门静脉高压症脾亢脾巨噬细胞数量及其吞噬功能的观察

目的观察门静脉高压症(PH)脾亢脾脏巨噬细胞(MΦ)数量及其吞噬功能的变化,为进一步探讨PH脾功能亢进(脾亢)的发病机制提供依据。方法取20例PH脾亢患者的手术脾脏作为PH组,按脾脏肿大程度的分级标准,再分为中度肿大组(11例)和重度肿大组(9例)。6例正常脾外伤性破裂患者的手术脾脏作为对照组。称重后贴壁法分离培养脾脏MΦ,用细胞计数板在显微镜下计数MΦ的相对数(每g脾脏组织中的MΦ数)并计算MΦ绝对数(整个脾脏内MΦ的总数),鸡红细胞吞噬法计算MΦ的吞噬率和吞噬指数。结果对照组、PH中度和重度脾大组MΦ的相对数分别为(13．13±3．72)×10~5/g、(8．80±0．97)×10~5/g、(7．29±1．33)×10~5/g,PH组比对照组均显著减少(P＜0．01),但PH的两组之间差异无统计学意义(P＞0．05)；PH组脾脏的重量明显增加(P＜0．01),可达正常脾重的3．5～6．0倍(放血后)；各组MΦ的绝对数分别为(1．94±0．55)×10~8、(4．91±1．12)×10~8、(6．86±0．77)×10~8,PH组比对照组均显著增多(P＜0．01),且PH重度肿大组也显著多于中度肿大组(P＜0．01)；各组MΦ的吞噬率和吞噬指数分别为(6,33±0．58)%和(0．07±0．01)、(11．25±2．19)%和(0．14±0．03)、(13．00±2．38)%和(0．16±0．04),PH组比对照组均显著增强(P＜0．01),但PH的两组之间比较差异无统计学意义(P＞0．05)。结论PH脾亢时,脾脏MΦ的相对数虽然减少,但绝对数增多,MΦ的吞噬功能增强。MΦ在PH脾亢的形成中可能扮演着非常重要的角色。进一步支持了脾亢发病中的“脾内阻留学说”。     

门静脉高压症脾功能亢进时脾脏巨噬细胞功能变化的研究

目的 观察门静脉高压症脾功能亢进时脾脏巨噬细胞(Mψ)的功能变化.方法 选取西安交通大学医学院第二附属医院2005年9月至2006年3月收治的门静脉高压症脾功能亢进患者12例,均为慢性乙型肝炎患者(实验组),同期外伤脾破裂患者4例(正常对照组).所有患者均行脾脏切除术.贴壁培养法分离纯化脾脏组织Mψ,RPMI-1640培养液将收获的细胞制备成细胞悬液,应用Vybant Phagocytosis Assay试剂盒、人TNF-α EliSpot试剂盒、DQTM ovalbumin试剂盒检测脾脏Mψ的吞噬、分泌及抗原呈递功能.结果 与正常脾脏Mψ相比,门静脉高压症脾功能亢进脾脏Mψ的吞噬率、抗原呈递阳性细胞比例和分泌TNF-α的阳性细胞数(每105个细胞中阳性分泌细胞数)明显增高(86.4±7.1比61.8±4.1,26.3±1.6比15.6±1.8,387.0±24.3比240.3±13.0,P<0.01).结论 门静脉高压症时脾脏Mψ吞噬、抗原呈递和分泌功能明显增强,细胞处于活化状态,进一步说明门静脉高压症时脾脏没有完全丧失免疫功能,但可能处于某种紊乱状态.     

门静脉高压症脾功能亢进脾巨噬细胞Toll样受体2、4 mRNA表达变化的研究

目的 检测门静脉高压症(PH)脾亢脾和正常脾巨噬细胞(Mφ)中Toll样受体2、4(TLR2、4) mRNA的表达差异,为进一步深入探讨Toll样受体在PH脾亢发生中的作用奠定基础.方法 选取门静脉高压症脾亢患者(均为慢性乙型肝炎患者)的手术切除脾脏(12例)为实验组,外伤性脾破裂患者的手术切除脾脏(4例)为正常对照组.贴壁培养法分离纯化脾脏组织Mφ,荧光定量PCR法对Mφ表面Toll样受体2、4 mRNA的表达进行检测,并将两组结果进行统计学分析比较.结果 与正常脾脏相比,PH脾亢脾Mφ TLR2、4 mRNA的表达水平明显增强(TLR2:2.29±0.55 vs 1.06±0.53,P <0.05;TLR4:2.32±0.41 vs 1.01±0.14,P <0.01).结论 PH脾亢脾Mφ TLR2、4的mRNA表达水平明显升高,与蛋白水平免疫组化的结果一致,进一步支持了"内毒素血症→脾脏Mφ Toll样受体活化→Mφ吞噬破坏血细胞增多"是PH脾亢发生可能机制的观点.     

