胰岛细胞瘤的诊治体会

目的：研究胰岛细胞瘤诊断和治疗。方法：回顾分析8例胰岛细胞瘤外科治疗的临床资料,功能性胰岛细胞瘤3例,无功能性胰岛细胞瘤5例。肿瘤位于胰头1例,胰颈与胰体交界处1例,胰体4例和胰尾2例。8例均施行手术,5例施行肿瘤部位胰腺部分切除术,3例施行胰体尾切除术。结果：8例均治愈出院,无手术并发症,3例功能性胰岛细胞瘤手术后血糖上升5．5mmol／L以上,无功能性胰岛细胞瘤术后腹部不适症状消失。结论：手术切除胰岛细胞瘤可取得满意的效果。     

非功能性胰岛细胞瘤16例临床分析

目的探讨非功能性胰岛细胞瘤的诊断和治疗方法。方法对近16年间收治的非功能性胰岛细胞瘤16例临床资料回顾性分析。其中位于胰头部4例,胰体尾部12例,瘤体长径平均12cm。结果行肿瘤摘除术6例,胰十二指肠切除术3例,行包括肿瘤在内的远端胰腺及脾脏切除3例,保留脾脏的胰体尾切除术3例,因肿瘤广泛侵浸未能切除1例。治愈性切除率为93.75%(15/16),全组无手术死亡。随访资料显示:11例良性肿瘤患者全部存活,已2～16年。5例恶性肿瘤患者中,1例因肿瘤广泛侵犯未能切除者,术后5个月死于多器官衰竭;1例胰体尾切除并左肝切除者存活2年;胰十二肠切除者2例,分别存活1年和6年,胰体尾切除加脾切除1例已存活12年8个月。结论钡餐,B超,CT,MRI,以及ERCP对该病有诊断价值,手术切除是治疗非功能性胰岛细胞瘤的主要方法,效果良好。     

2例恶性非功能性胰岛细胞瘤的临床分析

目的 探讨恶性非功能性胰岛细胞瘤的临床特点及诊断治疗方法。方法 对2例恶性非功能性胰岛细胞瘤患者进行回顾性分析。结果 首例病人初次手术时发现脾脏转移,行胰尾及脾脏切除,5年后因结肠脾曲转移再次行左半结肠癌根治术,术后5年死亡;次例病人首次手术已发现腹腔广泛转移,行病灶局部切除术,术后10个月死亡。结论 腹部B超、CT检查对定位诊断有帮助,最终诊断恶性胰岛细胞瘤只有肿瘤转移才是唯一可靠的标准。主要的治疗方法是手术根治及联合化疗。     

功能性胰岛细胞瘤患者围手术期血糖监测

目的:探讨功能性胰岛细胞瘤围手术期血糖监测方法.方法:总结9例手术切除功能性胰岛细胞瘤患者围手术期血糖监测临床经验.结果:7例单病灶行单纯胰岛细胞瘤切除术,2例多病灶行胰体尾切除术,术后血糖恢复正常,2例血糖水平略高,补充胰岛素后可控制正常.结论:功能性胰岛细胞瘤明确诊断后首选手术切除,围手术期严密监测血糖,对患者的康复有着重要的意义.     

胰岛细胞瘤的诊断和外科治疗

目的 探讨胰岛细胞瘤的诊断和外科治疗经验. 方法 收集我院1994年1月~2004年12月收治的26例胰腺胰岛细胞瘤患者的临床资料,对其临床表现、检查手段和治疗结果进行回顾分析. 结果 本组以反复发作性意识障碍和反复中上腹隐痛为主要症状,女性发病率高,占61.5%;胰岛素瘤和非功能性胰岛细胞瘤各13例;恶性占11.5%,良性占88.5%;26例手术者中,胰头、体、尾部分别占19.2%,30.8%,50%;2例为多发肿瘤,肿瘤最大直径8 cm;13例胰岛素瘤患者发作时血糖均<2.8 mmol/L(50 mg/dl),血浆胰岛素及C肽增高,胰岛素指数(胰岛素/血糖)>0.3,手术切除后,11例血糖恢复正常.本组患者均行B超和CT检查,88.5%胰腺发现有占位病变.脾胰体尾切除术、肿瘤局部切除术和胰头十二指肠切除术是主要的手术方式,术中均做活检.胰痿是术后主要并发症. 结论 胰腺胰岛细胞瘤发病隐匿,术前诊断困难,根据临床症状及B超和CT检查等可明确肿瘤的位置,而最终定性还是要依据术后病理检查,本病预后明显好于胰腺癌,因此一旦明确诊断应积极争取彻底切除肿瘤.胰腺胰岛细胞瘤具有较高的手术切除率,本组为100%.病理显示非功能性胰岛细胞瘤恶变率高于胰岛素瘤.对于恶性胰岛细胞瘤术后可运用化疗和介入治疗.     

