后腹腔镜肾小肿瘤剜除术12例报告

目的探讨后腹腔镜下肾浅在小肿瘤(3cm)剜除术中不阻断肾动脉的可行性。方法 2005年4月～2009年4月对12例肾单发直径1.2～3.0cm的小肿瘤行后腹腔镜肿瘤剜除术。术中游离肾动脉,预置血管夹,以备肾动脉阻断;常规不阻断肾动脉情况下,距离肿瘤边缘1cm以上褥式外翻缝合1～2针,收紧缝线打结,预先缝线阻断肾肿瘤区血供;距离肿瘤边缘0.5～1cm,剜除肾肿瘤。结果 12例后腹腔镜手术均获成功,无中转开放手术。手术时间90～170min,平均130.3min;1例剜除肾肿瘤时出血较明显,需阻断肾动脉,时间约20min。术中出血量80～400ml,平均150.6ml,无大出血输血病例。3例术后出现肉眼血尿,均在术后3d内消失。住院时间5～7d,平均6.7d。术后病理:肾脏透明细胞癌10例,错构瘤2例,切缘均阴性。12例术后随访3个月～3年,平均15.5月,复查肾功能正常,B超、CT检查无肿瘤复发,无肾脏萎缩。结论后腹腔镜肾小肿瘤剜除术中预先缝线阻断肾局部肿瘤区血供,不阻断肾动脉是安全可行的。     

后腹腔镜保留肾单位手术26例报告

目的：探讨后腹腔镜保留肾单位手术的方法和疗效。方法：2004年9月-2006年11月采用后腹腔镜技术使用超声刀、双极电凝对26例肾肿瘤患者行保留肾单位手术，其中局限性肾癌17例，肿瘤平均直径2．5cm（1．5～4．0cm）；肾错构瘤9例．肿瘤平均直径2．6cm（1．5～4．0cm）。观察手术时间、术中术后出血量、术后住院天数、并发症及手术疗效。结果：26例均完成腹腔镜保留肾单位手术，平均手术时间170min，平均出血量95m1．2例患者需要输血，1例术中输血200ml，另1例术后第3天输血800ml，无尿漏等其他并发症。术后住院时间平均9天，平均随访9个月，肿瘤无复发。结论：后腹腔镜保留肾单位手术安全可行，肿瘤切除彻底．创伤小，术后恢复快。     

硅胶管牵拉控制肾蒂在腹腔镜肾肿瘤剜除术中的应用

目的：探讨提高腹腔镜。肾肿瘤剜出术效果的方法。方法：对7例直径在4cm以下的肾肿瘤行腹腔镜肿瘤剜除术。术中采用硅胶管牵拉控制肾蒂．在无血的情况下完成手术。结果：7例手术均成功．肾脏热缺血时间平均33min；术后平均住院时间7．8d；6例术后随访2～15个月。肾功能良好．未见肿瘤复发。结论：腹腔镜肾肿瘤剜出术中应用硅胶管牵拉控制肾蒂，具有止血效果好、手术创伤小、术后恢复快等优点。     

腹腔镜保留肾单位手术的实验与临床研究

目的 探讨腹腔镜保留肾单位手术的可行性及疗效。方法 成功完成2例家猪腹腔镜肾部分切除术后，于2002年11月至2004年3月，行经腹途径腹腔镜保留肾单位手术8例（肾肿瘤剜除术3例，肾部分切除术5例）。男女各4例，平均年龄43岁。肾细胞癌5例，肾错构瘤3例。肿瘤直径2．0～3．8cm，平均2．6cm。左侧3例，右侧5例。术中采用血管束带实行瘤区肾实质血流阻断结合肾动脉阻断。创面止血结合采用电凝、超声刀、止血纱布、生物蛋白胶及镜下直接缝合技术。结果 8例手术均获成功。手术时间130～235min，平均165min。术中出血80～600ml，平均240ml。区域性肾实质血流阻断时间0～30min，平均18min。肾动脉阻断时间0～20min，平均14min。术后住院5～9d，平均7d。术中发生瘤体裂开1例，术后发生应激性溃疡1例。术后随访3～19个月，平均10个月，未见患肾功能损害和肿瘤复发或转移。结论 对于严格选择的肾脏小肿瘤病例，腹腔镜保留肾单位手术是一种安全可行的治疗选择。区域性肾实质血流阻断法，能缩短肾动脉阻断时间，减少患肾功能热缺血损害。熟练掌握镜下直接缝合技术是保证本术式成功的关键。     

后腹腔镜肿瘤剜除术治疗肾错构瘤(附20例报告)

目的:探讨后腹腔镜保留肾单位手术治疗肾错构瘤的手术技巧和临床效果。方法:采用后腹腔镜技术对20例肾错构瘤患者行肿瘤剜除术。其中择期手术患者19例,因肾错构瘤破裂出血急诊手术1例。肿瘤直径1.8～8.7cm,平均4.8cm。采用单纯肾动脉阻断并以吸引器吸除肿瘤的手术方法,观察手术时间、术中出血量、术后住院天数和术中术后并发症及手术效果。结果:20例手术均获得成功,无中转开放手术。平均手术时间119min,19例择期手术患者平均出血量85ml,急诊患者未行肾动脉阻断,术中出血约为1 000ml。平均术后住院时间9.9d。1例术后出现尿瘘,经保守治疗愈合出院。其他患者无围手术期并发症。术后随访3～60个月,无肿瘤复发。结论:后腹腔镜肾错构瘤剜除术应用肾动脉热缺血阻断、介入超声、吸引器吸除肿瘤、术前放置输尿管导管、止血手段等新技术安全可行,具有创伤小、并发症少、恢复快、住院时间短等优点。     

