2007年10月14日星期日
Critical of rheumatic valvular heart disease treatment
Methods 1. Giving cardiac preoperative diuretic, and so improve the heart function, blood transfusion, albumin, and so improve nutrition, treatment of 21-65 days. There are three cases of patients admitted to hospital within 48 hours of acute cardiac insufficiency emergency operation. 2. The whole group were 49 cases of patients in general anesthesia, low temperature, a cardiopulmonary bypass surgery, 12 cases of myocardial protection by the former 4 ° C cold crystalloid cardioplegia solution; 1:4 after 37 cases using potassium content of blood cardioplegia solution continuous perfusion, myocardial surface vapor cooling. Mitral valve replacement using 2-0 prolene continuous suture line, after reservations under the flap valve and the structure. Aortic valve replacement using aortic root oblique incision, using interrupted suture - suture. Tricuspid regurgitation were Devega Central Bank of or reduction of shrinkage kay ring. Results The 49 cases of early postoperative patient died 10 cases. One died after six cases of low cardiac output syndrome, two cases of death due to ventricular fibrillation treatment ineffective; One died of renal failure; One died of intracranial hemorrhage; Total mortality 20.41%. Long-term survival in 39 cases. Follow-up time, June 12. Follow-up rate of 100%. One patient died of intracranial hemorrhage three years. After 1 1 cases of endocarditis in two deaths; One case of six after one year left on the right side limbs cerebral embolism activities obstacles; After three years, one case of mechanical valves card flap death; One case of cerebral hemorrhage after 2-year legacy of epilepsy. Follow-up on the five-year survival rate has been 86.92%. Central to the same period tricuspid shrinkage of patients, follow-up found 10 cases are mild regurgitation, five cases of the closure of a moderate insufficiency, cardiac diuretic treatment required. Conclusion 1. Perioperative Management Critical rheumatic heart valve and lung Regenerated cycle of long-term high-pressure circulation system, congestion, in the lung, liver, kidney and other major organ dysfunction; Due to long-term congestion gastrointestinal mucosa caused digestion and absorption features low, evil heart of patients with quality. Therefore preoperative cardiac function should be strengthened support, and even intravenous drip positive inotropic drugs, the patient's preoperative cardiac function improved conditions, the importation of plasma, fresh blood, albumin, and so on, the correct patients with hypoproteinemia anemia; Pulmonary function conducted training. Heart failure generally to be corrected, improved nutritional status, to choose the timing of surgery to improve surgical treatment. Use of myocardial protection potassium content of blood cardioplegia solution continuous perfusion, thus ensuring the myocardial oxygen supply and energy metabolism, prevent myocardial reperfusion injury. After severe low cardiac output, in addition to positive inotropic drugs, the early adopters IABP, left ventricular bypass can improve left ventricular function; Renal failure patients early trip bedside peritoneal dialysis or hemodialysis; Tracheal intubation of patients can not eat by mouth early supplementary nutrition through nasal feeding or intravenous nutrition, favorable patient recovery. 2. Membrane Disease Treatment Rheumatic heart valve disease, a considerable number of patients in functional closed tricuspid valve insufficiency, cardiac function and postoperative effects of long-term survival, therefore, should take positive surgical approach, in replacement of mitral valve, aortic valve at the same time, that is more than functional mild tricuspid valve insufficiency, for reduction of the ring annuloplasty. Avoid early postoperative lesions increase in right ventricular failure. 3. Strengthening Prevention and Treatment with postoperative Critical rheumatic valvular heart disease cardiac functional recovery after surgery is the major cause of death bad one. According to observation, from heart failure for the performance of systemic venous blood stasis, jugular goats, hepatosplenomegaly, a serious lower extremity edema. Drugs can only temporary remission, re-operation complications and high mortality. Therefore, the importance of regular follow-up of patients, so Doppler echocardiography, early detection tricuspid regurgitation, timely treatment. 4. This group of early postoperative complications, according to the frequency followed by low cardiac output syndrome, ventricular arrhythmia, renal failure, and so on. After application of positive inotropic drugs and expansion of drug treatment of vascular low cardiac output syndrome; Correct hypokalemia, and other electrolyte imbalance to correct ventricular arrhythmias; Early renal failure patients bedside visit peritoneal dialysis or hemodialysis. 5. Late complications mainly cerebral hemorrhage, cerebral embolism, machinery card flap valve, the tricuspid valve insufficiency, and other functional closure. Prevention of cerebral hemorrhage and cerebral embolism, the key is to guide patients taking anticoagulant drugs, to do follow-up work at the same time, periodic testing prothrombin time ratio adjustment and international standards anticoagulant drug applications. The patients in one case of postoperative patients 2 years of epilepsy, and still lead to excessive anticoagulation related cerebral hemorrhage.
Advanced Surgical treatment of facial paralysis progress
Facial paralysis is the result of a combination of facial nerve damage, a loss of facial expression and organization functions as the main obstacles to performance nutrition comprehensive syndrome [1] . Over the course of more than 2002 facial paralysis for advanced facial paralysis [2] , their treatment has always been a major problem so far has not very satisfactory way [1 ~ 4] . 1 Advanced Surgical treatment of facial paralysis Review
Advanced treatment of facial paralysis and can be divided into non-dynamic dynamic treatment of major categories.
1.1 non-dynamic therapy
Treatment of advanced facial paralysis is the traditional method, is more commonly used clinical, on the improvement of the static effect of certain malformations, including fascia suspension, leather suspension, suspension and other organizations substitutes method [1,5] . One fascia lata suspended non-dynamic therapy the most representative of the way. This method was not suitable for the application of power from the various reasons for the treatment of advanced facial paralysis.
1.2 Dynamic treatment
There are mainly muscle flap transfer of nerve transfer anastomosis, the inter-facial nerve transplantation, muscle graft and undertaken in recent years neuromuscular free vascularized grafting, through facial expressions surgery was under the dynamic symmetry.
1.2.1 muscle flap transfer of: 1908 Eden first Lexer and masseter and temporalis muscle flap separation were transferred to, the lower lip and upper and lower eyelid deformity to correct facial paralysis. Gillies was temporalis muscle and fascia application for the transfer of facial paralysis, the effect affirmed the 1960s to the 1970s is widely used [5] , are still used. Anonson, etc. [6] launched in 1986 hypoglossal nerve loop neuromuscular pedicle shift to the clinical application of facial muscles. Xianghong, etc. [7 ] on the use of nerve and trapezius with vascular pedicle flap for the transposition to repair facial paralysis. The transfer of the muscle flap method is relatively simple, not to do any of the cases can be complicated surgery of this type [2] .
1.2.2 nerve transfer anastomosis: Facial nerve injury to the central terminal near impossible anastomosis, a nerve distal end anastomosis conditions, but no obvious facial expressions muscle atrophy, [1] . Drobnik 1896 application was first vice anastomosis treatment of facial nerve paralysis [1,2,5] , sublingual facial nerve anastomosis by Korte 1903 first reported [1,5] . There are other using phrenic nerve, the glossopharyngeal nerve, nerve movement of the mandibular nerve transfer of [8] . After the transfer of nerve, facial muscle movement with the transfer of the original disclaimer accompanying muscle movement, but is only a kind of coarse, mixed, the bulk nature of sports [8] , it now has fewer applications.
1.2.3 inter-facial nerve transplantation: By Scaramella 1970 was first reported that apply to facial expression of muscle atrophy or no serious expressions muscle atrophy choice secondary vascular anastomosis neural transplantation of the muscle-stage surgery [1] . Alain such [9] advocate for the second phase of the operation, in order to prevent scar impede nerve regeneration. This method has the advantage of being accepted from side-expression side muscle nerve fiber regeneration, and even the dynamic muscle contralateral facial expression, facial expressions more natural, holistic.
1.2.4 muscle graft: Thompson [10] 1971 First Free Application extensor digitorum brevis transplantation to treat facial paralysis, and surgery at two, more satisfied with the results. Thompson considered for the first stage of muscle Denervation is a prerequisite for successful operation. This method not vascular anastomosis, simple operation, applicable to advanced facial paralysis, facial muscles has been shrinking. Its inadequacies of the district must rely on the muscle for muscle can be nerve again dominated, it has limited application.
2 microsurgical technique in the treatment of advanced facial paralysis Application
2.1 points in the second phase with vascular surgery neuromuscular graft
The first-stage surgery for facial nerve transplant, Part II period for the free vascular anastomosis nerve muscle graft. The method in 1976, such as by Harii [11] report first, then gradually be popularized, in the past more than ten years been a relatively rapid development. 1989 Terzis, and other [12] use small chest muscle repair facial paralysis. He believes that small chest muscle is the ideal form, adequate size and dual innervation (chest lateral thoracic nerve and the medial nerve), the permissible level, the lower part of the independence movement, is the most ideal for muscle, the most suitable for children with facial paralysis. CAO Yi-lin, and other [13] used similar methods on 10 patients with advanced treatment of facial paralysis, three months after the myoelectric activity measured, six of muscle movement visible to the naked eye, to the best effect in one year. O'Brien, and other [14] Harii also with the use of vascularized nerve gracilis muscle graft to facial paralysis treatment. He believes that gracilis muscle easy to cut, fewer sequels can be divided into several segments play different functions, the better for muscle, but after more bloated. Ueda and other [15] with neurovascular using the gracilis muscle or latissimus dorsi free transplantation in the treatment of 4 to 15-year-old children facial paralysis, the result of the initial transplant muscle contraction earlier time than adults, adult functional recovery than good. But children with growth process, not found any deformation and facial area for any dysfunction District, recommends muscle transplantation in the treatment of children and young patients.
2.2 with neuromuscular a vascular graft
The second phase of vascular surgery with neuromuscular graft satisfied with the results, but to stage operation, increased patient suffering. Wang Wei, and other [16,17] 1989 raised for the first time long vascular pedicle flap nerve transplant a facial nerve paralysis treatment of the concept, so that an operation possible. As for surgery to latissimus dorsi muscle, choose their thin distal segments, this will ensure that there are 14 to 17 cm long nerve vascular pedicle, as long segment latissimus dorsi muscle pedicle flap transplantation. To make thinning muscle flap, flap resectable segments of the dirt layer, known as segmental fault muscle flap [1, 2] . The technique is based on the anatomy [18] : latissimus dorsi the blood supply comes mainly from thoracodorsal artery, the artery around the scapular angle under the plane into the top and lateral branch, the separation of muscle after segmental artery and the nerve thoracodorsal nerve and artery accompanied paragraph. As long pedicle graft, to 14 ~ 17 cm, from the subscapular arterial vascular pedicle the initial cut, but often need to be of the distal arterial anatomy within the muscle separation. The characteristics of the operation [1] : (1) to replace a second surgery completed, shortened the treatment cycle. (2) Variable block muscle transplant for segmental muscle flap transplantation, may need to be cut. (3) the non-vascular cross-face nerve graft replaced with the vascular graft is conducive to the growth and transplantation of nerve repair. (4) full-thickness change fault muscle transplant for transplant muscle flap, flap become thinner. After the way the gradual application and the improvement [3,19,20] . Jianghua [21] , such as Sun top 100 [22] use thumb Show muscle transplant for a free repair facial paralysis, has been successful.
More than 2.3 neurovascular pedicle flap transplantation
Free vascularized muscle nerve transplant muscle flap over a single nerve Beattie, only to face the next 2 / 3 expression repair, far from being able to restore the more muscular expression of sexual function. In recent years, more domestic and foreign scholars root nerve and muscle transplants carried out a full-scale restoration of the research [4,23 ~ 27] . The rectus abdominis muscles are used, as well as intra-abdominal superior oblique latissimus dorsi muscle and joint sawing before transplantation. These use the same technique is different muscle innervation, will be divided into two muscle flap or a total of two neighboring vascularized muscle and innervation different, as different parts to restore facial expression. The advantage is more nerve vascular pedicle, viable full restoration, but more complex surgery, trauma larger.
Application vascularized nerve muscle graft treatment of advanced facial paralysis, and after, there will be autonomous, more symmetrical and natural expression campaign by the majority scholars think is so far the treatment of advanced facial paralysis most effective approach, with no other operation by the superiority of late is the development of facial paralysis treatment direction. However, the scope and method of operation is very high, we must have skilled microsurgical technique and corresponding equipment, the hospital harder at the grassroots level to promote. The frail elderly who can not afford the operation is not appropriate.
3 Problems and Prospects
3.1 expressions resume incomplete: Because of expression muscle innervation of skeletal muscle than rich, the site looked different muscle fiber direction, its movement is rich and varied expressions, so to rely solely on one or two muscle is no substitute for all the expressions muscle [25] . But when the nerve regeneration and to the possibility of a labyrinth dislocation that facial symmetry coordinated action to be affected. This will be the future of a facial paralysis research direction [19] .
There is no ideal for 3.2 muscle: Although currently used for a variety of muscle [1,16] , but there is a lack of a greater or lesser extent, has not fully met the requirements of an ideal muscle [1,22] , this is still many scholars and experts in the course of our efforts.
3.3 transplant muscle atrophy: ischemic surgery is the main reason, the nerve trauma and vascular anastomosis not disposable and support for the transplant, such as muscle, so some people advocate using larger muscle [11] , but that could easily lead after bloated. He believed that after the accumulation and research will certainly be able to find a suitable proportion of transplant volume.
3.4 operation choice: one or two vascularized nerve muscle graft, two kinds of operation Which is more reasonable and the results better, how to choose clinical, still controversial. Terzis [12] that a nerve surgery vascular pedicle long, nerve growth slow in the muscle flap endplate shrinking, and so long to endplate nerve, muscle flap has been shrinking. But clinical results is not the case, a treatment efficacy also more satisfied with [3,16 ~ 19,22,25,26,28] . The reason for this may include the following: (1) As long associated with the vascular pedicle nerve dependent, easy to transplant survival, and has accelerated the process of healing [16,28] . (2) a method nerve axon regeneration only through a nerve suture, reduce scar effect on the quantity and quality of power source the adverse effects [28] . (3) the segmental fault muscle flap transplantation is a nerve with the target organ transplantation, such transplantation can produce a class of nerve induced directional growth, and nutrition and promote nerve growth of active substances [2] . So far, this has yet to see a comparison of two kinds of basic research reports. Animal model for the future can conduct a comprehensive, based on comparative studies, the choice of method for clinical provide a theoretical basis.
Apart from the above mentioned, along with the development of tissue engineering and continuous improvement, I believe nerves and muscles can be cultured in vitro, can waive time for the surgery. The development of gene technology is one of the fastest growing technology, if adopted transgenic approach to the treatment of facial paralysis, will undoubtedly achieve perfect results.
Advanced treatment of facial paralysis and can be divided into non-dynamic dynamic treatment of major categories.
1.1 non-dynamic therapy
Treatment of advanced facial paralysis is the traditional method, is more commonly used clinical, on the improvement of the static effect of certain malformations, including fascia suspension, leather suspension, suspension and other organizations substitutes method [1,5] . One fascia lata suspended non-dynamic therapy the most representative of the way. This method was not suitable for the application of power from the various reasons for the treatment of advanced facial paralysis.
1.2 Dynamic treatment
There are mainly muscle flap transfer of nerve transfer anastomosis, the inter-facial nerve transplantation, muscle graft and undertaken in recent years neuromuscular free vascularized grafting, through facial expressions surgery was under the dynamic symmetry.
1.2.1 muscle flap transfer of: 1908 Eden first Lexer and masseter and temporalis muscle flap separation were transferred to, the lower lip and upper and lower eyelid deformity to correct facial paralysis. Gillies was temporalis muscle and fascia application for the transfer of facial paralysis, the effect affirmed the 1960s to the 1970s is widely used [5] , are still used. Anonson, etc. [6] launched in 1986 hypoglossal nerve loop neuromuscular pedicle shift to the clinical application of facial muscles. Xianghong, etc. [7 ] on the use of nerve and trapezius with vascular pedicle flap for the transposition to repair facial paralysis. The transfer of the muscle flap method is relatively simple, not to do any of the cases can be complicated surgery of this type [2] .
