5例正常人胆管壁的组织构筑研究

对５例正常人胆管壁的组织构筑及其平滑肌（ＳＭＣ）、弹力纤维（ＥＦ）、胶原纤维（ＣＦ）进行了定量研究。结果发现：从胆总管胰后段至左右肝管汇合部，平滑肌的面积百分数从１３．３５±０．６５降到３．３４±０．３２；弹力纤维的含量以肝总管和左右肝管汇合部为高，与胆总管胰后段和十二指肠上段比较，差别有显著性（Ｐ＜０．０５）；胶原纤维的含量，肝外胆管各段及肝内胆管各段差别无显著性（Ｐ＞０．０５），但肝内、外胆管各段比较，差别有显著性（Ｐ＜０．０５）。对胆管壁的组织学观察发现，肝内与肝外胆管壁的组织构筑存在一定的差异，说明胆管不同部位的生理功能不同。     

失去肝动脉血液供应后大鼠肝门部胆管周围血管丛变化的三维构像研究

目的 探讨完全失去肝动脉血液供应后，大鼠肝门部胆管周围血管丛（PBP）的形态学变化。方法 将SD大鼠随机分为两组，对照组仅游离胆总管、门静脉、腔静脉和肝总动脉，不做切断；实验组结扎肝动脉，并切断肝十二指肠韧带除门静脉以外的其它组织，阻断其它侧支血管对肝门部胆管的血液供应。术后应用计算机对大鼠肝门部组织切片进行PBP三维可视化构建，并对PBP内层微血管进行定量分析，对胆管壁组织进行病理学检查。结果 实验组肝门部胆管分叉部位PBP平面结构显示胆管扩张，胆管壁明显增厚，壁内微血管尖细，排列紊乱，内层微血管密度减低；PBP立体构像显示空间结构紊乱，不规则，微血管细小，管壁不均匀增厚。与对照组相比，实验组肝门部PBP内层微血管总数明显减少（P〈0．01），肝门部PBP内层微动脉数也明显减少（P〈0．05）。实验组肝门部胆管壁呈慢性增生性炎症改变。结论 失去含氧量高的动脉血液供应时，PBP形态结构将会发生一系列改变，胆管壁组织也将发生相应的病理变化。     

完全失去动脉血供后大鼠肝门部胆管微血管数对胆管上皮细胞核增殖与ER表达影响

目的探讨完全失去动脉血供后肝门部胆管微血管数改变对胆管上皮细胞核增殖活性以及雌激素受体表达的影响。方法将SD大鼠随机分为对照组、实验组,应用免疫组化方法,观察肝门部胆管周围血管丛(PBP)内层微血管数改变、胆管上皮细胞核增殖指数(PI)和雌激素受体(ER)表达情况以及胆管壁组织病理学变化。结果与对照组相比,实验组肝门部胆管周围血管丛内层微血管总数和微动脉数均显著下降,胆管上皮细胞PI以及ER表达均显著升高,胆管壁组织呈慢性炎症增生性改变。结论一定流量与含氧量的血液对维持胆管周围血管丛灌注,保持胆管上皮细胞正常生理功能和胆管壁组织正常形态结构有重要的意义。     

大鼠移植肝胆道系统不同部位异质性对缺血再灌注损伤耐受性差异的比较

目的 研究胆道系统不同部位胆管上皮细胞的异质性以及胆管周围血管丛构筑形式的不同,对缺血再灌注损伤耐受性的差异.方法 30只SD大鼠随机分成3组,Ⅰ组(假手术组),Ⅱ组(胆道缺血1 h再灌注1 h组),Ⅲ组(胆道缺血1 h再灌注2 h组).对肝门部胆管、胆总管近端及小叶间胆管的上皮细胞行凋亡(TUNEL法)检测、病理形态学评分和超微结构的定量分析.结果 Ⅱ组的细胞凋亡及病理形态评分在胆总管近端与小叶间胆管无统计学差异(P＞0.05),但肝门部损伤较重(P＜0.05);线粒体平均体积(V)及微绒毛面积密度(AMv)比较在肝门部最重,胆总管近端最轻(P＜0.05).在Ⅲ组以上各指标都表现为肝门部最重,小叶间胆管次之,胆总管近端最轻(P＜0.05).结论 胆管上皮细胞的异质性以及周围血管丛不同部位构筑形式的不同导致了胆道系统各部位损伤程度的差异.该结果为解释肝门部胆管狭窄高发率的临床表现提供了一定的实验基础.胆总管近端损伤最轻这一结果提示,在临床肝移植中,应尽量以胆总管近端作为最佳吻合部位.     

