肝叶部分切除治疗肝内胆管结石

肝内胆管结石的发生率约占胆道结石的13％～20％,因其在肝内胆管,位置较深,易发生感染形成脓肿及狭窄,而且有相当一部分病人是手术后复发,所以治疗难度较大,对于这一类病人最有效的治疗方法就是行手术治疗。1996～1999年我院对17例肝内胆管结石的病人成功地实施了肝叶部分切除,肝内胆管取石Roux-Y胆肠吻合,胆道重建手术,取得了理想的效果,报道如下。     

胆系手术麻醉中并发胆心反射的防治

自2005年～2007年，我院共施行胆系手术150例。绝大多数病人术中出现程度不等的心率减慢和血压下降，其中1例发生心搏骤停。现就胆系手术中并发胆心反射的防治体会总结如下。     

胆道手术后胆漏的原因及治疗

目的 探讨胆道手术后胆漏的原因和治疗.方法 回顾分析24 例胆道手术胆漏病人的临床资料.结果 24 例病人术后发现胆漏,其中胆总管残端漏4例,T 管及拔除后胆漏18 例,T 管术后引流护理不当2 例.结论 胆漏多发生于胆囊切除和胆总管探查T 管引流术后,其原因主要与胆道变异、炎症粘连松解和操作不当有关,预防应正确处理胆道变异,认真对待术前、术中、术后三个环节,对预防术后胆漏的发生有重要的意义.     

肝移植术后不同胆道引流方式胆漏发生率的比较(附50例报告)

目的:探讨肝移植术后最佳胆道引流方式.方法:分析50例肝移植技术与不同胆道引流方式对术后胆道并发症的影响.结果:50例肝移植发生胆漏7例,发生率14.0%.采用小直径直管(硬膜外导管)作胆道引流管的患者术后胆漏发生率3.7%(1/27),低于"T"形管和小儿细吸痰管胆漏发生率45.5%(5/11)(P=0.005).7例中,6例治愈,1例死于胆漏腹腔感染.结论:小直径直管胆道引流可避免"T"管引流与不放引流管的缺点,硬膜外导管是最佳选择.     

探讨腹腔镜胆囊切除术中预防胆道损伤的对策

目的 探讨在腹腔镜胆囊切除术中预防胆道损伤的方法，提高手术的安全性。方法自2004年1月至2005年7月采用以Rouviere＇s沟或线为导向的胆囊三角区解剖方法结合术中胆道造影，对440例病人进行了腹腔镜胆囊切除术。结果 所有病人无一例发生胆道损伤及手术死亡。13例中转开腹（2．9％）。4例术后胆漏（0．8％），其中2例经腹腔引流管引流9天治愈；1例在“B”超引导下经皮穿刺抽吸二次治愈；1例经十二指肠内镜鼻胆管引流8天治愈。2例术后腹腔出血再次腹腔镜探查结扎止血而愈。1例因呼吸道并发症于术后一个月死亡。4次胆漏病人术后随访3-6个月无胆道遗留症状。结论 以Rouviere＇s沟或线为导向的胆囊三角区解剖方法结合术中胆道造影可以减少胆道损伤的几率，是值得推广应用的。     

子宫颈癌311例患者手术并发症的临床分析

目的探讨子宫颈癌患者手术并发症的发生原因及其防治策略。方法回顾性分析2003年1月至2008年4月间311例接受子宫颈癌根治术患者的资料,其中Ⅰ A2期10例,占3．21％;ⅠB1期88例,占28．29％;Ⅰ B2期42例,占13．50％;ⅡA期（局部病灶≤4cm）127例,占40．84％;ⅡA期（局部病灶〉4cm）44例,占14．14％。术后病理类型：鳞癌262例,占84．24％;腺癌37例,占11．90％;腺鳞癌7例,占2．30％;小细胞癌4例,占1．30％。下腹部手术史有96例,占30．87％。本组中,有71例术前接受化疗。结果全组121名患者出现手术并发症,发生率为38．91％;术中并发症有泌尿系损伤、血管损伤;术后并发症以尿潴留、淋巴囊肿、腹部伤口感染为主,发生率分别为13．50％、10．61％和7．07％。在发生术后尿潴留的患者中,术前化疗者29例,占40．85％（29／71）,与未接受过新辅助化疗13例（5．42％,13／240）相比较,差异有统计学意义（P=0．011）。结论子宫颈癌根治术后并发症有一定的发生率,与手术范围较大有关;新辅助化疗有可能增加手术并发症。     

