肝胰十二指肠器官簇移植围手术期营养支持疗法探讨

目的探讨肝胰十二指肠器官簇移植围手术营养支持疗法的合理方案。方法我中心自2004年5月至2010年9月共实施了10例肝胰十二指肠器官簇移植手术,其中5例为上腹部肿瘤伴腹腔多发转移病灶患者,行肝脏、胰腺及上消化道全切除术后进行器官簇移植,5例为乙型肝炎后肝硬化失代偿期合并2型糖尿病患者,予以单纯肝切除后行器官簇移植。对这10例患者进行围手术期营养支持疗法,术前经口进食辅以口服营养液改善患者营养状况,术后先给予全肠外营养（total parenteral nutrition,TPN）,后转为肠外联合肠内营养,逐渐过渡至肠内营养（enteralnutrition,EN）。观察患者术后肠道功能恢复情况、患者营养状况、各项实验室指标及并发症情况。结果10例患者手术顺利,术后肝脏、胰腺及十二指肠功能恢复良好。3例患者出现肠瘘,经TPN营养支持,2例死于感染致多器官功能衰竭,1例痊愈;其余7例患者均顺利由TPN过渡至EN,营养状况良好。5例肿瘤患者最长存活326d,3例死于多器官功能衰竭,2例死于肿瘤复发。5例肝硬化合并糖尿病患者除1例于术后4周死于移植物抗宿主病外,其余4例均存活,最长生存时间已超过24个月。结论合理的围手术期营养支持疗法对肝胰十二指肠器官簇移植成功有一定作用。     

Ultrasonically guided percutaneous fine needle aspiration biopsy of the hepatic and pancreatic focal lesions: accuracy of cytology in the diagnosis of malignancy.

Ultrasonically guided percutaneous fine-needle aspiration biopsies were carried out on 153 patients with focal liver and pancreatic lesions, and were subsequently evaluated cytologically. A correct diagnosis of malignancy was made in 66 of 74 patients with proven hepatic malignancy, and in 38 of 41 patients with proven pancreatic malignancy, showing an overall accuracy of 92% and 94%, respectively. The specificity of the procedure was 100%. Ultrasonically guided fine-needle aspiration biopsy followed by cytological examination appears indispensable in diagnosis and differentiation between benign and malignant hepatic and pancreatic focal lesions.     

Anorexia and anxiety in advanced malignancy:the relative problem

Background and aims Anorexia is frequently reported by patients with advanced malignancy and can be a source of considerable distress. This study was designed to quantify the anxiety related to anorexia in both patients and their relatives. Predisposing factors were also evaluated. A questionnaire was used to quantify anorexia in 145 patients with advanced malignancy and to examine demographic and disease factors associated with anorexia. Anxiety consequent to anorexia was also evaluated for patients and their relatives.
Results Anorexia amongst patients was reported by 115 patients (79%) and 83/101 (82%) of their relatives. Anorexia was found to be associated with upper gastrointestinal malignancy, metastatic disease and short estimated prognosis. Only 41 anorectic patients (36%) reported anxiety as a consequence of their anorexia compared with 72 (87%) of their relatives. Certain patient groups (younger age and community location) were more likely to report anxiety related to anorexia.
Conclusions The potential influence of anxiety on management decisions is discussed. The frequency of anxiety reported amongst relatives may reflect an unmet need. This may be an area for improving practice.     

Development of novel score based on Angiogenic panel for accurate diagnosis of hepatocellular carcinoma among hepatitis C virus high-risk patients

Background/aimsHepatocellular carcinoma (HCC) is a primary malignancy of the liver and a global health problem. It is often diagnosed at advanced stage where hopeless for effective therapies. Identification of more reliable biomarkers for early detection of HCC is urgently needed. HCC is identified with hyper-vascularity feature. Herein, we sought to develop a novel score based on the combination of the most significant angiogenic biomarkers with and routine laboratory tests for accurate detection of HCC.Material & methodsAngiopoietin II, copper, nitric oxide, albumin, platelets count and α-fetoprotein were assayed in HCC patients (75), liver cirrhosis patients (50) and healthy control (20). Areas under receiving operating curve (AUCs) were calculated and used for construction on novel score. A novel score named HCC-AngioScore = AFP (U/L) Albumin (g/dl) × 5.4 + Angiopoietin (ng/ml) × 0.001 + Copper (mg/dl) × (−0.004) + Platelets count (×109)/L × 0.003 + Nitric oxide (μ mol/L) × 0.27–36 was developed. HCC-AngioScore produce AUC of 0.919for differentiate patients with HCC from those with liver cirrhosis with sensitivity and specificity of a cut-off 0 (i.e., less than 0 the case is considered cirrhotic, whereas above 0 it is considered HCC.ConclusionHCC-AngioScore could replace AFP during screening of HCV patients and early detection of HCC.     

