经内镜胆管引流对恶性胆管梗阻术前肝功能恢复的疗效观察

目的　比较经内镜胆管引流术对梗阻性黄疸术前肝功能恢复的疗效。方法　腹壶周围癌、胰头癌共 76例 ,引流组 3 6例 ,其中行内置管引流 2 9例 ,鼻胆管引流 7例 ;对照组 40例 ,未做任何方式的胆管减压引流。结果　入院后第 14 d丙氨酸氨基转移酶 (ALT)、凝血酶原时间 (PT)和血清总胆红素 (TBIL)水平下降幅度分别为 :引流组 71.46± 11.81% ,2 3 .0 9±9.5 6% ,81.5 8± 7.5 0 % ;对照组 48.87± 19.3 2 % ,18.3 7± 9.3 1% ,5 .88± 3 .65 %。结论　经内镜胆管引流术能迅速改善梗阻性黄疸病的肝功能 ,为后续治疗创造良好的条件     

生长抑素对急性重症胰腺炎患者外周血TNFa水平的影响

目的　观察急性重症胰腺炎患者外周血肿瘤坏死因子α(TNFα)水平 ,以及施他宁对其的影响 ,为TNFα应用于急性胰腺炎的评估及施他宁应用于该病的治疗提供进一步的依据。方法　急性重症胰腺炎患者随机分成对照组 (n =10 )和治疗组 (n =10 ) ,两组入院第 1d抽血检测TNFα。对照组每d静滴 5 Fu 10 0 0mg ,共 3d ;治疗组静滴施他宁 5 0 0 μg ,维持 2 4h。 3d后抽血复查TNFα。另选同期非胰腺炎患者 8例于入院第 1d检测TNFα作基线对照。结果　 8例非胰腺炎患者外周血TNFα低于检测下限 (10 pg/ml) ,入院第 1d对照组和治疗组TNFα分别为 2 5 9.12± 10 5 .6 9pg/ml和2 5 1.32± 110 .47pg/ml,两者差异不显著。 3d后治疗组TNFα为16 6 .33± 5 0 .72 pg/ml,较对照组2 12 .0 5± 6 2 .0 4pg/ml,明显降低。 结论　急性重症胰腺炎患者入院第 1d即有TNFα显著升高 ,可作为评价本病严重程度的指标。早期应用施他宁能部分抑制重症胰腺炎患者外周血TNFα水平。这是施他宁治疗急性胰腺炎的一个重要机制     

经鼻胆管冲洗胆道+灌注高浓度抗生素治疗急性梗阻性化脓性胆管炎

目的：探讨B超监视下经内镜鼻胆管引流术(ENBD),用生理盐水冲洗胆道+局部灌注高浓度抗生素,治疗急性梗阻性化脓性胆管炎的疗效及安全性。方法：对22例急性梗阻性化脓性胆管炎的患者,采取B超监视下行ENBD术、术后经鼻胆管行胆道冲洗及灌注高浓度抗生素为主的非手术综合治疗,对比患者治疗前后的血清总胆红素水平、肝功能、胆总管内径变化,并对患者临床资料进行回顾性分析。结果：本组22例患者除1例因壶腹癌行保守治疗外,其余21例内镜下鼻胆管引流术成功,胆汁引流通畅,经胆道冲洗+灌注高浓度抗生素治疗后治愈。结论：急性梗阻性化脓性胆管炎在B超监视下行ENBD术较X监视行ENBD术,胰腺炎并发症发生率降低。经鼻胆管用生理盐水冲洗胆道+局部灌注高浓度抗生素为主的综合治疗是有效的、安全的。     

