肾功能监测对动脉灌注化疗的安全意义临床研究

目的:本研究旨在研究肾功能监测对动脉灌注化疗的临床安全意义.方法:对120例确诊肝癌、肺癌、盆腔部癌并符合行动脉灌注化疗的患者,于动脉灌注化疗前及灌注化疗14d内,隔日查尿常规、尿N-乙酰-β-D-葡萄糖苷酶(N-acetyl-β-D-glucosaminidase,NAG)、γ-谷氨酰转酞酶(gamma-glutam...     

术前胆道引流对肝门部胆管癌手术并发症的影响

但不能降低术后并发症发生率和住院病死率.Bismuth-Corlette分型、是否合并肝切除是预测患者术后风险的重要因素.     

腹腔镜胆囊切除致胆道损伤26例分析

目的 探讨腹腔镜抻囊切除术(laparoscopic cholecystectomy,LC)致胆管损伤的原因、类型、临床表现、诊断及处理原则. 方法回顾性分析1997-2007年收治的26例LC致胆管损伤的临床资料.结果 胆管损伤Ⅰ型5例、Ⅱ型13例、Ⅲ型2例、Ⅳ型6例;3例术中发现胆管损伤并中转开腹,23例术后发现胆管损伤,其中13例为LC术后1周内发现,8例为术后20～60 d发现,2例在术后2年表现反复胆管炎发作的症状;24例接受介入治疗,其中5例获得治愈,19例在胆管炎和黄疸控制后获得手术;切除毁损胆管20例,行肝总管或左右肝管的胆肠吻合术.结论 胆道损伤是严重的LC术后并发症,应高度警惕.合理运用介入或手术的方法及时进行必要的胆管内支撑和通畅的胆汁外引流,应避免再次医源性损伤和修补术后胆道再狭窄.     

胆道结石患者胆汁中头孢曲松钠的浓度分布和抗菌活性研究及评价

目的研究头孢曲松钠在胆道结石患者胆汁中的浓度分布和对胆道致病菌的抗菌活性并评估杀菌效力,为胆道感染合理用药提供参考和依据。方法 12例因胆道结石行胆囊切除、胆总管切开引流患者于手术前30 min静脉滴注头孢曲松钠2.0 g,术中收集胆囊和胆总管胆汁;采用高效液相色谱法行胆汁药物浓度测定;同时对近两年临床分离的157株胆道病原菌的抗菌活性进行测定,并计算其杀菌指数(C/MIC90)。结果头孢曲松钠在胆总管和胆囊中的浓度分别为(264.43±166.46)μg/ml和(85.39±48.16)μg/ml;其对胆道的最主要致病菌大肠埃希菌、肺炎克雷伯菌和肠球菌的MIC90分别为64μg/ml,32μg/ml和64μg/ml,对铜绿假单孢菌、鲍曼不动杆菌和凝固酶阴性葡萄球菌耐药。头孢曲松在胆汁中的杀菌指数分别为大肠埃希菌1.33～4.08、肺炎克雷伯菌2.67～8.17、粪肠球菌1.33～4.08,杀菌指数最大的是变形杆菌和链球菌,均为42.70～130.72μg/ml。结论头孢曲松钠在胆道结石患者胆汁中浓度较高、抗菌活性较强,杀菌效力较大。     

奥曲肽对二乙基亚硝胺诱导的大鼠肝癌的影响

目的 研究生长抑素类似物奥曲肽(oetreotide,OCT)抑制大鼠诱导肝癌形成的效果及其机制.方法 用二乙基亚硝胺溶液(DENA)诱导大鼠肝癌模型,随机分成OCT治疗组和对照组,观察两组大鼠存活情况和肝癌发生率,用免疫组化和半定量RT-PCR的方法检测肝脏和肝癌组织中生长抑素受体2(somatostatin receptor 2,SSTR2)蛋白和Mrna的水平.结果 OCT组的存活率70.0%(7/10)明显高于对照组30.0%(6/20)(x2=4.344,P＜0.05);DENA喂养16周的诱癌率,OCT组(0%,0/10)低于对照组(30.0%,6/20),但两组比较差异无统计学意义(X2=3.750,P＞0.05);DENA喂养22周的诱癌率,OCT组(22.2%,2/9)显著低于对照组(83.3%,10/12)(X2=7.843,P＜0.01).SSTR2mRNA和蛋白表达随肝硬化加重而增加,DENA喂养16周时最强,DENA喂养22周时明显下降,肝癌内的表达更低于周边组织(分别F=35.010和13.386,均P＜0.01);OCT治疗组DENA喂养8周和16周后的SSTR2mRNA和蛋白水平均近似于对照组,但DENA喂养22周时两者的水平均无明显下降,明显高于同期对照组(分别t=2.806和4.498,均P＜0.05).结论 OCT能有效地抑制大鼠肝癌的形成,并减少诱癌大鼠的死亡率,SSTR2表达的维持可能是OCT发挥作用的关键.     