1.2.2 nerve transfer anastomosis: Facial nerve injury to the central terminal near impossible anastomosis, a nerve distal end anastomosis conditions, but no obvious facial expressions muscle atrophy, [1] . Drobnik 1896 application was first vice anastomosis treatment of facial nerve paralysis [1,2,5] , sublingual facial nerve anastomosis by Korte 1903 first reported [1,5] . There are other using phrenic nerve, the glossopharyngeal nerve, nerve movement of the mandibular nerve transfer of [8] . After the transfer of nerve, facial muscle movement with the transfer of the original disclaimer accompanying muscle movement, but is only a kind of coarse, mixed, the bulk nature of sports [8] , it now has fewer applications.
1.2.3 inter-facial nerve transplantation: By Scaramella 1970 was first reported that apply to facial expression of muscle atrophy or no serious expressions muscle atrophy choice secondary vascular anastomosis neural transplantation of the muscle-stage surgery [1] . Alain such [9] advocate for the second phase of the operation, in order to prevent scar impede nerve regeneration. This method has the advantage of being accepted from side-expression side muscle nerve fiber regeneration, and even the dynamic muscle contralateral facial expression, facial expressions more natural, holistic.
1.2.4 muscle graft: Thompson [10] 1971 First Free Application extensor digitorum brevis transplantation to treat facial paralysis, and surgery at two, more satisfied with the results. Thompson considered for the first stage of muscle Denervation is a prerequisite for successful operation. This method not vascular anastomosis, simple operation, applicable to advanced facial paralysis, facial muscles has been shrinking. Its inadequacies of the district must rely on the muscle for muscle can be nerve again dominated, it has limited application.
2 microsurgical technique in the treatment of advanced facial paralysis Application
2.1 points in the second phase with vascular surgery neuromuscular graft
The first-stage surgery for facial nerve transplant, Part II period for the free vascular anastomosis nerve muscle graft. The method in 1976, such as by Harii [11] report first, then gradually be popularized, in the past more than ten years been a relatively rapid development. 1989 Terzis, and other [12] use small chest muscle repair facial paralysis. He believes that small chest muscle is the ideal form, adequate size and dual innervation (chest lateral thoracic nerve and the medial nerve), the permissible level, the lower part of the independence movement, is the most ideal for muscle, the most suitable for children with facial paralysis. CAO Yi-lin, and other [13] used similar methods on 10 patients with advanced treatment of facial paralysis, three months after the myoelectric activity measured, six of muscle movement visible to the naked eye, to the best effect in one year. O'Brien, and other [14] Harii also with the use of vascularized nerve gracilis muscle graft to facial paralysis treatment. He believes that gracilis muscle easy to cut, fewer sequels can be divided into several segments play different functions, the better for muscle, but after more bloated. Ueda and other [15] with neurovascular using the gracilis muscle or latissimus dorsi free transplantation in the treatment of 4 to 15-year-old children facial paralysis, the result of the initial transplant muscle contraction earlier time than adults, adult functional recovery than good. But children with growth process, not found any deformation and facial area for any dysfunction District, recommends muscle transplantation in the treatment of children and young patients.
2.2 with neuromuscular a vascular graft
The second phase of vascular surgery with neuromuscular graft satisfied with the results, but to stage operation, increased patient suffering. Wang Wei, and other [16,17] 1989 raised for the first time long vascular pedicle flap nerve transplant a facial nerve paralysis treatment of the concept, so that an operation possible. As for surgery to latissimus dorsi muscle, choose their thin distal segments, this will ensure that there are 14 to 17 cm long nerve vascular pedicle, as long segment latissimus dorsi muscle pedicle flap transplantation. To make thinning muscle flap, flap resectable segments of the dirt layer, known as segmental fault muscle flap [1, 2] . The technique is based on the anatomy [18] : latissimus dorsi the blood supply comes mainly from thoracodorsal artery, the artery around the scapular angle under the plane into the top and lateral branch, the separation of muscle after segmental artery and the nerve thoracodorsal nerve and artery accompanied paragraph. As long pedicle graft, to 14 ~ 17 cm, from the subscapular arterial vascular pedicle the initial cut, but often need to be of the distal arterial anatomy within the muscle separation. The characteristics of the operation [1] : (1) to replace a second surgery completed, shortened the treatment cycle. (2) Variable block muscle transplant for segmental muscle flap transplantation, may need to be cut. (3) the non-vascular cross-face nerve graft replaced with the vascular graft is conducive to the growth and transplantation of nerve repair. (4) full-thickness change fault muscle transplant for transplant muscle flap, flap become thinner. After the way the gradual application and the improvement [3,19,20] . Jianghua [21] , such as Sun top 100 [22] use thumb Show muscle transplant for a free repair facial paralysis, has been successful.
More than 2.3 neurovascular pedicle flap transplantation
Free vascularized muscle nerve transplant muscle flap over a single nerve Beattie, only to face the next 2 / 3 expression repair, far from being able to restore the more muscular expression of sexual function. In recent years, more domestic and foreign scholars root nerve and muscle transplants carried out a full-scale restoration of the research [4,23 ~ 27] . The rectus abdominis muscles are used, as well as intra-abdominal superior oblique latissimus dorsi muscle and joint sawing before transplantation. These use the same technique is different muscle innervation, will be divided into two muscle flap or a total of two neighboring vascularized muscle and innervation different, as different parts to restore facial expression. The advantage is more nerve vascular pedicle, viable full restoration, but more complex surgery, trauma larger.
Application vascularized nerve muscle graft treatment of advanced facial paralysis, and after, there will be autonomous, more symmetrical and natural expression campaign by the majority scholars think is so far the treatment of advanced facial paralysis most effective approach, with no other operation by the superiority of late is the development of facial paralysis treatment direction. However, the scope and method of operation is very high, we must have skilled microsurgical technique and corresponding equipment, the hospital harder at the grassroots level to promote. The frail elderly who can not afford the operation is not appropriate.
3 Problems and Prospects
3.1 expressions resume incomplete: Because of expression muscle innervation of skeletal muscle than rich, the site looked different muscle fiber direction, its movement is rich and varied expressions, so to rely solely on one or two muscle is no substitute for all the expressions muscle [25] . But when the nerve regeneration and to the possibility of a labyrinth dislocation that facial symmetry coordinated action to be affected. This will be the future of a facial paralysis research direction [19] .
There is no ideal for 3.2 muscle: Although currently used for a variety of muscle [1,16] , but there is a lack of a greater or lesser extent, has not fully met the requirements of an ideal muscle [1,22] , this is still many scholars and experts in the course of our efforts.
3.3 transplant muscle atrophy: ischemic surgery is the main reason, the nerve trauma and vascular anastomosis not disposable and support for the transplant, such as muscle, so some people advocate using larger muscle [11] , but that could easily lead after bloated. He believed that after the accumulation and research will certainly be able to find a suitable proportion of transplant volume.
3.4 operation choice: one or two vascularized nerve muscle graft, two kinds of operation Which is more reasonable and the results better, how to choose clinical, still controversial. Terzis [12] that a nerve surgery vascular pedicle long, nerve growth slow in the muscle flap endplate shrinking, and so long to endplate nerve, muscle flap has been shrinking. But clinical results is not the case, a treatment efficacy also more satisfied with [3,16 ~ 19,22,25,26,28] . The reason for this may include the following: (1) As long associated with the vascular pedicle nerve dependent, easy to transplant survival, and has accelerated the process of healing [16,28] . (2) a method nerve axon regeneration only through a nerve suture, reduce scar effect on the quantity and quality of power source the adverse effects [28] . (3) the segmental fault muscle flap transplantation is a nerve with the target organ transplantation, such transplantation can produce a class of nerve induced directional growth, and nutrition and promote nerve growth of active substances [2] . So far, this has yet to see a comparison of two kinds of basic research reports. Animal model for the future can conduct a comprehensive, based on comparative studies, the choice of method for clinical provide a theoretical basis.
Apart from the above mentioned, along with the development of tissue engineering and continuous improvement, I believe nerves and muscles can be cultured in vitro, can waive time for the surgery. The development of gene technology is one of the fastest growing technology, if adopted transgenic approach to the treatment of facial paralysis, will undoubtedly achieve perfect results.
The development of liver surgery
From the late 19th century through experimental animal studies, has been established through the liver parenchyma incision is feasible, liver resection of the 3 / 4, animals can still surviving, and more than can be regenerated liver in order to achieve its original size. Carl Langenbuch (1888) is considered the first successful implementation of the left hepatic lobe resection, but Langenbuch "patient" is a 30-year-old woman, abdominal pain because their belly, he found in liver on the left lobe of a mass, its pedicle ligation after resection of the weight of 370 g, that is due after Waist hard the oppressed by the liver, but after surgery the hepatic portal vascular hemorrhage, Langenbuch also done a second time for the surgery, the patients cured after all. Therefore, Langenbuch is considered a destination for the purposes of liver resection of the first surgeons. Lucke (1891) from the initial report of a left hepatic lobe resection of tumor and Wendel (1911) with right lobe of the liver. William William Keen (1899) be identified For the first liver resection of the American surgeon, when he reported three cases of successful surgery.
the development of modern science and technology has allowed for extensive liver resection. Today's liver surgeon must have superb skills teeth, a well-known human physiological and metabolic processes, and has a vast knowledge of modern science and technology, so surgery can achieve good results. The appearance of the human body is unaware of the liver as a whole, in the past has been the falciform ligament as liver left and right boundaries until 1888 Rex passed few mammalian liver rot Corrosion specimens observed that the portal vein left and right branches constitute two of the liver. 1898 Cantlie found around the liver is equal semi leaf from the gallbladder fossa through the inferior vena cava to the plane separated from Waterloo, later said that the line for the Rex-Cantlie line. With the anatomy of the initial understanding of the liver, surgeons began operations. 1909 VonHaberer left hepatic artery ligation of the left hepatic resection; 1911 Wendel in the right hepatic artery ligation outside the liver and right hepatic duct along the right lobe of the liver resection Cantlie line was started anatomy and the combination of surgery and promote the development of liver surgery. Subsequently, Wangensteen (1945) in the block under hepatic resection right lobe of the liver blood flow; Lortat-Jacob (1952), Quattlebaum, Pack and so have control of hepatic blood flow in the right lobe of the liver resection.
2 liver bleeding and bleeding
throughout the entire liver surgery question is "bleeding" and "stop bleeding." The liver is one college as full of blood "sponge", no matter how she is to you, always bloodshed, and more than a stream. For many years, surgeons were racking's minds this has been, I do not know how many have tried methods to stop bleeding, and some even appear in the current method is laughable.
until 1908, Pringle in the United States, "surgical Yearbook" magazine (Annals of Surgery) published an article entitled "Notes on hemostasis liver injury" (Notes on the arrest of hepatic hemorrhage due to trauma.) , Reported eight cases of liver trauma patients, four cases of dead before surgery, one case of refusing surgery, three cases for the purposes of a Caesarean section, surgery Pringle with his thumb and fingers pinching hepatic pedicle to temporarily stop bleeding that night able to see clearly, although the three cases patients were subsequently died, but Pringle spent three rabbit experiments to prove his envisaged is correct. Pringle papers published, it has responded quickly, this will become a way to stop bleeding liver surgical breakthroughs, still commonly used, and was later called Pringle practices (Pringle's maneuver). 1953 Rafucci through the experimental dogs, dogs can be made safe tolerance hepatic portal blood flow occlusion 15 min. This is still the standard has been adopted by the clinical basis, but we proved clinical hepatic portal blocked at room temperature up to 60 min time limit, or even how long is the limit, are still not identified. In the 1950s, Child spent many years of time to study blocked portal vein and hepatic artery of the issue, he discovered that the portal vein occlusion tolerance of different species of experimental animals are very different, such as rabbits, dogs, cats do not tolerated long blocked portal vein, but monkeys managed to survive long. Child and reported two cases of portal vein ligation after the patient did not have any adverse results. Child in 1954 published research on liver blood circulation of monographs that his 19 monkeys (Macaca mulatta monkey) in the experimental tolerance of 13 hepatic artery ligation, and do not have antibiotic treatment. Thus these studies to block the hepatic portal Pringle security applications laid a theoretical basis.
always practical needs of theoretical research is the most powerful stimulus agent in liver surgery, the surgeon needs to the internal anatomy of the liver have a better understanding. 1951 Swiss Hjortsj [1] established the first liver specimens pipeline corrosion and mold cholangiography research methods, after 10 cases observed by the hepatic artery and hepatolithiasis showed segmental distribution, and the liver is divided into inner and outer, after ago, a total of five of the tail. Later, Healey and Schroy [2] The study also confirmed Hjortsj further discovery in the distribution of intrahepatic portal vein is the same, and in accordance with the normal anatomy of the liver naming principle subparagraph naming system. Couinaud hepatic vein from the distribution function of the liver by subparagraph [3]. Anatomic study results show that the liver is a sub genitals, each has its liver of a separate pipeline system can be used as a surgical resection units. Anatomy of the liver, which in turn also urged Progressive development of the liver surgery. Internally, the Shanghai Second Military Medical University in the 1950s, Miss Mengchaodeng liver when the anatomical study.
50 in the mid - when, Goldsmith and Woodburne [4] stressed liver resection of the liver should be strictly complied with the internal anatomy, have proposed the rules of the liver resection of the concept of (regular hepatic lobectomy). In the late 1950s, Quattlebaum and Quattlebaum [5] stressed that the extensive liver resection surgery elements, including: fully reveal, hepatic vascular occlusion, completely free liver, blunt object isolated hepatic parenchyma. Such treatment is still views importance.
regardless of how you familiar with the anatomy of the liver, liver, but always open bleeding, how to reduce the loss of blood, liver, cut macrovascular not collision, which is the consensus. Quattlebaums stand off with a blunt object to the liver, but this concept has already seen early liver surgery. Various to blunt the main fault intrahepatic vascular liver preservation methods were used, such as has been recommended by a nail, Tong That Tung (Hanoi, Vietnam) in liver blood flow control blunt broken liver, Oglivie with vascular Clamp, Quattlebaum with surgical knife handle, Lintianyou (China Taiwan) fingers rubbed liver tissue, is now also used by the technique (finger fracture technique) [6]. The past 10 years and there used to reduce vascular hemorrhage broken liver specialized equipment, such as the most widely used "ultrasonic scalpel" (CUSA), In addition, there was still "water knife" [7], Peng Shuyou "including suction knife" in Renzhong "suction Cutter." The section on using bleeding in the liver while bleeding electrocoagulation with high frequency, infrared coagulation hemostasis, argon beam, "laser sword", plasma cutter, microwave hemostasis, various forms of liver clamp, liver tourniquet, and other equipment and tools; Drugs are like absorbable hemostatic fiber, fibrinogen , prothrombin, the collagen protein, macromolecular polymers products and this can be "spectacular", these new methods of hemostasis there is always accompanied by the development of liver surgery, in which development has not yet ended.
Une [8] compared the "Water Knife" (Water Jet Disector) and "ultrasonic scalpel" (Cavitron Ultrasonic Surgical Disector, CUSA) in a total of 68 cases of liver resection in patients using the advantages and disadvantages that, in the liver, cutting the blood loss, operation time, the two are not prescribed significant differences, but feel "water knife" will be organized by litter wash, and it could be more clear surgical field, in patients with cirrhosis, the liver also easy to cut, and the merit of equipment cheaper and easier maintenance of the use of safety, so that "water knife" as "ultrasonic scalpel" alternative supplies . The liquid is used saline. But the Chinese University of Hong Kong Liuyongyi professor in the discussion that "water knife" Although there is clearly more to the surgical field, but high-pressure water column splash can be formed by particulate pollution threat to the environment and the operating room staff, because of liver cancer patients have hepatitis B or hepatitis C virus infection, the other, there had been "water knife "tangential liver air embolism occurred when the report. Rau [9] cut to reduce the loss of blood when the liver, to become hypertonic saline brine to enhance their conductive properties, and water cannon installed on the high-frequency current, can be activated at any time hemostatic coagulation effect, does not require the replacement of equipment in order to save time.