大鼠肝门部胆管周围血管丛的研究

目的探讨大鼠肝门部胆管周围血管丛(PVP)的解剖结构及其研究方法。方法用碳素墨汁灌注大鼠肝动脉，经透明化处理后，观察大鼠肝门部PVP的形态结构，并用MoticBuaa3Dvol软件针对PVP空间构象进行三维重建。结果本研究所应用的墨汁灌注透明法能清楚地显示出大鼠肝门部胆管微血管的分布形式及PVP的平面结构，MoticBuaa3Dvol软件有效地重建出PVP的三维立体构象，效果逼真。结论在大鼠肝门部胆管周围血管丛形态学的研究中，墨汁灌注透明法是一简单易行的方法。MoticBuaa3Dvol软件在肝门部胆管微血管研究中具有一定的应用价值。     

肝胆管结石并狭窄时的胆管壁组织构筑变化及意义

对21例择期手术,行定位取材获得5例左右肝管汇合部狭窄、7例I级肝管狭窄、7例Ⅱ级肝管汇合部狭窄、10例Ⅱ级肝管狭窄及10例Ⅲ级肝管汇合部狭窄标本进行连续组织学观察,并对其弹性纤维和胶原纤维进行定量分析。结果:①狭窄胆管的上皮完整,上皮细胞增生,线粒体脱颗粒、断嵴,内质网扩张,提示狭窄胆管上皮细胞的功能有障碍;②狭窄胆管及周围组织粘液腺大量增生,在腺体破坏区有局部纤维化,并可参与胆管壁纤维化;③在各部位狭窄胆管壁组织中,可见部分弹性纤维断裂,排列紊乱,使狭窄胆管壁的应变能力减弱;④狭窄胆管胶原纤维排列紊乱,可见玻璃样变性,其体积密度较正常胆管相应部位增大。     

大鼠门静脉动脉化肝门部胆管微血管的三维重建观察

目的　探讨门静脉完全动脉化 (PVA)后大鼠肝门部胆管微血管的改变。方法　用墨汁灌注透明法 ,观察大鼠肝门部胆管微血管的改变 ,并用MoticBuaa3DVol软件针对胆管周围血管丛(PBP)进行三维重建。结果　本方法能清楚地显示出大鼠肝门部胆管微血管的分布情况 ,PVA组PBP外层血管显著增粗 ,内层血管密度增加。利用本软件能较好地重建出两组大鼠肝门部胆管PBP的三维结构。结论　PVA后肝门部胆管微血管数量未出现明显减少 ,动脉化的门静脉血可通过侧枝途径满足PBP需求 ,并能维持胆管正常的生理功能 ,这也是PVA能够施行的理论依据。MoticBuaa3DVol软件在肝门部胆管微血管研究中有一定的应用价值     

大鼠门静脉动脉化肝门部胆管微血管的三维重建观察

目的探讨门静脉完全动脉化(PVA)后大鼠肝门部胆管微血管的改变。方法用墨汁灌注透明法，观察大鼠肝门部胆管微血管的改变，并用MoticBuaa3DVol软件针对胆管周围血管丛(PBP)进行三维重建。结果本方法能清楚地显示出大鼠肝门部胆管微血管的分布情况，PVA组PBP外层血管显著增粗，内层血管密度增加。利用本软件能较好地重建出两组大鼠肝门部胆管PBP的三维结构。结论PVA后肝门部胆管微血管数量未出现明显减少，动脉化的门静脉血可通过侧枝途径满足PBP需求，并能维持胆管正常的生理功能，这也是PVA能够施行的理论依据。MoticBuaa3DVol软件在肝门部胆管微血管研究中有一定的应用价值。     

