal stromal tumors

目的 探讨十二指肠间质瘤的治疗及预后情况.方法 回顾性分析2003年6月至2007年5月经手术治疗的22例十二指肠间质瘤病人的临床病理资料.结果 22例中4例行胰十二指肠切除术(PD);18例行十二指肠局部切除,其中,口服甲磺酸伊马替尼6个月后手术切除者7例.1年及3年存活率分别为100％、90.9％.结论 PD手术创伤大,术后并发症多,故对于未侵犯十二指肠乳头或胰腺壶腹者,应尽量行局部切除而非PD.术前使用甲磺酸伊马替尼可提高切缘阴性率、降低手术风险.     

小肠间质瘤13例报告

目的探讨小肠间质瘤的临床特点及诊断、治疗经验。方法回顾性分析自1997年6月至2009年10月经手术治疗并确诊的13例小肠间质瘤的临床资料。结果全组均行手术治疗,术后加用伊马替尼治疗2例。全组随访6个月～12年,复发1例,再手术后目前存活,应用伊马替尼治疗的2例症状缓解,其余10例均存活至今,无复发。结论小肠间质瘤预后较好,但对不明原因的消化道出血、腹痛应及早行特殊检查或手术探查,以免误诊;伊马替尼对晚期小肠间质瘤有较好疗效。     

胃大部切除术后反复黑便6个月

本文对1例主诉“胃大部切除术后反复黑便6个月”的病例进行讨论。该病患者6个月前因呕血人当地医院,诊断为十二指肠球部溃疡出血,急诊行胃大部切除术。术后6个月来反复出现黑便,入院后诊断为腹腔肿物。剖腹探查术中发现肿物来源于十二指肠降段．根据肿瘤大小及所在位置,行胰头十二指肠切除术。术后病理符合十二指肠间质瘤,中等恶性潜能。术后口服甲磺酸伊马替尼治疗。     

十二指肠间质瘤18例的临床特征和外科治疗

目的探讨十二指肠间质瘤的临床特征、外科治疗方法及效果。方法回顾性分析复旦大学附属中山医院1995-2004年间收治的18例十二指肠间质瘤患者的临床资料。结果本组患者临床表现为黑便者7例,腹痛6例,饱胀5例,贫血3例。分别经上消化道钡餐造影、胃镜、内镜超声及CT诊断,肿瘤位于十二指肠降部13例,水平部2例,球部2例,升部1例;肿瘤直径2.0-9.0(平均4.8)cm。肿瘤恶性15例(83.3%),交界性2例(11.1%),良性1例(5.6%);梭形细胞型14例,混合型3例,上皮细胞型1例。9例十二指肠降部肿瘤者行胰十二指肠切除术,术后病理检查均无淋巴结转移;4例十二指肠降部和1例球部肿瘤者行肿瘤及十二指肠壁局部切除术;2例十二指肠水平部和1例升部肿瘤者行十二指肠节段切除术:另有1例十二指肠球部肿瘤者行胃远端大部切除术。15例术后获得17个月至8年的随访,1、3年生存率分别为100%和86.7%。结论十二指肠间质瘤恶性多见。手术治疗为主。手术方式的选择取决于肿瘤的位置和大小。     

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.