胆结石患者腹腔镜胆囊切除术治疗的有效性及对患者并发症发生的影响

目的探讨胆结石患者腹腔镜胆囊切除术治疗的有效性及对患者并发症发生的影响。方法选取2019年3月至2020年3月行手术治疗的胆结石患者114例,随机分为两组,每组各57例,对照组行传统开腹手术治疗,研究组行腹腔镜胆囊切除术治疗。比较两组的治疗总有效率、疼痛评分、住院时间、排气时间、术中出血量、手术时间、并发症总发生率。结果研究组治疗总有效率为94.7%,高于对照组的73.7%,两组比较,差异有统计学意义(P0.05);研究组疼痛评分为(2.0±0.3)分,低于对照组的(5.7±1.1)分,两组比较,差异有统计学意义(P0.05);研究组住院时间为(6.9±1.0)d、排气时间为(23.0±2.1)h,均短于对照组的(14.0±2.4)d、(37.5±2.6)h,两组比较,差异有统计学意义(P0.05);研究组术中出血量为(27.4±2.5)mL、手术时间为(53.1±1.1)min,均少于对照组的(60.3±1.9)m L、(77.3±2.0)min,两组比较,差异有统计学意义(P0.05);研究组并发症总发生率为17.5%,低于对照组的38.6%,两组比较,差异有统计学意义(P0.05)。结论胆结石患者采用腹腔镜胆囊切除术治疗,患者术后恢复快、并发症总发生率低,与传统开腹手术相比,患者疼痛更轻、术中出血量更少、手术时间更短、安全性更高,且操作简单、创伤性小,值得临床推广应用。     

Spilled gallstones during laparoscopic cholecystectomy

Introduction

Incidental gallbladder cancer is found in 0.6–2.1% of patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. Patients with Tis or T1a tumours generally undergo no further intervention. However, spilled stones during surgery may have catastrophic consequences. We present a case and suggest aggressive management in patients with incidental gallbladder cancer who had spilled gallstones at surgery.

Case History

A 37-year-old woman underwent a laparoscopic cholecystectomy for symptomatic gallstones, during which some stones were spilled into the peritoneal cavity. Subsequent histological examination confirmed incidental pT1a gallbladder cancer. Hepatopancreatobiliary multidisciplinary team discussion agreed on regular six-monthly follow-up. The patient developed recurrent pain two years after surgery. Computed tomography revealed a lesion in segment 6 of the liver. At laparotomy, multiple tumour embedded gallstones were found on the diaphragm. Histological examination showed features (akin to the original pathology) consistent with a metastatic gallbladder tumour.

Conclusions

This case highlights the potential for recurrence of early stage disease resulting from implantation of dysplastic or malignant cells carried through spilled gallstones. It is therefore important to know if stones were spilled during original surgery in patients with incidental gallbladder cancer following a laparoscopic cholecystectomy. Aggressive and early surgical management should be considered for these patients.     

Cholecystosonography in children with sickle cell disease: technical approach and clinical results

Forty-five children with sickle cell anemia were studied with meticulous cholecystosonograms using a 5-MHz thyroid transducer. Good-quality images were obtained. The most informative and useful view was the left-side-down decubitus study with the ultrasound gantry angled 45% to the anteroposterior axis. Rotating the patient rapidly through 360 degrees did not increase the information content of the examination. We found that one third of a random group fo children with sickle cell anemia will have gallstones and one fifth will have"sludge". A kinked deformity of the gallbladder may simulate a gallstone. Neither age, sex, weight, physical findings (except for hepatomegaly), nor a variety of biochemical measurements of the blood will be of much value in predicting gallbladder disease in any given patient.     

红外光谱分析技术评价MRI对胆囊结石成分预判的研究

利用傅里叶变换红外光谱(FT-IR)检测胆囊结石成分,评价MRI对胆囊结石成分预判的准确性。方法 选取2020 年12月～2021年8月我院100例预行胆囊切除的胆石病患者,另取同期50例无结石患者的MRI做阴性对照。术前行MRI检查,术后取胆囊结石进行FT-IR分析,分析FT-IR图及与MRI的相关性。配对样本计数资料组间比较使用McNemar检验,使用Kappa检验、ROC曲线下面积AUC、灵敏度、特异度和准确度等指标对MRI预判结石成分的准确性进行评估。结果 MRI各序列信号表现与FT-IR对比：McNemar=4.00、P=0.135,Kappa=0.962、P.＜0.05,AUC (95% CI)为0.980(0.943～0.996),准确度为97.33%,灵敏度为96.00%,特异度为100.00%,约登指数为0.96;MRI各序列信号值与FT-IR对比：McNemar=0.20,P=0.655,Kappa=0.953、P＜0.05,AUC (95% CI)为0.975(0.935～0.994),准确度为96.67%,灵敏度为95.00%,特异度为100.00%,约登指数为0.95。结论 MRI可以较准确地预判胆囊结石成分,可为临床诊疗胆石病提供新思路,为胆石病的预防及流行病学研究提供理论基础。     

胆道结石并发肝内胆管癌风险的Meta分析

目的 明确肝外胆管结石及胆囊结石并发肝内胆管癌(Intrahepatic cholangiocarcinoma,ICC)风险,为胆道结石的临床治疗提供参考.方法 计算机检索PubMed、EmBase以及CBM等数据库,查找胆道结石以及胆囊结石并发ICC风险的队列研究或者病例对照研究.应用STATA软件对所获得研究数据行Meta分析,根据研究间异质性选择固定效应模型或者随机效应模型.采用Egger检验评估发表偏倚.结果 共有6篇病例对照研究纳入分析,包括123 713例患者,其中ICC 4 753例,无瘤对照118 960例.Meta分析结果显示,胆管结石为ICC发病的高危因素(OR:17.64,95％ CI:11.14 ～27.95),除外肝内胆管结石,肝外胆管结石导致的ICC发病风险仍较高(OR:11.79,95％ CI:4.17～ 33.35).此外,胆囊结石也是ICC发病危险因素(OR:2.07,95％ CI:1.17 ～3.67).结论 肝外胆管结石与胆囊结石均为ICC发病的重要危险因素.     