胆道造影检查在腹腔镜胆囊切除术中的应用

目的探讨腹腔镜胆囊切除术中经胆囊管胆道造影的临床价值。方法通过对58例Lc术中经IOC的病人临床资料进行回顾性分析。结果本组病例成功55例,占94．83％,失败3例,占5．17％。50例胆总管未发现结石,占90．91％,发现胆总管小结石（0．4cm）5例,占9．09％。其中4例经中转开腹行胆道探查,1例经腹腔镜胆总管切开胆纤镜网篮取石。胆囊管汇入右肝管1例。全组病例无胆道损伤、胆总管结石残留、胆漏、腹腔感染及IOC相关并发症。结论LC术中行IOC操作简单易行,成功率高,显影效果好,能及时发现胆道解剖变异;对基层医院减少胆道阴性探查、术中胆道损伤、术后胆总管结石残留等具有重要的临床应用价值。     

右叶活体供肝移植术中的胆道重建：321例受者间不同术式的比较研究

目的：旨在确定右叶活体供肝移植术（Living—Donor Liver Transplantation，LDLT）后，接受胆总管端端吻合术或Roux—en—Y胆总管空肠吻合术重建胆道的患者其胆道并发症的发生率。概要背景资料：胆道并发症一直以来都是肝移植术后最严重的并发症之一。迄今未进行过任何大型系列研究比较LDLT中的这两种技术。本研究对应用的胆道重建方法利报道的并发症间的关系作了一项刚顷性评价。方法：1998年2月至2004年6月间，共有321例患者接受了柯叶LDLT。121例接受Roux—en—Y胆总管空肠吻合术，192例接受胆总管端端吻合术，8例接受Roux—en—Y和端端胆总管吻合术，均成功重建胆道。对胆管移植物和吻合数量、吻合方法、支架的应用，胆道并发症的处理都作了分析。结果：胆道并发症的总发病率为24．0％。单变量分析显示，肝动脉片发症，臣细胞病毒感染和由型不合址发生胆道并发症的重要危险闲素。Roux—en—Y和端端吻合重建术的胆漏和胆道狭窄的发病率分别为12．4％与8．3％和4．7％与26．6％。研究显示，胆总管端端吻合术中胆漏发生率较低而胆道狭窄的发生率较高；然而，74．5％的胆道狭窄都可通过内镜得到治疗。结论：作者发现胆总管端端吻合术中，胆道狭窄的发生率增高。端端吻合的胆道重建术由于保持较好的胆肠生理连续性，所以胆漏发生率更低，加之内镜治疗的简便易行，它成为石叶LDLT中较为适宜的一种手术方法。     

32例胆道手术后胆漏的原因分析及治疗

目的 探讨胆道手术后发生胆漏的原因及其预防和治疗的措施.方法 对1999～2009年间胆道手术后发生胆漏的32例患者的临床资料进行回顾性研究.结果 32例发生胆漏保守治疗26例,再手术6例.均治愈,治愈率100%.结论 32例胆漏原因为肝外胆道损伤、T管处理不恰当、胆肠吻合口技术不过关,从中吸取教训,注意预防,发生胆漏后采取合适的方法积极治疗.     

丁丙诺啡合芬太尼应用于术后病人静脉自控镇痛

目的 探讨丁丙诺啡与芬太尼用于术后病人静脉自控镇痛（PCIA）的效果。方法 选开胸手术30例，上腹部手术60例手术后病人，实施术后PCIA随机，PCIA镇痛液配方丁丙诺啡0．6mg＋芬太尼0．5mg＋赛格恩5nag＋0．9％生理盐水稀释至100ml．记录病人术后止痛效果术后48小时呕吐发生情况。结果 所有患者术后止痛效果满意，部分病人有恶心呕吐反应，尤其是胆道手术患者反应较为明显。结论 使用丁丙诺啡做PCIA止痛用药，避免了鸦片类药物所致的成癌反应，无嗜睡现象，利于病人的术后康复。但丁丙诺啡易引起恶心呕吐反应，尤其是胆道及腹部手术反应较为明显，可在药泵里加入赛格恩，可减少呕吐的发生.     

