良性胆管狭窄病变组织中的成纤维细胞活性

目的：观察胆管良性狭窄组织中的成纤维细胞活性。方法：收取良性胆管狭窄病理组织标本8例，常规病理切片染色观察局部病理变化，用免疫组化方法测定标本的组织内增殖细胞核抗原（PCNA）。结果：良性胆管狭窄标本中，胆管固有膜及瘢痕组织内均有较多的成纤维细胞并伴有炎细胞浸润，所有标本均显示了较强的PCNA阳性细胞表达。结论：成纤维细胞的持续增殖，是良性胆管狭窄的主要原因。     

肝内胆管结石并胆管狭窄的治疗

为探讨肝内胆管结石并胆管狭窄的外科治疗，对１０年来收治的１６８例肝内胆管结石并胆管狭窄的术前检查、结石及狭窄的部位和分布情况、手术方式、手术后并发症及残余结石的处理进行了分析。结果显示：１６８例中，左肝内胆管结石、全肝结石和右肝内胆管结石分别是８３，５９和２６例；左外叶及左半肝切除１１６例；右肝段切除２２例；高位胆管切开整形胆肠大口吻合９６例；残石率３％；１３例出现手术后并发症；随访１４２例，优良效果９６．５％。结果提示肝叶、肝段切除联合肝胆管空肠大口吻合是肝内胆管结石并胆管狭窄的最佳治疗选择。     

Unusual Segmental Stricture of the Lower Common Bile Duct Mimicking Bile Duct Cancer

In some cases of bile duct stricture, malignancy cannot be diagnosed preoperatively even with the use of various diagnostic imaging modalities and histologic examination. As long as malignancy cannot be ruled out completely, surgery can be undertaken for the purposes of diagnosis and treatment. We report a case of unusual segmental stricture of the lower common bile duct mimicking bile duct cancer and discuss the differential diagnosis.     

胆管损伤后良性狭窄形成过程中c-FLIP的表达及意义

目的观察凋亡抑制因子人类细胞同源FLICE样抑制蛋白(cellular homolog FLICE-like inhibitoryprotein,c-FLIP)在胆管良性狭窄形成过程中的表达和定位情况,并探讨其意义。方法利用原位杂交法分别对15只犬(实验组)胆管损伤后2、3、4、5、6个月及其配对的15只假手术组犬的吻合口组织中c-FLIP表达和定位情况进行分析,计算每张切片的平均积分光密度值,分别比较c-FLIP在实验组及其配对的假手术组的胆道吻合口间质组织与腺体组织中表达的差异。结果实验组各时相的间质组织中c-FLIP均呈强阳性表达,以纤维细胞胞浆表达为主,而腺体组织很少表达或几乎无表达;在相应时相的间质组织中的表达明显强于在腺体组织中的表达(P0.05);间质组织或腺体组织中c-FLIP表达在不同时相之间差异均无统计学意义(P0.05)。假手术组各时相的间质组织和腺体组织中c-FLIP均呈弱阳性表达;在相应时相的间质组织和腺体组织中c-FLIP表达差异无统计学意义(P0.05);间质组织或腺体组织中c-FLIP表达在不同时相之间差异均无统计学意义(P0.05)。c-FLIP在实验组间质组织中的表达明显强于相应时相的假手术组(P0.05);而c-FLIP在腺体组织中的表达2组间差异无统计学意义(P0.05)。结论胆管损伤后,吻合口间质组织内的c-FLIP呈持续表达状态,由此所造成的细胞凋亡持续受阻效应可能与胆管良性狭窄的形成关系密切。     

损伤性胆管狭窄外科治疗所存在的问题

胆道外科手术治疗失误造成的损害及其预后有时难以估测，即便是有着较丰富腹部外科经验的医师，在亲自遇见高位或肝门部胆管损伤时，也会不知何故而为，更不知如何处理为好。我们从外科事业的发展中也不难看出胆道并发症始终是腹部外科的一大难题，如肝移植术后的胆道并发症，尤其是活体肝移植术（包含供体与受体），胆道并发症是最为常见和很难处理的手术并发症。目前的胆道外科发展趋势，越来越不主张行开腹的胆总管探查术。对继发性肝外胆管结石主张行腹腔镜胆囊切除的同时，在腔镜下行胆总管探查取石（经胆道镜）；也有人主张在术前或术…     

Surgical Management of Bile Duct Stricture Following Laparoscopic Cholecystectomy