Serum cytokeratins in alcoholic liver disease: contrasting levels of cytokeratin-18 and cytokeratin-19.

Serum cytokeratin (CK) levels are widely used as tumor markers. Serum levels of CK-18, a tumor marker also known as tissue polypeptide specific antigen (TPS), are increased in patients with alcoholic liver disease. Cytokeratin-18 is the main component of Mallory bodies, a hallmark of alcoholic hepatitis, which may also contain CK-19. Serum levels of CK-18 and CK-19, a tumor marker also known as CYtokeratin FRAgment 21-1 (CYFRA 21-1) were investigated in (a) heavy drinkers with alcoholic liver disease (n=15), (b) patients with malignancy (n=22), and (c) healthy controls (n=10). Serum levels of CYFRA 21-1 (CK-19) were markedly increased in patients with malignancy, but were similar in heavy drinkers and healthy controls. In contrast, serum levels of TPS (CK-18) in heavy drinkers were higher than those of healthy controls, and even tended to be higher than those of patients with malignancy. Both CK-19 and CK-18 levels were higher in cases of alcoholic hepatitis than in cases of fatty liver. Correlation with hepatocyte CK inclusions was stronger for serum TPS (CK-18) than for CYFRA 21-1 (CK-19). In conclusion, serum CYFRA 21-1 (CK-19) and TPS (CK-18) show a different pattern of increase that could reflect the composition of the altered hepatocyte CK network in alcoholic liver disease. Their usefulness as tumor markers, particularly that of serum TPS (CK-18), may be limited in patients with alcoholic liver disease.     

肝硬化合并医院感染的危险因素分析

目的 探讨肝硬化患者合并医院感染的相关危险因素.方法 选择2008年6月—2011年9月医院收治的肝硬化合并医院感染患者613例,所有入选病例经明确诊断后详细收集和记录患者的性别、年龄、既往病史、并发症等相关危险因素,并充分结合实验室及其特殊检查进行回顾性分析.结果 613例肝硬化患者中,92例发生医院感染,感染率为15.01％年龄大、白蛋白低、住院时间长、有侵入性操作、有并发症、有合并症、预防性应用抗菌药物为医院感染的危险因素,其中年龄＞40岁患者感染率为19.75％,白蛋白＜3.0 g/dl患者感染率为19.71％,住院时间≥20 d患者感染率为21.43％,有侵入性操作感染率为18.23％,有并发症、合并症患者感染率为18.05％、25.23％,预防性应用抗菌药物患者感染率为19.61％.结论 只有充分重视引起肝硬化患者合并医院感染的危险因素,并据此积极采取多角度、全方位的防治措施,才能尽可能的将肝硬化合并医院感染的比率控制在最低范围.     

Relation of Liver Siderosis to Liver Fibrosis in Hemodialysis Patients With Severe Hyperferritinemia Secondary to High Doses of Intravenous Iron Supplementation

ObjectiveAggressive iron substitution in hemodialysis (HD) patients leads to iron overload. The association between liver siderosis and fibrosis is still debatable. We studied the association of liver siderosis with liver fibrosis in HD patients. Furthermore, we studied the performance of liver stiffness measurements (LSMs) in identifying advanced liver fibrosis. We investigated the performance of biochemical indicators of iron status in identifying advanced liver fibrosis.MethodsFifty-five HD patients (average HD duration 6 ± 2 years) with hyperferritinemia secondary to intravenous iron supplementation (weakly iron dose 252.7 ± 63 mg; median blood transfusions 3 [2-5]) were recruited. The liver fibrosis grade was determined with Fibroscan, aminotransferase-to-platelet ratio index (APRI), and Fib-4 index. Liver iron concentration (LIC) was estimated with magnetic resonance imaging (MRI). Iron parameters and liver function biochemical indicators were also assessed.ResultsThe median serum ferritin and transferrin saturation (TSAT) were 3531 μg/L and 77%, respectively. 34.5%, 20%, and 45.5% of the patients showed mild, moderate, or severe liver siderosis, respectively. All patients with severe liver siderosis showed advanced liver fibrosis. Patients with severe liver siderosis and advanced liver stiffness showed higher serum iron, TSAT, aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum bilirubin, APRI, and Fib-4 index scores than those with mild liver siderosis. Serum iron and TSAT showed good utility in identifying advanced liver fibrosis determined with Fibroscan, APRI, and Fib-4 index. Liver stiffness exhibited good utility in identifying advanced liver fibrosis diagnosed with APRI and Fib-4 index.ConclusionsHigh weekly intravenous iron dose associated with severe hyperferritinemia, high serum iron, and TSAT might lead to severe liver siderosis and concomitant liver fibrosis in HD patients. Serum iron, TSAT, Fibroscan, Fib-4, and APRI scores might offer noninvasive tools for identifying advanced liver fibrosis in those patients.     

