普鲁卡因静脉复合麻醉对肝脏血流和氧耗影响的实验研究

采用电磁血流仪和血气分析等技术，研究普鲁卡因静脉复合麻醉对犬体循环血流动力学及肝脏血流和氧耗影响。 １％普鲁卡因复合液以 １．０ｍｇ· ｋｇ－１／ｍｉｎ速度静滴时，随麻醉时间延长，血浆普鲁卡因浓度逐渐升高，６０分钟达５６．９±８．７ｍｇ／Ｌ。体循环各项血流动力学参数趋于稳定，仅在６０分钟产生明显的体循环抑制效应。心率和平均动脉压分别降低２７％、２５％，心指数由３．５２±０．２１Ｌ·ｍｉｎ－１／ｍ２降至 ３． ０８±０．１２Ｌ· ｍｉｎ－１／ｍ２。肝总血流量和氧耗与体循环动力学呈一致性变化。因此，肝脏疾患及肝手术的患者，只要控制血中普鲁卡因浓度不过高，仍可安全实施普鲁卡因静脉复合麻醉。     

Effect of halothane and enflurane on hepatic blood flow and oxygen consumption in dogs

We investigated the relative effects of 0.5, 1.0, 1.5, 2.0 MAC halothane and enflurane, and concurrent noxious stimulus on hepatic blood flow and oxygen consumption in 14 mongrel dogs randomly divided into groups of seven each. Hepatic arterial and portal venous blood flow (HABF and PVBF, respectively) were measured continuously using ultrasonic transit time flow meter. Mean arterial blood pressure (MAP), cardiac index (CI), hepatic oxygen supply, and hepatic oxygen consumption (H _{O 2}) were measured. Halothane significantly deceased HABF, but not PVBF in a dose dependent manner. Enflurane did not affect HABF and PVBF significantly. MAP and CI decreased in both groups, with halothane producing more marked decreases than enflurane. H _{O 2} did not change with enflurane, but did with halothane, producing significant differences, with halothane being greater at 1.5, 2.0 MAC. A noxious stimulus only caused minor change in blood flow. The results suggest that liver blood flow and oxygen consumption are affected differently by halothane and enflurane and that halothane has a stronger tendency to cause an imbalance between liver oxygen supply and consumption than dose enflurane.(Masaki E, Yasuda N, Tanifuji Y et al.: Effect of halothane and enflurane on hepatic blood flow and oxygen consumption in dogs. J Anesth 3: 118–122, 1989)     

Effects of olprinone on hepatosplanchnic circulation and mitochondrial oxidation in a porcine model of endotoxemia

Purpose This study was performed in order to assess the effects of olprinone, a phosphodiesterase III inhibitor, on hepatic oxygen delivery (DO₂H), oxygen consumption (VO₂H), and mitochondrial oxidation in the liver of a porcine endotoxemia model. Methods Fourteen pigs received continuous infusion of endotoxin via the portal vein for 240 min. From t = 150 to t = 240 min, animals were randomly divided into two groups to receive saline (control [CONT]; n = 7), or olprinone (OLP; n = 7) via the central vein. Results In the OLP group, prior to olprinone treatment at 150 min, endotoxin induced significant decreases in the cardiac index (CI; from 120 ± 31 to 65 ± 13 ml·kg⁻¹·min⁻¹; P < 0.01) and DO₂H (from 3.58 ± 0.81 to 1.55 ± 0.49 ml·kg⁻¹·min⁻¹; P < 0.01), while VO₂H was maintained. After administration of olprinone (from t = 150 to t = 240 min), CI was unchanged, while DO₂H increased from 1.55 ± 0.49 to 1.93 ± 0.38 ml·kg⁻¹·min⁻¹ (P < 0.01) and VO₂H increased from 0.42 ± 0.28 to 0.69 ± 0.38 ml·kg⁻¹·min⁻¹ (P < 0.01). At t = 240 min, the oxidation level of cytochrome aa3 was significantly higher in the OLP group than in the CONT group (OLP, 66.2 ± 19.3% vs CONT, 26.4 ± 17.3%; P < 0.01). Conclusion Our data for this porcine endotoxemia model suggest that olprinone may have beneficial therapeutic effects in restoring not only systemic and hepatic circulation but also mitochondrial oxidation in the liver.     