The reported incidence of amputation varies enormously between countries, races and communities, but gives an indication of the suffering and costs caused by disease of the foot in diabetes. However, the field is highly complex and interpretation of available data requires great care; many factors underlie the differences which have been reported. Community-wide information is not widely available, and most published work derives from selected populations. Published work is also characterised by lack of consensus in the use of terms such as “lower extremity amputation”, “major” and “minor” amputation, as well as by the use of inconsistent criteria for the selection of operations for study. Some publications refer to all operations performed, while others refer to the latest undertaken on any one limb or in any one patient. Incidence may be expressed in terms of either the total (diabetic and non-diabetic), or the “at risk” (diabetic) populations. The former may be useful as a (partial) measure of disease burden in a community, while the latter can be used as an indirect measure of the quality of overall management of diabetes in a population. However, the extent to which either can be used as a measure of the quality of specialist care of an individual presenting with limb-threatening disease is uncertain. Ultimately, an amputation is only a treatment, and in no other medical condition is the number of operations, or other treatments, used as an indication of either disease burden or the quality of care. Quality of care of foot disease in diabetes can, and should, be best assessed in terms of survival, function/incapacity and well-being.     

Management of Post-Cholecystectomy Benign Bile Duct Strictures: Review

Cholecystectomy is one of the common surgical procedure performed across the world and bile duct injury is a dreaded complication. The present review addresses the classification of injuries, preoperative preparation and evaluation of these patients and appropriate timing of surgery. A detailed preoperative evaluation combined with a meticulous wide anastomosis by experienced surgeons is the key in achieving long term success. Vascular injuries and its consequences on repair and outcome is also reviewed. Long term results of surgical repair and quality of life in these patients are excellent     

以肝段切除为主的联合手术治疗肝胆管结石并狭窄

目的探讨以肝段切除为主的联合手术治疗肝胆管结石并狭窄的临床疗效。方法肝胆管结石并狭窄患者66例,均行肝段切除加胆总管探查、T管引流术,行Roux-en-Y胆肠吻合术17例,肝门部胆管、肝断面胆管-空肠双吻合术9例,肝门部胆管扩张成形术4例。结果手术均获得成功,术后发生胆管残石5例(7.6%),切口感染3例(4.5%),胆漏2例(3.0%)。41例(62.1%)获随访,2例肝内胆管结石复发,1例仍有右上腹隐痛,其余随访结果优良。结论根据患者结石及狭窄的具体情况采用以肝段切除为主的联合手术是治疗肝胆管结石并狭窄的有效手段。     

规则性肝段(叶)切除治疗肝内胆管结石并狭窄

目的探讨规则性肝段(叶)切除治疗肝内胆管结石并狭窄的临床疗效。方法48例肝胆管结石并狭窄患者,行左外叶切除19例,左半肝切除2例,左外叶+右后叶(或单纯Ⅵ、Ⅶ段)切除7例,右半肝(或单纯Ⅵ、Ⅶ段)切除20例;均行胆总管探查、T管引流术;行胆管空肠Roux-en-Y吻合术13例。结果术后胆管残石5例(10.4%),切口感染3例(6.2%),胆漏2例(4.2%)。随访41例(85.4%),2例肝内胆管结石复发,1例右上腹隐痛,其余随访结果优良。结论根据患者结石及狭窄的具体情况采用以肝段切除为主的手术方式是治疗肝内胆管结石并狭窄的有效手段。     

Fibroinflammatory Biliary Stricture: A Rare Bile Duct Lesion Masquerading as Cholangiocarcinoma

Introduction  Fibroinflammatory biliary stricture (FIBS) is a rare benign tumor-like process of the extrahepatic bile duct that masquerades as cholangiocarcinoma. Methods  In order to distinguish this unusual entity from cancer, we performed a systematic analysis of 11 patients with FIBS. All patients presented with jaundice; six patients had coexisting autoimmune disease. Preoperative evaluation included computed tomography scan and endoscopic retrograde cholangiopancreatography with benign brush cytology. Surgical treatment included nine bile duct resections with five concurrent liver resections and two incisional biopsies. Light microscopy demonstrated fibrous lesions admixed with chronic inflammation. Results and discussion  Immunohistochemistry demonstrated smooth muscle actin expression in all lesions except one; five tumors exhibited IgG4 positive plasma cells. The lesions were negative for cytokeratin, ALK1, CD21, S100, Ki67, and p53. Six patients received postoperative immunosuppression. At 41 month median follow-up (range 15–58 months), there was no evidence of recurrent FIBS in ten patients, while one was lost to follow-up. Conclusion  FIBS is a rare myofibroblastic lesion with an immunohistochemical profile distinct from other epithelial and stromal neoplasms of the extrahepatic bile duct. A subset of these cases appear to represent IgG4-related sclerosing cholangitis. Because preoperative cytology is not diagnostic of FIBS, surgical resection remains the mainstay of diagnosis and treatment, while immunosuppression may reduce the risk of recurrence. Poster Presentation at Digestive Disease Week, May 2006, Los Angeles CA, USA.     

