肝移植术后腹腔间隙综合征的诊治体会

目的 总结肝移植术后腹腔间隙综合征(ACS)的诊治体会。方法 采用膀胱内压检测法间接测量腹内压(IAP),监测术后心、肺、肾功能。术后IAP大于20mmHg,同时有一项或多项器官功能受损诊断为ACS。合理补液,采用腹腔内重新置管引流、腹腔穿刺、肌松药等非开腹减压方法以治疗ACS。结果 9例ACS患者中,6例出现急性肾功能损害,其中4例表现为少尿或无尿;6例出现低氧血症,机械通气时间延长;4例心率明显增快,其中3例并发心衰。除2例死于多器官功能不全综合征外,7例患者经上述治疗后腹胀显著减轻,心肺肾功能恢复正常。结论 肝移植术后加强对ACS的重视、术后早期IAP的严密监测以及尽早的非开腹减压治疗具有较重要的临床意义。     

重症急性胰腺炎并发腹腔室隔综合征的急症处理

目的探讨重症急性胰腺炎(SAP)并发腹腔室隔综合征(ACS)的诊断和急症处理。方法对我院2000年10月～2004年10月收治的13例SAP并发ACS的临床资料进行回顾性分析。结果本组13例ACS患者,9例(69．2％)发生在SAP急性反应期(即早发性ACS)。3例(23．1％)发生在SAP感染期(即迟发性ACS),1例(7．7％)发生在SAP急性反应期和感染期(即混合性ACS)。9例早发性ACS中。1例(7．7％)行短时血液滤过。2例(15．4％)行左、右下腹部小切El灌洗引流术,3例(23．1％)行腹腔镜灌洗引流术。3例(23．1％)行开腹减压术;3例(23．1％)迟发性ACS均行开腹减压术;1例(7．7％)混合性ACS早期行腹腔镜灌洗引流术,后期行开腹减压术。治愈7例(53．8％),死亡6例(46．2％)。结论ACS是SAP的严重并发症。死亡率极高。早期、及时的诊断与根据不同ACS类型采取的个体化综合治疗是改善ACS预后的关键。     

重症急性胰腺炎并发腹腔室隔综合征的诊断和治疗

总结重症急性胰腺炎(SAP)并发腹腔室隔综合征(ACS)的诊治经验。方法结合SAP病史,复苏液体量已足够时,在腹膨胀、腹壁紧张后出现心肺肾功能不全即可诊断ACS,膀胱测压作诊断辅助。诊断确立后及时开腹减压引流,3升静脉营养袋暂时性关腹。结果21例(23例次)。ACS患者中,行开腹减压术18例次,死亡3例(16．7％),未手术5例次,死亡4例(80％),总死亡率33．3％(7／21);7例死亡中,4例合并急性梗阻性化脓性胆管炎;诊断ACS5h内手术者无死亡;正规关腹多在开腹减压术后3～5d进行,最迟1例为术后8d;6例迟发性Acs均由腹腔腹膜后感染性坏死引起。结论SAP患者在SIRS和感染期均可发生ACS,并在病理基础上有其特殊性;及时诊断ACS和开腹充分减压,3升静脉营养袋暂时性关腹是治疗ACS的关键。     

EFFECTS OF THE EXTRADURAL ADMINISTRATION OF MORPHINE OR BUPIVACAINE, ON THE METABOLIC RESPONSE TO UPPER ABDOMINAL SURGERY

The influence of thoracic extradural local anaesthetics (0.5%bupivacaine) or extradural morphine on the metabolic responseto upper abdominal surgery was compared with the administrationof morphine i.v. in the period after operation. The extradurallocal anaesthetic group had significantly lower blood glucoseand plasma FFA concentrations and consistently, but not significantly,lower blood glycerol and lactate concentrations than both theother groups. At 4 h both extradural groups had significantlylower plasma FFA and blood 3-hydroxybutyrate concentrationsthan the control group. Blood alanine concentration decreasedin all three groups with a minimum at 24 h. There were no differencesin serum insulin concentrations between the groups. It is concludedthat thoracic extradural morphine differs from thoracic extradurallocal anaesthetics in being much less able to suppress the metabolicresponse associated with upper abdominal surgery.     