175例胆系恶性肿瘤的外科处理

总结了本院1976年～1995年间收治的129例胆管癌和46例胆囊癌.胆囊癌与同期良性胆囊疾病(2597例)的比例为1:56.46,后10年比前10年增加1.83倍.27例(59%)并胆囊结石,B超对胆囊癌的诊断准确率为73.9%,高于CT确诊率,129例胆管癌中高位胆管癌68例.中位37例和低位24例.与同期良性胆管疾病(5605例)的比例为1:43.45,后10年比前10年增长1.49倍,59例(46%)并胆管结石.19例曾行胆道手术的病例中12例属胆管空肠Roux—Y吻合术,且癌肿发生部位位于吻合口上10厘米以内.CT对胆管癌的诊断准确率高于B超,且在术前分期中有一定价值.前10年本组所有胆道癌病例行根治术仅16.3%,而后10年上升至38.95%.     

A bile based study of Clonorchis sinensis infections in patients with biliary tract diseases in Ulsan, Korea

Stool examination is believed to be the most reliable method for detecting Clonorchis sinensis (CS) eggs. However, it has limited value for diagnosing clonorchiasis when the biliary tract is obstructed or when there is a light infection. We evaluated the infection states of CS in patients with biliary tract diseases using a bile sample. From January 2001 to August 2003, 238 patients who had undergone endoscopic biliary drainage were prospectively included in the study. The patients' bile samples were obtained directly from the nasobiliary drainage tube and then analyzed to detect CS eggs. The overall CS egg positive rate was 28.2% (35.4% in males, 19.4% in females). The egg positive rate was similar in all age groups examined: 26.7% in 30-39 years, 25.0% in 40-49 years, 24.4% in 50-59 years, 30.2% in 60-69 years, 35.3% in 70-79 years, and 25.0% in 80 years of age and over. There were no significant differences in the egg positive rate between the disease groups: 32.6% in bile duct cancer, 38.5% in gallbladder cancer, and 26.4% in gallstone diseases. Our results show that the CS infection rate was very high, regardless of the age, gender, and type of diseases of the patients. Although the study population was limited to patients with biliary tract diseases, it is assumed that clonorchiasis is still an endemic disease in Ulsan, Korea.     

Evaluation of the biliary excretion of a ticarcillin-clavulanic acid combination in man

The association of a beta-lactamase inhibitor, clavulanic acid (CA) (0.2 g) to ticarcillin (TIC) (3 g) enhances the activity of the latter on resistant strains. The aim of the present study was to assess their biliary elimination in man. Serum, urine and bile concentrations of TIC and CA were measured in biological samples collected in 10 cholecystectomized patients provided with a T-tube, during 12 hours after the IV administration of 3.2 g of claventin. Concerning TIC, a mean biliary peak of 177 +/- 49 (SEM) micrograms/ml was reached during the 2nd hour; the total biliary output (0-12 h) (AB) was 8.8 +/- 2.6 mg (0.28% of the administered dose), the hepato-biliary clearance CL HB 0.34 ml/min and the biological half-life, TB 1/2 1.2 h. The mean biliary peak of CA was 2.7 +/- 0.5 micrograms/ml and occurred during the first hour. AB amounted to 98.5 +/- 34.7 micrograms (0.04% of dose), CLHB to 0.10 ml/min and TB 1/2 1.2 h. In per-operatively sampled serum, choledochal bile, gallbladder bile and gall-bladder wall, the following concentrations were measured 1 hour after the IV administration of 3.2 g of Claventin. TIC: 105 +/- 11; 386 +/- 66; 72 +/- 20 micrograms/ml and 36 +/- 11 micrograms/g. CA: 3.6 +/- 0.7; 5.9 +/- 1.5; 0.3 +/- 0.3 micrograms/ml and 0.1 +/- 0.1 micrograms/g. The biliary pharmacokinetic profiles allow to favorably consider the prophylactic use of Claventin in the surgery of the biliary tract as well as its therapeutic administration in biliary tract infections.     