Hepatic ischemia time tolerance 3
block in the hepatic portal surgery can not bleeding, but the hepatic vascular occlusion can last long?
Dong Jiahong [10] experiments with rats, to avoid blocking of the portal vein blood stasis to prove that rats can be safely blocked for 90 min, then clinically? Clinical Practice has proved that a large number of block hours in the hepatic portal within 15-20 min is safe, but for the wider and the complex liver surgery, this time within the limits of safety inevitably too short, so many 20 min 5-10 min interval blocking the blood flow open from clinical practice has proved to be effective. Elias [11] in 112 cases of hepatic resection of liver cancer patients, 20 cases of blocking the cumulative time over 90 min (mean 109 min), and each block is not sustained over 20 minutes, in which two cases of liver resection (IV, V, VIII segments) complex surgery , two cases of clamping time more than 140 min. Results after 20 cases without surgery died within 30 days, after the operation liver function changes are not significant differences. Elias repeatedly that the intermittent hepatic portal can be used to block abnormal hepatic parenchyma (often have hepatic artery embolization after chemotherapy), in hepatectomy broad cross-section of liver, surgery to reduce blood loss.
graded block hepatic blood flow Although it is safe, but the restoration of blood flow in each when it is inevitably increased blood loss. Whether the human liver can tolerate a long ischemic time? The previous time limit is only 15 minutes from the dog's information derived from the experiment, such as the Child by the different species of animals tolerance clamping time very different. Some of the reported hepatic portal block (portal triad clamping, PTC) or hepatic vascular isolation (hepatic vascular exc Lusion, HVE) security can be achieved time 60 min.
4 hepatic vascular occlusion in total hepatic vascular isolation
Heaney (1966) first proposed total hepatic vascular isolation (total hepatic vascular exclusion) of the purposes of liver resection of the concept [12]. Surgery clamp porta hepatis, liver, the liver of the inferior vena cava, while occlusion of the abdominal aorta. Huguet 1978 years using this method, which include liver cirrhosis patients with liver cancer, but surgical mortality rates higher, up to 28% (in patients with liver cirrhosis). Bismuth [13] (1989) this method has been applied to 5 One case of the patient, the surgical mortality rate dropped to 20%, the average time hepatic vascular occlusion is less than 50 min (46.5 min), and saw no need for occlusion of the abdominal aorta, not for cirrhosis patients. The low temperature liver perfusion (Fortner, 1974 advocates) is not necessary, because the process of surgery will naturally lower body temperature, and sometimes it drop too low, so Huguet used in the operation to control the temperature blankets. Thereafter total hepatic vascular isolation methods to cut liver The multi-use.
Huguet (1992) pointed out that although the liver resection is now widely used, but when the huge tumor in the liver or near the Central Department of inferior vena cava and hepatic vein, the general should not use conventional methods of surgical resection or great danger of . Conventional surgery is the main danger may be torn liver after the inferior vena cava or hepatic vein in massive loss of blood and air embolism. Hepatic vascular isolation can prevent this complication. The main points of hepatic vascular isolation is indeed under the control of the peritoneal cavity after intravenous branch. Emre [14] (1992) with total hepatic vascular isolation of liver for the treatment of 16 cases of patients with liver tumors huge, the average tumor diameter of 10.7 cm, the outcome of two cases of death, the author stresses must complete vascular isolation in the porta hepatis many small collateral vessels if not completely block still will cut more of the liver, bleeding, and even blocking blood loss were greater than not, the use of noninvasive vascular wide to block clamp liver duodenal ligament more effective.
Huguet [15,16] method is in the supine patients, the use of blankets to avoid hypothermia, bilateral long incision under the rib edge along the center line extending upward from cream, if large tumor size, the upper and lower vena cava revealed liver problems, while the right side of No. 7 or 8 intercostal incision more appropriate, and fully free of the liver ligament and adhesive is an important step in this procedure. Block liver duodenal ligament, should pay attention to whether ectopic left hepatic artery (from the left gastric artery); Under hepatic inferior vena cava in high blocker, should be in the right adrenal vein into the inferior vena cava above plane; The liver separation clearly superior vena cava, bypassing a sling, when a huge tumor, liver revealed after the inferior vena cava wall is often difficult. Therefore, this right thoraco-abdominal incision helpful. Next on the inferior vena cava, the two bleeding beneath the clamp Commissioner clamp most important, to request two clamp Tsim rounded to the inferior vena cava blood flow will be isolated. Do not cut liver before hepatic portal anatomy, but to reduce the clamping time, we and the author advocated some domestic anatomy of the hepatic portal first, the final steps on the block [17,18]. Huguet in 53 cases of liver resection patients using continuous block approach, compared blocked for more than one hour in 15 cases and blocked for 1 h following, not long after blocking opponents mortality and complication rates, changes in liver function between any obvious implications, will author liver ischemic tolerance time there limit? Hannoun [19] (1993) of 34 cases of patients underwent extensive surgical resection of the liver in a liver blocked blood flow sustained more than 60 min retrospective analysis, of which 15 cases at the same time blocking the liver and hepatic inferior vena cava, to prevent intraoperative hypothermia, the result of a continuous block, an average of between 73.6 minutes, the longest blocking one cases of 127 min, surgery difficult because the relationship between the body temperature of patients in an average of 35 ° C after liver dysfunction and no significant block of time, not one case of the whole group after surgery died within 30 days. Thus Hannoun come to the conclusion that in the absence of cirrhosis patients, can be a continuous block of time to 90 min; However, if the estimated time to block 120 min, suggested UW (University of Wisconsin) of cryogenic preservation of liver perfusion.
5 vitro Hepatectomy
with liver transplantation and in vitro technologies mature kidney surgery Enlightenment, the Hanover, Germany Pichlmayr [20] began in 1988 when the first cases were Fortner [21] in vitro perfusion of the liver cooling liver resection, the desire to achieve a more thorough tumor resection and removal in some patients with liver transplantation , to 1990, has done 11 cases of surgery. When fashion is a preliminary report, which it is difficult to comment on the significance of surgery, but the report has revealed that all patients with jaundice (a total of four cases) do not have good results, a surgical failure, and liver tumors (liver metastases) will have some effect. Cooling under in vitro perfusion of the liver resection technically demanding than orthotopic liver resection more complex, so can be used in complete surgical excision methods, generally do not choose in vitro resection.
in vitro liver resection because of their own liver replantation and the complex technical and time-consuming, France Sauvanet [22] (1994) to simplify the isolated liver surgery. The main points of this operation is not cut off hepatic portal pipeline structure, within the portal vein catheter inserted hypothermic perfusion, portal - IVC in vitro blood flow to the liver separation from top to bottom IVC pericardial sentenced Lee to re-anastomosis, the upper and lower cut off liver inferior vena cava and hepatic inferior vena cava under when the two ends will be cut off inferior vena cava, then liver in vitro can be moved out (the only gate structure Linked), the general method to resection of the tumor resection difficult. Author done five cases received better results. To further simplify operation, but was designed to address invasive liver after liver vein and inferior vena cava resection of the tumor, Hannoun's isolated position (Ex-situ In-vivo) of the liver resection. Domestic Dong Jiahong [23] (1996) with total hepatic blood flow and cooling to the semi-vitro perfusion of the liver in the treatment of transgression and the inferior vena cava and hepatic veins of the right of hepatocellular carcinoma, the patients have mild liver cirrhosis, had surgery after a transient liver dysfunction.
6 cirrhosis of the liver, blocking blood flow
liver cirrhosis at the time of vascular isolation cooling and liver perfusion can lead to increased liver cell damage adverse results, even in patients with obstructive jaundice, the same result is disappointing, therefore obvious obstructive jaundice and cirrhosis are considered hepatic portal blocked for a long time taboo. A large number of facts have proven that in the hepatic portal blocking limit within 15-20 min, the recovery of surgical patients there was no apparent impact, and the more time blocking and blocking the limits, have not yet been resolved. Orient primary liver cancer often associated with cirrhosis, 85% of China's primary liver cancer with cirrhosis, hepatitis and mostly after cirrhosis, total hepatic injury obviously universal, with obvious liver fibrosis and sometimes partial liver atrophy, portal hypertension and decompensated hepatic arterial blood flow increased, broken surgery when liver bleeding than normal liver tissue. So when cirrhosis of the liver blocked blood flow in China's more special significance.
vascular isolation of the liver can reduce undoubtedly the rules of non-cirrhotic liver resection and postoperative bleeding complications, the current is more of this surgery to stop bleeding in the microwave coagulation under implementation of effective good, but sometimes smaller because of tumor blood vessels and adjacent important, bile duct, the separation must need surgery resection. Japan Nagasue [24] (1985) Comparison of the three groups or liver resection of liver patients: not blocking (17 cases), Pringle blocker (19 cases), liver inflow and outflow channel blocker (11 cases) the results of the latter is in Pringle blocking in addition to any incision falciform ligament liver and crown ligament, isolated from the side of the hepatic vein surgery were to be blocked and not block the inferior vena cava, the longest time 47 min block, the results of the third group were bleeding decreased significantly compared with the former, no operative deaths, the complication rate also decreased significantly. However, isolated hepatic vein and hepatic vein were blocking is not easy, it is still not widely used.
Pringle vascular occlusion reduce the scope of influence, is also against cirrhosis resection of the measures proposed. Japan Makuuchi [25] (1987) suggested that liver cirrhosis of liver resection of vascular occlusion half when the safety of this method in the country have been Huaxi Medical University Guang Zheng Qi, Yan Lunan, etc. and our extensive use of this can withstand the liver tissue from the contralateral ischemic damage. Half of hepatic vascular occlusion method is simple and easy [26-28]. The doors of the system in the intrahepatic course is wrapped in fiber intrathecal Glisson, all liver independent of the formation of a liver, biliary vascular pedicle, or Gate of triple (portal triad) but this triple pipelines (especially Couinaud Ⅶ, Ⅷ liver) is not easy to find the building in the liver, which is not easy from the hepatic portal the Department of fiber sheath, the anatomy of the liver was found. However, the use of intrahepatic channels (intrahepatic approach), can be more easily separated from the fibrous sheath of the liver bile duct of the vascular pedicle and the respective control, the method called intrahepatic fiber sheath diameter Road (intrahepatic extrafacial approach), or known as the intrahepatic after Pathfinder (posterior intrahepatic approach) [29], its high biliary stricture repair and hilar cholangiocarcinoma surgery often be applied. Open surgery is the right caudate process and the liver parenchyma of the liver and liver capsule on the door edge of the liver capsule, liver door along the deep-Blunt (commonly used finger separation) separation, it can be fibrous sheath, in separation of the second stage of the liver and gallbladder bile duct vascular pedicle and were home to tape or clamp block. However, the Japanese Gotoh [30] relatively selective hepatic portal blocker (n = 13) and blocked hepatic portal liver (n = 8) cirrhosis of the liver cancer patients of liver surgery at the reaction results in the latter than the former operative time and blood loss were significantly reduced in that paragraph liver hepatic pedicle blocking their surgery complicated, there has been no obvious advantages.
at low temperature can be extended liver cells hypoxia tolerance time. Cirrhosis, if additional cooling treatment, it is possible to strengthen the liver cells to hypoxia tolerance. Yamanaka [31] in 50 cases of hepatocellular carcinoma right lobe of the liver cirrhosis of the liver resection, compared normothermic liver and liver vascular occlusion of vascular occlusion additional cooling vents partial results, there was no significant difference between the two groups, although the cooling group clamping time significantly longer; Yamanaka and that the liver under local cooling Ye vascular occlusion time could be extended to 60-90 min. Time is expected to block the blood flow of up to 30 minutes or more, should be supplemented by using partial hepatectomy blocking cooling more appropriate.
7 hepatectomy technology development
liver surgery is actually surgical anatomy of the liver and the combination, when surgeons understand the anatomy of the liver after liver surgery will be rapid development in the 50-60 age, liver resection have been standardized, the more practices, rules of liver resection (regular hepatic lobectomy ), that is, first of all deal with hepatic portal from the liver and the hepatic vascular and liver resection in real terms. This method has been contained in the general teaching, in spite of the author also certain technical amendments. 1952 Lortat-Jacob, Quattlebaum 1953 Pack and the rules of hepatectomy laid a foundation for liver surgery, Europe and the United States for metastatic liver tumors without cirrhosis, so this has been along the way, so Schwartz [32] published in 1984 resection of the right lobe of the liver; Starzl [ 33] (1980) by the expansion of right lobe of the liver resection or three paragraphs called resection of the right (right hepatic trisegmentectomy) at current commonly used method; However, in liver resection of the left side of the expansion, Starzl [34] published by the three resection of the left (left hepatic trisegmentectomy) surgical methods , are still not perfect enough, the blood loss surgery and postoperative complication rates were higher, remains to be desired. Expand the left hepatic lobe, the largest technical difficulties in the isolated liver parenchyma should strictly follow the right hepatic crack (right hepatic fissure) plane, and this fissure in the liver liver It is also not obvious on the surface, it is V, VIII and VI of the liver, liver Ⅶ paragraph of the sub-interface, thus if there are deviations from surgery, , it may be right hepatic vein injury, in particular the right posterior segment of the liver caused very difficult situation. Huguet [35] (1994) with hepatic vascular isolation method left hepatic resection of leaf expansion in the hepatic vascular isolation, in the case of blood along the right hepatic vein to the distal separation surgery at the end, we could clearly see the right hepatic vein on the following firms liver section. Huguet 8 patients with vascular isolation time for 58-85 min, an average of 70 minutes, without surgery within 30 days after death, but one died after the first 40 days, one case of 17 days postoperative hemorrhage and hepatic coma due to acute liver transplantation purposes, and left another one case of biliary fistulas. Thus, the left hepatic resection of leaves to the current expansion is still doing the surgery and rarely has a high complication rate, the use of "ultrasonic scalpel" isolated hepatic parenchyma, it is possible to reduce the operation of vessels and bile duct injury. The left hepatic resection of leaf expansion (left three resection) technical problems remain to be perfect.
liver cancer in China is a big country "," many patients, liver surgery has been very active. During the 1950s, Beijing and Guangzhou Cheng - En Wang Professor Professor ZENG Xian - nine representatives has accumulated more than 50 cases of hepatocellular carcinoma of the liver resection of the rules of the experience, but a higher surgical mortality, then experience is summed up by: (1), liver cancer with cirrhosis of the liver resection should be <50%; ( 2) extensive liver resection should be very careful; (3) liver failure is the leading cause of death surgery; (4) Long-term treatment with hepatic resection seems disproportionate amount; (5) cirrhotic patients should be more conservative hepatectomy. 50-60 in the period, Wu Mengchao, Professor liver [36,37] committed to the research and development of the anatomy of the hepatic portal blocking the liver surgery, Up to today, and accumulated the world's largest series of cases of liver cancer resection. 1971 in the then "beat cancer three years" under the call, et al [38] Professor of AFP in the early diagnosis of liver cancer, "tailor" type of liver resection, liver cancer surgical treatment of a breakthrough, and the development of China and even in Asia to become the surgical treatment of liver cancer model.
liver bleeding problems, like anatomy of the liver surgery in the clinical interpretation, it is surgery technological changes over the years is not great until the liver surgeon noted that the caudate lobe of the liver. Since anatomical location, liver caudate lobe resection of the tumor is still liver surgery has been the "forbidden zone." The purposes of the past once the liver caudate lobe resection of the liver together with most of the left, right lobe of the liver or hilar biliary additional surgery, not yet finalized their separate liver caudate lobe resection (isolated hepatic caudate labectomy). For example, Elias [39] 212 cases of malignant tumor resection of the liver, only one case of as separate the caudate lobe resection. In fact, the caudate lobe of benign and malignant tumors are not rare.
