低位直肠癌保留肛门内括约肌捆扎套入法超低位结肠-肛管吻合术

目的介绍用支撑捆扎套入法完整保留齿状线和肛门内括约肌的超低位结肠肛管吻合术。方法87例低位直肠癌在完成全直肠系膜切除后,保留距离齿状线≤1cm的直肠,剥离直肠黏膜,保留齿状线。近端结肠内置入肛门支撑吻合管,经肛门拖出与直肠残端吻合。结果87例保留内括约肌的超低位结肠肛管吻合术无手术死亡及吻合口漏,随访2～60个月,随访率89%,无吻合口复发;盆腔内软组织肿瘤复发3例,闭孔淋巴结复发2例,异时肝转移6例。术后12个月吻合口狭窄6例。术后6个月对79例排便功能进行评价,平均每日排便2～3次,可以区分排气和排便,可以控制半成形便,排便不规律52例。结论低位直肠癌根治术后,支撑捆扎套入法可以完成保留肛门内括约肌的超低位结肠肛管吻合术。     

支撑捆扎套入法结肠-肛管吻术(Povrk)在低位或超低位直肠癌保肛手术中的应用

目的:介绍用支撑捆扎套入法结肠肛管吻合术(Povrk)在保留齿状线和肛门内括约肌的低位或超低位直肠癌中的应用方法。方法:37例低位直肠癌在术前放疗,在全直肠系膜切除基础上用支撑套入法结肠肛管吻合术完成手术,术后予希罗达口服化疗。结果:本组37例无死亡病例。近期吻合口瘘2例,均引流后治愈,直肠癌距肛门4～7cm术后排便功能恢复好。结论:支撑法结肠肛管吻合术用于低位直肠癌保肛手术可作为双吻合器保肛手术的替代或改良方法以应用。     

全直肠系膜切除支撑捆扎法低位或超低位结肠-直肠(肛管)吻合术

目的介绍在全直肠系膜切除基础上用支撑捆扎法完成低位直肠癌低位或超低位结肠-直肠(肛管)吻合手术术式。方法对346例低位直肠癌在全直肠系膜切除和根治性清扫基础上,用支撑捆扎法进行保留肛门括约肌手术,对直肠断端距齿状线≥1cm者用改良Welch手术完成结肠-直肠吻合术;直肠断端距齿状线≤1cm者行保留肛门内括约肌的结肠-肛管吻合术。结果本组346例手术中无死亡病例,术后近期出现吻合口漏4例(1·2%),局部引流2周治愈2例、横结肠造口转流2例,无吻合口出血。吻合口距离齿状线距离:2~3cm者114例,1~2cm者145例,0~1cm者87例。术后吻合口狭窄10例,狭窄率2·9%。Lifetable法计算5年生存率和局部复发率分别为78·6%及6·3%。手术后3个月排便功能的优良率为82·6%。结论支撑捆扎法用于低位直肠癌保肛手术可以完成耻骨直肠肌上缘到肌间沟平面的吻合,吻合口漏和吻合口狭窄发生率较低。     

腹腔镜下低位直肠癌保肛术中支撑吻合管的应用价值

【摘要】〓目的〓探讨腹腔镜下低位直肠癌保肛术中支撑吻合管的应用价值。方法〓腹腔镜下对14例低位直肠癌病人实施全直肠系膜切除(TME)根治性切除,用支撑吻合管完成超低位结直肠-肛管吻合术。结果〓超低位结直肠-肛管吻合成功14例,吻合时间l5~30 min,直肠系膜均完整切除,其中结肠与外科肛管吻合8例,结肠与解剖肛管吻合6例。术后病人肛门括约肌功能、排尿功能良好,未发生吻合口狭窄与吻合口瘘者。术后6个月排便功能优良率为85.71%(12/14)。寿命表法计算5年生存率和局部复发率分别为78.57%(11/14)及7.14%(1/14)。结论〓腹腔镜下低位直肠癌保肛术中支撑吻合管的应用是安全可行的。     

支撑捆扎法在超低位直肠癌保留肛门括约肌手术中的应用

目的探讨支撑捆扎法在超低位直肠癌保留肛门括约肌手术中的应用。方法对117例直肠癌患者采用支撑捆扎法完成超低位结肠-直肠(肛管)吻合术。患者均在术前行纤维结肠镜检查和活组织检查,确诊为直肠腺癌,且经直肠腔内B超、盆腔CT及MR I排除肿瘤侵犯肛提肌和盆腔淋巴结广泛转移。结果117例超低位直肠癌保肛手术围手术期呼吸衰竭死亡1例,术后吻合口漏2例,1例局部引流治愈,1例直肠阴道瘘行横结肠造瘘转流手术。未发生吻合口狭窄,术后3月排便功能评价:优29例,良44例,一般31例,差13例,优良率为62.4%(73/117)。结论支撑捆扎法用于直肠癌保留肛门括约肌手术安全、可行,可以完成从肛提肌内口到括约肌间沟的结肠-直肠(肛管)吻合,效果良好。     

完全腹腔镜下直肠癌全直肠系膜切除根治术29例报告

目的探讨四孔法完全腹腔镜下完成全直肠系膜切除(total mesorectal excision,TME)、直肠拖出低位或超低位行结肠-直肠、结肠-肛管吻合治疗直肠癌的可行性。方法2008年4月~2009年5月,按TME原则,四孔法完全腹腔镜下对29例低位直肠癌实施低位或超低位结肠-直肠、结肠-肛管吻合术,全系膜游离后拖出肛门外切除并手工吻合或吻合器吻合。结果29例均完全在腹腔镜下完成,无辅助切口,保肛率100%。手术时间150~310min,平均185min。术中出血20~120ml,平均50ml。术后2~3d恢复胃肠功能并下床活动,住院时间12~35d,平均15d。术后28例应用止痛剂。1例直肠阴道瘘。29例随访3~13个月,平均8个月,未发现穿刺口种植和局部复发。结论四孔法完全腹腔镜下行TME低位或超低位结肠-直肠、结肠-肛管吻合术治疗直肠癌安全可行,具有创伤小、出血少、保肛率高、术后疼痛轻、恢复快等优点。     