前入路右半肝切除术与传统右半肝切除术治疗大肝癌的对比观察

Objective To compare the outcomes between anterior versus conventional approach right hepatectomy for large hepatocellutar carcinoma(HCC).Methods A total of 188 consecutive patients with large HCC(≥5 cm)undergoing right hepatectomy were reviewed retrospectively.Among them,92patients received anterior approach right hepatectomy(anterior group)while the other conventional right hepatectomy(conventional group).Their clinicopathologic data and survivals were compared.Results There were five surgical deaths(2.7%),two in the anterior group and three in the conventional group.The biochemical and tumor pathological data(except for tumor size) of these two groups were comparable.The mean intranperative blood loss,the number of patients with massive hemorrhage(＞3000ml)and the volume of blood transfusion of the anterior group were markedly less than those of conventional group.The 1-,3-year disease-free survival rates of the anterior group were significantly better than those of the conventional group anterior group were also markedly higher than those of conventional group.The Cox regression model indicated that tumor size[P=0.014,odd ratio(OD):1.074] and surgical procedure(P:0.009,OD=0.468) were independent risk factors correlated with disease-free survival.And the surgical procedure(P=0.003,OD=0.369) was the only independent risk factor for postoperative cumulative survival.Conclusion Anterior approach right hepatectomy can significantly decrease intraoperative blood loss.The postoperative survivals of large HCC patients are significantly improved by anterior approach right hepatectomy.     

依赖天冬氨酸特异性半胱氨酸蛋白酶-3的肝细胞凋亡在肝硬化大鼠肝缺血再灌注损伤中的作用

目的:探讨肝硬化大鼠肝缺血/再灌注(I/R)损伤是否与肝细胞凋亡相关及天冬氨酸特异性半胱氨酸蛋白酶-3(caspase-3)活性变化与肝细胞凋亡的关系。方法:Pringle法复制肝I/R模型,将肝硬化大鼠随机分为2组:A组:单纯肝门阻断;B组:血流阻断+抑制剂:N-苯甲基氧化碳酰-缬氨酸-丙氨酸-天冬氨酸-氟化丙酮(ZVAD-fmk)15mg/kg;取无肝硬化大鼠,作单纯肝门阻断为C组。各组肝门阻断时间均为30min,再灌注72h。比较3组的血清天冬氨酸转氨酶(AST)、肝组织的caspase-3活性和肝细胞凋亡数。结果:A组大鼠肝组织caspase-3活性、肝细胞凋亡数在再灌注后6h达高峰,分别为(18.1±1.8)μmolAMC·h^-1·g^-1(tissue)和20.9%±4.9%,与I/R前的(6.6±2.0)μmolAMC·h^-1·g^-1(tissue)和0.5%±0.3%相比,P＜0.01。肝细胞凋亡数、caspase-3的活性随灌注时间的延长而减低,两者随时间的变化一致。3组中A组肝损伤最严重,表现为再灌注后6h血清AST最高,与B、C组比较有显著差异,大鼠7d生存率只为62.5%。进一步研究表明,再灌注后6h,A组的肝组织caspase-3活性、肝细胞凋亡数亦明显比B、C组高。结论:肝细胞凋亡是肝硬化大鼠肝I/R损伤的主要病理改变。肝细胞凋亡的发生可能主要依赖于肝组织caspase-3活性的改变,抑制caspase-3能明显减轻肝I/R损伤。肝硬化肝脏比无硬化肝脏对缺血损伤敏感性高的病理机制与依赖caspase-3的肝细胞凋亡密切相关。     