肝门部胆管癌根治与淋巴结清扫范围

正由于胆管壁较薄,淋巴结转移在肝门部胆管癌中较为常见,是影响预后的最重要因素之一[1-2]。文献[2]报道,在可切除肝门部胆管癌患者中,淋巴结转移发生率高达31%~58%。因此,淋巴结清扫范围一直是肝门部胆管癌根治术中的一个热点问题。有研究[3]表明,肝门部胆管癌的淋巴结转移与肝门部胆管癌浸润程度(T)和Bismuth分型呈正相关。但肝门部胆管癌中淋巴结清扫范围在患者预后中的作用尚未达成共识,且肝门部胆管周围的解     

核酸内切酶在肝门部胆管癌组织和细胞株中的表达和临床意义

目的 研究核酸内切酶(Dicer)在肝门部胆管癌组织和胆管癌细胞株(QBC939)中的表达及其与临床病理因素和预后的相关性.方法 采用免疫组化染色检测40例肝门部胆管癌和10例正常胆管组织中Dicer的表达;Western-blot和RT-PCR检测人胆管癌细胞株QBC939与人胆管上皮细胞株HIBEpic中Dicer的表达量;分析Dicer表达与临床病理因素的相关性.对根治性切除的肝门部胆管癌患者术后总生存期和无病生存期进行单因素和多因素分析.结果 Dicer在肝门部胆管癌组织中的表达明显低于正常胆管组织(P＜0.05),在QBC939中的表达明显低于HIBEpic(P＜0.05),高分化胆管腺癌中Dicer表达明显高于中、低分化腺癌.单因素生存分析结果显示Dicer低表达组的根治性切除术后总生存期和无病生存期均短于高表达组(P＜0.01).多因素分析显示Dicer表达水平为与预后相关的独立危险因素(P＜0.05).结论 在肝门部胆管癌和胆管癌细胞株Dicer表达下调;低表达Dicer的胆管癌患者预后更差.Dicer可能为肝门部胆管癌的诊断和判断预后的分子标志物.     

Extensive hilar bile duct resection using a transhepatic approach for patients with hepatic hilar bile duct diseases

BACKGROUND: Extensive hilar bile duct resection beyond the second- or third-order intrahepatic biliary radicals is usually required for patients with hilar cholangiocarcinoma as well as those with benign inflammatory stricture. Most hilar cholangiocarcinoma is resected with combined major hepatectomy to obtain free surgical margins. The purpose of this study was to show the surgical procedure and the usefulness of extensive hilar bile duct resection using a transhepatic approach for patients with hilar bile duct diseases. METHODS: Five patients with hepatic hilar bile duct disease and who were unfit for major hepatectomy for several reasons underwent extensive hilar bile duct resection by way of a transhepatic approach. Four of the patients had hilar bile duct cancer, including 1 with mucous-producing bile duct cancer of low-grade malignancy and 1 with a postsurgical benign bile duct stricture. RESULTS: After extensive hilar bile duct resection, bile duct stumps ranged in number from 3 to 7 mm (mean 4.4). Surgical margins at bile duct stump were free of cancer in all 4 cancer patients. The long-term outcomes were as follows: 3 patients are alive at the time of publication, and 2 patients have died. CONCLUSIONS: A transhepatic approach may be useful when performing extensive hilar bile duct resection bile duct stricture of biliary disease at the hepatic hilus, especially in high-risk patients who are unfit for major hepatectomy as well as in those having benign bile duct stricture and low-grade malignancy.     

高位胆管良性狭窄的原因和治疗

目的探讨高位胆管良性狭窄的原因和防治。方法回顾性总结分析高位胆管良性狭窄460例的病因和治疗方法。结果病因依次为肝胆管结石(383例)、高位胆管损伤(54例)、胆囊结石Mirizzi综合征(21例)、单纯良性狭窄(2例)。分别行肝叶或肝段切除；经肝剖开狭窄胆管，肝胆管或肝门胆管空肠吻合；肝门胆管狭窄切开整形后与空肠大口吻合；吻合口狭窄切开扩大吻合；肝门胆管狭窄切开整形后T管支撑等手术。效果满意，优良率为90．1％。结论高位胆管良性狭窄的主要原因是肝胆管结石(83．3％)和高位胆管损伤(11．7％)。肝叶或肝段切除，或联合肝内胆管或肝门胆管空肠大口吻合是治疗肝胆管结石并肝胆管狭窄的有效方法。高位胆管损伤初期修复后较易发生胆管或吻合口狭窄，再次修复以胆管空肠Roux-en-Y大口吻合术效果最好。强调重在预防，在行胆道手术时避免胆管损伤。     