Controlling cancer pain

More than a third of patients undergoing therapy for cancer and 60% to 90% of those with advanced malignancy report significant pain. Effective analgesic therapy is available, yet large segments of this population--in particular, elderly patients in nursing homes, minorities, and women--receive inadequate palliative therapy.     

Dysphagia with a thyroid nodule: is there a primary aerodigestive malignancy?

Three cases of laryngopharyngeal primary squamous cell carcinoma presenting with thyroid nodules are described. The key message to take away from these cases is that patients with advanced malignancy of the upper aerodigestive tract can present with a thyroid nodule.     

分期系统在中、晚期肝癌生存关系的评价

目的运用已有完整资料来评价目前世界上常见几种肝癌生存分期系统在中、晚期肝癌中特点,为临床中恰当运用分期预后系统作指引。方法收集2000～2003年201例来自我院确诊的中、晚期肝癌患者的完整临床资料并观察其生存时间,以UICC(国际抗癌联盟)、Okuda、CLIP(cancer of the liver Italian program)、CUPI(Chinese university prognostic index)分期系统为基础,分别制作Kaplan-Meier评价生存曲线,并做比较分析。结果根据Kaplain-Meier估计生存曲线及Log-rank检验证实Child-Pugh、UICC临床分期系统区分差、Okuda、CUPI分期区分度好,CLIP分期大部分满意,其中4～5级区分度最差。结论Okuda、CUPI分期系统在中、晚期肝癌运用满意,而CLIP分期系统基本满意,Child-pugh、UICC临床分期单独不适应用在中、晚期肝癌生存预后中。     

分期系统在中、晚期肝癌生存关系的评价

目的运用已有完整资料来评价目前世界上常见几种肝癌生存分期系统在中、晚期肝癌中特点，为临床中恰当运用分期预后系统作指引。方法收集2000-2003年201例来自我院确诊的中、晚期肝癌患者的完整临床资料并观察其生存时间．以UICC（国际抗癌联盟）、Okuda、CLIP（cancer of the liver Italian program）、CUPI（Chinese university prognostic index）分期系统为基础，分别制作Kaplan—Meier评价生存曲线，并做比较分析。结果根据Kaplain—Meier估计生存曲线及Log—rank检验证实child—Pugh、UICC临床分期系统区分差、Okuda、CUPI分期区分度好，CLIP分期大部分满意，其中4～5级区分度最差。结论Okuda、CUPI分期系统在中、晚期肝癌运用满意，而CLIP分期系统基本满意，Child—pugh、UICC临床分期单独不适应用在中、晚期肝癌生存预后中。     

Pyogenic liver abscess as endemic disease, Taiwan

Pyogenic liver abscess has become a health problem in Taiwanese society. However, the extent of this problem has remained unclear because of the lack of a population-based study. We therefore performed a nationwide analysis of pyogenic liver abscess in Taiwan from 1996 through 2004. We analyzed 29,703 cases from the Taiwan National Health Insurance database and 506 cases from National Taiwan University Hospital. Our analysis showed that the annual incidence of pyogenic liver abscess increased steadily from 11.15/100,000 population in 1996 to 17.59/100,000 in 2004. Diabetes, malignancy, renal disease, and pneumonia were associated with a higher risk for the disease. By contrast, death due to pyogenic liver abscess decreased over time, although population-based abscess-related death increased slightly. Renal disease, malignancy, pneumonia, and heart disease correlated with higher death rates; Klebsiella pneumoniae infection and therapeutic procedures were related to lower death rates. Diabetes did not significantly change death rates for the 506 patients from the hospital.     

Hepatocellular carcinoma: Where are we?

