扶正利胆汤对贲门癌术后胆囊收缩障碍的临床疗效观察

目的 研究扶正利胆汤对贲门癌术后胆囊收缩障碍的临床治疗作用及其机制探讨.方法 选择120例贲门癌术后患者,随机分为试验组60例和对照组60例;试验组患者,在术后第10天开始口服扶正利胆汤,连服20天;对照组患者,在术后第10天口服等体积的水,连服20天;在实验治疗期间,对上述两组患者均进行常规抗炎、补液等治疗.所有患者分别于术前3天、术后30天对胆囊进行超声波指标测定,测定条件是空腹、服用脂餐0.5小时后、服用脂餐1小时后,应用超声波测定胆囊最大纵切面积、长径、短径,计算胆囊超声容积、排空率指标,并在术前3天、术后30天测定空腹血清胆囊收缩素浓度.比较两组患者手术前后胆囊的容积、排空、排空率及空腹血清胆囊收缩素浓度.结果 1）两组患者手术前后胆囊收缩功能比较：对照组患者术后胆囊容积较术前明显增大（P＜0.05）,治疗组患者术后胆囊容积较术前没有显著性改变;术前治疗组和对照组患者胆囊容积无显著差别（P＞0.05）;术后试验组胆囊容积比对照组患者的胆囊容积明显缩小,两组比较具有显著性差异（P＜0.05）.2）两组患者手术前后空腹血清胆囊收缩素（CCK）浓度比较：术前两组CCK浓度无明显差别（P＞0.05）;术后对照组患者CCK浓度较术前明显下降（P＜0.05）,治疗组患者术后CCK浓度较术前无明显改变（P＞0.05）,术后试验组患者较对照组血清CCK浓度明显升高,两组比较有显著性差异（P＜0.05）.结论 贲门癌术后出现胆囊排空障碍,术后胆囊容积与术前相比明显增大.扶正利胆汤可以提高血清CCK浓度,改善术后胆囊容积,对于贲门癌术后的胆囊收缩障碍有一定的治疗作用.     

Determinants for gallstone formation – a new data cohort study and a systematic review with meta-analysis*

Objective: Only few determinants of gallstone formation have been identified in cohort studies. The aim was to identify further determinants for gallstones in a Danish cohort and to perform a meta-analysis of results from existing cohorts.

Material and methods: Data from a cohort study was used. Gallstone incidence was assessed through repeated ultrasound examinations. Body mass index (BMI), blood pressure, self-rated health, lifestyle variables, blood lipids, and use of female sex hormones were measured at the baseline examination. Statistical analyses included logistic regression. Based on a prospective protocol, a systematic review of the literature was performed identifying all articles dealing with determinants of incident gallstones. Meta-analyses of comparable determinants were performed through fixed effect models.

Results: Participants with no gallstones at baseline and with at least one re-examination were followed-up completely (mean 11.6 years, N?=?2848). The overall cumulative incidence of gallstones was 0.60% per year. Independent positive determinants for incident gallstones were age, female sex, non-high density lipoprotein (non-HDL) cholesterol, and gallbladder polyps. In addition, BMI was positively associated in men. The systematic review additionally identified associations for comorbidities, parity, and dietary factors. Meta-analysis confirmed the significant associations for incident gallstones and age, female sex, BMI, and non-HDL cholesterol. No significant associations were found for blood pressure, smoking, alcohol consumption, HDL cholesterol, or triglycerides in meta-analyses.

Conclusions: Age, female sex, BMI, non-HDL cholesterol, and polyps are independent determinants for gallstone formation. Incident gallstones and the metabolic syndrome share common risk factors. More studies are needed for further exploration.     

Functional MR cholangiography of the cystic duct and sphincter of Oddi using gadoxetate disodium: Is a 30‐minute delay long enough?

Purpose:

To determine if excreted contrast is consistently visualized in the gallbladder and duodenum after a 30‐minute delay using gadoxetate disodium‐enhanced MRI in patients without hepatobiliary disease.

Materials and Methods:

Twenty‐two patients without evidence of liver or biliary disease underwent gadoxetate disodium‐enhanced magnetic resonance imaging (MRI) from February 17, 2009 through October 3, 2011. The mean age was 45 years (range 25–72). T1‐weighted hepatobiliary phase images at 5, 10, 20, and 30 minutes after contrast injection were reviewed in consensus by two radiologists to determine the delay at which enhancement of the gallbladder and duodenum first occurred.

Results:

Thirteen of 22 (59.1%) patients demonstrated duodenal filling by 20 minutes and 16/22 (72.7%) filled by 30 minutes. The mean time to duodenal enhancement was 19.9 minutes (range 11.4–30.2 min). Seventeen of 22 (77.3%) patients demonstrated gallbladder filling by 20 minutes and 21/22 (95.5%) filled by 30 minutes. The mean time to gallbladder enhancement was 16.5 minutes (range 4.4–30.2 min).

Conclusion:

A significant number of normal patients do not show duodenal filling by 30 minutes, while the majority fill the gallbladder by 30 minutes using functional MR cholangiography (fMRC) with gadoxetate disodium. These findings will guide fMRC protocol design for patients with suspected acute cholecystitis and sphincter of Oddi dysfunction. J. Magn. Reson. Imaging 2013;37:993–998. © 2012 Wiley Periodicals, Inc.     

Endoscopic ultrasound gallbladder drainage: Patient selection,preparation, and performance

Acute cholecystitis is a common cause of hospital admissions and can result in critically ill patients. For those patients not amenable to cholecystectomy, endoscopic drainage via transpapillary cystic duct stenting or transmural drainage offers a temporizing method for urgent gallbladder decompression. Endoscopic ultrasonography (EUS) and the development of novel lumen apposing metal stents can allow for more permanent drainage with comparable outcomes to percutaneous transhepatic catheters. The merits of this approach including the technical and clinical advantages of EUS-guided drainage are discussed further in this review article.     