肝移植术后并发高位胆管狭窄的原因及诊治八例

目的 探讨原位肝移植术后并发高位胆管狭窄的原因及诊治.方法 对8例肝移植后并发高位胆管狭窄患者的资料进行回顾性分析,8例均行背驮式肝移植,胆管采取端端吻合,其中2例置婴儿胃管.结果 高位胆管狭窄发生于术后3～18个月,5例以阻塞性黄疸为主要临床表现,3例以慢性胆管炎为主要临床表现.经保守治疗无效后,均行手术治疗,切除肝门部胆管狭窄段,再行胆肠Roux-en-Y吻合术.手术治疗后随访1～5年,除1例患者因肝癌复发死亡外,其余患者均生存良好.结论 胆道缺血、胆汁腐蚀以及保存性损伤是并发高位胆管狭窄的主要因素;B型超声波和磁共振胰胆管成像是有效诊断手段;胆肠Roux-en-Y吻合是处理高位胆管狭窄的有效方法.     

肝门部胆管梗阻的病因分析——附80例报告

复习1991年9月至1996年9月的5年病历资料,将其中80例手术证实、以肝门部胆管梗阻为主要临床表现的病历进行了分析。结果:80例病人中,恶性梗阻57例,占63.8％;良性梗阻29例,占36.2％。恶性梗阻主要包括肝门部胆管癌、胆囊癌、肝癌、肝门部转移癌,以肝门部胆管癌最为常见。良性梗阻主要包括Mirizzi综合征、肝门部结石及其他。结论:肝门部胆管梗阻临床上主要表现为黄疸、肝内胆管扩张,应引起高度警惕,防止漏诊,但另一方面有些其他疾病也可造成肝门部胆管阻塞,临床上出现与胆管癌的类似病症,易误诊为胆管癌,也应仔细分析,才能得出正确的诊断。     

Targeting chemotherapy for intrahepatic periductal lymphatic invasion by mitomycin C adsorbed to activated charcoal in hepatic hilar bile duct cancer

A new dosage form of anticancer agent, mitomycin C adsorbed to activated charcoal (MMC-AC), was evaluated in the rabbit model of hepatic hilar bile duct cancer. The model was produced by inoculation of VX2 cells into the wall of the hepatic hilar bile duct. Histologic examination revealed that the mode of spreading of VX2 cells in the model closely resembles that of human bile duct cancer. On the other hand, selective accumulation of MMC-AC into the lymphatic vessels around the intrahepatic bile duct was observed after its injection into the hepatic hilum in rabbits. To assess the anticancer effect, 1 ml of MMC-AC was injected into the bile duct wall near the VX2 tumor. The numbers of lymphatic vessels where necrosis of VX2 cells was observed in one-third or more were 34 of 103 vessels 0.5 cm away from the tumor, 23 of 80 vessels 1.5 cm away, and 9 of 67 vessels 2.5 cm away. We believe that the injection of MMC-AC into the hepatic hilum can be effective adjuvant therapy for hepatic hilar bile duct cancer.     