Hepatocellular carcinoma (HCC) is the second cause of death due to malignancy in the world, following lung cancer. The geographic distribution of this disease accompanies its principal risk factors: Chronic hepatitis B virus and hepatitis C virus infection, alcoholism, aflatoxin B1 intoxication, liver cirrhosis, and some genetic attributes. Recently, type II diabetes has been shown to be a risk factor for HCC together with obesity and metabolic syndrome. Although the risk factors are quite well known and it is possible to diagnose HCC when the tumor is less than 1 cm diameter, it remains elusive at the beginning and treatment is often unsuccessful. Liver transplantation is thus far considered the best treatment for HCC as it cures HCC and the underlying liver disease. Using the Milan criteria, overall survival after liver transplantation for HCC is about 70% after 5 years. Many attempts have been made to go beyond the Milan Criteria and according to recent works reasonably good results have been achieved by using a histochemical marker such as cytokeratine 19 and the so-called “up to seven criteria” to divide patients into categories according to their risk of relapse. In addition to liver transplantation other therapies have been proposed such as resection, tumor ablation by different means, embolization and chemotherapy. An important step in the treatment of advanced HCC has been the introduction of sorafenib, the first oral, systemic drug that has provided significant improvement in survival. Treatment of HCC patients must be multidisciplinary and by using the different approaches discussed in this review it is possible to offer prolonged survival and quite good and sometimes even excellent quality of life to many patients.     

Surgery for carcinoma of the gallbladder. Our experience

BACKGROUND: Carcinoma of the gallbladder is a gastrointestinal malignancy with a very poor prognosis. The 5-year survival rate amounts to less than 5% in most series. In this study we reviewed the results of surgical treatment for gallbladder carcinoma with special reference to extended radical procedures. METHODS: Between 1995 and 2000 we enrolled 36 patients (17 males and 19 females), 24 of whom were treated with simple cholecystectomy and 12 with radical resection (partial hepatectomy, regional lymphadenectomy, and common bile duct resection). The tumours were classified by stage using the criteria of the American Joint Committee on Cancer (AJCC). Stages, operative procedures, results of pathologic examinations and the outcome of the resected cases were reviewed. RESULTS: There were 2 postoperative deaths (0.55%). The mean follow-up period was 19.1 months (range 1-60). For stage I and II disease extended cholecystectomy had a better result than simple cholecystectomy: the 5-year survival rates were 38.4 versus 19%, respectively. For the patients with advanced stage III or IV gallbladder carcinoma, a significant advantage of survival resulted in case of liver resection as compared to surgical treatment without liver resection: the 5-year survival rates were 20 and 0%, respectively. CONCLUSIONS: The survival of stage I-II patients was good. For the patients in higher stages the prognosis was significantly worse. In these cases more aggressive surgery may be needed.     

STAT4遗传变异与原发性肝癌病理特征的关联

  目的  探讨STAT4遗传变异及其与运动的交互作用对原发性肝癌患者病理特征的影响。  方法  在601例新发肝癌患者中,采用多因素Logistic回归分析模型分析rs7574865、rs897200、rs1031507与肿瘤淋巴结转移（tumor node metastasis,TNM）分期、门脉癌栓的关联。应用相乘交互项和"Delta"法分别评价相乘和相加交互作用。  结果  在显性模型下,rs897200变异与患者首诊时晚期的风险存在临界统计学关联（调整OR=0.64,95%CI:0.41~1.01,P=0.057）。携带rs1031507 CC+AC基因型的患者晚期风险低于AA基因型患者（调整OR=0.63,95%CI:0.40~0.99,P=0.046）。叉生分析中,与携带rs897200 CT+CC基因型且有运动的患者相比,缺乏运动的TT基因型患者晚期风险增高（OR=3.71,95%CI:1.97~6.98,P < 0.001）。类似,rs1031507AA基因型与缺乏运动共同升高患者的晚期风险（OR=3.78,95%CI:2.01~7.13,P < 0.001）。但未观察到rs897200、rs1031507与运动存在影响肝癌分期的统计学交互作用。  结论  STAT4 rs897200和rs1031507遗传变异的独立效应及与运动的联合效应影响肝癌患者首诊时的临床分期。     

循证护理用于原发性肝癌晚期患者临终关怀效果观察

目的：探讨如何做好肝癌患者的临终关怀护理工作。方法：对某院收治的32例原发性肝癌终末期患者，依据循证护理原则，实施最佳关怀和支持护理。结果：患者疼痛减轻，肝性脑病改善，顽固性腹水及自发性腹膜炎部分得到控制，焦虑、恐惧、悲观等不良情绪缓解，严重营养不良改善。结论：临终关怀可有效提高原发性肝癌晚期患者的生活质量。     