Yammamoto [40] (1992) report one case of caudate lobe tumor left by separation, at the junction of the former approach right liver lobe (anterior approach) Act resection; Later, Yamamoto [41] reported five cases separate caudate lobe resection, four cases of hepatocellular carcinoma, and one case of colon cancer metastasis after more than four years are to survive, the surgical method is used separately liver median cleft of the former approach, the right hepatic surgery will be free to cut off the inferior vena cava vein short before the liver, isolated right hepatic vein; Free liver to the left outer leaves, cut off and left hepatic vein ligament connecting vein, caudate lobe static from the inferior vena vein Isolation, isolated left hepatic vein in the liver, and around the block with. Subglottic in blocking the liver through the hepatic vein in the liver left off, will be adjacent to inferior vena cava (paracaval) part of the caudate lobe from the liver door separating the cut caudate lobe of the liver and portal branches in the vein until the rear, separated from the right caudate process with the attachment and liver resection of the entire caudate lobe tumor. Yamamoto separate road that before the caudate lobe resection of the liver although not so commonly used, but still have cirrhosis can consider as a curative surgery. Domestic Peng Shuyou resection with six cases before the Pathfinder caudate lobe tumor. Colona [42] (1993) with the left channel with two cases of liver metastases and one case of nodular hyperplasia; After Lerut approach (posterior approach) with one case of caudate lobe tumors but not very successful, as required bleeding gauze packing. Huang [43] The left - right - left a joint approach (left-right-left combined approach) with three cases of primary caudate lobe tumor. Bartlett [44] and their colleagues report four cases of separate caudate lobe resection is the former approach, and through the implementation of bilateral approach, the author之一Blumgart paper also recognized that the bilateral approach in accordance with the principle of liver resection caudate lobe resection is feasible without the necessary liver parenchyma. Facts have proven that separate caudate lobe resection of liver surgery is no longer a "forbidden zone" [45] However, the author also proposed a separate caudate lobe resection in the treatment of primary liver cancer, is reasonable. Nagasue [46] reported six cases of primary liver cancer in the caudate lobe caudate lobe resection alone the long-term effect, determine its efficacy in line with other parts of primary liver cancer resection. Therefore, separate caudate lobe resection for the caudate lobe of primary and secondary tumors is feasible and reasonable, especially when combined with cirrhosis when.
the development of modern science and technology has allowed for extensive liver resection. Today's liver surgeon must have superb skills teeth, a well-known human physiological and metabolic processes, and has a vast knowledge of modern science and technology, so surgery can achieve good results. The appearance of the human body is unaware of the liver as a whole, in the past has been the falciform ligament as liver left and right boundaries until 1888 Rex passed few mammalian liver rot Corrosion specimens observed that the portal vein left and right branches constitute two of the liver. 1898 Cantlie found around the liver is equal semi leaf from the gallbladder fossa through the inferior vena cava to the plane separated from Waterloo, later said that the line for the Rex-Cantlie line. With the anatomy of the initial understanding of the liver, surgeons began operations. 1909 VonHaberer left hepatic artery ligation of the left hepatic resection; 1911 Wendel in the right hepatic artery ligation outside the liver and right hepatic duct along the right lobe of the liver resection Cantlie line was started anatomy and the combination of surgery and promote the development of liver surgery. Subsequently, Wangensteen (1945) in the block under hepatic resection right lobe of the liver blood flow; Lortat-Jacob (1952), Quattlebaum, Pack and so have control of hepatic blood flow in the right lobe of the liver resection.
2 liver bleeding and bleeding
throughout the entire liver surgery question is "bleeding" and "stop bleeding." The liver is one college as full of blood "sponge", no matter how she is to you, always bloodshed, and more than a stream. For many years, surgeons were racking's minds this has been, I do not know how many have tried methods to stop bleeding, and some even appear in the current method is laughable.
until 1908, Pringle in the United States, "surgical Yearbook" magazine (Annals of Surgery) published an article entitled "Notes on hemostasis liver injury" (Notes on the arrest of hepatic hemorrhage due to trauma.) , Reported eight cases of liver trauma patients, four cases of dead before surgery, one case of refusing surgery, three cases for the purposes of a Caesarean section, surgery Pringle with his thumb and fingers pinching hepatic pedicle to temporarily stop bleeding that night able to see clearly, although the three cases patients were subsequently died, but Pringle spent three rabbit experiments to prove his envisaged is correct. Pringle papers published, it has responded quickly, this will become a way to stop bleeding liver surgical breakthroughs, still commonly used, and was later called Pringle practices (Pringle's maneuver). 1953 Rafucci through the experimental dogs, dogs can be made safe tolerance hepatic portal blood flow occlusion 15 min. This is still the standard has been adopted by the clinical basis, but we proved clinical hepatic portal blocked at room temperature up to 60 min time limit, or even how long is the limit, are still not identified. In the 1950s, Child spent many years of time to study blocked portal vein and hepatic artery of the issue, he discovered that the portal vein occlusion tolerance of different species of experimental animals are very different, such as rabbits, dogs, cats do not tolerated long blocked portal vein, but monkeys managed to survive long. Child and reported two cases of portal vein ligation after the patient did not have any adverse results. Child in 1954 published research on liver blood circulation of monographs that his 19 monkeys (Macaca mulatta monkey) in the experimental tolerance of 13 hepatic artery ligation, and do not have antibiotic treatment. Thus these studies to block the hepatic portal Pringle security applications laid a theoretical basis.
always practical needs of theoretical research is the most powerful stimulus agent in liver surgery, the surgeon needs to the internal anatomy of the liver have a better understanding. 1951 Swiss Hjortsj [1] established the first liver specimens pipeline corrosion and mold cholangiography research methods, after 10 cases observed by the hepatic artery and hepatolithiasis showed segmental distribution, and the liver is divided into inner and outer, after ago, a total of five of the tail. Later, Healey and Schroy [2] The study also confirmed Hjortsj further discovery in the distribution of intrahepatic portal vein is the same, and in accordance with the normal anatomy of the liver naming principle subparagraph naming system. Couinaud hepatic vein from the distribution function of the liver by subparagraph [3]. Anatomic study results show that the liver is a sub genitals, each has its liver of a separate pipeline system can be used as a surgical resection units. Anatomy of the liver, which in turn also urged Progressive development of the liver surgery. Internally, the Shanghai Second Military Medical University in the 1950s, Miss Mengchaodeng liver when the anatomical study.
50 in the mid - when, Goldsmith and Woodburne [4] stressed liver resection of the liver should be strictly complied with the internal anatomy, have proposed the rules of the liver resection of the concept of (regular hepatic lobectomy). In the late 1950s, Quattlebaum and Quattlebaum [5] stressed that the extensive liver resection surgery elements, including: fully reveal, hepatic vascular occlusion, completely free liver, blunt object isolated hepatic parenchyma. Such treatment is still views importance.
regardless of how you familiar with the anatomy of the liver, liver, but always open bleeding, how to reduce the loss of blood, liver, cut macrovascular not collision, which is the consensus. Quattlebaums stand off with a blunt object to the liver, but this concept has already seen early liver surgery. Various to blunt the main fault intrahepatic vascular liver preservation methods were used, such as has been recommended by a nail, Tong That Tung (Hanoi, Vietnam) in liver blood flow control blunt broken liver, Oglivie with vascular Clamp, Quattlebaum with surgical knife handle, Lintianyou (China Taiwan) fingers rubbed liver tissue, is now also used by the technique (finger fracture technique) [6]. The past 10 years and there used to reduce vascular hemorrhage broken liver specialized equipment, such as the most widely used "ultrasonic scalpel" (CUSA), In addition, there was still "water knife" [7], Peng Shuyou "including suction knife" in Renzhong "suction Cutter." The section on using bleeding in the liver while bleeding electrocoagulation with high frequency, infrared coagulation hemostasis, argon beam, "laser sword", plasma cutter, microwave hemostasis, various forms of liver clamp, liver tourniquet, and other equipment and tools; Drugs are like absorbable hemostatic fiber, fibrinogen , prothrombin, the collagen protein, macromolecular polymers products and this can be "spectacular", these new methods of hemostasis there is always accompanied by the development of liver surgery, in which development has not yet ended.
Une [8] compared the "Water Knife" (Water Jet Disector) and "ultrasonic scalpel" (Cavitron Ultrasonic Surgical Disector, CUSA) in a total of 68 cases of liver resection in patients using the advantages and disadvantages that, in the liver, cutting the blood loss, operation time, the two are not prescribed significant differences, but feel "water knife" will be organized by litter wash, and it could be more clear surgical field, in patients with cirrhosis, the liver also easy to cut, and the merit of equipment cheaper and easier maintenance of the use of safety, so that "water knife" as "ultrasonic scalpel" alternative supplies . The liquid is used saline. But the Chinese University of Hong Kong Liuyongyi professor in the discussion that "water knife" Although there is clearly more to the surgical field, but high-pressure water column splash can be formed by particulate pollution threat to the environment and the operating room staff, because of liver cancer patients have hepatitis B or hepatitis C virus infection, the other, there had been "water knife "tangential liver air embolism occurred when the report. Rau [9] cut to reduce the loss of blood when the liver, to become hypertonic saline brine to enhance their conductive properties, and water cannon installed on the high-frequency current, can be activated at any time hemostatic coagulation effect, does not require the replacement of equipment in order to save time.
Hepatic ischemia time tolerance 3
block in the hepatic portal surgery can not bleeding, but the hepatic vascular occlusion can last long?
Dong Jiahong [10] experiments with rats, to avoid blocking of the portal vein blood stasis to prove that rats can be safely blocked for 90 min, then clinically? Clinical Practice has proved that a large number of block hours in the hepatic portal within 15-20 min is safe, but for the wider and the complex liver surgery, this time within the limits of safety inevitably too short, so many 20 min 5-10 min interval blocking the blood flow open from clinical practice has proved to be effective. Elias [11] in 112 cases of hepatic resection of liver cancer patients, 20 cases of blocking the cumulative time over 90 min (mean 109 min), and each block is not sustained over 20 minutes, in which two cases of liver resection (IV, V, VIII segments) complex surgery , two cases of clamping time more than 140 min. Results after 20 cases without surgery died within 30 days, after the operation liver function changes are not significant differences. Elias repeatedly that the intermittent hepatic portal can be used to block abnormal hepatic parenchyma (often have hepatic artery embolization after chemotherapy), in hepatectomy broad cross-section of liver, surgery to reduce blood loss.
graded block hepatic blood flow Although it is safe, but the restoration of blood flow in each when it is inevitably increased blood loss. Whether the human liver can tolerate a long ischemic time? The previous time limit is only 15 minutes from the dog's information derived from the experiment, such as the Child by the different species of animals tolerance clamping time very different. Some of the reported hepatic portal block (portal triad clamping, PTC) or hepatic vascular isolation (hepatic vascular exc Lusion, HVE) security can be achieved time 60 min.
4 hepatic vascular occlusion in total hepatic vascular isolation
Heaney (1966) first proposed total hepatic vascular isolation (total hepatic vascular exclusion) of the purposes of liver resection of the concept [12]. Surgery clamp porta hepatis, liver, the liver of the inferior vena cava, while occlusion of the abdominal aorta. Huguet 1978 years using this method, which include liver cirrhosis patients with liver cancer, but surgical mortality rates higher, up to 28% (in patients with liver cirrhosis). Bismuth [13] (1989) this method has been applied to 5 One case of the patient, the surgical mortality rate dropped to 20%, the average time hepatic vascular occlusion is less than 50 min (46.5 min), and saw no need for occlusion of the abdominal aorta, not for cirrhosis patients. The low temperature liver perfusion (Fortner, 1974 advocates) is not necessary, because the process of surgery will naturally lower body temperature, and sometimes it drop too low, so Huguet used in the operation to control the temperature blankets. Thereafter total hepatic vascular isolation methods to cut liver The multi-use.
Huguet (1992) pointed out that although the liver resection is now widely used, but when the huge tumor in the liver or near the Central Department of inferior vena cava and hepatic vein, the general should not use conventional methods of surgical resection or great danger of . Conventional surgery is the main danger may be torn liver after the inferior vena cava or hepatic vein in massive loss of blood and air embolism. Hepatic vascular isolation can prevent this complication. The main points of hepatic vascular isolation is indeed under the control of the peritoneal cavity after intravenous branch. Emre [14] (1992) with total hepatic vascular isolation of liver for the treatment of 16 cases of patients with liver tumors huge, the average tumor diameter of 10.7 cm, the outcome of two cases of death, the author stresses must complete vascular isolation in the porta hepatis many small collateral vessels if not completely block still will cut more of the liver, bleeding, and even blocking blood loss were greater than not, the use of noninvasive vascular wide to block clamp liver duodenal ligament more effective.
Huguet [15,16] method is in the supine patients, the use of blankets to avoid hypothermia, bilateral long incision under the rib edge along the center line extending upward from cream, if large tumor size, the upper and lower vena cava revealed liver problems, while the right side of No. 7 or 8 intercostal incision more appropriate, and fully free of the liver ligament and adhesive is an important step in this procedure. Block liver duodenal ligament, should pay attention to whether ectopic left hepatic artery (from the left gastric artery); Under hepatic inferior vena cava in high blocker, should be in the right adrenal vein into the inferior vena cava above plane; The liver separation clearly superior vena cava, bypassing a sling, when a huge tumor, liver revealed after the inferior vena cava wall is often difficult. Therefore, this right thoraco-abdominal incision helpful. Next on the inferior vena cava, the two bleeding beneath the clamp Commissioner clamp most important, to request two clamp Tsim rounded to the inferior vena cava blood flow will be isolated. Do not cut liver before hepatic portal anatomy, but to reduce the clamping time, we and the author advocated some domestic anatomy of the hepatic portal first, the final steps on the block [17,18]. Huguet in 53 cases of liver resection patients using continuous block approach, compared blocked for more than one hour in 15 cases and blocked for 1 h following, not long after blocking opponents mortality and complication rates, changes in liver function between any obvious implications, will author liver ischemic tolerance time there limit? Hannoun [19] (1993) of 34 cases of patients underwent extensive surgical resection of the liver in a liver blocked blood flow sustained more than 60 min retrospective analysis, of which 15 cases at the same time blocking the liver and hepatic inferior vena cava, to prevent intraoperative hypothermia, the result of a continuous block, an average of between 73.6 minutes, the longest blocking one cases of 127 min, surgery difficult because the relationship between the body temperature of patients in an average of 35 ° C after liver dysfunction and no significant block of time, not one case of the whole group after surgery died within 30 days. Thus Hannoun come to the conclusion that in the absence of cirrhosis patients, can be a continuous block of time to 90 min; However, if the estimated time to block 120 min, suggested UW (University of Wisconsin) of cryogenic preservation of liver perfusion.
5 vitro Hepatectomy
with liver transplantation and in vitro technologies mature kidney surgery Enlightenment, the Hanover, Germany Pichlmayr [20] began in 1988 when the first cases were Fortner [21] in vitro perfusion of the liver cooling liver resection, the desire to achieve a more thorough tumor resection and removal in some patients with liver transplantation , to 1990, has done 11 cases of surgery. When fashion is a preliminary report, which it is difficult to comment on the significance of surgery, but the report has revealed that all patients with jaundice (a total of four cases) do not have good results, a surgical failure, and liver tumors (liver metastases) will have some effect. Cooling under in vitro perfusion of the liver resection technically demanding than orthotopic liver resection more complex, so can be used in complete surgical excision methods, generally do not choose in vitro resection.
in vitro liver resection because of their own liver replantation and the complex technical and time-consuming, France Sauvanet [22] (1994) to simplify the isolated liver surgery. The main points of this operation is not cut off hepatic portal pipeline structure, within the portal vein catheter inserted hypothermic perfusion, portal - IVC in vitro blood flow to the liver separation from top to bottom IVC pericardial sentenced Lee to re-anastomosis, the upper and lower cut off liver inferior vena cava and hepatic inferior vena cava under when the two ends will be cut off inferior vena cava, then liver in vitro can be moved out (the only gate structure Linked), the general method to resection of the tumor resection difficult. Author done five cases received better results. To further simplify operation, but was designed to address invasive liver after liver vein and inferior vena cava resection of the tumor, Hannoun's isolated position (Ex-situ In-vivo) of the liver resection. Domestic Dong Jiahong [23] (1996) with total hepatic blood flow and cooling to the semi-vitro perfusion of the liver in the treatment of transgression and the inferior vena cava and hepatic veins of the right of hepatocellular carcinoma, the patients have mild liver cirrhosis, had surgery after a transient liver dysfunction.