Anatomy of the hepatic hilar area: the plate system

To surgically manage hilar bile duct carcinoma successfully, it is important to be familiar with the principal anatomical variations of the biliary and vascular components of the plate system in the hepatic hilar area, because all the variations in the bile ducts and vessels occur in the plate system. The plate system consists of bile ducts and blood vessels surrounded by a sheath. There are three plates in the hilar area: the hilar plate, the cystic plate, and the umbilical plate. The bile duct and blood vessel branches penetrate the plate system and form Glisson's capsule in all segments of the liver, except for the medial segment. The right hepatic duct is usually (in 53%–72% of individuals) formed by the union of the anterior segmental duct and the posterior segmental duct in the hilar area. However, three other variations have been found in which these segmental ducts do not form the right hepatic duct. Few anatomical variations have been identified in the left hepatic duct, but confusion arises because of the variations in the medial segment ducts (B4) which join the left hepatic duct at different sites. In 35.5% of individuals they join the hepatic duct in the vicinity of the hilar confluence (type I B4 anatomy), and in 64.5% of individuals they join the left hepatic duct some distance away from the confluence (type II B4 anatomy). Because B4 is very close to the hilar confluence in type I, hilar bile duct carcinoma can easily invade B4 and, for that reason, for curative resection of hilar bile duct carcinoma, resection of S4a (the inferior part of the medial segment) should be considered along with the resection of extrahepatic bile duct and caudate lobe. Variations in the portal vein and hepatic artery are found in 16%–26% and 31%–33% of individuals, respectively. Because a considerable number of anatomical variations in the bile ducts and vessels persist in the hilar area, and the reported proportions of the different variations vary, it is necessary to have a good knowledge of the plate system and the variations in the bile ducts and blood vessels in the hilar area to perform safe and curative surgery for hilar bile duct carcinoma. Received: June 3, 2000 / Accepted: July 20, 2000     

肝圆韧带修复肝门部胆管治疗右肝动脉骑跨引起的胆管狭窄

目的探讨带蒂肝圆韧带修复右肝动脉骑跨引起的肝门部胆管狭窄的效果。方法回顾性分析2007年1月～2011年2月利用带蒂肝圆韧带修复右肝动脉骑跨引起的肝门部胆管狭窄5例的临床资料。胆管狭窄处直径1.5～3 mm。5例均采用离断右肝动脉,游离带蒂肝圆韧带,将肝圆韧带覆盖于胆管缺损处,自上而下,以3-0血管缝合线间断全层缝合胆管切缘与肝圆韧带,重建胆管前壁,放置T管引流的方法。结果 5例手术均获成功,手术时间90～170 min,平均120 min。肠蠕动3～4 d恢复。无围手术期死亡。T管放置3～6个月,平均4.3月。5例随访8～26个月,平均18.8月,未发生腹痛、黄疸、发热等胆管狭窄、胆管炎症状。结论利用带蒂肝圆韧带修复右肝动脉骑跨引起的肝门部胆管狭窄,能有效地避免胆管再狭窄、逆行性胆道感染等手术并发症的发生。     

带蒂胆囊瓣修复肝门胆管狭窄(附53例报告)

目的提高良性肝门胆管狭窄的治疗效果。方法采用带血管蒂胆囊瓣肝门胆管成形术(plastics of hilar bile duct stricture，PHBDS)治疗合并肝内胆管结石的肝门胆管炎性狭窄，并回顾性分析我院近10年间行PH—BDS及胆管空肠Roux-en-Y吻合术(RYCJ)治疗的肝门胆管狭窄患者的临床资料。结果随访16～87个月，平均47个月。PHBDS组与RYCJ组术后胆管炎发生率分别为5．66％和21．88％，差异有统计学意义(P=0.010)；胆管结石复发率分别为3．77％和16．67％．差异有统计学意义(P=0．021)。结论PHBDS术后远期效果优于RYCJ组。     

Surgical anatomy of the hepatic hilar area

It is important to understand the main variations of the biliary and vascular elements inside the plate system for hilar bile duct carcinoma because all variations of these elements occur in this plate system. The plate system consists of the hilar plate, cystic plate, and umbilical plate which cover the extrahepatic vascular system and are fused with the hepatoduodenal ligament. The bile duct and vascular system that penetrate the plate system form Glisson's capsule in the liver, but the caudate branch and the medial segmental branch are exceptions. The bile duct and hepatic artery accompanying the plate system can be exfoliated from the portal vein with numerous lymph ducts and nerves. The bile ducts in the right hepatic lobe are classified into 4 types, and the standard type is present in 53-72% of cases. In the left bile duct, the medial segmental bile duct is connected in the vicinity of the hilar area in 35.5% of cases, and these cases should be treated the same as the caudate lobe in hilar bile duct carcinoma. Generally, there is little main variation of the portal vein (16-26%), but more variation in the hepatic artery (31-33%). During surgery for hilar bile duct carcinoma, it is important to observe the plate system and the many variations of the bile duct and vascular system.