血管内电凝瓣膜修复治疗下肢深静脉瓣膜功能不全的手术探讨

目的探讨股部小切口修复静脉瓣膜、血管内电凝曲张静脉治疗原发性下肢深静脉瓣膜功能不全的微创手术方法。方法选择67例原发性下肢深静脉瓣膜功能不全的病人,在硬膜外麻醉或腰麻下取股部小切口,行第一对股浅静脉瓣膜外修复,同时利用40 W手术电刀对迂曲扩张的浅静脉进行血管内电凝。总结手术入路和手术体会。结果患者术后7 d拆线,股部小切口愈合良好,下肢曲张浅静脉消失,无淋巴漏等并发症发生;随访1~5年,超声多普勒检查电凝后的大隐静脉和曲张浅静脉均已闭合,无曲张静脉复发现象,但有2例瓣膜修复处术后3年有轻度返流。结论股部小切口修复瓣膜结合血管内电凝曲张静脉,是一种较好的治疗下肢深静脉瓣膜功能不全的微创手术方法,操作简便、创伤小、恢复快、并发症少,值得推广应用。     

激光光凝技术结合静脉瓣膜修复治疗下肢深静脉瓣膜功能不全的手术探讨

目的探讨股浅静脉瓣窦环包联合激光光凝技术治疗下肢深静脉瓣膜功能不全的手术治疗方法. 方法 33例下肢深静脉瓣膜功能不全的患者,在硬膜外麻醉下首先在卵圆窝下方4 cm做长约4 cm小切口,行股浅静脉瓣膜外修复,同时高位结扎切断大隐静脉,再由大隐静脉远端插入4F导管,光导纤维跟入,使用810 nm波长的半导体激光器,对下肢迂曲扩张的大隐静脉及其浅静脉进行血管内光凝术. 结果术后6 h即可自由活动,术后8 d拆线,切口愈合良好,肢体活动自如,无皮肤灼伤、皮下血肿和下肢水肿.平均随访18(6～24)个月,超声检查示大隐静脉和曲张浅静脉均已闭合、深静脉瓣膜外修复处均无返流,无复发或再通现象,局部皮肤营养障碍性病变明显减轻,下肢酸胀感减轻或消失. 结论激光光凝技术结合静脉瓣膜修复治疗下肢深静脉瓣膜功能不全,方法可行、疗效可靠、操作简便、创伤小、美观、恢复快,是一种较好的微创治疗方法,值得推广应用.     

血管镜下股浅静脉瓣膜修复成形术12例分析

目的 探讨血管镜直视下股浅静脉壁外瓣膜修复术治疗深静脉瓣膜功能不全的可行性和效果。方法 通过血管镜从大隐静脉断端导入至股浅静脉第1对瓣膜近侧，同时阻断股总、股深、股浅静脉，应用含肝素的冲洗液建立清晰水柱，直接观察瓣膜的形态、缺损和变形的程度，对12例原发性深静脉瓣膜功能不全患者实施直视下壁外静脉瓣膜成形术。结果 12例术后行静脉顺行造影证实9例患肢股浅静脉第1对瓣膜返流基本消失，3例静脉瓣膜返流明显改善，无静脉血栓和其他并发症。结论 血管镜直视下行股浅静脉瓣膜壁外修复术准确有效、微创和安全。     

小切口瓣膜修复联合血管内电凝治疗原发性下肢深静脉瓣膜功能不全

目的:探讨股部小切口修复深静脉瓣膜联合血管内电凝曲张的大隐静脉和浅静脉，治疗原发性下肢深静脉瓣膜功能不全的临床应用价值。方法:67例原发性下肢深静脉瓣膜功能不全的患者，在硬膜外麻醉下取股部小切口，行第一对股浅静脉瓣膜外修复；同时选用40W输出功率的电刀，对迂曲扩张的大隐静脉或浅静脉进行血管内电凝。结果:患者于手术5～10h后下床活动，7d天拆线，股部小切口愈合良好，无淋巴瘘等并发症发生。随访1～5年，超声检查电凝后的大隐静脉和曲张浅静脉均已闭合，无曲张静脉复发。2年内临床治愈率为100%；3年后2例股静脉瓣膜修复处轻度反流，临床治愈率96.36%。结论:股部小切口修复瓣膜功能联合血管内电凝曲张静脉，是一种较好的治疗下肢深静脉瓣膜功能不全的手术方法，操作简便、创伤小、恢复快，适合基层医院推广应用。     

股浅静脉第一对瓣膜环缩术治疗原发性下肢深静脉瓣膜功能不全(附40例报告)

目的 评估应用股浅静脉第一对瓣膜环缩术治疗原发性下肢深静脉瓣膜功能不全的疗效。方法 对原发性下肢深静脉瓣膜功能不全的40例患者(共45条下肢)施以股浅静脉第一对瓣膜环缩术．环缩材料选用7—0或6—0无损伤缝线。结果 经上述治疗后．全组病例术后随访2～24个月．临床症状均明显缓解。彩超复查88．6％(31／35)的患肢瓣膜无返流发生。结论 股浅静脉第一对瓣膜环缩术是治疗原发性下肢深静脉瓣膜功能不全比较理想和有效的方法。     