Bile acid analysis in biliary tract cancer

The etiology of biliary tract cancer is obscure, but there are evidences that bile acid plays a role in carcinogenesis. To find the association between biliary tract cancer and bile acid, this study compared the bile acid concentration and composition among patients with biliary cancer, biliary tract stones, and no biliary disease. Bile was compared among patients with biliary tract cancer (n = 26), biliary tract stones (n = 29), and disease free controls (n = 9). Samples were obtained by percutaneous transhepatic biliary drainage, endoscopic nasobiliary drainage, or gallbladder puncture, and analyzed for cholic, deoxycholic, chenodeoxycholic, lithocholic, and ursodeoxycholic acid composition. Total bile acid concentration was lower in the cancer group than the biliary stone and control groups; the proportions of deoxycholic (2.2% vs. 10.2% and 23.6%, p < 0.001 and p < 0.001, respectively) and lithocholic acid (0.3% vs. 0.6% and 1.0%, p = 0.065 and p < 0.001, respectively) were also lower. This result was similar when disease site was limited to bile duct or gallbladder. Analysis of cases with bilirubin 相似文献   

Experimental and clinical study of the biliary elimination of mezlocillin (author's transl)

The biliary elimination of mezlocillin was studied in 5 perfused rabbit liver preparations. After adding 10 mg of mezlocillin to the perfusion medium, the biliary peak averaged 758 +/- 129 microgram/ml and total mezlocillin recovery within 3hr amounted to 20.3% of the administered dose. In 5 healthy subjects, the mean levels in the duodenal fluid collected during the 4 hrs following an infusion of 5 g of mezlocillin ranged from 440 to 637 microgram/ml. In cholecystectomized patients provided with a T-tube drainage, the maximal concentration after the same dosage (n = 10) was 505 +/- 158 microgram/ml and cumulative biliary excretion of mezlocillin over a 12 hr period corresponded to 1.3% of the administered dose. Under the same conditions, after intra-muscular injection of 1 g of mezlocillin to 10 subjects, the biliary peak averaged 292 +/- 58 microgram/ml and the total biliary recovery 2.6% of the administered dose. In 10 patients undergoing biliary tract surgery, the levels determined 1 hr after IV injection of 2 g of mezlocillin reached 896 +/- 196 microgram/ml and 402 +/- 133 microgram/ml in the main duct and in the gallbladder bile, respectively. These results were compared with the values obtained under identical conditions with 12 other beta-lactam antibiotics.     

Experimental and clinical evaluation of the biliary elimination of ceftazidime

After adding 10 mg of ceftazidime to the circulating blood of five isolated rabbit liver perfusions, total antibiotic excretion over a 3 hours period accounted for 1.4% of the administered dose; only 0.9% was found to be metabolized by the liver. In five healthy subjects given 2 g ceftazidime intravenously, 0.05% (102 +/- 576 micrograms) was recovered in the duodenal fluid over a four-hour period. In 10 patients with a T-tube inserted following cholecystectomy, 0.21% of a 2 g dose of ceftazidime injected intravenously was found in the bile collected over a 12-hour period (4 161 +/- 489 micrograms); a mean biliary peak of 36.3 +/- 4.0 micrograms/ml was recorded during the second hour. In 10 patients in whom serum, choledochal bile and gallbladder bile were sampled simultaneously during surgery 1 hour after IV administration of ceftazidime, the concentrations found were 40.6/e 2.1, 78.3 +/- 12.0 and 17.9 +/- 7.5 micrograms/ml respectively. Our results suggests that ceftazidime may be suitable in the treatment of biliary tract infections.     