孤立肾巨大肿瘤保留肾单位的手术治疗

目的：探讨孤立。肾巨大肿瘤的诊治方法。方法：对2例孤立肾肾肿瘤直径≥8．0cm的患者,先行腹腔镜手术游离肾脏血管,再行开放手术将。肾肿瘤剜除。结果：2例手术均获成功,1例术后发生肾功能不全,1例完全康复,术后随访12个月,肿瘤均无复发或转移。结论：对于孤立。肾巨大肿瘤,术前行肾动脉血管检查、肾肿瘤超选择性栓塞,术中运用腹腔镜游离肾血管、开放手术冷缺血阻断肾动脉,使肿瘤与正常肾组织分界清楚、减少出血、加快手术操作、有助于保护患者肾功能,提高患者生活质量。     

腹腔镜下肾血管平滑肌脂肪瘤单纯剜除术

目的探讨后腹腔镜肾血管平滑肌脂肪瘤单纯剜除术的手术方法及临床疗效。方法2005年6月～2006年12月,采用后腹腔镜途径对11例肾血管平滑肌脂肪瘤行单纯剜除术。术中沿瘤体边缘外用电钩或超声刀切开肾包膜,肿瘤突出部分沿边缘整块取出,深部剩余部分富脂瘤体组织由吸引器吸出,再以小方纱擦拭瘤窝表面,双极电凝止血。生物蛋白胶、止血纱布及可吸收线缝合肾脏创面。结果11例手术均成功完成,无中转开放者。平均手术时间84.5min(60～110min),平均术中出血量51ml(20～100ml),平均术后住院时间8.8d(6～14d),无并发症。术后肾功能正常。随访7～23个月(平均13.4月),影像学检查无局部肿瘤组织残留或复发。结论后腹腔镜肾血管平滑肌脂肪瘤单纯剜除术具有创伤小、出血少、恢复快、住院时间短等优点。     

机器人辅助腹腔镜剜除加肾部分切除治疗肾错构瘤6例报告

目的：总结机器人辅助腹腔镜剜除加肾部分切除治疗肾错构瘤的手术经验,探讨此术式的疗效及安全性。方法：2008年8月～2009年1月,在机器人（DaVinciS手术机器人系统）辅助腹腔镜下对6例肾错构瘤患者行剜除加切除手术,肾皮质部分肿块采用剜除方法,。肾髓质部分肿块采用肾部分切除方法。收集手术相关资料后与国外此手术初期的相关资料及我院同组人员腹腔镜保留肾单位肾部分切除术的资料进行比较分析。结果：6例手术均取得成功,无一例转换术式。肿瘤平均直径6．3（2～20）cm,手术时间（不包括术前机器人准备时间）158（120-210）min,肾动脉阻断时间29（20-45）min,术中出血量388（30～1000）ml,术后5～6天下床活动,3天拔除引流管,术后住院8（7～9）天。术后病理检查提示6例均为肾错构瘤。随访21～24个月,所有患者未见局部病灶残留,肾功能均在正常范围。结论：机器人辅助腹腔镜下剜除加切除治疗肾错构瘤操作灵活,创伤小,安全可靠,疗效确切。     

后腹腔镜手术治疗肾脏肿瘤5例报告

目的：探讨后腹腔镜肿瘤剜除术和肾部分切除术治疗肾脏肿瘤的应用价值。方法：采用后腹腔镜经后腹腔途径对5例肾肿瘤患者分别行肿瘤剜除术和肾部分切除术，并观察手术时间，术中出血量，术后住院天数和术中术后并发症及手术效果。结果：5例手术全部获得成功，平均手术时间为87min，平均出血量55ml，平均术后住院时间为5．8d，手术效果好，无并发症。结论：该术式肿瘤切除精确彻底，创伤小，出血少，恢复快，有推广应用价值。     

腹腔镜保留肾单位手术治疗小肾癌18例报告

目的探讨腹腔镜保留肾单位手术治疗小肾癌的方法和疗效。方法选择小肾癌患者18例,肿瘤直径1．5～3．0cm,经后腹腔途径腹腔镜保留肾单位肿瘤切除11例,经腹腔途径手术7例。术中距瘤体0．5～1cm用超声刀切除肿瘤,肿瘤床多处活检送快速病理。结果幅例手术均获成功,无中转开放。手术时间85—140rain,平均110min;术中出血量50～600ml,平均145ml;术后住院时间8～13天,平均9．6天。术后随访8～30个月,未见肿瘤局部复发,未见转移,切口未见种植。结论腹腔镜保留肾单位手术治疗小肾癌,创伤小、临床效果肯定,可作为小肾癌首选治疗方法。     

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.     

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.     

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.     

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.     

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.     

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.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.