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目的分析下肢深静脉瓣膜修复成形术治疗下肢深静脉瓣膜功能不全的临床疗效。方法对下肢原发性深静脉瓣膜功能不全的101例116条肢体实施股静脉瓣膜外修复成形术,并利用静脉功能不全评分、双向彩超、流速剖面图彩超技术和空气体积描记仪(APG)等方法对其疗效进行分析。结果随访率87.9%,随访病例症状消失,96.1%的肢体浅静脉曲张消失无复发。13例溃疡肢体中有11条在术后3～6个月溃疡消失,2条明显缩小。术前Ⅲ度返流肢体术后90%以上静脉瓣膜功能达Ⅱ度以下,67.6%的瓣膜功能恢复正常或接近正常;静脉功能不全评分从术前15.33±1.83改善到术后5.07±0.60(P<0.01);术前Ⅳ度返流肢体术后80%以上静脉瓣膜功能达Ⅱ度以下,40.5%的瓣膜功能恢复正常或接近正常,静脉功能不全评分从术前17.38±2.67改善到术后7.25±1.12(P<0.01)。51例58条肢体经流速剖面图彩超检查示,术后静脉返流量均值比术前明显减少(P<0.01);经APG检测术后VFI均值比术前明显减少(P<0.01)。结论下肢深静脉瓣膜外修复成形术能有效地治疗深静脉瓣膜功能不全,并可大大改善血流动力学指标,对静脉性溃疡也有一定的疗效。     

激光焊接技术修复深静脉瓣膜功能不全初步探讨

目的探讨激光焊接修复深静脉瓣膜功能不全的新技术,总结激光微创治疗本病的临床经验。方法选择40例深静脉瓣膜功能不全患者,在硬膜外麻醉下取股部小切口,显出股浅静脉瓣膜环,选择1 470 nm半导体激光器3W激光输出功率,折叠焊接瓣膜环,缩窄管腔修复瓣膜关闭不全,同时选用6W激光功率光凝闭合曲张的浅静脉。术后采用超声多普勒连续随访观察6～36月。结果术后6 h下床活动,手术后3 d即活动自如,术后5 d更换敷料见4例出现下肢少量瘀斑,手术后10 d完全消失。手术后7 d拆除股部皮内缝合线,切口愈合良好活动自如,原迂曲扩张的浅静脉消失。所有接受治疗病例均无皮下血肿,无皮肤灼伤,无淋巴漏或下肢水肿等并发症。手术后3、6、12、24和36个月复查,大隐静脉和曲张浅静脉均已闭合,深静脉瓣膜修复处均未见返流。平均随访16(6～36)个月,均未见复发。结论激光焊接技术修复深静脉瓣膜功能不全是一种较好的微创方法,值得临床进一步深入探讨和应用。     

股浅静脉戴戒术术中彩色多普勒超声的应用体会

目的 研究术中彩色多普勒超声指导股浅静脉戴戒术治疗原发性深静脉瓣膜功能不全疗效。方法 对原发性下肢深静脉瓣膜功能不全的患者63例69条肢体采用股浅静脉戴戒术，术中应用彩色多普勒超声测量静脉返流，瓣环扩大及判定瓣膜的功能．指导最佳环缩位置及程度，并于术中判断瓣环及瓣膜修复情况。结果 全组病例均于术中证实，瓣环环缩适当，瓣膜开闭良好，静脉返流完全控制。结论 术中彩色多普勒超声的应用使股浅静脉戴戒术更精确有效，避免了盲目环缩的位置不当、环缩程度不够、返流控制不完善等弊端。     

下肢深静脉瓣膜包窄术缩窄比例的个体化初探

目的　评价缩窄比例个体化行人造血管股浅静脉第一瓣膜包窄术治疗原发性下肢深静脉瓣膜功能不全的疗效。方法　对 5 4例 ( 5 6条肢体 )施以人造血管股浅静脉第一瓣膜包窄术 ,并根据瓣膜反流程度施以不同的缩窄比例 ,术后观察临床疗效和瓣膜反流情况。结果　术中检查显示 5 4条肢体瓣膜在包窄术完成后不再反流。 5 5条肢体获随访 14～ 3 5个月 (平均 2 3个月 ) ,临床有效率为94.5 %。双功彩超复查瓣膜功能修复率 85 .5 % ,轻、中度反流两组术后瓣膜功能修复率无显著性差异( P >0 .0 5 ) ;重度反流组术后瓣膜功能修复率 66.7%明显低于轻中度反流组的 92 .5 % ( P <0 .0 5 )。结论　行人造血管股浅静脉第一瓣膜包窄术治疗原发性下肢深静脉瓣膜功能不全时 ,应根据术中情况选择不同的缩窄比例。尤其对于轻中度返流的病例 ,缩窄比例的个体化是可行而有效的     

小切口瓣膜修复联合腔内激光治疗原发性下肢深静脉瓣膜功能不全(附1146例临床分析)

目的总结股部小切口瓣膜修复结合血管内激光光凝曲张静脉治疗原发性下肢深静脉瓣膜功能不全的临床体会。方法下肢深静脉瓣膜功能不全1 146例共1 278条患肢均在硬膜外麻醉下手术:首先取股部小切口,行第一对股浅静脉瓣膜外修复;选用810 nm的半导体激光器,对迂曲扩张的大隐静脉行血管内光凝术。结果术后当天患者即可下床,无淋巴漏、皮下血肿或下肢水肿等并发症。均获随访,平均3.0(0.5~8)年,手术后不同阶段的临床治愈率分别为:6月97.96%,1年96.95%,2年96.06%,3年95.60%,4年95.51%,5年95.40%,6年95.05%,7年94.52%,8年93.68%。结论微小切口瓣膜修复联合血管内激光光凝技术,是治疗原发性下肢深静脉瓣膜功能不全较好的方法,操作简单,创伤小,恢复快,美观,近期和远期疗效较好,值得进一步推广应用。     

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.