北京市50家医疗机构重点职业危害及职业健康管理现状调查

肝脏原发性神经内分泌肿瘤（primary hepatic neuroendocrine tumors, PHNETs）是一组极其罕见、分化良好的低度恶性肿瘤，其临床特征、实验室检查与影像学结果等缺乏特异性表现。因此，需要在病理诊断的基础上排除其他部位神经内分泌肿瘤肝转移的情况，才能确诊该疾病。目前，PHNETs主要采用以手术切除为主的综合治疗方法。本文收集并整理了206例国内外PHNETs的病例报告及相关文献，对PHNETs的起源、临床特点、病理特征、临床诊治进展总结分析，以期为PHNETs的全面认识和临床诊疗提供重要依据。     

Prevalence,Evolution, and Risk Factors for Advanced Liver Fibrosis in Adults Undergoing Intestinal Transplantation

Introduction

Intestinal failure–associated liver disease (IFALD) occurs commonly in intestinal transplant (ITx) candidates receiving parenteral nutrition (PN). The aim of this study is to establish the prevalence and risk factors for advanced liver fibrosis in adults at the time of ITx.

Methods

Retrospective chart review of all ITx was performed in adults between January 2000 and May 2014. Advanced liver fibrosis was defined as stage 3 or stage 4 fibrosis.

Results

Fifty‐three patients met the inclusion criteria. The mean age was 50.6 ± 10.9 years, and the majority were female (60.4%) and Caucasian (67.9%). The mean body mass index was 21.7 ± 3.8 kg/m² and the median duration of PN was 402 (interquartile range: 529) days. Advanced liver fibrosis at the time of ITx was found in 13 patients (24.5%). The multivariate analysis revealed that female gender and white race were significant predictors of advanced liver fibrosis. A total bilirubin >3.0 mg/dL for > a month prior to ITx was associated with an odds ratio of 8.9 for advanced fibrosis at the time of ITx but did not reach statistical significance (P = 0.055).

Conclusion

Close to one‐quarter of the ITx recipients had advanced liver fibrosis. In the current era of improved PN management, our data suggests that previously reported risk factors for IFALD, such as extreme short gut syndrome and PN duration, may have a lesser impact on development of liver fibrosis. A prolonged duration of bilirubin elevation may be associated with advanced liver fibrosis in patients with IFALD, but this requires validation in a larger cohort.     

肝动脉与门静脉双介入治疗原发性肝癌的临床研究

目的 研究与探讨肝动脉及门静脉双介入化疗栓塞对治疗原发性中晚期肝癌的可行性及临床疗效.方法 36例中晚期肝癌患者分为A、B两组,A组20例,应用肝动脉与门静脉双介入灌注化疗及栓塞（TACE＋SPVE）方法治疗,B组16例,单纯采用肝动脉灌注化疗及栓塞（TACE）方法治疗.结果 A、B两组的近期有效率分别为90%和82.4%,治疗后0.5、1、2年生存率相比较,两组间差异有统计学意义（P〈0.05）.两组并发症比较无统计学意义.结论 应用肝动脉与门静脉双介入治疗原发性肝癌的效果,优于单纯肝动脉介入治疗,可显著提高患者的生命质量并延长生存周期,值得临床推广.     

Decreased serum osteocalcin level in non-alcoholic and alcoholic chronic liver diseases

Serum level of osteocalcin (OC) is believed to be a specific biochemical parameter of bone formation. Decreased serum OC has been reported in alcohol-intoxicated subjects, in patients with primary biliary cirrhosis and in patients with chronic alcoholic liver disease. The question was, whether lower OC level could be detected in patients with nonalcoholic and non-cholestatic chronic liver disease. The serum OC was measured by RIA developed in our laboratory. Results were compared to age and sex matched controls. Decreased OC level was found in 35 out of 47 (74%) patients with non-alcoholic and non-cholestatic liver disease as chronic persistent hepatitis, chronic active hepatitis, fatty liver and cirrhosis, in 21 out of 26 (80%) patients with alcoholic liver disease and in 8 out of 15 (53%) primary biliary cirrhosis. None of the patients had elevated value. There was no correlation between the decreased OC level and the duration or severity of the liver disease and the laboratory parameters as bilirubin, AST, ALT, alkaline phosphatase, albumin, prothrombin, and serum 25-OH-D3 vitamin level. Decreased OC was found also in the patients without cirrhosis. The possible causes are discussed. Relying upon these findings it is supposed that chronic liver disease by itself can influence the osteoblast activity also by some unknown mechanism.