胆囊造瘘后内镜下胆囊黏膜电凝消除术

目的探讨胆囊造瘘后经内镜电凝消除胆囊黏膜的可行性。方法20例胆囊造瘘术后病人在硬膜外麻醉或基础加局部麻醉下行电切镜检查和治疗。通过胆囊造瘘窦道插入Storz前列腺电切镜，分别用滚球和滚桶电极电凝消除胆囊黏膜，电凝功率60～70w，滚桶移动速度10～15mm／s，使胆囊内壁呈均匀棕灰色。结果内镜下操作时间25～55min，平均35min。术后1个月胆囊腔完全闭合者12例，3个月完全闭合者5例，另3例未闭合者形成潴留性囊肿。结论用电切镜电极消除胆囊黏膜是胆囊造瘘后胆囊硬化闭塞的可行方法，可避免再次胆囊切除术。     

腹腔镜治疗胆囊内瘘7例报告

目的总结腹腔镜手术诊治胆囊内瘘的经验。方法回顾分析2002年1月～2005年12月我院2113例腹腔镜胆囊切除术中遇到的7例（0．3％）胆囊内瘘的诊治经过。结果7例均系术中确诊，其中胆囊十二指肠瘘5例，胆囊横结肠瘘和胆囊胃瘘各1例。6例在腔镜下完成胆囊切除和瘘口关闭，平均手术时间130min（50～180min），术中无意外出血和损伤，术后恢复顺利；1例胆囊十二指肠瘘中转开腹。随访6个月～4年（平均22，6个月），无手术相关并发症发生。结论对于Lc中遇到的胆囊内瘘，可以酌情选择镜下完成手术，同样安全可靠。腔镜下瘘管的处理可以采用：夹闭或套扎、缝合、造疼和内镜切割吻合器切断闭合．     

电凝法处理胆囊动脉在腹腔镜胆囊切除术中的应用

目的：探讨电凝法处理胆囊动脉在腹腔镜胆囊切除（ laparoscopic cholecystectomy ,LC）术中的安全性、可行性。方法我院2004年5月～2013年9月采用电凝法处理胆囊动脉行三孔法LC 376例。结果中转开腹9例（腹腔粘连致胆囊三角解剖不清）,其余367例在腹腔镜下完成手术,均以电凝法处理胆囊动脉,12例同期行腹腔镜阑尾切除术,1例行左肾囊肿开窗引流术。术后1例因胆总管结石致胆道梗阻行二次手术胆总管切开取石。结论胆囊良性疾病行LC时,电凝法处理胆囊动脉是安全、可行的。     

腹腔镜胆囊切除术中肝我胆管损伤及处理

自１９９２年１月－１９９６年１月，１２５０人因胆囊结石或胆囊息肉样病变在本院施行ＬＣ，胆管损伤７例，损伤类型包括：（１）这或直管横断各１例；９２）直管部分横断２例；（３）电凝损伤总肝管及右肝和各１例；（４）钛夹钳夹石肝眨１例。本组处理方法为胆管修补、胆管对端吻合及空肠Ｒｏｕｘ－Ｙ吻合术。本文认为术者损伤经验不足、不适当的止血操作、胆囊病因素及解剖不清是导致胆管损伤的原因。胆管损伤最重要的仍然是术中     

腹腔镜下单纯电凝胆囊动脉行胆囊切除120例分析

目的:探讨腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)术中胆囊动脉单纯电凝后切断的技术,观察其临床效果。方法:120例LC术中采用镜下分离胆囊动脉电凝后切断,不使用钛夹而完成手术。结果:除1例中转开腹外,其余均顺利完成手术,术后恢复顺利,随访3个月无不适。结论:腹腔镜下胆囊动脉单纯电凝后切断而不使用钛夹,手术安全可靠。     

联合后-前胆囊三角入路在腹腔镜胆囊切除中的应用

目的探讨联合后-前胆囊三角入路在腹腔镜胆囊切除中的应用价值。方法回顾性分析我院2007年1月至2010年1月期间经联合后-前胆囊三角入路解剖胆囊管及胆囊动脉行腹腔镜胆囊切除的240例患者的临床资料。结果 238例患者安全地完成腹腔镜胆囊切除,术中出血4例,均于镜下止血成功;中转开腹2例。全组无胆管损伤,发生漏胆2例,经引流自愈。结论联合后-前胆囊三角入路解剖胆囊管及胆囊动脉行腹腔镜胆囊切除是一种安全、容易掌握的手术方法。     

应用普通腹腔镜器械行经脐单孔腹腔镜胆囊切除术

2011年4～11月行52例经脐单孔腹腔镜胆囊切除术,采用5 mm腹腔镜,单孔多通道套管,塑料trocar,常规腹腔镜器械(分离钳、电凝钩、电凝棒等)。trocar和器械错落放置,不要在一个水平面。可吸收夹夹闭胆囊管,超声刀凝固离断胆囊动脉。手术时间18～40 min,平均27 min,术中出血<5 ml。2例放置腹腔引流,48 h后拔除。无胆漏、出血、腹腔积液等并发症。     

电凝钩在腹腔镜胆囊切除术中的应用

目的探讨腹腔镜胆囊切除术中胆囊床止血方式的不同对肝功能的影响。方法选择术前肝功能正常的患者100例行腹腔镜胆囊切除术,随机使用电凝钩和电凝棒各50例进行胆囊床止血,手术后24h分别检测肝功能状况。结果手术后24h使用电凝钩组ALT、AST明显升高,而使用电凝棒组基本在正常范围内。结论使用电凝钩进行胆囊床止血会对患者造成一过性的肝功能损伤。腹腔镜胆囊切除术中选择合理的手术操作会减少肝功能损伤。     

腹腔镜胆囊切除术后胆囊管瘘的诊断和处理

目的 探讨腹腔镜胆囊切除术(LC)后胆囊管瘘的诊断和处理方法。方法 回顾性分析3例LC术后胆囊管瘘病例的临床资料。结果 3例均为女性，因慢性结石性胆囊炎行LC。临床表现分别为原有心律失常的加重，腹腔引流管引流出胆汁，以及脐部穿刺孔溢出胆汁样液。确定诊断的时间分别是术后第1天、第2天和第20天。2例再次行腹腔镜手术，套扎关闭开放的胆囊管，腹腔冲洗并引流；1例行腹腔穿刺置管引流，并经内镜乳头切开及置入胆道支架。3例均获治愈。结论 LC术后胆囊管瘘临床表现多样，B超可以发现腹腔积液，确定诊断依赖于MRCP和ERCP。微创手术可以安全有效地处理这一并发症。腹腔镜再手术可以有效地关闭开放的胆囊管；内镜下引流的方法要有有效的腹腔引流的配合。     

经皮胆囊镜下化学性胆囊切除术的可行性研究

化学性胆囊切除术（ｃｈｅｍｉｃａｌｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙ）是Ｓａｌｏｍｏｎｏｖｉｔｚ等〔１〕于１９８４年首次提出的代替手术胆囊切除的方法。１０余年来，国内外学者对该技术进行了较深入的研究，但仍然存在着胆囊管及胆囊闭合不全的问题。笔者通过动物...     

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.