小儿非功能性胰岛细胞瘤的治疗体会

目的 报告小儿非功能性胰岛细胞瘤的症状、诊断及治疗。方法 对3例非功能性胰岛细胞瘤患儿的资料进行回顾性分析。结果 小儿非功能性胰岛细胞瘤生长缓慢。症状不典型，以腹部疼痛时轻时重、右上腹肿块为主，均手术摘除肿瘤。结论 小儿非功能性胰岛细胞瘤的临床表现以腹部肿块为主，B超、CT和X线钡餐透视是主要检查手段，治疗原则是将肿瘤完整切除。     

功能性胰岛细胞瘤的手术切除分析

目的探讨如何提高功能性胰岛细胞瘤的手术切除率,减少肿瘤遗漏,增加治疗效果。方法回顾分析2003-2005年功能性胰岛细胞瘤4例的临床诊治过程。结果功能性胰岛细胞瘤4例,1例影像学检查未能明确定位者,行保守治疗;2例分别行胰头部肿瘤及胰尾肿瘤切除术,术后血糖恢复正常;1例行胰体尾加脾切除术,术后2个月复查血糖为1.53mmol/L并有低血糖临床症状。结论DSA的检查,对进一步明确细肿瘤的位置有肯定的作用;术前影像学定位检查资料的综合分析,可提高肿瘤的手术切除率。     

超声引导下胰岛细胞瘤精细切除的临床研究

目的 探讨在术中B超引导下胰岛细胞瘤精确切除术的临床价值.方法 对我院2000.1-2013.9近13年间收治的22例胰岛细胞瘤患者的临床特点、诊断和治疗方法进行回顾性分析总结.结果 22例患者中功能性胰岛细胞瘤占17例,无功能性5例;前者的主要表现为各种各样的低血糖症状,均有典型的Whipple三联征;后者主要是腹部包块就诊.血清胰岛素测定对诊断功能性胰岛细胞瘤有重要价值.22例经腹B超发现10例（45.5％）,17例患者术前行CT检查,阳性率76.5％ （13/17）,而薄层CT扫描的敏感性可达91.7％ （11/12）.术中B超阳性率100％（19/19）,14例采用非精确切除发生胰瘘6例,8例采用术中在B超引导下对功能性胰岛细胞瘤患者实施精确切除胰瘘l例,超声引导下胰岛细胞瘤精确切除术可有效降低术后胰瘘发生率及胰瘘的严重程度（P＜0.05）.结论 典型的临床表现、CT薄层扫描、结合胰岛素水平测定是诊断胰岛细胞瘤诊断的有效方法;术中超声不仅有助于术中肿瘤的定位,超声引导下精确切除肿瘤,最大限度的保留正常胰腺组织可有效降低术后并发症.     

胰岛细胞瘤32例诊治分析

目的:探讨胰腺内分泌肿瘤的诊断和外科治疗经验。方法:32例中行肿瘤摘除术18例,胰体尾联合脾切除术4例,胰十二指肠切除术4例,肿瘤切除并胃大部切除术2例,Whipple术3例,捆绑式胰体空肠吻合术1例。结果:B超、CT、MRI、DSA诊断胰岛细胞瘤的敏感性分别为62.5%、75%、80%、87.5%。术后并发症包括胰瘘、切口感染、腹腔内出血。结论:无功能胰岛细胞瘤恶性率显著高于功能性胰岛细胞瘤(P<0.01)。胰腺内分泌肿瘤的外科治疗方案主要取决于肿瘤的大小、定位和恶性度。对良性者宜行单纯肿瘤切除或胰腺部分切除,对恶性肿瘤应以扩大范围的根治性肿瘤切除术为主的综合治疗。     

胰十二指肠切除术治疗胰腺内分泌肿瘤(综合报道)

首例胰岛细胞瘤是1902年在一次尸检中偶然发现的.1927年Wilder等人报告了首例功能性胰岛细胞瘤,2年以后Graham完成了首例胰岛细胞瘤切除术.1935年Whipple成功的为一胰岛细胞瘤病人施行了首例胰腺十二指肠切除术.大多数胰岛细胞瘤可采用肿瘤摘除或胰尾切除术治疗.但是,当肿瘤位于胰头或胰腺钩突部时就应行胰十二指肠切除术.考虑到胰十二指肠切除术有较高的死亡率和并发症率,许多外科医生对此术式的应用持慎重态度.然而近年来,随着手术死亡率和并发症率的不断降低,胰十二指肠切除术已渐成为一安全的术式,其指征也较前放宽.本文报告了Johns Hopk-ins医院在过去10年中对12例胰岛细胞瘤的病人行胰十二指肠切除术的情况.资料和方法     

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.     

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.     

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.