K-ras codon 12 and p53 mutations in biopsy specimens and bile from biliary tract cancers

To evaluate whether it is useful for diagnosis to detect K-ras and p53 mutations in biopsy specimens and bile of biliary tract lesions, 12 cholangiocarcinomas (CC), eight cases of cholangitis, seven gallbladder carcinomas (GBC), seven gallbladder cholesterol polyps, four cases of adenomyomatosis of the gallbladder and five cases of cholecystitis were examined. K-ras and p53 mutations in bile were detected by a two-step polymerase chain reaction (PCR) and nested PCR-single-strand conformation polymorphism (SSCP) analysis. In addition, p53 protein expression in biopsy specimens from CC were examined by immunostaining. K-ras mutations at codon 12 were detected in 50% of CC and 57.1% of GBC in both biopsy specimens and bile. The incidence of p53 mutations was 33.3% in CC and 42.9% in GBC. p53 protein overexpression was observed in 60% CC biopsy specimens. In contrast, K-ras and p53 abnormalities were not detected in any non-neoplastic biliary tract lesion. K-ras and p53 mutations in biliary tract cancers showed the same mutation patterns in spite of differences in the collection methods used between bile and biopsy specimens or surgically resected tissue. Genetic analysis of K-ras and p53 mutations in biopsy specimens and bile may be useful for the diagnosis of biliary tract cancers, although it may be effectively limited to patients with advanced disease.     

盐酸异丙嗪的阴道杀精避孕作用及其作用机理的研究

目的：评价盐酸异丙嗪的阴道避孕（抗生育）作用及其杀精作用机理。方法：选用未经产雌性金黄地鼠,于交配前阴道内注入盐酸异丙嗪溶液,交配后第１０ｄ剖腹检查妊娠动物数;采用精子尾低渗肿胀试验法和透射电镜观察探讨药物的杀精机理。     

Evaluation of the biliary excretion of penicillin G. (author's transl)]

Biliary excretion of penicillin G was studied experimentally by perfusion of isolated rabbit liver. Under these conditions, bile recovery accounted for 5% of the amount of penicillin G added to the perfusing blood (10 mg); peak biliary level averaged 135.3 micrograms/ml. In man after intravenous administration of a 599 mg dose of penicillin G (1 MU) to patients provided with T-tube drainage (n = 10), the maximum biliary concentration averaged 18.0 +/- 8.0 micrograms/ml at 2 hours; biliary recovery of penicillin G accounts for 0.12% of the administered dose. The excretion of penicillin G in the juice collected through duodenal tubing in normal subjects averaged 0.07% of the administered dose (599 mg IV). Per-operative assays showed that the concentration determined at 1 hour after intravenous administration of the drug (599 mg) in the gallbladder bile (45.7 +/- 16.7 micrograms/ml) and common duct bile (93.5 +/- 16.3 micrograms/ml) were definitely higher (4.5--9 times) than the serum levels measured simultaneously. The biliary excretion of penicillin G is compared with the biliary elimination of a certain number of beta-lactam derivatives studied under the same conditions (ampicillin, metampicillin, carbenicillin, cefalothin, cefaloridine, cefacetrile, cefalexin, cefazolin).     

Biliary excretion of apalcillin. Experimental study and evaluation in man

Biliary excretion of apalcillin, a new derivative of the ureido-penicillin group, was investigated both experimentally and in humans. After adding 10 mg of this antibiotic to the circulating blood of an isolated rabbit liver perfusion model (n = 5), mean total apalcillin biliary recovery (0-3 h) accounted for 30.7% of the administered dose; the biliary peak averaged 686.0 +/- 135.9 micrograms/ml. In 5 healthy subjects, a mean maximum level of 1088 +/- 582 micrograms/ml was measured in the duodenal fluid collected during the 4 hours following an i.v. injection of Ig of apalcillin. In 10 cholecystectomized patients provided with T-tube drainage, after the same dosage, a mean biliary peak of 2093 +/- 859 micrograms/ml was reached at the third hour and cumulative biliary recovery of apalcillin over a period of 12 hours amounted to 12.1% of the injected dose. In 20 patients, undergoing biliary tract surgery, intra-operative assays performed 1 hour after i.v. injection of 1 g of apalcillin, showed simultaneous mean antibiotic activity of 65.5 +/- 5.0 micrograms/ml in serum, 3860 +/- 551 micrograms/ml in main duct bile and 2552 +/- 627 micrograms/ml in gallbladder bile. The results of these investigations were compared with data previously obtained under identical procedures with 13 other beta-lactam derivatives.