肝移植术后肝动脉血栓的处理及预后

目的了解肝移植术后肝动脉血栓（HAT）的处理方法及预后。方法收集2004年至2010年在北京佑安医院肝移植中心施行的427例肝移植病例的临床资料,分析HAT的临床处理方法及预后情况。结果 427例肝移植患者中,共发生HAT5例（1.2%）,发生时间为4～91d（中位时间28d）。经尿激酶介入溶栓、血栓取出、肝动脉重建、再次肝移植及高压氧等治疗后,5例患者中死亡3例。移植物存活时间为8～690d（中位时间298d）,患者存活时间为13～1005d（中位时间298d）。结论肝移植术后HAT发生率较低,但预后极差。一旦确诊及时采用尿激酶介入溶栓、血栓取出、肝动脉重建、再次肝移植及高压氧等治疗,以降低病死率。     

胰岛素对烫伤大鼠肝脏氧自由基损伤的保护作用

目的 了解大鼠严重烫伤后早期应用胰岛素对肝脏氧自由基损伤的保护作用.方法 雄性SD大鼠84只,随机分为正常组、盐水组、胰岛素组,每组各28只.后2组大鼠在背部造成30%TBSAⅢ度烫伤,伤后立即腹腔注射等渗盐水40 ml/kg或皮下注射胰岛素3 U/kg.伤后6、12、24、48 h,检测盐水组和胰岛素组大鼠肝脏总抗氧化能力(T-AOC)、超氧化物歧化酶(SOD)、活性氧(ROS)及血清丙氨酸转氨酶(ALT)含量,同时检测肝脏胞间黏附分子1(ICAM-1),光学显微镜下观察肝细胞形态学改变.正常组大鼠亦作相应检测.结果 与正常组比较,盐水组大鼠伤后6 h肝脏T-AOC、SOD明显降低,ROS明显升高(P＜0.05或P＜0.01);伤后12～48 h血清ALT及ICAM-1均高于正常组(P＜0.01).伤后24 h,胰岛素组大鼠肝脏T-AOC、SOD分别为(386±75)、(210±39)U/g,较盐水组(124±18)、(111±9)U/g明显升高(P＜0.01);ROS为(154±29)U/g,较盐水组(351±41)U/g明显降低(P＜0.01).伤后48 h,胰岛素组大鼠血清ALT及肝脏ICAM-1与盐水组比较呈下降趋势(P＜0.01).组织病理学结果显示,胰岛素可减轻烫伤后肝细胞损伤程度.结论 严重烫伤后早期用胰岛素干预,可增强大鼠肝脏抗氧化损伤能力,对肝脏有保护作用.     

Pneumatosis intestinalis and hepatic portal venous gas

We report two cases of pneumatosis intestinalis and hepatic portal venous gas. The first case was in a 67-year-old woman who complained of strong right lower abdominal pain and high fever on the twelfth day after pancreatoduodenectomy (PD) with portal vein (PV) resection. Abdominal X-ray and computed tomography showed hepatic portal venous gas and pneumatosis intestinalis. The emergency laparotomy performed disclosed extensive necrosis of the bowel from the jejunum to the ascending colon. All necrotic parts of the bowel were resected and a jejunostomy was performed. The residual intact small intestine was 30 cm in length. Her postoperative course was stable. This is a rare complication after PD and cannot be cured by any other treatment but surgery. The second case was in a 45-year-old woman with the chief complaint of abdominal pain and constipation. She had a past history of chronic toluene inhalation. Abdominal X-ray and computed tomography also showed hepatic portal venous gas and pneumatosis intestinalis, as well as free air, but no physical examination or laboratory test results supported a diagnosis of bowel necrosis. Hyperbaric oxygen (HBO) therapy effectively controlled the symptoms and signs.     