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目的　探讨早期如何运用血液滤过改善重症急性胰腺炎 (SAP)的预后。方法　 1997年 4月至 2 0 0 2年7月采用血液滤过治疗SAP49例。其中普通型SAP(CSAP组 ) 3 4例 ,暴发性SAP(FSAP组 ) 15例 ,分析血滤参数和观察病人的手术率、非手术治愈率、总体存活率、住院时间和费用。结果　SAP和FSAP的血滤时间分别为 (5 45± 3 3 8)h与 (2 3 7± 2 2 1 6)h ,血液净化量、超滤液量和血滤器数目分别为 (75 0± 18 7)L与 (3 0 8 0± 3 61 6)L ;(2 2 45 5± 1186 1)mL与 (4 83 4 1± 2 83 2 8)mL ;(2 6± 1 3 )与 (2 9± 1 5 )个。CSAP组和FSAP组的中转手术率、非手术治愈率、总体存活率、住院时间、住院费用分别为 2 0 6% (7/ 3 4)与 73 3 % (11/ 15 ) ;10 0 % (2 7/ 2 7)与 2 5 % (1/ 4) ;91 2 % (3 1/ 3 4)与 60 % (9/ 15 ) ;(3 2 3± 10 4)天与 (13 5± 5 6 9)天 ;(5 3 4± 3 0 1)万元与 (2 9 3± 11 9)万元。结论　发病 72h内 ,重症胰腺炎加用短时血液滤过和暴发性胰腺炎急诊手术引流腹腔、后腹膜加持续血液滤过是进一步改善预后的良好措施     

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对于急性胆源性胰腺炎,内镜治疗具有重要的地位。行内镜逆行胰胆管造影术(ERCP)及内镜超声检查可明确诊断,指导进一步治疗。早期行经内镜鼻胆管引流(ENBD)、经内镜乳头括约肌切开术(EST)、胰管支架置入可及时解除梗阻,降低胆管、胰管压力,引流胆汁及胰液,缓解胰腺炎,降低并发症的发生率。内镜治疗可能导致出血、穿孔、胰腺炎加重、腹膜后感染等严重并发症,因此应严格掌握适应证,对于伴有急性胆管炎的急性胆源性胰腺炎,早期内镜治疗是绝对适应证;对于不伴有急性胆管炎的重症急性胰腺炎,应严密观察,除留置空肠营养管之外的早期内镜治疗并没有明显益处。     

鼻胆管引流对于ERCP术后并发症的防治

目的探讨内镜下鼻胆管引流术预防和治疗ERCP术后胰腺炎、胆道感染、穿孔等并发症的效果。方法回顾分析2003年5月至2005年5月间868例ERCP患者的临床资料,其中657例于内镜治疗后行置鼻胆管引流,211例患者未行鼻胆管引流。在行鼻胆管引流的患者中,胆道结石为354例,胆道恶性梗阻为128例,胆总管扩张为56例,胆总管囊肿为17例,缩窄性乳头炎为34例,ERCP未见明显异常68例;未行鼻胆管或内支架引流的患者中,胆总管结石116例,胆总管扩张51例,胆总管囊肿3例,缩窄性乳头炎11例,ERCP未见明显异常30例。结果两组术后急性胰腺炎发生率分别为1.4%和3.8%(P>0.05),但引流组均为轻症胰腺炎,而非引流组50%为重症胰腺炎。急性胆管炎的发生率分别为0.5%和2%(P<0.05),而且非引流组中40%出现AOSC,需手术治疗。胰管显影率分别为13%和14%(P>0.05);穿孔各2例(0.3%vs0.9%),其中未行鼻胆管引流组中1例经手术后痊愈,其余均经非手术治疗痊愈。结论内镜下鼻胆管引流能有效预防和治疗部分ERCP并发症。     

内镜下胆道金属支架置入联合鼻胆管引流治疗恶性梗阻性黄疸

目的探讨经内镜胆道金属支架置入术(EBMSD)联合鼻胆管引流术(ENBD)治疗恶性梗阻性黄疸的疗效。方法回顾2009年1月至2010年3月采用内镜逆行胰胆管造影术(ERCP)并留置胆道金属支架,同时联合ENBD治疗的恶性梗阻性黄疸患者共17例,并对疗效、鼻胆管引流情况及术后并发症进行分析。结果 17例恶性梗阻性黄疸患者,行ERCP操作22例次,一次置管成功21例次,操作成功率95.45%。术后1周黄疸明显消退,肝功能改善,生活质量提高。术后2例患者鼻胆管引出血性胆汁、6例患者胆汁引流不畅,通过对症处理恢复正常。17例患者中仅2例术后发生高淀粉酶血症,无出血、穿孔、急性胰腺炎、胆管炎发生。结论胆道金属支架置入联合鼻胆管引流具有创伤小、并发症少、疗效确切、重复性强、方便观察、术后恢复快的特点,成为目前治疗恶性梗阻性黄疸的重要姑息性治疗手段。     