腹壁成形术后合并呼吸窘迫综合征

报道3例腹部减肥,腹壁成形术后合并成人呼吸窘迫综合征。均经及时,有效的治疗而痊愈。讨论了ARDS的诊断标准,强调早期诊断的重要性,介绍了治疗方法。     

EFFECTS OF THE EXTRADURAL ADMINISTRATION OF MORPHINE, OR BUPIVACAINE, ON THE ENDOCRINE RESPONSE TO UPPER ABDOMINAL SURGERY

The endocrine response, and the relief of pain, following theextradural administration of morphine or a local anaestheticagent bupivacaine (0.5%) were studied for 24 h after abdominalsurgery and compared with a control group given conventionali.v. morphine after operation. Samples were taken before andat 2, 4, 6, 12 and 24 h after skin incision. Pain relief inboth extradural groups was significantly better when comparedwith the control group. In all three groups, the plasma concentrationof cortisol was increased immediately after surgery. Thereafter,significantly lower values were seen in the extradural groups.Plasma adrenaline concentration was lower immediately aftersurgery only in the group given the extradural local anaesthetic.Plasma noradrenaline concentration remained unchanged afterextradural local anaesthesia while an intermediate increaseoccurred after extradural morphine. Plasma noradrenaline concentrationwas significantly greater in the controls compared with bothextradural groups. Our results indicate that extradural analgesiawith a local anaesthetic drug can suppress the increases inthe plasma concentrations of the catecholamines and cortisolafter surgery. In contrast to extradural local anaesthetic extraduralmorphine cannot suppress the endocrine response immediatelyafter surgery. However, later in the postoperative period, extraduralmorphine can suppress the endocrine response, thus indicatingthat postoperative pain is a factor involved in the stress responsefollowing surgery.     

DIVARICATION OF THE RECTI,OR ABDOMINAL INCISIONAL HERNIA? A SIMPLE DIFFERENTIATING CLINICAL TEST

We describe a simple clinical test to differentiate divarication—a condition of unusually wide separation of the rectus abdominis muscles which requires no treatment, from incisional hernia, which usually merits surgical repair.     

EFFECTS OF UPPER OR LOWER ABDOMINAL SURGERY ON DIAPHRAGMATIC FUNCTION

Changes in abdominal (AB) and rib cage (RC) movements, and invital capacity, were compared between 23 patients undergoingupper or lower abdominal surgery at 1, 3 and 7 days after surgery.Diaphragmatic index was obtained by measuring the relative abdominalmotion (AB/ AB+RC) using magnetometers. Electrical activityof abdominal muscles was assessed using needle electrodes afterupper abdominal surgery in four additional patients. After upperabdominal surgery, the vital capacity and the diaphragmaticindex were markedly reduced for 1 week. No abdominal muscleactivity was observed at day 1. After lower abdominal surgery,the vital capacity returned to the normal range within 3 daysof operation, without any diaphragmatic impairment. These findingssubstantiate the role of diaphragmatic dysfunction in postoperativereduction in vital capacity observed after upper abdominal surgery.     

肠腔分流或联合下腔静脉内支架置入术治疗布—加氏综合征

目的 探讨肠腔分流术或联合下腔静脉内支架置入术治疗布－加氏综合征（BCS）的效果。方法 回顾性分析15例肠腔分流术或联合下腔静脉内支架置入术治疗BCS的临床资料。结果 4例行肠腔侧侧直接吻合,11例应用PTFE人造血管行肠腔分流;12例联合下腔静脉内支架置入术,门静脉压降低10－27cmH2O(0.98J-2.65kPa)。1例术后因肝昏迷肝脏功能衰竭死亡。14例存活患者肝脾肿大缩小,腹水消失,无并发症,随访5－26个月,均恢复正常生活。结论 肠腔分流或联合下腔静脉内支架置入术成功率高,创伤小,疗效满意,是治疗BCS的有效实用术式。     

MESENTERIC HERNIAS THROUGH DEFECTS OF THE MESOSIGMOID

Internal herniation through defects in the gastrointestinal mesentery is extremely rare. Two patients with small bowel herniation involving the sigmoid mesocolon are reported. The condition has a high incidence of stranulation, with rapid onset of gangrene of the bowel. The mortality is high and the role of early surgical intervention is stressed.     

CIMETIDINE IN THE PREVENTION OF THE PULMONARY ACID ASPIRATION (MENDELSON'S) SYNDROME

Cimetidine 200 mg was given i.v. 1 h before induction of anaesthesiato 20 patients about to undergo emergency surgery. There wasan increase in pH of gastric aspirate in all patients (P <0.001) and in 80% pH was greater than 2.5 units at the timeof induction of anaesthesia. The pH of gastric aspirate continuedto increase after induction of anaesthesia and was greater than4 units in all patients at the time of tracheal extubation andin the early recovery period.