Assessment of hepatic reserve for the indication of hepatic resection: how I do it

This author has personally carried out in excess of 700 major hepatic resections for tumor, and runs a unit with a current resection rate of 200 per year, yet uses no scientific tests designed to judge hepatic reserve. In our unit, we have an advantage in that we deal with a northern European population, with a low rate of viral hepatitis, although alcoholism is becoming an increasing feature within our practice and we are dealing with more elderly patients that in the past, and more who have undergone neoadjuvant chemotherapy. In these patients, there appear to be greater risks of postoperative sepsis and slower regeneration. Approximately 65% of our current resection practice is hemihepatectomy or more and the majority is trisectionectomy (extended hepatectomy) and bilateral resection work. Preoperative, operative, and postoperative factors affect the occurrence of postoperative hepatic failure and these aspects are considered. Case series studies are presented to illustrate the incidence of significant hepatic failure we have encountered.     

大鼠营养状况对肝脏能量代谢的影响

本实验观察了不同营养状况对大鼠肝脏能量代谢的影响。结果显示：饥饿与食糖５天的大鼠肝脏ＡＴＰ含量、肝能荷值均明显低于正常进食组（Ｐ＜０．００１）；而饥饿及食糖大鼠经短期（４天）的静脉营养后，其肝脏ＡＴＰ、肝能荷值均恢复至正常组水平。由此表明饥饿及食糖均可导致肝脏营养不良以及肝脏能量代谢紊乱，但这种改变在短期内是可逆的，并可通过短期静脉营养得以改善。     

肝切除术治疗重症肝外伤的疗效评价

目的 探讨肝切除治疗重症肝外伤的效果。方法 总结４１３例肝外伤中施行肝切除术３４例，其中肝外伤Ⅲ级９例，Ⅳ级２１例，Ⅴ级４例，行规则性肝切除１１例，清创性肝切除２３例，结果 死亡８例，死亡率为２３．５３％，８例发生术后并发症；规则性肝切除死亡率明显高于清创性肝切除，两种术式间并发症发生率无显著差异。结论 肝切除为治疗重症肝外伤最后选择的措施，施行规则性肝切除需严格掌握手术批片；肝外伤行肝切除下择期     

永久阻断肝静脉对肝创面出血量和肝功能的影响

目的　了解永久阻断肝静脉后对肝脏手术患者出血量和肝功能的影响。方法　回顾性统计分析 2 9例在结扎右肝静脉情况下行肝右后叶肝脏肿瘤切除术 (结扎组 )和 9例缝扎肝静脉 (左 4、中 3、右 2 ) (缝扎组 )控制近第二肝门肝损伤大出血后患者腹腔出血量和肝功能的变化 ,并与同期同部位未行肝静脉结扎的 36例肝脏肿瘤切除术患者和 15例按其它方法处理的合并肝静脉损伤的近第二肝门肝损伤患者进行对照。结果　结扎组、缝扎组患者术后立即出现转氨酶增高 ,但无明显黄疸 ,术后 1周肝功能均全部恢复正常 ;无严重手术并发症发生 ,无手术死亡 ,一期愈合率 10 0 %。对照组 2例死于术后肝功能衰竭 ;1例因出血不止死亡 ;2例因术后再出血、膈下脓肿行二次手术。结扎组术中出血量是 42 8± 2 5 3ml,对照组是 789± 2 71ml;缝扎组术后出血量为 2 6 2± 10 2 ml,对照组为 831± 387m l,P<0 .0 1。结论　永久结扎阻断一支肝静脉能明显减少肝脏手术特别是合并肝静脉损伤创面的出血量 ,对术后肝功能的恢复无明显影响     