6 cirrhosis of the liver, blocking blood flow
liver cirrhosis at the time of vascular isolation cooling and liver perfusion can lead to increased liver cell damage adverse results, even in patients with obstructive jaundice, the same result is disappointing, therefore obvious obstructive jaundice and cirrhosis are considered hepatic portal blocked for a long time taboo. A large number of facts have proven that in the hepatic portal blocking limit within 15-20 min, the recovery of surgical patients there was no apparent impact, and the more time blocking and blocking the limits, have not yet been resolved. Orient primary liver cancer often associated with cirrhosis, 85% of China's primary liver cancer with cirrhosis, hepatitis and mostly after cirrhosis, total hepatic injury obviously universal, with obvious liver fibrosis and sometimes partial liver atrophy, portal hypertension and decompensated hepatic arterial blood flow increased, broken surgery when liver bleeding than normal liver tissue. So when cirrhosis of the liver blocked blood flow in China's more special significance.
vascular isolation of the liver can reduce undoubtedly the rules of non-cirrhotic liver resection and postoperative bleeding complications, the current is more of this surgery to stop bleeding in the microwave coagulation under implementation of effective good, but sometimes smaller because of tumor blood vessels and adjacent important, bile duct, the separation must need surgery resection. Japan Nagasue [24] (1985) Comparison of the three groups or liver resection of liver patients: not blocking (17 cases), Pringle blocker (19 cases), liver inflow and outflow channel blocker (11 cases) the results of the latter is in Pringle blocking in addition to any incision falciform ligament liver and crown ligament, isolated from the side of the hepatic vein surgery were to be blocked and not block the inferior vena cava, the longest time 47 min block, the results of the third group were bleeding decreased significantly compared with the former, no operative deaths, the complication rate also decreased significantly. However, isolated hepatic vein and hepatic vein were blocking is not easy, it is still not widely used.
Pringle vascular occlusion reduce the scope of influence, is also against cirrhosis resection of the measures proposed. Japan Makuuchi [25] (1987) suggested that liver cirrhosis of liver resection of vascular occlusion half when the safety of this method in the country have been Huaxi Medical University Guang Zheng Qi, Yan Lunan, etc. and our extensive use of this can withstand the liver tissue from the contralateral ischemic damage. Half of hepatic vascular occlusion method is simple and easy [26-28]. The doors of the system in the intrahepatic course is wrapped in fiber intrathecal Glisson, all liver independent of the formation of a liver, biliary vascular pedicle, or Gate of triple (portal triad) but this triple pipelines (especially Couinaud Ⅶ, Ⅷ liver) is not easy to find the building in the liver, which is not easy from the hepatic portal the Department of fiber sheath, the anatomy of the liver was found. However, the use of intrahepatic channels (intrahepatic approach), can be more easily separated from the fibrous sheath of the liver bile duct of the vascular pedicle and the respective control, the method called intrahepatic fiber sheath diameter Road (intrahepatic extrafacial approach), or known as the intrahepatic after Pathfinder (posterior intrahepatic approach) [29], its high biliary stricture repair and hilar cholangiocarcinoma surgery often be applied. Open surgery is the right caudate process and the liver parenchyma of the liver and liver capsule on the door edge of the liver capsule, liver door along the deep-Blunt (commonly used finger separation) separation, it can be fibrous sheath, in separation of the second stage of the liver and gallbladder bile duct vascular pedicle and were home to tape or clamp block. However, the Japanese Gotoh [30] relatively selective hepatic portal blocker (n = 13) and blocked hepatic portal liver (n = 8) cirrhosis of the liver cancer patients of liver surgery at the reaction results in the latter than the former operative time and blood loss were significantly reduced in that paragraph liver hepatic pedicle blocking their surgery complicated, there has been no obvious advantages.
at low temperature can be extended liver cells hypoxia tolerance time. Cirrhosis, if additional cooling treatment, it is possible to strengthen the liver cells to hypoxia tolerance. Yamanaka [31] in 50 cases of hepatocellular carcinoma right lobe of the liver cirrhosis of the liver resection, compared normothermic liver and liver vascular occlusion of vascular occlusion additional cooling vents partial results, there was no significant difference between the two groups, although the cooling group clamping time significantly longer; Yamanaka and that the liver under local cooling Ye vascular occlusion time could be extended to 60-90 min. Time is expected to block the blood flow of up to 30 minutes or more, should be supplemented by using partial hepatectomy blocking cooling more appropriate.
7 hepatectomy technology development
liver surgery is actually surgical anatomy of the liver and the combination, when surgeons understand the anatomy of the liver after liver surgery will be rapid development in the 50-60 age, liver resection have been standardized, the more practices, rules of liver resection (regular hepatic lobectomy ), that is, first of all deal with hepatic portal from the liver and the hepatic vascular and liver resection in real terms. This method has been contained in the general teaching, in spite of the author also certain technical amendments. 1952 Lortat-Jacob, Quattlebaum 1953 Pack and the rules of hepatectomy laid a foundation for liver surgery, Europe and the United States for metastatic liver tumors without cirrhosis, so this has been along the way, so Schwartz [32] published in 1984 resection of the right lobe of the liver; Starzl [ 33] (1980) by the expansion of right lobe of the liver resection or three paragraphs called resection of the right (right hepatic trisegmentectomy) at current commonly used method; However, in liver resection of the left side of the expansion, Starzl [34] published by the three resection of the left (left hepatic trisegmentectomy) surgical methods , are still not perfect enough, the blood loss surgery and postoperative complication rates were higher, remains to be desired. Expand the left hepatic lobe, the largest technical difficulties in the isolated liver parenchyma should strictly follow the right hepatic crack (right hepatic fissure) plane, and this fissure in the liver liver It is also not obvious on the surface, it is V, VIII and VI of the liver, liver Ⅶ paragraph of the sub-interface, thus if there are deviations from surgery, , it may be right hepatic vein injury, in particular the right posterior segment of the liver caused very difficult situation. Huguet [35] (1994) with hepatic vascular isolation method left hepatic resection of leaf expansion in the hepatic vascular isolation, in the case of blood along the right hepatic vein to the distal separation surgery at the end, we could clearly see the right hepatic vein on the following firms liver section. Huguet 8 patients with vascular isolation time for 58-85 min, an average of 70 minutes, without surgery within 30 days after death, but one died after the first 40 days, one case of 17 days postoperative hemorrhage and hepatic coma due to acute liver transplantation purposes, and left another one case of biliary fistulas. Thus, the left hepatic resection of leaves to the current expansion is still doing the surgery and rarely has a high complication rate, the use of "ultrasonic scalpel" isolated hepatic parenchyma, it is possible to reduce the operation of vessels and bile duct injury. The left hepatic resection of leaf expansion (left three resection) technical problems remain to be perfect.
liver cancer in China is a big country "," many patients, liver surgery has been very active. During the 1950s, Beijing and Guangzhou Cheng - En Wang Professor Professor ZENG Xian - nine representatives has accumulated more than 50 cases of hepatocellular carcinoma of the liver resection of the rules of the experience, but a higher surgical mortality, then experience is summed up by: (1), liver cancer with cirrhosis of the liver resection should be <50%; ( 2) extensive liver resection should be very careful; (3) liver failure is the leading cause of death surgery; (4) Long-term treatment with hepatic resection seems disproportionate amount; (5) cirrhotic patients should be more conservative hepatectomy. 50-60 in the period, Wu Mengchao, Professor liver [36,37] committed to the research and development of the anatomy of the hepatic portal blocking the liver surgery, Up to today, and accumulated the world's largest series of cases of liver cancer resection. 1971 in the then "beat cancer three years" under the call, et al [38] Professor of AFP in the early diagnosis of liver cancer, "tailor" type of liver resection, liver cancer surgical treatment of a breakthrough, and the development of China and even in Asia to become the surgical treatment of liver cancer model.
liver bleeding problems, like anatomy of the liver surgery in the clinical interpretation, it is surgery technological changes over the years is not great until the liver surgeon noted that the caudate lobe of the liver. Since anatomical location, liver caudate lobe resection of the tumor is still liver surgery has been the "forbidden zone." The purposes of the past once the liver caudate lobe resection of the liver together with most of the left, right lobe of the liver or hilar biliary additional surgery, not yet finalized their separate liver caudate lobe resection (isolated hepatic caudate labectomy). For example, Elias [39] 212 cases of malignant tumor resection of the liver, only one case of as separate the caudate lobe resection. In fact, the caudate lobe of benign and malignant tumors are not rare.
Yammamoto [40] (1992) report one case of caudate lobe tumor left by separation, at the junction of the former approach right liver lobe (anterior approach) Act resection; Later, Yamamoto [41] reported five cases separate caudate lobe resection, four cases of hepatocellular carcinoma, and one case of colon cancer metastasis after more than four years are to survive, the surgical method is used separately liver median cleft of the former approach, the right hepatic surgery will be free to cut off the inferior vena cava vein short before the liver, isolated right hepatic vein; Free liver to the left outer leaves, cut off and left hepatic vein ligament connecting vein, caudate lobe static from the inferior vena vein Isolation, isolated left hepatic vein in the liver, and around the block with. Subglottic in blocking the liver through the hepatic vein in the liver left off, will be adjacent to inferior vena cava (paracaval) part of the caudate lobe from the liver door separating the cut caudate lobe of the liver and portal branches in the vein until the rear, separated from the right caudate process with the attachment and liver resection of the entire caudate lobe tumor. Yamamoto separate road that before the caudate lobe resection of the liver although not so commonly used, but still have cirrhosis can consider as a curative surgery. Domestic Peng Shuyou resection with six cases before the Pathfinder caudate lobe tumor. Colona [42] (1993) with the left channel with two cases of liver metastases and one case of nodular hyperplasia; After Lerut approach (posterior approach) with one case of caudate lobe tumors but not very successful, as required bleeding gauze packing. Huang [43] The left - right - left a joint approach (left-right-left combined approach) with three cases of primary caudate lobe tumor. Bartlett [44] and their colleagues report four cases of separate caudate lobe resection is the former approach, and through the implementation of bilateral approach, the author之一Blumgart paper also recognized that the bilateral approach in accordance with the principle of liver resection caudate lobe resection is feasible without the necessary liver parenchyma. Facts have proven that separate caudate lobe resection of liver surgery is no longer a "forbidden zone" [45] However, the author also proposed a separate caudate lobe resection in the treatment of primary liver cancer, is reasonable. Nagasue [46] reported six cases of primary liver cancer in the caudate lobe caudate lobe resection alone the long-term effect, determine its efficacy in line with other parts of primary liver cancer resection. Therefore, separate caudate lobe resection for the caudate lobe of primary and secondary tumors is feasible and reasonable, especially when combined with cirrhosis when.
On sports and health courses and the development and utilization of resources
In the dawn of the new century, in order to adapt to social development and the advent of the knowledge economy, China launched a new round of reform of basic education. A new round of reform of basic education is the core of the curriculum reform. Next, the state will not draw up a unified plan and the teaching syllabus, in its place is a curriculum standards. Curriculum standards no longer teaching content and teaching process for specific requirements. Meanwhile, in order to adapt to different regions, the requirements of schools and students, have also established a national, local and school curricula of the three-tier management system. And schools and teachers teaching in the curriculum management and implementation of a greater autonomy in accordance with their own characteristics and advantages of the development of courses. To develop courses, the courses must have enough resources, curriculum resources as a result of a brand new concept was raised. A new round of "Sports and Health" (primary schools are still said sports) the implementation of the curriculum standards, we also need places, schools and sports teachers fully tap the resources and the use of curriculum, developed with the characteristics of the local and school physical education curriculum. Therefore, the physical education and health curriculum resources development and utilization of the study is a much-needed new issues, it will become the new round of reform of the physical education curriculum a bright spot. This paper mainly uses literature research, visit research, logic analysis methods, the current combination of physical education and health curriculum reform practice observation, the physical education and health curriculum resources and the concept of classification, development and utilization and the development of the main principles and ways to conduct a comprehensive and in-depth study. 1 sports and the concept of health curriculum resources Resources refers to "sources of capital and goods. Generally refers to natural resources. "[1] As the development of human society, the concept of resources is continually expanding, that natural resources no longer just the resources, but also includes a variety of community resources. The practice of various human activities calls for a certain resources. Curriculum resources is a result of the new round of reform of the basic education curriculum to the needs of a new concept. "Curriculum resources is the key source of a course curriculum and the implementation of the necessary conditions directly [2]." "In accordance with the functional characteristics of curriculum resources, curriculum resources can be classified as material resources and the conditions of the two major categories of resources. ... In accordance with the curriculum of different spatial distribution of resources , can be roughly divided into the curriculum resources outside the school curriculum resources and curriculum resources [3]. "As a physical education and health courses in basic education a major courses, a new round of curriculum reform to achieve the goal, of course, also need to have a certain curriculum resources as a prerequisite. Sports and health curriculum resources refers formation of the physical education and health curriculum sources and the implementation of elements of physical education and health courses and direct the necessary conditions. According to this concept, sports and health curriculum resources can SCA resources and the conditions of the two major categories of resources. Sports and health curriculum material resources, including major sports and health knowledge, physical training methods and measures, Physical Education Organization and teaching, curriculum goals, feelings and values, and other sports in five aspects. Sports and health conditions of the courses include resources for the implementation of this course of human resources, financial resources, time resources, space resources and sports equipment supplies and resources five aspects. Material resources are the physical education and health curriculum elements of the source, that is, building sports and health curriculum objectives, course content and curriculum implementation of the method of sources. It can be seen as a physical education and health courses running software. Modern information transmission channels varied, physical education curriculum material resources can be from a variety of materials, books, newspapers, magazines, radio, television, audio-visual materials, such as CD-ROM and Internet access. On the other hand, a lot of physical education curriculum material resources exist in various places, communities, we need to rely on the development, selection and use. Conditions for the implementation of physical education curriculum resources are needed hardware, the lack of physical education resources conditions it is difficult to proceed smoothly, therefore, it determines the scope of the implementation of sports programs and practical level. Sports courses on time and space conditions demand is relatively high, the physical education curriculum objectives of the need for more time and space as guarantor, in addition, also calls for a certain human, financial and sports equipment support. Curriculum resources sports and health courses is the prerequisite for the creation, but only after the abundant resources after the screening and processing can we truly enter the courses. Therefore, in order to achieve physical education and health curriculum reform objectives, the need to improve curriculum resources development and application level. 2 sports and health curriculum resources development and utilization of the need for For a long time, we have become accustomed to the implementation of the unified curriculum physical education curriculum management system. According to experts from the logic of sports disciplines prepared by the unified framework, the school year of teaching content, teaching hours, teaching schedule was very detailed and thoughtful, unified throughout the country will act in accordance with the outline of the implementation of Physical Education. A key link in the national curriculum management system, authoritative, management is very convenient, and schools and sports teachers to implement it more easy characteristics. However, China is a large country, the region's geography, climate, economic development levels, cultural backgrounds, and so on the basis of students very significant differences, which in many places because of the conditions and restrictions can not be implemented outline. The outline contains a lot of competitive sports without a transformation of the content of some of these elements for the majority of students, and is expected to be, but also to promote the healthy development of children can not play a positive role. A new round of physical education curriculum reform, in accordance with the requirements of the current reform of basic education is no longer formulate unified national sports program, but will raise the physical education and health curriculum standards (hereinafter referred to lessons subscript). Course superscript "Health First" as the guiding ideology, the curriculum goals, objectives and the level of learning areas to target specific requirements, and the goal of completion of the course contents and methods need only a broad scope, regions, schools and sports teachers have a great choice. Because of the standard does not require teaching hours, according to the students meet learning targets situation, teachers may at any time on the different aspects of teaching hours to adjust [4]. Course objective is for all students to the basic requirement and the various places, schools, and teachers should strive to achieve. But for how to achieve class standard, and schools and teachers have more autonomy. Local, schools, teachers should be in accordance with their respective needs, characteristics and advantages, we should fully tap the rich resources sports and health courses, and has also selected by the students, effective and practical method of teaching content and creative way to achieve the goal of course, to share the same objectives , converge. In addition, the state, local, school courses at the three levels of the management system, but also to mobilize local, schools and teachers develop curriculum resources enthusiasm, we go all out to better accomplish the task of Curriculum Reform. These reform measures not only implies giving places, schools and teachers decentralization, but also means that local schools and teachers to a higher demand. For physical education teachers, the future no longer have ready-made fixed "script" reproduces, each physical education teachers should be in the pursuit of the target premise, according to the actual situation, select contents and methods of teaching, develop their own "script", on its own characteristics lesson. Three new concepts, the development of a comprehensive physical education and health curriculum resources For a long time, physical education curriculum be understood as merely by curriculum row, in the school playground on the PE is a limit in the schools and provisions of the 45 minutes of closed system. Sports courses on this understanding, limit our rich sports programs around the concerns and resources development. Now, with the sports curriculum reform continued to deepen, people have gradually breaking the previous closed course concept, as is the physical education curriculum in schools, the overwhelming majority exists in the space of 45 minutes and not subject to restrictions of open systems. "Therefore, the full use of all available resources for education, physical education out of school playgrounds, and the extracurricular activities of students, family and community life combine the modern physical education curriculum is the inevitable requirement for development [5]." This new concept of the physical education curriculum will help us open up horizons , the full development and utilization of the rich resources sports programs, sports programs better achieve goals. 