生长激素对急性坏死性胰腺炎大鼠肠粘膜上皮细胞凋亡的影响

目的观察生长激素 (GH)对急性坏死性胰腺炎 (ANP)大鼠早期肠粘膜上皮细胞凋亡的调节作用。方法ANP模型大鼠分ANP组和ANP加GH治疗组 ,假手术组 (SO组 )作为对照。分别用DNA琼脂糖凝胶电泳、流式细胞仪分析和dUTP缺口末端标记法研究肠粘膜细胞凋亡 ,免疫组织化学方法检测肠粘膜凋亡相关蛋白FasL及Bax表达。结果ANP大鼠各时点肠粘膜DNA电泳均可见典型的凋亡“梯形”条带 ,而GH治疗组仅于 3h出现“梯形”条带。术后 3h、6h、12h、2 4h肠粘膜脱落细胞凋亡比例分别为 :SO组为 (5 4± 4) %、(2 8± 6 ) %、(39± 5 ) %、(2 9± 11) % ,ANP组为 (5 0± 11) %、(80± 9) %、(4 8± 17) %、(5 0± 10 ) % ,术后 6h较SO组明显增高 (P <0 0 1) ;GH治疗组 ,(4 8± 11) %、(2 7± 15 ) %、(4 2± 7) %、(30± 10 ) % ,与SO组各时点比较差异无显著意义 ,且术后 6h较ANP组降低(P <0 0 1)。术后 3h、6h、12h、2 4h各时点肠粘膜细胞凋亡指数分别为 :SO组为 (6± 2 )、(8± 2 )、(11±1)、(5± 1) ,ANP组为 (18± 4)、(2 0± 3)、(15± 2 )、(14± 2 ) ,较SO组明显增高 (P <0 0 1) ;GH治疗组为(10± 2 )、(10± 2 )、(13± 2 )、(14± 4) ,其中术后 3h、6h较ANP组降低 (P <0 0 1)。FasL及Bax蛋白在假手术组呈弱表达 ,AN     

胆管结石患者胆汁对人胆管癌细胞增殖的影响

目的观察胆管结石患者胆汁对人胆管癌细胞QBC939生长的影响 ,探讨胆管结石与胆管癌发生、发展的关系。方法应用噻唑蓝比色法检测 2 0份胆管结石患者胆汁和 10份正常胆汁对QBC939增殖的影响 ,应用流式细胞仪测定细胞周期和凋亡。结果胆管结石患者胆汁与正常胆汁比较 ,明显促进QBC939细胞增殖 ,用胆管结石患者胆汁处理 4 8h的QBC939细胞增殖指数显著上升 (P <0 0 1) ,胆管结石胆汁组 (47%± 10 % )S期细胞比例比正常胆汁组 (2 3%± 3% )明显增高 (P <0 0 1) ,G0 /G1期细胞比例 (42 %± 8% )比正常胆汁组 (6 3%± 10 % )明显降低 (P <0 0 5 )。结论胆管结石患者胆汁具有潜在的促增殖活性 ,胆管结石与胆管癌的发生、发展关系密切     

内镜鼻胆管引流术在腹腔镜和开腹胆总管探查术中的应用

目的　评价内镜鼻胆管引流术 (Endoscopicnasobiliarydrainage ,ENBD)配合腹腔镜和常规开腹手术治疗胆总管结石的疗效。　方法　回顾分析 1997年 1月～ 2 0 0 1年 7月应用ENBD配合完成腹腔镜胆总管探查、I期缝合术 4 4例及开腹胆总管探查、I期缝合术 34例。　结果　 78例均手术成功 ,术后无胆漏、胆道出血、胆管炎等并发症。术中结石取净率 10 0 % (78 78)。术后住院时间 :腹腔镜组为 (6 2±1 3)d ,开腹组为 (7 4± 2 1)d。随访 5 7例 ,时间 (1～ 4 5 )年 ,平均 2 6年 ,腹部彩色B超检查无胆管狭窄及结石复发。　结论　ENBD配合腹腔镜和开腹胆总管探查取石、胆总管I期缝合术安全、可靠。     

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.     

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.     

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.     

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.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.