三维超声评估胆囊动力功能时相

目的探讨三维超声评估胆囊功能及胆囊胆汁动力时相的临床意义。方法利用三维超声对50例正常体检者(正常组)和50例胆囊结石患者(胆石组)进行脂餐试验,记录餐前、餐后每隔10 min的胆囊容积,共计380 min,计算胆囊最大收缩率(GBEF_(max))和最大收缩时间(Tmax),并绘制胆囊容积变化曲线图。结果正常组餐前胆囊容积为(16.75±7.14)mL,餐后90 min胆囊容积最小为(1.90±0.98)mL,GBEF_(max)为(88.61±10.39)%,Tmax为(90.34±12.36)min,360 min胆囊容积恢复到餐前水平。与正常组比较,胆石组餐前胆囊体积(19.06±6.93)mL明显增大(P0.05),GBEF_(max)(67.27±7.26)%明显降低(P0.05),Tmax(110.85±10.33)min明显延长,餐后约360 min胆囊容积恢复到餐前水平。依据胆囊胆汁动力相变化,胆囊胆汁排出相为餐后0~90 min,胆囊胆汁充盈相为餐后90~360 min,胆囊胆汁浓缩相为餐后360 min。结论三维超声等影像学只需检测餐前和餐后90 min胆囊容积即可达到评估胆囊功能,胆囊胆汁动力时相的变化可能更全面体现胆囊功能,对临床手术方式及时机的选择有较高实用价值。     

Metastatic melanoma to the gallbladder

Melanoma is an aggressive neoplasm with a tendency to recur and metastasize to distant, including unusual sites. Only 2–4% of patients with melanoma develop gastrointestinal tract metastasis with the small intestine being the most frequent site of involvement. Melanoma metastasizing to the gallbladder is rare, is usually associated with disseminated disease and accompanied by a very poor prognosis. Most metastatic gallbladder melanomas originate from cutaneous lesions that may or may not be clinically apparent at the time of diagnosis. The distinction between primary and metastatic gallbladder melanoma is extremely difficult, especially when the primary cutaneous lesion has undergone spontaneous regression. We report a case of disseminated metastatic melanoma presenting as a gallbladder polyp, in the clinical scenario of a regressed primary cutaneous lesion.     

胆囊切除与脂质代谢异常的研究进展

胆囊结石病与代谢异常相关。胆囊切除术仍是目前胆石病的主要治疗方法，但其对机体特别是脂质代谢如胆汁酸、三酰甘油、胆固醇代谢会产生影响，甚至导致代谢疾病如增加非酒精性脂肪肝（non-alcoholic fatty liver disease, NAFLD）的发生风险。本文对胆囊切除与脂质代谢的关系作一综述。     

Contrast‐enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions

Background and Aim

Differential diagnosis of localized gallbladder lesions is challenging. The aim of the present study was to evaluate the utility of contrast‐enhanced harmonic endoscopic ultrasonography (CH‐EUS) for diagnosis of localized gallbladder lesions.

Methods

One hundred and twenty‐five patients with localized gallbladder lesions were evaluated by CH‐EUS between March 2007 and February 2014. This was a single‐center retrospective study. Utilities of fundamental B‐mode EUS (FB‐EUS) and CH‐EUS in the differentiation of gallbladder lesions and sludge plug were initially compared. Thereafter, these two examinations were compared with respect to their accuracy in the diagnosis of malignant lesions. Five reviewers blinded to the clinicopathological results evaluated microcirculation patterns in the vascular and perfusion images.

Results

In the differentiation between gallbladder lesions and sludge plug, FB‐EUS had a sensitivity, specificity, and accuracy of 82%, 100%, and 95%, respectively, whereas CH‐EUS had a sensitivity, specificity, and accuracy of 100%, 99%, and 99%, respectively. FB‐EUS‐based diagnosis of carcinomas based on tumor size and/or shape had a sensitivity, specificity, and accuracy of 61–87%, 71–88%, and 74–86%, respectively. Additional information regarding irregular vessel patterns in the vascular image and/or heterogeneous enhancement in the perfusion image on CH‐EUS increased the sensitivity, specificity, and accuracy for the diagnosis of carcinomas to 90%, 98%, and 96%, respectively. There was a significant difference between FB‐EUS and CH‐EUS in terms of carcinoma diagnosis.

Conclusion

CH‐EUS was useful for the evaluation of localized gallbladder lesions.     

Successful laparoscopic management of duplicate gallbladder: A case report and review of literature

IntroductionGallbladder duplication is a rare congenital anomaly. Recognition of this anomaly and its various types is important since it can complicate a simple hepatobiliary surgical procedure.Presentation of caseWe report a case of a 42 year old female who presented a 6 year history of intermittent right upper quadrant abdominal pain. Her basic blood investigations including liver function tests were normal. Pre-operative imaging revealed a cystic lesion communicating with biliary tree representing duplicated gallbladder. She subsequently underwent successful laparoscopic cholecystectomy. The operative challenges were more than those anticipated at the usual laparoscopic gallbladder procedures. After six months follow up the patient remained asymptomatic.DiscussionPreoperative diagnosis plays a crucial role in planning surgery, and preventing possible biliary injuries or re-operation if accessory gallbladder has been overlooked during initial surgery. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for suspected duplicate gallbladder. Laparoscopic cholecystectomy for duplicate gallbladder is a challenging operation and should be performed with meticulous dissection of the cysto-hepatic triangle.ConclusionGallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder. The laparoscopic cholecystectomy remains feasible for intervention and should be done by an experienced laparoscopic surgeon.