经肝动脉灌注平阳霉素碘油乳剂对兔正常肝脏组织的影响

目的：探讨平阳霉素碘油乳剂（PLE）经肝动脉灌注对兔正常肝脏组织的影响。方法：14只4～5个月龄日本大耳白兔，体重（2.5±0.2）kg，按注入生理盐水或PLE的量分为假手术组、实验A组（低剂量组）和实验B组（高剂量组）。各组兔均开腹穿刺肝动脉，按分组剂量注入PLE。术后1，2，4，6周取病理切片，HE染色，光镜下观察肝脏组织学改变;免疫组织化学（免疫组化）染色标记血小板衍化生长因子B链（PDGF-B），并行图象分析。结果：A组HE染色肝细胞呈一过性水样变，变性在2周时最重，至6周已明显减轻。B组HE染色2周时肝细胞明显水样变，4周时可见汇管区纤维组织增生，6周时部分肝组织出现明显假小叶结构。免疫组化染色显示，PDGF-B在肝细胞胞膜及纤维间隔中有明显表达。结论：经肝动脉灌注PLE可导致正常肝脏组织产生不同程度的肝纤维化;PDGF-B参与了肝纤维化的病理过程。     

小鼠全肝缺血再灌注时肺泡巨噬细胞TLR2的激活与肺损伤的机制

目的：探讨肺泡巨噬细胞Toll样受体2（TLR2）的激活机制及其在肝脏缺血再灌注（HIR）中肺损伤的意义。方法：用野生型小鼠C3h/Heouj和TLR4缺失小鼠C3h/Hej建立HIR动物模型。于再灌注1，6，12h后经支气管肺泡灌洗液获取肺泡巨噬细胞，采用荧光定量PCR方法检测TLR2/4mRNA的表达。同时检测支气管肺泡灌洗液中内毒素及肿瘤坏死因子（TNF）的水平，肺组织湿干重比值，肺组织髓过氧化物酶的浓度，并进行肺组织学评分。结果：C3h/Heouj组HIR缺血再灌后各时点肺泡巨噬细胞TLR2/4mRNA表达升高，TLR2mRNA表达持续升高，TLR4mRNA6h达到最高值。同时C3h/Heouj组HIR后支气管肺泡灌洗液中TNF水平明显升高，肺损伤加重，肺组织湿干重比值持续升高，肺组织髓过氧化物酶持续增加(P<0.05)。C3h/Hej组HIR后TLR2mRNA表达仅轻度升高，且支气管肺泡灌洗液中TNF水平低于C3h/Heouj组(P<0.05)，肺损伤轻于C3h/Heouj组(P<0.05)。结论：HIR可致肺泡巨噬细胞表面TLR4的激活，可上调TLR2的表达，从而可加重HIR时的肺损伤。     

原位肝移植中受体血管异常时的肝动脉重建

摘要：目的 探讨原位肝移植中动脉异位重建的方法及效果。 方法 回顾性分析我院10年来的440例肝移植中36例因受体血管异常而行异位重建的方法及术后处理措施等。 结果 36例中行供肝动脉与受体肾下腹主动脉吻合20例，与肾上腹主动脉吻合10例，与胃左动脉吻合4例，与脾动脉吻合2例。5例围手术期死亡，但吻合口通畅，31例存活3个月至4年无血管相关并发症，仅1例术后2个月因胆道缺血坏死行再次肝移植。 结论 肝移植时受体肝动脉有病变或异常改变时，应将受体肾下或肾上腹主动脉、脾动脉、胃左动脉与供肝动脉进行异位重建，可取得满意效果。     

胆囊癌GBC-SD细胞经顺铂处理后的survivin表达及意义

目的: 探讨经顺铂（DDP）处理胆囊癌细胞后survivin表达及其与肿瘤细胞耐药之间的关系。 方法:采用MTT比色法测定胆囊癌细胞对4种化疗药物的敏感性。RT-PCR检测survivin mRNA的表达。Western blot检测survivin蛋白表达的变化。结果:GBC-SD细胞对化疗药物的敏感性从高到低依次为DDP>ADM>5-FU>MMC。化学药物处理后的第1天，3组胆囊癌细胞的survivin mRNA表达水平均降低;其中0.5μg/mL DDP＋GBC-SD组下降了10%，3μg /mL DDP＋GBC-SD组下降36%，6μg /mL DDP＋GBC-SD组下降了28%。第3天，0.5μg/mL DDP组和3μg/mL DDP组GBC-SD细胞的survivin mRNA表达与第1天比较，分别上升22%和64%，但6μg/mL DDP组仍持续降低，仅为第1天的66%。0.5μg/mL DDP组和3μg/mL DDP组作用3d后的GBC-SD细胞中survivin蛋白含量分别升高了15%和12%，而6μg/mL DDP组则下降了80%。 结论:低浓度的DDP即能诱导胆囊癌细胞内survivin的表达增加，这可能是胆囊癌细胞对化疗药物产生耐药性的因素之一。     