3.1 to foster a new physical education and health curriculum time outlook To achieve physical education and health curriculum goals, the first time have the guarantee, relying on 2 to 3 times per week of physical education time is far from sufficient. Courses include homework with the process, which is not the only refers to the process of classroom teaching process, but it also should include students in the school extra-curricular sports activities and extracurricular sports process, including the participation of students holidays, families, communities, and other sports process. These students physical exercise time should be seen as an extension of physical education time, a physical education curriculum areas of the time. Resources sufficient time to implement the physical education curriculum that physical education teachers should be open to the positive vision of the development and use of the physical education curriculum time resources. Sports Curriculum Reform in the process of teaching content and organization because of the diversification of time often makes the arrangements for physical education in the past did not fixed. To meet the need for reform in terms of time allocation of resources should be flexible and mobile. At present, many elective classes in schools, clubs, and a system of school reform, will not only break the original class teaching system, but also broke the conventional fixed teaching time. The diversification of teaching content, and sometimes also requires us to break a course of 45 min, some of the contents of teaching need to take lessons combination of centralized and scattered approach and, where necessary, can be arranged at the weekend. Of course, the time the flexible deployment of resources, is not meant to be casual and unplanned, any time of the deployment should be prior consent of the school agreed, and included in school curricula. 3.2 expand the implementation of the physical education and health curriculum space The implementation of sports programs need more room, there is not enough room, it would be difficult to carry out physical education, physical education curriculum is a prominent feature. However, the actual situation in China at present, the majority of school sports are very limited space, this is the sports curriculum reform disadvantage. Therefore, we strive to expand the school sports space at the same time, it should be an open vision to the school physical education curriculum development space. New schools should promote educational ideals into an open system. At present, schools are being called on the stadiums should open society, in turn, to foster lifelong physical education students the awareness and ability, the school's physical education curriculum should also be toward society and nature. China's vast territory and abundant resources, the region's geography, climate, economy and culture vastly different, the region boasts rich and unique extracurricular sports curriculum resources, the rational development of these resources will provide sports curriculum reform is very favorable terms. In recent years, in order to make physical education in a lively, many schools have begun to actively try to develop extracurricular sports resources. For example, in order to make Shenzhen City High School physical education and extra-curricular sports activities, integrate the club is trying to sports in the form of teaching, students can according to their own hobbies option classes. In addition to the school set up baskets, Pai, Ping, feathers, martial arts, aerobics and other projects courses, but also set up a bar softball, football, hockey, tennis and higher demands on the project site courses. To address these courses venues, they organize the students out of school classes. For example, the school's tennis club, every weekday evening, the club will be organized hundreds of students to Guanlan Country Club Tennis Center, and paid careful study happily playing tennis [6]. And short of the rural economy developed regions, although the lack of modern stadiums, but the city has not developed the unique sports space, where the beautiful rivers and mountains, beaches, green spaces, which are all good sports space resources, as long as we pay attention development, rational use, able to play a unique role, so that physical education curriculum goals can be realized. Concern extracurricular sports programs in the space resources development, should also attach importance to the development of space resources in schools, after all, mainly to physical education in schools on. Although the school can be developed relatively limited space resources, but the total still some potential. Many school sports programs in order to free up more space and fully tap the potential of schools, the building of a number of practical Stadium, the Museum, schools and even some cities will be asked to field athletics, track and field below left field with the same large area into the gym, gym, table tennis rooms and venues, the implementation of the physical education curriculum to provide more space. 3.3 Development of the rich sports and health curriculum material resources For a long time, and schools and physical education teachers are accustomed to in accordance with the unified national program of teaching, mandated in the outline of what we have to teach what. But in the outline of the provisions of the majority of teaching content is the formal competitive sports content, as is the uniform provisions, so whether schools are unconditionally, whether students interested, students can learn and teachers can only copying Physical Education. This makes places, schools, and teachers do not need to consider this issue curriculum resource development. The experiment is the physical education and health curriculum standards, the only course objectives, learning objectives and the level of field goals put forward clear demands, but no specific course content for hard and fast rules. This requires places, schools and teachers should be based on the actual situation independently to choose the course contents and methods. "Health First" is the physical education and health curriculum purposes. Therefore, the physical education teaching content should be the fitness of the body of knowledge and training methods and means. Human means and methods of fitness is very rich, but also with the development of society in constant development. At present, apart from competitive sports, the community, there are still many of the masses of young people emerging favorite sports, entertainment sports, leisure sports, civil and national sports content, such as the various fashion aerobics, fitness dance, folk dance, street dance, soft volleyball, gas, volleyball, roller-skating, climbing (artificial), Frisbee and the characteristics of sports and so on, can be rightfully introduce sports classroom. Some sports teachers also use their brains to find ways, according to the actual situation in schools, according to local conditions and now to not only create a lot of students like and promote the physical and mental health training methods. PE teaching content should also include the development of competitive sports on common projects and the use of the transformation, many competitive sports, as long as we reduce the technical requirements or equipment standards and highlighted their fitness and entertainment functions, is still loved by the students good material. Sports and health courses taught teaching also includes certain health-related knowledge. In modern society, people generally concerned about their own health. So, pay attention to all the various media reports about fitness, health aspects of new knowledge, new ideas, new methods. These sources of knowledge, it is very rich and, therefore, in the process of teaching good addition to a selection of teaching materials, should also through various books, newspapers, magazines, radio, television and the Internet, gather relevant material, added some new time teaching content. 3.4 fully develop sports and health human resources courses Sports courses human resources can be understood as the intervention programs and courses and play a positive role in the implementation of the human sources. Curriculum physical education curriculum requirements should be an open system, its human resources, not only in school physical education teachers, school leaders, teacher, student, but also outside experts, instructors, community sports instructors, parents, and so on. These people are likely to the implementation of sports programs play a positive role. Previously, in addition to physical education teachers, very few people will be directly involved the implementation of the physical education curriculum. However, the openness of the physical education curriculum, due to time and space business development, the diversification of contents and methods, the need for multi-human intervention can be better implemented. In order to better implement the "Health First" the guiding ideology, in school and need school leadership, academic administrators, the class teacher and students actively involved in school sports work. The content and methods of teaching physical education reform, relying on the strength of PE teachers often is not enough, and where necessary, and can fully consider hiring outside experts, coaches, and community sports instructors as part of the teaching work. In fact, some schools have already started to do so. Some schools also promote sports in schools, the mutual flow of human resources, the school will not only promote the necessary flexibility to hire outside staff for teaching, but also in promoting the circumstances allow for the first complete physical education teachers to serve as the guiding community sports, participate in various business education increased in order to raise the the overall quality of teachers. Of course, no matter how physical education curriculum reform, physical education teachers remains the most important human resources. Physical education teachers are the main perpetrators of course, is the physical education curriculum resource development and material resources carrier. Therefore, we should fully tap the potential of PE teachers, enhance their overall quality, and human resource development is the most important link. Curriculum Reform in the process of physical education teachers should be completed as soon as possible role of the conversion, from the original implementation of courses for policy makers to shift from a "lecturer" into a curriculum researchers. Role of the conversion is a difficult task, we should create conditions for the physical education teachers so that they have the opportunity to study and master modern education, teaching theories and techniques, constantly update our concepts, and constantly raising the professional standard. PE teachers themselves should also step up study, positive thinking, participate in teaching and research in the practice of reform to improve their capacity to adapt to the curriculum reform the development of the situation. 4 physical education and health curriculum resource development principles and the way When we establish a new concept of the curriculum, we will expand the vision, will find physical education curriculum resources are very abundant. It can be said that all students can promote the development of physical and mental health resources available for the program resources. But the fact is we can not have all the resources to develop and use, but they should be based on the merits and school resources to the actual situation of choosing the most appropriate resources be developed and utilized. 4.1 Development of principle Principle 4.1.1 fitness "Health First" is the guiding ideology of the education reform schools, sports and health courses is the primary objective. Therefore, we in the development of curriculum resources, we must first consider the principle is fitness. Both primary and secondary students is in a period of rapid development physically and mentally, in their different stages of growth and development, have different physical development sensitive period. Therefore, we in the choice of material resources, shall, in accordance with students at different stages of the development of physical characteristics, to be scientific and rational choice, to ensure that these materials can really help promote the healthy growth of the students physical role. Avoid use some practical, not helpful to the health of students material resources. 4.1.2 interested in the principle of Students interested in studying physical education and health courses momentum, only students in the teaching contents and methods interested in the environment, to take the initiative and active participation in learning. In the development of physical education curriculum material resources, we must guard against those who choose technical requirements too high, students will learn fundamental, or dull material. Lively and active young people, we shall, in accordance with their psychological characteristics, and welcome to choose their favorite sports material, including some entertainment, leisure and emerging physical exercise, so that they can learn the fun in full physical and mental development. Principle 4.1.3 adaptability Adaptability refers to the principle in the development of physical education curriculum resources, and consideration should be given to schools, teachers and students in line with the actual situation. The development of curriculum resources in the process, we may find that many good curriculum resources, but is not able to use very well, depends on schools, teachers and students in specific circumstances, such as the school site equipment, financial resources and the environment, whether or not the desired conditions, the availability of a physical education teachers the ability of the students is the desired basis, or even to consider the parents can not get the understanding and support. 4.2 physical education and health curriculum resources development means Physical Education and Health Curriculum Resources is a new concept, its development and use is a need to seriously deal with the new issues. However, the physical education curriculum resource development can not rely on behind closed doors, and does not blindly way to racking our brains, and the investigation should be the subject of extensive analysis, and in teaching practice to be evidence, use practice to test the use of resources more scientific and effective and experiences should also be carried out exchanges and promote. Only by these means can be achieved through effective resource development and utilization. 4.2.1 research In China's vast land, all provinces, municipalities and autonomous regions, and even where each school community, there are many objective can be developed for physical education and health curriculum resources. But if these resources not found it, dig it, there will be no use of it. Therefore, the development of physical education curriculum resources is the primary task through extensive investigation and research, the use of resources can be fully grasp the actual situation, through comparative analysis, which choose the best use of resources. 4.2.2 Experimental Study Experimental research is the development of physical education and health curriculum resources necessary means, only through teaching practice test, can be confirmed by the development of the resources whether it is conducive to achieving the objective of course is subject to the pupils. Therefore, in the development of curriculum resources, we should promote the adoption of scientific investigation, the results of experiments to confirm the choice of the effectiveness of resources, and make them choose the best use of resources. 4.2.3 promote exchanges Curriculum resource development is the physical education and health curriculum reform in a new bright spot. In recent years, many localities and schools in this work has been made a very good experience, their characteristics of the material resources, the conditions in the community in the use of resources, or human, financial resource development, have broken with the original old curriculum framework and achieved very good results. Their good experience is worth learning and drawing upon. Therefore, in the development of curriculum resources in the work should promote mutual exchanges and learn from each other, to the sharing of information resources. All three work by the local education authority or school district teaching and research department of the teachers in some backbone, but also by the Department of Physical Education in schools launched with the support of research and development, they can even have the enthusiasm and the ability to conduct independent development of physical education teachers. In short, should extensively mobilize the forces on all sides development and utilization of physical education and health curriculum resources, sports and health courses more lively and the like by the students, and to promote the students receive comprehensive physical and mental development. 5 Conclusion 1. Sports and health curriculum resources refers to a physical education and health courses source of the factors directly with the necessary conditions. Under the Resource features, it will be sports and health curriculum resources SCA resources and the conditions of the two major categories of resources. 2. In the new round of reform of the basic education curriculum, the curriculum of physical education and health status has been further improved. To implement the new curriculum standards sports and health management system with three courses, and schools and sports teachers to be actively developing this program resources. 3. The development of physical education and health curriculum resources should first update our ideas, breaking the framework of the original courses, courses will be considered open systems, expanding the time and space programs, comprehensive development and utilization of resources and material conditions of resources. 4. Physical education curriculum resources development must undergo strict screening, in accordance with the fitness of interest and the principles of adaptability to choose the best use of resources. The physical education curriculum resource development is the main means of investigation and research, laboratory research and the exchange of promotion.
Critical of rheumatic valvular heart disease treatment
1. Perioperative Management Critical rheumatic heart valve and lung Regenerated cycle of long-term high-pressure circulation system, congestion, in the lung, liver, kidney and other major organ dysfunction; Due to long-term congestion gastrointestinal mucosa caused digestion and absorption features low, evil heart of patients with quality. Therefore preoperative cardiac function should be strengthened support, and even intravenous drip positive inotropic drugs, the patient's preoperative cardiac function improved conditions, the importation of plasma, fresh blood, albumin, and so on, the correct patients with hypoproteinemia anemia; Pulmonary function conducted training. Heart failure generally to be corrected, improved nutritional status, to choose the timing of surgery to improve surgical treatment. Use of myocardial protection potassium content of blood cardioplegia solution continuous perfusion, thus ensuring the myocardial oxygen supply and energy metabolism, prevent myocardial reperfusion injury. After severe low cardiac output, in addition to positive inotropic drugs, the early adopters IABP, left ventricular bypass can improve left ventricular function; Renal failure patients early trip bedside peritoneal dialysis or hemodialysis; Tracheal intubation of patients can not eat by mouth early supplementary nutrition through nasal feeding or intravenous nutrition, favorable patient recovery. 2. Membrane Disease Treatment Rheumatic heart valve disease, a considerable number of patients in functional closed tricuspid valve insufficiency, cardiac function and postoperative effects of long-term survival, therefore, should take positive surgical approach, in replacement of mitral valve, aortic valve at the same time, that is more than functional mild tricuspid valve insufficiency, for reduction of the ring annuloplasty. Avoid early postoperative lesions increase in right ventricular failure. 3. Strengthening Prevention and Treatment with postoperative Critical rheumatic valvular heart disease cardiac functional recovery after surgery is the major cause of death bad one. According to observation, from heart failure for the performance of systemic venous blood stasis, jugular goats, hepatosplenomegaly, a serious lower extremity edema. Drugs can only temporary remission, re-operation complications and high mortality. Therefore, the importance of regular follow-up of patients, so Doppler echocardiography, early detection tricuspid regurgitation, timely treatment. 4. This group of early postoperative complications, according to the frequency followed by low cardiac output syndrome, ventricular arrhythmia, renal failure, and so on. After application of positive inotropic drugs and expansion of drug treatment of vascular low cardiac output syndrome; Correct hypokalemia, and other electrolyte imbalance to correct ventricular arrhythmias; Early renal failure patients bedside visit peritoneal dialysis or hemodialysis. 5. Late complications mainly cerebral hemorrhage, cerebral embolism, machinery card flap valve, the tricuspid valve insufficiency, and other functional closure. Prevention of cerebral hemorrhage and cerebral embolism, the key is to guide patients taking anticoagulant drugs, to do follow-up work at the same time, periodic testing prothrombin time ratio adjustment and international standards anticoagulant drug applications. The patients in one case of postoperative patients 2 years of epilepsy, and still lead to excessive anticoagulation related cerebral hemorrhage.