脾动脉缩窄式远端脾肾分流术七例

目的 探讨脾动脉缩窄式(splenic artery coarctation，SAC)远端脾肾静脉分流术(USRS-SRC)治疗门脉高压症的疗效。方法 7例肝硬化门脉高压症病人行DSRS-SAC术，术后随访3～11个月。术前和术后观察门静脉压力、门静脉直径和脾脏大小变化，以及外周血细胞计数、肝功能的改变。结果 DSRS-SAC术后脾胃区静脉压力明显下降(P＜0．01)，又能维持良好的向肝血流灌注，脾脏显著缩小（P＜0．01)，脾亢纠正，无肝性脑病和再出血。血清总胆红素升高(P＜0．05)，3例腹水一度增多。结论 DSRS-SAC是一种治疗门脉高压症可选择的较理想术式。     

脾脏巨噬细胞在门静脉高压症脾功能亢进发生中的作用

目的 探讨脾脏巨噬细胞（Mφ)在门静脉高压症（PHT）脾功能亢进发生中的作用。方法 采用免疫组化和透射电镜等方法，对比观察正常脾脏和PHT脾脏Mφ的数量、分布、超微结构、Mφ内酸性磷酸酶（ACP）含量以及Mφ吞噬破坏血细胞数量的变化。结果 与正常脾脏相比，PHT脾内Mφ细胞密度相对减少，Mφ内ACP含量增多，Mφ表面伪足增多、增长，胞内溶酶体数量增多，Mφ吞噬破坏血细胞的数量明显增多。结论 脾脏Mφ在PHT脾亢的发生中可能起着重要作用。     

脾动脉栓塞治疗脾功能亢进

自1973年Maddison 首先应用介入放射技术作脾动脉栓塞,治疗1例晚期肝硬化伴门脉高压、脾功能亢进(简称脾亢)病人以来,脾栓塞术已有近20年历史.但直至80年代初,脾栓塞技术才广泛应用于临床.通过脾动脉外周分支的拴塞,使脾实质发生无菌性梗死,从而削弱脾脏对血细胞的破坏吞噬功能,脾亢得以改善.     

肝硬化肝移植术后脾功能亢进的研究进展

脾功能亢进(脾亢)指各种原因造成的表现为脾脏肿大及一种或多种血细胞减少的临床综合征,是肝硬化门静脉高压症的常见严重并发症。肝移植术能够有效缓解大部分肝硬化患者合并的脾亢,极少数顽固性脾亢患者可采用脾切除术、部分脾栓塞术或给予重组人粒细胞集落刺激因子治疗。     

肝硬化门静脉高压症时脾功能与脾的病理生理

肝硬化门脉高压症时脾脏的过度淤血致脾脏肿大，肿大的脾脏使脾的吞噬功能增强致脾功能亢进。一般来说，脾亢是指：脾大；贫血，白细胞减少和（或）血小板减少症；骨髓代偿性增生；切脾可改善病情。脾亢的发生机制至今仍不清楚，目前仍停留在三种学说阶段：脾内阻留学说、脾激素学说、抗体学说。其中影响较广的脾内阻留学说认为脾亢时血细胞减少是因为其在脾内被阻留，并被吞噬细胞破坏所致。脾切除和部分脾切除之所以可有效治疗脾亢就是因为它消灭和减少了脾内血细胞池。     

门静脉高压性脾功能亢进患者的外周血细胞变化

门静脉高压性脾肿大、脾功能亢进（简称脾亢）的患者由于脾脏病理性功能增强，导致了循环血液中的血细胞呈现不同程度的减少，但血细胞减少的程度、范围是否有一个量化的指标？近15年来，笔者经治门静脉高压性脾肿大脾亢患者278例，占同期收治门静脉高压性脾肿大病例的90%，报告如下。[第一段]     

脾切除对肝硬化门静脉高压脾功能亢进患者影响的研究进展

肝炎后肝硬化通常合并门静脉高压症,后者常致脾功能亢进(脾亢).对于同时伴有脾亢的患者,是否联合行脾脏切除,目前尚存在争议.持保脾观点的一方认为,脾切除后会降低免疫功能,增加感染机会和肝肿瘤的发生,同时会增加门静脉系统并发血栓的风险.而主张切脾的一方认为,联合脾切除作为外科治疗门脉高压症的主要方法之一,除了能降低门静脉压...     

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.