左侧结肠癌性梗阻一期切除吻合治疗:附58例报告

摘要：为探讨左侧结肠癌并急性肠梗阻理想的处理原则和方法,回顾分析58例左侧结肠癌并发急性肠梗阻行一期切除吻合术患者的临床资料。本组均成功手术，无手术死亡，术后除7例有切口不同程度液化感染外，无吻合口漏、腹腔感染等并发症，均痊愈出院。提示：对能耐受手术切除的左侧结肠癌并发梗阻，在必要的围手术期处理前提下，一期切除吻合是可行的。避免了横结肠造口、二期手术、癌肿扩散及并发症的发生。     

骨盆骨折合并盆腔血肿的髂内动脉介入栓塞治疗

笔者采用明胶海绵或不锈钢圈栓塞双侧髂内动脉治疗骨盆骨折合并盆腔血肿7例，其中6例患者术前处于休克前期或休克期，血压低，出血明显，栓塞成功后，出血停止，血压回升，栓塞后2d血压恢复正常基础水平。提示：双侧髂内动脉栓塞对治疗骨盆骨折合并盆腔血肿效果明显，是一种有效的治疗手段。     

经外膜缓释雷公藤内酯醇抑制自体移植静脉内膜增生

目的:探讨经外膜缓释雷公藤内酯醇（triptolide）对自体移植静脉内膜增生的抑制作用。方法:健康雄性新西兰大白兔24只，建立颈外静脉-颈总动脉移植模型。随机将动物等分为3组。空白组移植血管不给任何处理， F-127多聚凝胶对照组在移植血管外膜喷洒20 %F-127多聚凝胶0.5 mL，实验组在移植血管外膜喷洒携带雷公藤内酯醇300μg的F-127多聚凝胶0.5 mL。术后2周取标本。用组织形态学方法检测血管内膜增生程度，免疫组化检测标本中bcl-2和Fas的表达，TUNEL法检测标本中血管平滑肌细胞(VSMC)凋亡的水平。结果:静脉移植2周后，与空白组和F-127对照组比较，实验组血管内膜增生明显受抑制（P<0.05），bcl-2的表达［（18.2±8.4） %］显著减少，而Fas的表达［（21.4±8.9） %］显著增加，凋亡细胞［（28.4±7.6） %］也显著增加（P<0.05）。结论:经外膜缓释雷公藤内酯醇可有效抑制移植静脉内膜增生，这一作用可能系通过促进VSMC凋亡而实现的。     

股动脉假性动脉瘤外科治疗18例分析

回顾性分析股动脉假性动脉瘤18例的临床资料。1例因介入穿刺引起的股动脉假性动脉瘤行局部压迫治疗,15例行假性动脉瘤切除术,2例行股动脉结扎术。结果示1例股动脉结扎术患者术后出现肢体坏死，行膝上截肢后康复出院，另17例痊愈出院。提示对股动脉假性动脉瘤行动脉瘤切除、股动脉端端吻合可作为首选的手术方式。     

手法张力美容切口治疗乳腺纤维瘤的体会

目的:探索一种治疗彻底、创伤少、瘢癍痕小、费用低的乳腺纤维瘤治疗方法。方法:回顾近3年来465例采用手法张力美容切口治疗乳腺纤维瘤患者的临床资料。结果:465例手术均最大限度争取行乳晕或腋窝皱褶或乳腺下方皱褶切口。切口均甲级愈合，无明显瘢痕，双乳对称，外形功能无影响，站立时切口不明显。结论:手法张力美容切口治疗乳腺纤维瘤是一种适合大部分乳腺纤维瘤患者的手术方法，具有治疗彻底、创伤少、瘢痕小、费用低。     