Propafenone treatment of supraventricular tachycardia 47 cases
Supraventricular tachycardia (paroxysmal supraventricular tachycarelia, PSVT) is a common clinical arrhythmia, severe PSVT can lead to heart failure, shock, the immediate termination of their attack is one of the main purposes treatment. Author June 1994 - 1999-1 measurements on pacemaker therapy PSTV47 cases, better results are reported as follows.
1 clinical data
General information on 47 cases of 110 patients, male 30 cases, 17 cases of female, age 18 - 71 years old. Hypertensive patients with coronary heart disease 21 cases, seven cases of rheumatic heart disease, Wolff - Parkinson-White Syndrome eight cases, 11 cases of unknown causes. ECG showed: QRS complex rules, frequency 150 - 250 times. Min. The author of 14 cases repeatedly, the largest one case of recurrent eight, the incidence to appointments to 4 mi - 13h range. Suddenly flustered for the clinical manifestations, chest tightness, lightheadedness, heart palpitations, shortness of breath; ECG with PSVT performance. Conventional carotid sinus massage, oppression eyeball and posterior pharyngeal stimulation are invalid.
1.2 ECG monitor treatment under propafenone 7 mg +10 20% glucose injection, intravenous injection, the time> 10 min, PSVT termination of suspended substances; Repeat the above may be invalid if the dosage 2 h, the total does not exceed 250 mg.
1.3 efficacy standard medication within 1 h 3 h to sinus rhythm and no recurrence for the effective, in a specified time, the failure to law or law shortly after the recurrence were invalid.
1.4 Results The 47 cases of 44 cases of effective, efficient 93.6%, rhythm calm Note 1 (≤ 70 mg) were 42 cases, to the legal time 5 - 14 minutes, with an average of 8.77 +5. Olmin; One case of application to propafenone after the legal transfer of 140 mg, at 26 min; one case of drug law to 200 mg, at 44 min. Three cases of propafenone to 250 mg3h law has yet to give up propafenone treatment programs. After administration obviously does not apply to 16 cases, of which 14 cases of nausea and vomiting, blood pressure dropped an average of 0.5 - 3.5 kPa six cases, in the four cases of premature beat, with sedation, and other symptomatic treatment shortly after symptoms ease.
2 discussion
Rhythm-ping is the only country capable of producing the type of IC antiarrhythmic drugs, antiarrhythmic broad spectrum of high and fast onset of action, side effects. Its main role of electrophysiology: (1) inhibit the action potential of the speed and magnitude; (2) blocking myocardial cells quickly satisfied that ion channels; (3) extend the action potential duration and effective refractory period; (4) inhibition of Pu's fiber spontaneous Except for a four rate. PSVT mechanism is returned, self-discipline and trigger increased activity. Propafenone for the electrophysiological basis of PSVT is inhibited bypass conduction, inhibit conduction stronger than before to reverse conduction, should not be extended to the period before. Based on the above theory author of rhythm in the treatment of PSVT, to the law are found in patients with progressive heart rate slowed down to the form 150. Min, and then there were 11 cases of 1 to sinus rhythm, Ms are to gradually drop to sinus rhythm. PSTV to sinus rhythm in the two cases when suddenly stopped Bo sinus, the immediate chest cardiac massage was sinus rhythm. When the rhythm is still in the application carefully, mind, and under the temporary care with necessary rescue drugs.
1 clinical data
General information on 47 cases of 110 patients, male 30 cases, 17 cases of female, age 18 - 71 years old. Hypertensive patients with coronary heart disease 21 cases, seven cases of rheumatic heart disease, Wolff - Parkinson-White Syndrome eight cases, 11 cases of unknown causes. ECG showed: QRS complex rules, frequency 150 - 250 times. Min. The author of 14 cases repeatedly, the largest one case of recurrent eight, the incidence to appointments to 4 mi - 13h range. Suddenly flustered for the clinical manifestations, chest tightness, lightheadedness, heart palpitations, shortness of breath; ECG with PSVT performance. Conventional carotid sinus massage, oppression eyeball and posterior pharyngeal stimulation are invalid.
1.2 ECG monitor treatment under propafenone 7 mg +10 20% glucose injection, intravenous injection, the time> 10 min, PSVT termination of suspended substances; Repeat the above may be invalid if the dosage 2 h, the total does not exceed 250 mg.
1.3 efficacy standard medication within 1 h 3 h to sinus rhythm and no recurrence for the effective, in a specified time, the failure to law or law shortly after the recurrence were invalid.
1.4 Results The 47 cases of 44 cases of effective, efficient 93.6%, rhythm calm Note 1 (≤ 70 mg) were 42 cases, to the legal time 5 - 14 minutes, with an average of 8.77 +5. Olmin; One case of application to propafenone after the legal transfer of 140 mg, at 26 min; one case of drug law to 200 mg, at 44 min. Three cases of propafenone to 250 mg3h law has yet to give up propafenone treatment programs. After administration obviously does not apply to 16 cases, of which 14 cases of nausea and vomiting, blood pressure dropped an average of 0.5 - 3.5 kPa six cases, in the four cases of premature beat, with sedation, and other symptomatic treatment shortly after symptoms ease.
2 discussion
Rhythm-ping is the only country capable of producing the type of IC antiarrhythmic drugs, antiarrhythmic broad spectrum of high and fast onset of action, side effects. Its main role of electrophysiology: (1) inhibit the action potential of the speed and magnitude; (2) blocking myocardial cells quickly satisfied that ion channels; (3) extend the action potential duration and effective refractory period; (4) inhibition of Pu's fiber spontaneous Except for a four rate. PSVT mechanism is returned, self-discipline and trigger increased activity. Propafenone for the electrophysiological basis of PSVT is inhibited bypass conduction, inhibit conduction stronger than before to reverse conduction, should not be extended to the period before. Based on the above theory author of rhythm in the treatment of PSVT, to the law are found in patients with progressive heart rate slowed down to the form 150. Min, and then there were 11 cases of 1 to sinus rhythm, Ms are to gradually drop to sinus rhythm. PSTV to sinus rhythm in the two cases when suddenly stopped Bo sinus, the immediate chest cardiac massage was sinus rhythm. When the rhythm is still in the application carefully, mind, and under the temporary care with necessary rescue drugs.
Cerebral venous thrombosis diagnosis and treatment of the status quo
Cerebral venous thrombosis (cerebral venus thrombosis, CVT) into venous sinus thrombosis and cerebral venous thrombosis was due to infectious or non-infectious causes formation of venous system thrombosis, caused congestion, resulting in venous return obstacles have brain bleeding, edema and intracranial hypertension , which show a series of related clinical symptoms and signs. CVT complexity of the etiology, involving all age groups, from dissatisfaction with 1-year-old infants to seniors. Its clinical and neuroimaging performance also changed greatly. If taken in the early onset of effective treatment measures, good prognosis. Therefore, early diagnosis is very important.
1, the diagnosis of CVT
Whether there is a clear 1.1 CVT Have the following four kinds of clinical syndrome one should doubt the CVT (1) partial nerve defect with or without intracranial hypertension, the most common form. There will be aphasia, hemiplegia and Blind, etc.. If accompanied by headache, seizures or a state of awareness of the changes will be highly suspected CVT. (2) of pure high intracranial pressure, it is a common type, manifested as headache, as papillary edema and six pairs of cranial nerve palsy, and similar benign intracranial hypertension. (3) subacute encephalopathy type, the level of awareness for the performance drop, sometimes accompanied by epilepsy, no clear positioning signs or intracranial hypertension identifiable characteristics, this type of easily misdiagnosed. (4) the cavernous sinus thrombosis, the incidence usually acute and chronic progress was accompanied with moderate pain and 3 or 6 pairs of cranial nerve palsy. The only headache symptoms for the CVT, with lumbar puncture headache, subarachnoid hemorrhage-induced headache or migraine, and other identification. 1.2 diagnosis 1.2.1 neuroimaging: MRI and magnetic resonance angiography (MRA): MRI and MRA Joint Inspection CVT diagnosis and follow-up is the best way. CVT highly suspected as clinical, MRI and MRA should be a first-line inspection tool MRI shows signs of thrombosis direct different changes with time. The acute phase thrombosis (one week) with a performance of the T1; Such signals, T2 low signal. Subacute (2-4 weeks), T1 and T2 are high signal. Phase III (l months later), recanalization, or thrombosis persistent residues, showed sinus wall and sinus change. Subacute thrombosis period of the typical high signal on the larger significance of the disease, other phases signal not typical, the lack of specificity, coupled with the flow-related artifacts impact on conventional MRI images to make the diagnosis more difficult, especially in the acute phase. MRI, the superior sagittal sinus, and the transverse sinus straight sinus thrombosis most easily identify, brain vein thrombosis and cerebral vein identification has been difficult. MRI showed that the indirect signs including diffuse brain swelling (for the normal signal), edema or infarction (T1 signal or low signal, T2 high-signal), and more in periventricular white matter; Hemorrhagic infarction, T1 and T2 are high signal. MRA showed that the direct signs of thrombosis for development or normal cerebral venous sinus blood flow signal loss or reflect the venous sinus recanalization or on the verge of fuzzy rules without the lower blood flow signal. Indirect signs of venous obstruction distal collateral or other form of abnormal venous drainage channel expansion. These are not signs of thrombosis signal changes of the time, a clear indication of straight sinus, the large vein and the brain brain vein. Application of two-dimensional and three-dimensional time leap Act (time of flight, TOF) and phase control (phase contrast), and other methods to increase the diagnosis rate of MRA. Conventional MRI and MRA of the Joint Inspection CVT will greatly improve the diagnosis rate, arterial angiography instead of the tendency. CT: If no contraindications or MRI MRI, CT scan should first trip. 80% of the cases may have abnormal performance, but a typical example of the CVT only 20%. CVT direct signs of thrombosis are two kinds: air sign (enhanced scan, the superior sagittal sinus in the rear, straight Galen venous sinus and more common, conventional scanning performance for the high-density site) and dense 1.30 levy (dense triangle sign conventional scanning, superior sagittal sinus showed high density). Direct signs of a relatively rare, but high specificity. Indirect signs of non-specific three brain abnormalities (edema or infarction suggested that low-density, high-density suggested that hemorrhagic infarction), fracture - like brain ventricle and the sickle and cerebellum screen strengthening. Spiral CT venography CVT is a valuable inspection tool, a common abnormal filling defect, and the strengthening of sinus wall measurement of the increase in venous drainage. Intra-arterial angiography, was once a key diagnostic method, now used only for inspection MRI and MRA with the CVT is still not clear circumstances. Typical signs include some or all of sinus not by the expansion and enhancement of collateral blood vessels surrounded the spiral cortical venous suddenly interrupted. Ridge 1.2.2 brain wave inspection: Inspection of conventional, chemical, biological and intracranial pressure value. For exclude infection, identifying subarachnoid hemorrhage (Hint hemorrhagic infarction), intracranial pressure and set down intracranial pressure drug application is valuable. Diagnosis 1.3 Many factors can cause or causes CVT (Table 1).
Table 1 cause of cerebral venous thrombosis risk factors or Infection causes Local Post-traumatic infection Intracranial infection: brain abscess, empyema, meningitis Local infection: otitis media, tonsillitis, sinusitis, stomatitis Systemic Bacteria: sepsis, endocarditis, typhoid, tuberculosis Virus: measles, hepatitis, encephalitis (herpes, human immunodeficiency virus), cytomegalovirus Parasites: malaria, Trichinosis Fungi: Aspergillus Non-infectious causes Local Head injury (open or closed, with or without fracture) Neurosurgery Cerebral infarction or cerebral hemorrhage Tumor: Brain (ridge) membrane tumor, metastatic tumors, gliomas Penetrating brain malformation, arachnoid cyst Subdural dynamic - arteriovenous malformation Systemic Surgery: with or without any of deep vein thrombosis surgery Obstetrics and Gynecology: pregnancy and puerperium Oral contraceptives: Estrogen and progesterone hormones Medicine Heart: congenital heart disease, heart failure, pacemaker placement Cancer: Any visceral cancer, lymphoma, leukemia, L Dong-lactamase day treatment Red blood cell disorders: Erythrocytosis, after hemorrhagic anemia, sickle-cell anemia, paroxysmal Night Hemoglobinuria, iron deficiency, anemia Thrombocytopenia disease: primary or secondary coagulation dysfunction: 3 antithrombin, protein C S and the lack of protein, and activated protein C anticoagulant substances circulating in the resistance increase, and the resulting San intravascular coagulation, heparin and heparin-induced red blood cell type material reduction in amino acid has been Treatment, the lack of blood-fiber, for any reason dehydration caused serious Digestive system: cirrhosis, Crohn's disease, ulcerative colitis Connective tissue: systemic lupus disease, temporal arteritis, Wegener's granulomatosis venous thromboembolism STDs Changed, Hughes-Stovin syndrome Other: Behcet's disease, sarcoidosis (meat-like: a), nephrotic syndrome, neonatal asphyxia, intestinal The injection, the male hormone treatment Primary
Although the infection is still a major CVT clear cause, but with the advent of antibiotics, in the developed countries and some developing countries, the infection rate of CVT has been a marked decline. Infectious CVT usually occurs in facial triangle after infection, the other parts such as the ethmoid sinus infection, the sphenoid sinus, and otitis media periodontal abscess caused by less. In developing countries, young women in the postpartum occurred CVT ratio higher than the gestation period, but in the developed countries, oral contraceptives is an important factor. The large number of non-medical causes of infection, congenital thrombophilia disease is the most common cause, particularly with coagulation factor V leiden variation of activated protein C resistance of the patients and increased prothrombin 20210G-A gene mutation patients. Poort, and other recent reports, the choice of a personal and family history of venous thrombosis of the Netherlands (all types) patients, prothrombin 20210A mutation rate was 18%, the first time without a choice in patients with deep venous thrombosis of prothrombin 20210 A gene mutation rate was 6.2%, normal control of 2.3%. Biousse, and so found 35 cases of patients with cerebral venous thrombosis, prothrombin gene mutation 2021 OA incidence of 5.7%. But the study also found that the single coagulation factor V leiden OA 2021 or prothrombin gene mutation led to the occurrence of thrombosis in low rate, when combined with other congenital thrombophilia or induced thrombosis certain factors, such as trauma, post-natal, head trauma, lumbar puncture and oral contraceptives, the thrombosis risk will be greatly enhanced. Therefore, screening coagulation factor Vleiden 20210 A and prothrombin gene mutation on the prevention of venous thrombosis has important significance. China's 97 cases of venous thrombosis patients and 100 normal study found no leiden coagulation factor V and prothrombin 20210 A gene mutation, and whether the race is not yet clear.