低位直肠癌拖出型结肠肛管吻合术的临床应用

目的：探讨拖出型结肠肛管吻合术治疗低位直肠癌的安全性及效果。方法：对98例低位直肠癌应用拖出型结肠肛管吻合术，即肿瘤切除后将直肠远端外翻，近端结肠经外翻的直肠拖出，于肛门外行结肠肛管一期吻合，并立即送回盆腔。结果：术后吻合口瘘7．15％，局部复发率13．27％，5年生存率69．39％，术后3～6个月肛门功能接近正常人，无1例大便失禁。结论：应用拖出型结肠肛管吻合术治疗低位直肠癌应选择合适的病例，可获得较高的生存率及生活质量。     

支撑捆扎法回肠Pouch-直肠肌鞘内肛管一期吻合术

目的 探讨用肛门支撑吻合管支撑捆扎法进行回肠囊袋（Pouch）－直肠肌鞘内肛管一期吻合术，并分析该术式对结、直肠息肉病、溃疡性结炎治疗的价值。方法 对结、直肠息肉病行全结肠及上段直肠切除，保留齿状线上4－6cm直肠。距齿状线处2cm剥离直肠粘膜。回肠“J”型、“S”型、“W”型Pouch内置入肛门支撑吻合管8cm，结扎－缝扎、固定。距直肠粘膜残端1cm处用2号肠线全层内荷包缝合一周，在直肠肌鞘套内回肠Pouch与外科肛管吻合。溃疡性结肠炎直肠肌鞘内与解剖肛管吻合。结果 一期完成手术，吻合口愈合良好。无肌间血肿，无吻合口漏及吻合口狭窄。术后6个月排便功能优良率达88.8%，随访1－5年未发现息肉复发。结论 全结肠及部分直肠切除后用支撑捆扎法行一期手术即可完成回肠Pouch-直肠肌鞘内肛管吻合术，保留肛管直肠移行区的回肠Pouch外科肛管吻合术优于回肠Pouch解剖肛管吻合术。     

荷包缝合钳代替直线型吻合器行直肠癌低位保肛术

目的 探讨经济、实用、安全的直肠癌低位保肛手术方法。方法 对245例中低位直肠癌患者按全直肠系膜切除术(TME)要求切除直肠，荷包缝合钳封闭直肠残端，管型直肠吻合器行低位保肛术。结果 低位前切除106例，超低位前切除117例，结肠肛管吻合术22例。本组切缘均无肿瘤残留。术后出现吻合口瘘10例(4．1％)，均经横结肠造瘘后痊愈；尿潴留16例(6．5％)；手术死亡1例(0．4％)。结论 用荷包缝合钳代替直线型吻合器行直肠癌低位保肛术安全、简便、经济。     

全系膜切除加吻合器技术在中低位直肠癌保肛手术中的应用

目的探讨全直肠系膜切除（total mesorectal excision，TME）＋吻合器技术在中低位直肠癌手术的应用效果。方法对103例中低位直肠癌患者实施TME原则的根治性手术，应用可重复管状消化道吻合器行低位结肠-直肠端端吻合术。结果103例均完整切除直肠系膜，无手术死亡，吻合口距齿状线4 cm以上46例，2-4 cm47例，2 cm以内者10例。均获随访，平均26（3-48）个月，术后发生吻合口漏1例，重置肛管引流一周治愈；吻合口狭窄3例，经定期扩肛后缓解；术后患者肛门括约肌功能良好。局部复发伴腹腔广泛转移6例（5.8%），死亡12例（11.7%）。结论TME术式基础上应用可重复弯管消化道吻合器行结肠-直肠低位吻合符合直肠肛门生理要求，具有操作简单安全，费用较低，吻合成功率高等优点，值得推广。     

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 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.     

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.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

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.     

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.     

Intrathecal administration of sameridine to patients subjected to arthroscopic knee joint surgery

Background: Sameridine, a new substance with both local anesthetic and opioid effects, was administered intrathecally for the first time to humans, i. e. in patients subjected to arthroscopic knee joint surgery.
Method: A dose-escalating (10, 15, 20 and 25 mg), open study was performed in 33 patients. Only two patients were included in the 25 mg group.
Results: Sameridine provided good quality of surgical anesthesia in all patients except those receiving 10 mg. The maximum level of sensory block, Th5–Th7, was reached within 30 min with a median duration of 3.6–3.9 h. The motor block was more profound with increasing dose, but never lasted longer than the sensory block. The influence on heart rate and blood pressure was minor and atropine and ephedrine were needed in four patients. No clinically significant ECG-changes were detected and no arrhythmias were recorded. Oxygen saturation and respiratory rate did not decrease in a clinically significant way and were not affected by concomitant morphine given i. v. postoperatively. There were few side-effects, the most frequent being mild pruritus (10/33).
Conclusion: Sameridine provided clinically adequate anesthesia for the patients receiving the doses of 15, 20 and 25 mg. Further studies are needed to evaluate the substance and it is of great interest to clinically investigate the opioid component with respect to postoperative analgesia.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.