胆道再手术原因分析：附828例报告

目的:分析导致再次胆道手术的原因，以期减少胆道再手术率。方法:总结1990—1999年间收治的再次胆道手术患者828例的临床资料，对胆道疾病再次手术的原因进行归类分析。结果:再手术的主要原因是结石复发或残留，占65.10%;结石合并Oddi括约肌狭窄占33.82%;单纯Oddi括约肌狭窄占9.54%;胆管损伤性狭窄和胆肠吻合口狭窄占10.39%;胆道系统肿瘤占6.52%。结论:胆道再手术的主要原因仍以结石复发或残留为主，其次为Oddi括约肌狭窄;损伤性胆管狭窄等与手术有关的因素不容忽视。减少胆道再次手术的关键在于初次手术的彻底性和手术方法的合理性。     

烧伤休克期补液与监测相关问题的探讨

The index of monitoring bum shock resuscita- tion includes clinical signs and symptoms, laboratory examina- tions, hemodynamic variables. In recent years, there exists a tendency that the amount of transfused fluid for burn shock re- suscitation is notably increased and complications of some cases, such as abdominal compartment syndrome have been reported. One of the major reasons for excessive fluid resuscitation is to try to normalize hemodynamic parameters with the help of invasive hemodynamic monitoring. Instead of hemodynamic variables, u- rinary output combined with other traditional variables still should be considered primary criteria of adequate fluid therapy. Specification of the variables of monitoring burn shock resuscita- tion is also the basis to revise and optimize the fluid resuscitation formula.     

烧伤休克期有关补液公式的临床应用与评价

目的 评价第三军医大学烧伤休克期补液公式(简称三医大公式)在大面积烧伤患者休克防治中的应用.方法 选择2005-2007年笔者单位收治的热力烧伤患者(烧伤总面积大于或等于30%TBSA、伤后8 h内入院且无特殊疾患)共71例,分为成人组(46例)、小儿组(25例).患者入院后即按照三医大公式进行液体复苏治疗,同时监测尿量、心率、血压等指标,根据患者实际情况随时调整补液速度.记录并统计2组患者补液量、实际补液系数、尿量. 结果 71例患者均平稳度过休克期,未发生明显的因液体复苏引起的相关并发症.成人组伤后第1、2个24 h及小儿组伤后第2个24 h的实际补液量超过各自计划补液量的16%～38%.成人组第1、2个24 h的实际补液系数大于公式所要求的补液系数.2组患者第1个24 h尿量为1.1～1.2 mL·kg-1·h-1左右;第2个24 h成人组为(1.2±0.4)mL·kg-1·h-1,小儿组为(1.7±0.5)mL·kg-1·h-1. 结论 三医大公式是大面积烧伤患者休克期治疗的较好选择,在应用此公式时须强调进行个性化液体复苏治疗.     

烧伤脓毒症与多器官功能障碍综合征临床防治的现状与思考

Most of the major advances in the prevention and treatment of burn sepsis and MODS have been made within the last 20 years. Improvements have been made in gaining a better understanding of the pathophysiology of burn sepsis and MODS, in revising the definition of sepsis and MODS, and in prevention and treatment of burn shock. Additionally, improvements have been made in fluid resuscitation in patients with burn shock and in early gastrointestinal feeding to prevent transloca tinn of endotoxins from the gut. Other achievements have been made in using recombinant human growth hormone combined with intensive insulin therapy to control hyperglycemia, and potassium chloride to prevent hypokalemia in order to accelerate protein synthesis. Additional advances include early closure and coverage of the burn wound, rational use of antibiotics, immuno logical modulation to combat immunological dissonance. Also, advances have been made by using early anticoagulation treatment to prevent coagulopathy. In prevention and treatment of burn sepsis and MODS, comprehensive support for all organs during the course of treatment is emphasized. Although the advances in burn treatment have been extremely encouraging over the last 50 years, burn sepsis and MODS remain the most common cause of mortality in the criticalill. To cope with extreme environmental conditions, such as armed conflict and natural disasters, research is needed to optimize the oral resuscitation regime, and more efficacious treatment strategies that are based on an indepth understanding of the pathogenesis of sepsis.     