2 treatment
CVT is a rare disease. Because of its clinical manifestations, imaging, attack forms of diversity, its prognosis still a large degree of unpredictability. At present, this neurological disease physicians still lack experience, the relevant treatment has not yet reached the consistency of views. 21 antithrombotic treatment 2.1.1 low molecular weight heparin (low molecular weight heparin) Nadroparin 90 anti-factor Xa IU / kg subcutaneously 2 times / day, sharing two weeks. After oral anticoagulant applications (such as warfarin) about three months, the international standardization ratio (international normalizedratio, INR) maintained at slips. Meta-analysis of two more influential experimental results show that heparin enable the absolute risk of thrombosis rate dropped 14%, death or disability completely dropped 15%, relative risk rate dropped by their respective 70% and 56%. Currently, advocated heparin as a first-line drug for the treatment of CVT. 2.1.2 thrombolytic therapy: Recently, the 50 cases of patients with thrombolytic results strongly support thrombolytic therapy (urokinase, rt-PA vein thrombosis in the application or direct application). But accurate assessment of the benefit / risk ratio is still very difficult. At present there is no scientific evidence to support the local CVT thrombolytic therapy as the first line of treatment. Only partial thrombolysis for treatment of heparin and symptomatic disease patients is still progress, and the exclusion of other causes of deterioration, such as poor control of epilepsy, secondary pulmonary embolism and physical condition deteriorated. Moderate anticoagulant in the conditions, because thrombosis progress is a result of the deterioration of the rare. This is the indication thrombolysis. 2.2 symptomatic treatment 2.2.1 antiepileptic treatment: According to choose the form of epilepsy corresponding Antiepileptic drugs. 2.2.2 drop intracranial pressure: mannitol, hormones, acetazolamide, lumbar puncture, cerebrospinal fluid (CSF) drainage, the most obvious effect is barbiturate coma (barbiturate coma) and surgical decompression, and so on. Lumbar puncture is necessary, a rapid lowering CSF pressure advantages, especially when vision is threatened. Mannitol and hormone is commonly used method, the other methods use less. 2.2.3 the handling of mental disorders: restlessness obviously can give perphenazine, stability and drugs. 2.2.4 headache treatment: give analgesics such as paracetamol. 2.3 etiology treatment Behcet's disease such as high doses of hormones necessary and sufficient amount of immunosuppressant; Infectious CVT given broad-spectrum antibiotic therapy, sometimes combined surgical treatment required, lesion resection of primary infection.
3 prognosis
CVT's prognosis changed greatly. CVT only in the past when the autopsy to clear diagnosis. Early in the angiography, the mortality rate remains at 30% -50%. In recent years, numerous studies confirm the results, the mortality rate is 10% or less. Factors suggested that the poor prognosis in age too big or too small, coma, cerebellum or deep venous system vein involvement, severe high intracranial pressure, severe infections or malignant reasons, CT showed a hemorrhagic infarction and control bad epilepsy, complications such as pulmonary embolism. Although CVT better prognosis than arterial thrombosis, but there is still a large extent the unpredictability, drowsiness or serious dramatic hemiplegic patients can be left without the restoration of sequelae; On the contrary, only a headache for the patients complained of a sudden deterioration of conditions, such as from the venous sinus thrombosis quickly spread to vein, there will be severe hemiplegia.
References L Bousser MG. Cerebra1 venous thrombosis: diagnosis and mana-gement. J Neurol, 2000,247: 252-258. 2 Isensee C, Reul J, Thron A. Magnetic resonance imaging of throm - bosed dural sinus. Stroke, l994 ,25:198-200. 3 Gao Yong An, Kun-Cheng Li, Wang Xinmin, and so on. Cerebral venous thrombosis Cypriot magnetic resonance imaging of blood flow diagnostic value. Chinese Radiology magazine ,1997,31,805 - 808. 4 Daif A, Awada A, al-Rajeh S, et al. Cerebral venous thrombosis in adu1ts. A study of 40 case from saudi arabia. Stroke, l995 ,26:1193 - 1195 5 Poort SR, Rosendaal FR, Rcitsnla PH, et al. A common genetic variation in the 3 untranslate (l region of the prothrombin gene is associated with elevated plasma prothrombin levels and increase in venous thrombosis. Blood, l996 ,88:3698 - 3703 . 6 Biousse V, Conard J, Brouzes C, et al. Frequency of the 202l0A mutation in the 3 untranslated region of the prothrombin gene in 35 case of cerebral venous thrombosis. Stroke, l998, 29: l398-1400. 7 Bai, Pan Qi, LI Xiu-rong, and so on. Venous thrombosis patients and normal coagulation factor V and prothrombin 20210A leiden gene mutation studies. Chinese Journal of Medicine, 1999,79:900-902
Stroke, l999 ,30:484-485. 9 Einhpl KM, Villringer A, Meister W, et al. Heparin treatment in sinus venous thrombosis.Lancet, 199l ,338:597-600. L0 Bosser MG. Cerebral venous thrombosis. Nothing, heparin or local thrombolysis? Stroke, l999, 30:48 l -483. 11 Horowitz M, Purdy P, Unwin H, et al. Treatment of dural sinus thrombosis using selective catheterization and urokinase. Ann Neurol, 1995,38:58-67. 12 Kim SY, Suh JH. Direct endovascular thrombolytic therapy fordural sinus thrombosis: infusion of alteplase. AJNR Am J Neuroradiol, 1997, 18:639-645
1, the diagnosis of CVT
Whether there is a clear 1.1 CVT Have the following four kinds of clinical syndrome one should doubt the CVT (1) partial nerve defect with or without intracranial hypertension, the most common form. There will be aphasia, hemiplegia and Blind, etc.. If accompanied by headache, seizures or a state of awareness of the changes will be highly suspected CVT. (2) of pure high intracranial pressure, it is a common type, manifested as headache, as papillary edema and six pairs of cranial nerve palsy, and similar benign intracranial hypertension. (3) subacute encephalopathy type, the level of awareness for the performance drop, sometimes accompanied by epilepsy, no clear positioning signs or intracranial hypertension identifiable characteristics, this type of easily misdiagnosed. (4) the cavernous sinus thrombosis, the incidence usually acute and chronic progress was accompanied with moderate pain and 3 or 6 pairs of cranial nerve palsy. The only headache symptoms for the CVT, with lumbar puncture headache, subarachnoid hemorrhage-induced headache or migraine, and other identification. 1.2 diagnosis 1.2.1 neuroimaging: MRI and magnetic resonance angiography (MRA): MRI and MRA Joint Inspection CVT diagnosis and follow-up is the best way. CVT highly suspected as clinical, MRI and MRA should be a first-line inspection tool MRI shows signs of thrombosis direct different changes with time. The acute phase thrombosis (one week) with a performance of the T1; Such signals, T2 low signal. Subacute (2-4 weeks), T1 and T2 are high signal. Phase III (l months later), recanalization, or thrombosis persistent residues, showed sinus wall and sinus change. Subacute thrombosis period of the typical high signal on the larger significance of the disease, other phases signal not typical, the lack of specificity, coupled with the flow-related artifacts impact on conventional MRI images to make the diagnosis more difficult, especially in the acute phase. MRI, the superior sagittal sinus, and the transverse sinus straight sinus thrombosis most easily identify, brain vein thrombosis and cerebral vein identification has been difficult. MRI showed that the indirect signs including diffuse brain swelling (for the normal signal), edema or infarction (T1 signal or low signal, T2 high-signal), and more in periventricular white matter; Hemorrhagic infarction, T1 and T2 are high signal. MRA showed that the direct signs of thrombosis for development or normal cerebral venous sinus blood flow signal loss or reflect the venous sinus recanalization or on the verge of fuzzy rules without the lower blood flow signal. Indirect signs of venous obstruction distal collateral or other form of abnormal venous drainage channel expansion. These are not signs of thrombosis signal changes of the time, a clear indication of straight sinus, the large vein and the brain brain vein. Application of two-dimensional and three-dimensional time leap Act (time of flight, TOF) and phase control (phase contrast), and other methods to increase the diagnosis rate of MRA. Conventional MRI and MRA of the Joint Inspection CVT will greatly improve the diagnosis rate, arterial angiography instead of the tendency. CT: If no contraindications or MRI MRI, CT scan should first trip. 80% of the cases may have abnormal performance, but a typical example of the CVT only 20%. CVT direct signs of thrombosis are two kinds: air sign (enhanced scan, the superior sagittal sinus in the rear, straight Galen venous sinus and more common, conventional scanning performance for the high-density site) and dense 1.30 levy (dense triangle sign conventional scanning, superior sagittal sinus showed high density). Direct signs of a relatively rare, but high specificity. Indirect signs of non-specific three brain abnormalities (edema or infarction suggested that low-density, high-density suggested that hemorrhagic infarction), fracture - like brain ventricle and the sickle and cerebellum screen strengthening. Spiral CT venography CVT is a valuable inspection tool, a common abnormal filling defect, and the strengthening of sinus wall measurement of the increase in venous drainage. Intra-arterial angiography, was once a key diagnostic method, now used only for inspection MRI and MRA with the CVT is still not clear circumstances. Typical signs include some or all of sinus not by the expansion and enhancement of collateral blood vessels surrounded the spiral cortical venous suddenly interrupted. Ridge 1.2.2 brain wave inspection: Inspection of conventional, chemical, biological and intracranial pressure value. For exclude infection, identifying subarachnoid hemorrhage (Hint hemorrhagic infarction), intracranial pressure and set down intracranial pressure drug application is valuable. Diagnosis 1.3 Many factors can cause or causes CVT (Table 1).
Table 1 cause of cerebral venous thrombosis risk factors or Infection causes Local Post-traumatic infection Intracranial infection: brain abscess, empyema, meningitis Local infection: otitis media, tonsillitis, sinusitis, stomatitis Systemic Bacteria: sepsis, endocarditis, typhoid, tuberculosis Virus: measles, hepatitis, encephalitis (herpes, human immunodeficiency virus), cytomegalovirus Parasites: malaria, Trichinosis Fungi: Aspergillus Non-infectious causes Local Head injury (open or closed, with or without fracture) Neurosurgery Cerebral infarction or cerebral hemorrhage Tumor: Brain (ridge) membrane tumor, metastatic tumors, gliomas Penetrating brain malformation, arachnoid cyst Subdural dynamic - arteriovenous malformation Systemic Surgery: with or without any of deep vein thrombosis surgery Obstetrics and Gynecology: pregnancy and puerperium Oral contraceptives: Estrogen and progesterone hormones Medicine Heart: congenital heart disease, heart failure, pacemaker placement Cancer: Any visceral cancer, lymphoma, leukemia, L Dong-lactamase day treatment Red blood cell disorders: Erythrocytosis, after hemorrhagic anemia, sickle-cell anemia, paroxysmal Night Hemoglobinuria, iron deficiency, anemia Thrombocytopenia disease: primary or secondary coagulation dysfunction: 3 antithrombin, protein C S and the lack of protein, and activated protein C anticoagulant substances circulating in the resistance increase, and the resulting San intravascular coagulation, heparin and heparin-induced red blood cell type material reduction in amino acid has been Treatment, the lack of blood-fiber, for any reason dehydration caused serious Digestive system: cirrhosis, Crohn's disease, ulcerative colitis Connective tissue: systemic lupus disease, temporal arteritis, Wegener's granulomatosis venous thromboembolism STDs Changed, Hughes-Stovin syndrome Other: Behcet's disease, sarcoidosis (meat-like: a), nephrotic syndrome, neonatal asphyxia, intestinal The injection, the male hormone treatment Primary
Although the infection is still a major CVT clear cause, but with the advent of antibiotics, in the developed countries and some developing countries, the infection rate of CVT has been a marked decline. Infectious CVT usually occurs in facial triangle after infection, the other parts such as the ethmoid sinus infection, the sphenoid sinus, and otitis media periodontal abscess caused by less. In developing countries, young women in the postpartum occurred CVT ratio higher than the gestation period, but in the developed countries, oral contraceptives is an important factor. The large number of non-medical causes of infection, congenital thrombophilia disease is the most common cause, particularly with coagulation factor V leiden variation of activated protein C resistance of the patients and increased prothrombin 20210G-A gene mutation patients. Poort, and other recent reports, the choice of a personal and family history of venous thrombosis of the Netherlands (all types) patients, prothrombin 20210A mutation rate was 18%, the first time without a choice in patients with deep venous thrombosis of prothrombin 20210 A gene mutation rate was 6.2%, normal control of 2.3%. Biousse, and so found 35 cases of patients with cerebral venous thrombosis, prothrombin gene mutation 2021 OA incidence of 5.7%. But the study also found that the single coagulation factor V leiden OA 2021 or prothrombin gene mutation led to the occurrence of thrombosis in low rate, when combined with other congenital thrombophilia or induced thrombosis certain factors, such as trauma, post-natal, head trauma, lumbar puncture and oral contraceptives, the thrombosis risk will be greatly enhanced. Therefore, screening coagulation factor Vleiden 20210 A and prothrombin gene mutation on the prevention of venous thrombosis has important significance. China's 97 cases of venous thrombosis patients and 100 normal study found no leiden coagulation factor V and prothrombin 20210 A gene mutation, and whether the race is not yet clear.
2 treatment
CVT is a rare disease. Because of its clinical manifestations, imaging, attack forms of diversity, its prognosis still a large degree of unpredictability. At present, this neurological disease physicians still lack experience, the relevant treatment has not yet reached the consistency of views. 21 antithrombotic treatment 2.1.1 low molecular weight heparin (low molecular weight heparin) Nadroparin 90 anti-factor Xa IU / kg subcutaneously 2 times / day, sharing two weeks. After oral anticoagulant applications (such as warfarin) about three months, the international standardization ratio (international normalizedratio, INR) maintained at slips. Meta-analysis of two more influential experimental results show that heparin enable the absolute risk of thrombosis rate dropped 14%, death or disability completely dropped 15%, relative risk rate dropped by their respective 70% and 56%. Currently, advocated heparin as a first-line drug for the treatment of CVT. 2.1.2 thrombolytic therapy: Recently, the 50 cases of patients with thrombolytic results strongly support thrombolytic therapy (urokinase, rt-PA vein thrombosis in the application or direct application). But accurate assessment of the benefit / risk ratio is still very difficult. At present there is no scientific evidence to support the local CVT thrombolytic therapy as the first line of treatment. Only partial thrombolysis for treatment of heparin and symptomatic disease patients is still progress, and the exclusion of other causes of deterioration, such as poor control of epilepsy, secondary pulmonary embolism and physical condition deteriorated. Moderate anticoagulant in the conditions, because thrombosis progress is a result of the deterioration of the rare. This is the indication thrombolysis. 2.2 symptomatic treatment 2.2.1 antiepileptic treatment: According to choose the form of epilepsy corresponding Antiepileptic drugs. 2.2.2 drop intracranial pressure: mannitol, hormones, acetazolamide, lumbar puncture, cerebrospinal fluid (CSF) drainage, the most obvious effect is barbiturate coma (barbiturate coma) and surgical decompression, and so on. Lumbar puncture is necessary, a rapid lowering CSF pressure advantages, especially when vision is threatened. Mannitol and hormone is commonly used method, the other methods use less. 2.2.3 the handling of mental disorders: restlessness obviously can give perphenazine, stability and drugs. 2.2.4 headache treatment: give analgesics such as paracetamol. 2.3 etiology treatment Behcet's disease such as high doses of hormones necessary and sufficient amount of immunosuppressant; Infectious CVT given broad-spectrum antibiotic therapy, sometimes combined surgical treatment required, lesion resection of primary infection.
3 prognosis
CVT's prognosis changed greatly. CVT only in the past when the autopsy to clear diagnosis. Early in the angiography, the mortality rate remains at 30% -50%. In recent years, numerous studies confirm the results, the mortality rate is 10% or less. Factors suggested that the poor prognosis in age too big or too small, coma, cerebellum or deep venous system vein involvement, severe high intracranial pressure, severe infections or malignant reasons, CT showed a hemorrhagic infarction and control bad epilepsy, complications such as pulmonary embolism. Although CVT better prognosis than arterial thrombosis, but there is still a large extent the unpredictability, drowsiness or serious dramatic hemiplegic patients can be left without the restoration of sequelae; On the contrary, only a headache for the patients complained of a sudden deterioration of conditions, such as from the venous sinus thrombosis quickly spread to vein, there will be severe hemiplegia.
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