肝切除术治疗肝内胆管结石术后发生并发症的危险因素分析

目的 探讨肝切除治疗肝内胆管结石术后并发症的危险因素.方法 对中山大学附属第一医院近4年来择期行肝切除术的肝内胆管结石363例病人的临床资料进行回顾性分析.根据术后是否发生并发症分成两组,A组为并发症组(n=110);B组为无并发症组(n=253).对可能引起并发症的因素进行单因素和多因素统计分析.结果 本组因并发症病死2例,手术病死率为0.6%.110例病人术后出现并发症,发生率为30.3%.术后并发症包括:伤口感染/液化42例(11.6%)、胸腔积液41例(11.3%)、膈下积液36例(9.9%)、胆漏21例(5.8%)、腹腔积液/感染13例(3.6%)、消化道出血3例(0.8%)、胆道出血2例(0.6%)、肝功能衰竭1例(0.3%).多因素分析结果 显示,既往胆道手术史(P=0.042,OR=0.617,95%CI:0.388～0.982)和手术时间(P=0.0001,OR=0.994,95%CI:0.991～0.997)是术后发生并发症的独立危险因素.结论 既往胆道手术史与手术时间的长短是影响肝内胆管结石肝切除术后并发症发生的独立危险因素.对既往有胆道手术史的病人充分的术前准备,提高手术技巧,仔细分离,尽量缩短手术时间是防止肝切除术后出现并发症的关键因素.     

改良胆肠袢式吻合术的疗效分析

Objective To evaluate the long-term efficacy of modified loop choledochojejunostomy (MLC). Methods The clinical data of 259 patients who had underwent choledochojejunostomy in First Affiliated Hospital of Sun Yat-Sen University from January 2000 to December 2006 were retrospectively analyzed. Of all the patients, 130 underwent MLC (MLC group) and 129 underwent Roux-en-Y choledochojejunostemy (RYC, RYC group). The changes in incidence of cholangitis and liver function between the 2 groups were compared. All the data were analyzed by t test, chi-square test or Fisher exact probability. Results The levels of alaninetransa-minase and alkaline phosphomonoesterase were (63±42) U/L and (147±147) U/L in MLC group, and (84±52)U/L and (256±201)U/L in RYC group, with statistical difference between the 2 groups (t=1.634, 1.655, P>0.05). The level of gamma-glutamyl transferase in MLC group was (116±91)U/L, which was signifieandy lower than (169±96)U/L in RYC group (t=2.461, P<0.05). Three patients (2.3%) in MLC group and 9 (7.0%) in RYC group suffered from acute cholangitis after operation, with no statistical difference in the incidence between the 2 groups (P>0.05). Of the 12 patients with acute cholangids, 1 in MLC group and 7 in RYC group were hospitalized, with statistical difference between the 2 groups (P<0.05). Conclusions The incidence of acute cholangitis in patients who underwent MLC is comparable to that of RYC. However, the procedure of MLC is simpler than RYC, and patients have milder symptom and lesser frequency of reflux cholangitis onset after MLC.     

美罗培南在家兔胆汁中的药物浓度-时间分布的实验研究

目的研究美罗培南在家兔胆汁中的浓度及其分布规律,为预防和治疗胆道感染用药提供参考和依据。方法家兔行胆总管造瘘术,先留取空白胆汁,静脉注射美罗培南后分别于不同时间点采集胆汁标本。行专属性试验后,取空白胆汁加美罗培南对照品和流动相,配成0.5~500μg/ml不同浓度的系列胆汁样品,经高效液相色谱仪分析,采用外标法行药物色谱峰面积定量,以胆汁样品药物浓度对色谱峰面积进行线性回归,得回归方程。注射美罗培南后的家兔胆汁样品经预处理后用高效液相色谱仪测定峰面积,按标准曲线回归方程计算得出胆汁药物浓度,从而了解美罗培南的胆汁药物浓度-时间分布情况。结果专属性试验显示,在本研究的流动相色谱条件下测定药物,胆汁杂质峰、美罗培南药物色谱峰分离效果良好。标准曲线回归方程为S=2209.10C-1251.34,r=0.9999,美罗培南的最低定量限为0.5μg/ml。家兔静脉注射美罗培南(75mg/kg)后即时在胆汁中达(38.36±14.17)μg/ml,远远超过其对革兰阴性杆菌的最小抑菌浓度(MIC90)0.031~2μg/ml,之后美罗培南的胆汁药物浓度随时间而迅速降低。用药后180min,胆汁中的药物均被完全消除。结论美罗培南在胆汁中能达到较高的有效杀菌浓度,可作为预防和治疗胆道感染的较佳的药物。由于消除速度较快,临床用药应缩短间隔时间。