A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation

BACKGROUND: Ever since Charles Baxter's recommendations the standard regime for burn shock resuscitation remains crystalloid infusion at a rate of 4 ml/kg/% burn in the first 24h following the thermal injury. A growing number of studies on invasive monitoring in burn shock, however, have raised a debate regarding the adequacy of this regime. The purpose of this prospective, randomised study was to compare goal-directed therapy guided by invasive monitoring with standard care (Baxter formula) in patients with burn shock. PATIENTS AND METHODS: Fifty consecutive patients with burns involving more than 20% body surface area were randomly assigned to one of two treatment groups. The control group was resuscitated according to the Baxter formula (4 ml/kg BW/% BSA burn), the thermodilution (TDD) group was treated according to a volumetric preload endpoint (intrathoracic blood volume) obtained by invasive haemodynamic monitoring. RESULTS: The baseline characteristics of the two treatment groups were similar. Fluid administration in the initial 24h after burn was significantly higher in the TDD treatment group than in the control group (P = 0.0001). The results of haemodynamic monitoring showed no significant difference in preload or cardiac output parameters. Signs of significant intravasal hypovolemia as indicated by subnormal values of intrathoracic and total blood volumes were present in both treatment groups. Mortality and morbidity were independent on randomisation. CONCLUSION: Burn shock resuscitation due to the Baxter formula leads to significant hypovolemia during the first 48 h following burn. Haemodynamic monitoring results in more aggressive therapeutic strategies and is associated with a significant increase in fluid administration. Increased crystalloid infusion does not improve preload or cardiac output parameters. This may be due to the fact that a pure crystalloid resuscitation is incapable of restoring cardiac preload during the period of burn shock.     

早期口服补液对犬50%总体表面积烧伤休克期血流动力学和组织灌流的影响

目的 研究早期口服补液对犬50%总体表面积(TBSA)烧伤休克期血流动力学和组织灌流的影响.方法 成年雄性Beagle犬18只,先期无菌手术行颈总动脉、颈外静脉、胃、空肠及膀胱置管,24 h后用凝固汽油燃烧法造成其颈、背和胸、腹部约50%TBSA Ⅲ.烧伤.随机分为不补液(NR)、口服补液(OR)和静脉补液(IR)三组,每组6只.伤后第1个24 h NR组无治疗,OR和IR组于伤后30 min开始按Parkland公式分别从胃管和静脉输注葡萄糖.电解质溶液,伤后24 h起各组犬均实施静脉补液.测定犬伤前(0 h)和伤后2、4、8、24、48和72 h非麻醉状态下的平均动脉压(MAP)、全身血管阻力(SVR)、心输出量(CO)、左室内压最大变化速率(dp/dtmax)、尿量以及胃黏膜CO2分压(PgCO2)和小肠黏膜血流量(IMBF),并记录伤后72 h死亡率.结果 与伤前相比,各组犬MAP、CO、dp/dtmax,、IMBF和尿量在伤后2 h均大幅降低(P<0.01),而SVR和PgCO2显著升高.两补液组上述指标伤后8 h开始恢复,72 h IR组除IMBF外均恢复至伤前水平,但OR组CO、SVR及胃肠组织灌流指标仍差于伤前水平(P<0.01).NR组上述指标持续恶化,伤后24 h内无尿并全部死亡.OR组血液动力学和内脏组织灌流指标显著优于NR组,但差于IR组.伤后72 h死亡率NR组为6/6、OR组3/6,而IR组为0/6.结论 50%TBSA烧伤后早期口服葡萄糖-电解质溶液复苏效果虽差于静脉补液,但相比不补液,能显著改善血流动力学指标和内脏组织灌流,减少早期死亡,有潜力成为战争或灾害时静脉液体复苏的替代方法.     

烧伤休克液体复苏研究进展

The aim of fluid resuscitation is to restore tissue perfusion,ameliorate cellular injury,increase tissue perfusion and oxygenation,and improve end-organ functions.Many researches in the field of fluid resuscitation strategy have been made in the last decade,but vigorous debate on optimal method of resuscitation still exists.The hypotensive resuscitation strategy is particularly applicable in patients with uncontrollable hemorrhage,whereas,it is uncertain whether the theory could be used in burn shock management.Resuscitation using both colloid and crystalloid has a better outcome in treating extensive burns and septic shock.Caution should be exercised when using higher concentrations of artificial colloid and lactated Ringer's solution,of which some adverse effects have been observed.Along with the increasing use of novel hemodynamics monitoring in intensive care,parameters including stroke volume variation (SVV),intrathoracic blood volume index (ITBVI),and cardiac index (CI) have been examined as indexes of resuscitation endpoint.However,further studies should be made when applying SVV,ITBVI,and CI in guiding fluid resuscitation in burns.     