肝癌供血动脉变异1例

Hepatic arteries;Variation;Hepatic neoplasms     

肝巨大血管平滑肌脂肪瘤误诊肝癌1例及文献复习

【摘要】〓目的〓探讨肝血管平滑肌脂肪瘤(HAML)的临床特点、病理及免疫组化特征、诊断及其治疗方法,旨在提高临床诊治水平。方法〓回顾性分析1例于外院误诊为肝癌而于我院经病理证实为肝巨大血管平滑肌脂肪瘤的临床表现、影像学、病理和免疫组化资料并结合文献知识复习。结果〓HAML,多好发于女性,多数无明显不适症状。组织学上,肿瘤主要由平滑肌细胞、血管及脂肪3种成分按不同比例混合而成。免疫组化染色显示:瘤细胞对HMB45、Melan-A、SMA表达阳性。结论〓HAML临床症状缺乏一定特殊性,影像学检查表现多样,术前容易误诊。诊断不明时建议可行肝穿刺活检以进一步明确性质,确诊有赖于术后病理及免疫组化。     

肝血流阻断技术的研究进展

因各种原因行肝切除术时,保留肝功能保护及减少术中出血非常重要,应用选择性肝血流阻断技术进行肝切除时术中可以保持保留肝血供,出血量比应用其他血流阻断技术少,术后肝功能恢复快.该技术值得临床应用和推广.本文回顾了肝血流阻断技术的发展过程及最新研究成果,介绍选择性肝血流阻断技术的最新研究现状、进展及热点问题.

Abstract：

It is important to reduce blood loss and protect the function of reserved liver during hepatectomy.Selective hepatic vascular occlusion can keep the blood supply of reserved liver and make blood loss less than other methods of blood occlusion, so it helps more to the recovery of liver function.In summary, promotion and application of this technology is worth while.This article reviews the developing progress and the latest studies of selective hepatic blood occlusion to introduce the latest advancement in this area.     

肝胆管结石并狭窄的外科治疗研究

目的　探讨肝胆管结石并狭窄外科治疗的有效方式。方法　总结６８ 例肝胆管结石并狭窄病人的诊疗结果、经验和体会。联合运用肝叶切除、狭窄胆管切开整形、胆肠吻合、盲袢置于皮下为主的方式方法治疗。结果　术后残留结石１７ 例，无死亡，随访５６ 例，随访时间１ － １０ 年，优良率８８．４２％ ，差者４ ．７３ ％ ，效果满意。结论　充分把握病情，合理选用并联合运用不同的方法是本病治疗的最佳选择。     

肝外伤的诊断和治疗

目的 探讨降低肝外伤治疗的并发症和死亡率的有效途径。方法：对１９７９年１月￣１９９８年１２月２０年连接１４６例肝外伤的资料,分前、后１０年两期进行回顾性对比分析。结果 １４６例肝外伤１３０例（８９％）采用手术治疗,１６例（１１％）采用非手术治疗（ＮＯＭ）。住院天数前１０年是２２．３８天,近１０年２１．４天,Ｐ〈０．０５）。与肝外伤直接相关的并发症发生率为２０．５％（３０例）,共４４例次,其中前１０     

腹腔镜肝切除术6例报告

2002年4月～2004年6月腹腔镜下超声刀结合氩气刀完成肝切除6例,其中原发性肝癌2例,肝海绵状血管瘤4例.手术时间0.5～4.0 h,平均1.8 h.术中出血量80～320 ml,平均220 ml.术后住院5～7 d,平均5.7 d.超声刀结合氩气刀是腹腔镜肝切除术的理想手术工具.     

True hepatic teratoma with high alpha fetoprotein in serum.

True hepatic teratoma is very rare, and only 23 cases including 7 in adults have been reported in the literature. In this report a case of true hepatic teratoma producing high alpha fetoprotein is presented.