Implementation of a novel emergency surgical unit significantly improves the management of gallstone pancreatitis

Introduction

Emergency surgery is changing rapidly with a greater workload, early subspecialisation and centralisation of emergency care. We describe the impact of a novel emergency surgical unit (ESU) on the definitive management of patients with gallstone pancreatitis (GSP).

Methods

A comparative audit was undertaken for all admissions with GSP before and after the introduction of the ESU over a six-month period. The impact on compliance with British Society of Gastroenterology (BSG) guidelines was assessed.

Results

Thirty-five patients were treated for GSP between December 2013 and May 2014, after the introduction of the ESU. This was twice the nationally reported average for a UK trust over a six-month period. All patients received definitive management for their GSP and 100% of all suitable patients received treatment during the index admission or within two weeks of discharge. This was a significantly greater proportion than that prior to the introduction of the ESU (57%, p=0.0001) as well as the recently reported national average (34%). The mean length of total inpatient stay was reduced significantly after the ESU was introduced from 13.7 ± 4.7 days to 7.8 ± 2.1 days (p=0.03). The mean length of postoperative stay also fell significantly from 6.7 ± 2.6 days to 1.8 ± 0.8 days (p=0.001).

Conclusions

A dedicated ESU following national recommendations for emergency surgery care by way of using dedicated emergency surgeons and a streamlined protocol for common presentations has been shown by audit of current practice to significantly improve the management of patients presenting to a busy district general hospital with GSP.     

The impact of ursodeoxycholic acid on gallstone disease after bariatric surgery: a meta-analysis of randomized control trials

BackgroundUrsodeoxycholic acid (UDCA) is a bile acid that has been shown to reduce the formation of gallstones after significant weight loss.ObjectiveThis study aimed to evaluate the impact of UDCA on the incidence of gallstones after bariatric surgery.SettingsAn electronic search of PubMed (Medline), Cochrane Central Register of Controlled Studies (CENTRAL), Scopus (Elsevier) databases, EMBASE, CINAHL, Clinicaltrials.gov, and Web of Science.MethodsA meta-analysis of randomized control trials was performed. The primary outcome was the incidence of gallstones after bariatric surgery. Secondary outcomes included type of operation and time interval to and characteristics associated with gallstone formation.ResultsTen randomized control trials including 2583 patients were included, 1772 patients (68.6%) receiving UDCA and 811 (31.4%) receiving placebo. There was a significant reduction in gallstone formation in patients who received UDCA postoperatively (risk ratio [RR] .36, 95% confidence interval [CI] .22–.41, P < .00001). The overall prevalence of gallstone formation was 24.7% in the control group compared to 7.3% in the UDCA group. A dose of ≤600 mg/day had a significantly reduced risk of gallstone formation compared to the placebo group (risk ratio .35; 95% CI .24–.53; P < .001). The risk reduction was not significant for the higher dose (>600 mg/day) group (risk ratio .30; 95% CI, .09–1.01, P = .05).ConclusionsUDCA significantly reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. A dose of 600 mg/day is associated with improved compliance and better outcomes regardless of type of surgery. UDCA should be considered part of a standard postoperative care bundle after bariatric surgery.     

胆色素结石患者胆道系统幽门螺杆菌研究

目的探讨幽门螺杆菌（Hp）感染与胆色素结石形成的关系。方法取35例胆色素性结石患者（实验组）及10例对照组患者胆汁进行需氧菌、厌氧菌及Hp培养，采用PCR方法检测胆囊管黏膜、胆管黏膜、胆汁和胆石核心中的Hp-DNA；所有黏膜用Warthin-Starry银染色法染色，Western印迹法检测胆汁中Hp感染相关蛋白。结果所有胆汁培养均未发现Hp生长。实验组胆石核心、胆汁和黏膜的Hp-DNA扩增阳性率分别为14．29％、31．43％和56．67％。Hp-DNA阳性胆汁中，检出细胞毒素相关抗原（Cag A）7例，细胞空泡毒素（Vac A）6例，同时检出Hp Vac A相关亚单位（相对分子质量37000）、糖蛋白（相对分子质量35000）、尿素酶B和尿素酶A。实验组30例胆管黏膜经Warthin-Starry染色后有7例（23．33％）镜下观察到类似Hp的菌体。对照组胆汁和黏膜Hp-DNA阴性，胆汁中未检出Hp感染相关蛋白，黏膜Warthin-Starry染色后，镜下未观察到类似Hp的菌体。结论胆色素结石患者胆道系统中存在Hp感染依据，并存在多种Hp感染相关蛋白，Hp感染可能参与胆色素性结石的形成。