烧伤后早期心肌损害与防治

Isehemia/hypoxia is one of the key clinical issues following severe burns, and isehemic/hypoxic damage of tissues and organs is still hard to be prevented or minimized by various fluid resuscitation regimens . To those who suffered severe bums, even though fluid replacement therapy is delivered promptly, isehemic/hypoxie damage of organs is still inevitable. Previously, blood flow in vital organs such as heart was eonsidered not to be reduced because of blood redistribution under the circumstance of stress. The postbum cardiac dysfunction has been mainly attributed to the reduced blood flow returned to the heart due to decreased blood volume caused by increased capillary permeability. Therefore, postbum cardiac dysfunction has been considered to be the result of burn shock. During the past two decades, we have performed serial studies on severe burns, and found that isehemie/hypoxie myocardial damage and functional impairment of myocardium due to activation of reninangio tensin system existing in the heart itself occur immediately after severe bums even before significant reduction in blood volume secondary to an increase of capillary permeability . Such prompt myocardial damage leads to cardiac deficiency, and it is also a precipitating factor for bum shock and isehemic/hypoxie injury of systemic tissues and organs. Therefore, we called it " shock heart" in our reports. The cellular and molecular mechanisms leading to myocardial damage were systematically investigated. Strategies for prevention of early postburn myocardial damage and dysfunction, and a new effective burn shock resuscitation regimen "volume replacement" plus "dynamic support" (cardiac support and myocardial protection) have been proposed based on our previous studies.     

"容量补充"加"动力扶持"——烧伤休克有效复苏方案的思考

It is well known that shock is one of the main complications occurring during early stage of severe burn,and presently,ischemic/hypoxjc damage of tissues and organs is still hard to be prevented by various fluid resuscitation regimens.Findings in recent years demonstrated that postburn cardiac dam-age occurs promptly and much earlier than any other organs.Ap-plication of measures to ameliorate cardiac damage may improve organ blood flow in liver,kidney,and intestines,and mitigate organ damage concomitant with fluid resuscitation according to Parkland formula.These facts suggest that cardiac damage oc-curring promptly at early stage of severe burn is one of the im-portant factors leading to ischemia/hypoxia of tissues and or-gans,therefore,new resuscitation regimen including"volume re-placement"plus"dynamic suppofl"may conduce to more effec-tire burn shock resuscitation,and reduce organ complications as a result of either insufficient or over fluid infusion.     

New multifactorial burn resuscitation formula offers superior predictive reliability in comparison to established algorithms

The Parkland–Baxter formula is a widely utilized resuscitation guideline for the initial management of fluid deficits in burn victims. Implementation of resuscitation formulas has helped to reduce the incidence of shock and hypovolemic organ failure such as acute renal failure in the setting of burn trauma. However, it has been shown that indiscriminate implementation of these formulas may inappropriately suit individual patient’s requirements. In our experience resuscitation by the Parkland formula often forced corrections in order to reach predefined resuscitation goals.     

Intrathoracic blood volume as an end point in resuscitation of the severely burned: an observational study of 24 patients

BACKGROUND: Treatment of burn shock according to empirical resuscitation formulas is still considered the gold standard, and the burn community does not advocate the use of invasive cardiorespiratory monitoring in general. As a consequence, data dealing with early postburn hemodynamics are sparse, and only few studies have paid attention to the topic of end-point burn shock resuscitation. However, recent studies have suggested that burn survival may be improved when invasive monitoring is used to guide fluid therapy during the shock phase. MATERIALS AND METHODS: In an observational study of 24 patients with severe burns, the transpulmonary double indicator dilution technique was used for semi-invasive hemodynamic monitoring. The clinical utility of the intrathoracic blood volume (ITBV) as an end-point variable for fluid resuscitation was evaluated, comparing correlation of filling pressure obtained by a pulmonary artery catheter and intrathoracic blood volume to cardiac index and oxygen delivery. In addition fluid volume predicted by the Parkland burn formula was compared with the actual fluid volume given when ITBV was used as end point for resuscitation. RESULTS: ITBV-guided resuscitation was associated with restoration of preload and peripheral delivery of oxygen within 24 hours in the majority of patients. Augmentation of ITBV was significantly correlated with changes in cardiac index and oxygen transport rate. No such correlation could be demonstrated for the conventional preload parameters such as central venous pressure and pulmonary capillary wedge pressure. Thus, ITBV seemed in burned, hypovolemic patients a better indicator of the preload component of the cardiac output than the conventional preload parameters obtained with the pulmonary artery catheter. Significantly larger volumes of crystalloids than predicted by the Parkland formula were administered when ITBV was used as end point for resuscitation. The extravascular lung water remained normal during this extraordinary high volume load. CONCLUSION: ITBV may be a reliable preload indicator to guide volume therapy in life-threatening burns, and end-point-fixed resuscitation to this parameter seems to be associated with significantly higher fluid administration than calculated compared with traditional burn formulas. The effects of burn resuscitation to fixed end points on survival and multiple organ failure should be evaluated in future randomly assigned trials.