胆道镜下气囊扩张治疗胆道术后肝内外胆管狭窄

目的探讨胆道术后肝内、外胆管狭窄的治疗方法。方法回顾性分析吉林大学第一医院自2003年1月至2007年12月期间应用胆道镜对37例胆道术后肝内、外胆管狭窄患者行气囊扩张治疗的结果。结果本组37例患者42处肝内、外胆管狭窄均行胆道镜下气囊导管扩张,29例（78.4%）系胆管狭窄伴肝内胆管结石,经气囊扩张后,胆道镜通过狭窄部位,取净远端胆管结石;另8例（21.6%）系单纯胆管狭窄无结石,仅行导管扩张。本组成功率达97.3%（36/37）;1例因胆汁性肝硬变伴弥漫性胆管狭窄扩张失败后行肝叶切除手术。27例狭窄仅需一次性扩张,9例因胆管多处严重狭窄而行多次扩张。全部患者均获随访,随访时间6～24个月,平均12个月,未见结石复发。结论胆道镜下气囊导管扩张治疗胆管狭窄微创、直观、安全、简便易行且疗效可靠,是治疗胆管狭窄并取净结石的理想方法。但需注意操作方法及技巧,防止并发症的发生。     

Benign Oesophageal Stricture

During a ten-year period, 25 patients were treated for benign oesophageal strictures of varying aetiology. Thirteen were treated successfully with dilatation alone. Ten patients with low strictures, of which eight were due to peptic oesophagitis, underwent oesophageo-plasty, which cannot be recommended, while two had colon transposition because of extensive corrosion due to lye or acid.     

胆总管下段良性肿瘤的诊断和治疗

肝外胆管良性肿瘤极少见，文献上仅见个例报道。至1994年为止，收集到的全世界有关肝外良性肿瘤的报告不超过150例[1]。肝外良性肿瘤多位于胆总管和壶腹部。胆总管下段良性肿瘤分类胆总管下段良性肿瘤可起源于胆管黏膜上皮细胞、神经内分泌细胞、间质和异位组织。发生于胆管黏膜上皮细胞的良性肿瘤有乳头状瘤、腺瘤和囊腺瘤。发源于胆管间叶组织的良性肿瘤有脂肪瘤、黏液纤维瘤、神经纤维瘤、神经鞘瘤和平滑肌瘤等。胆总管下段良性肿瘤可分为真性良性肿瘤和假性良性肿瘤两大类。真性良性肿瘤包括乳头状瘤、腺瘤、多发性胆道乳头状瘤病、颗粒…     

胆管良性疾病再手术原因与诊治分析(附91例报告)

目的探讨胆管良性疾病再次手术的原因及其诊断与治疗。方法回顾性分析1991年1月至2005年12月期间我院收治的胆管良性疾病再次手术91例患者的临床资料。结果91例中接受2次手术者87例（95．60％），3次手术者4例（4．40％），无手术死亡。再次手术原因：结石残留或复发42例（46．15％），胆管损伤36例（39．56％），残留胆囊5例（5．49％），胆肠吻合口狭窄2例（2．20％），返流性胆管炎2例（2．20％），胆总管下端炎性狭窄2例（2．20％），肠瘘2例（2．20％）；再次手术方式：胆肠Roux-en-Y吻合、T管支撑56例（61．54％），肝叶切除13例（14．29％），肝门整形、肝管空肠Roux-en-Y吻合10例（10．99％），残余胆囊切除5例（5．49％），胆总管切开取石、T管引流3例（3．29％），胆管修复、T管支撑2例（2．20％），胆管对端吻合、T管支撑2例（2．20％）。结论降低结石残留以及预防胆管损伤是防止再次胆道手术的关键。进行胆道再次手术时应积极术前准备，制定合理治疗方案，以避免多次手术。     

A Gallbladder Conduit for Bile Duct Reconstruction to Treat Benign Biliary Stenosis

A benign extrahepatic biliary stricture is life-threatening and usually requires open repair, although it can sometimes be treated percutaneously or endoscopically with balloon dilatation and long-term stenting. I describe an alternative method of managing a benign extrahepatic biliary stricture, using a gallbladder conduit.     

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。     

胆管良性狭窄的治疗

胆管良性狭窄的治疗 ,是目前胆道外科存在较多的问题之一 ,因为手术的成功与患者本身情况、个体差异、手术次数等多种因素的影响有关。根据不同情况及具体的病理改变 ,把握治疗原则及手术时机 ,选择不同的治疗方式 ,至关重要。1　良性狭窄的治疗原则手术主要是切除狭窄段的瘢痕 ,修复和重建胆道 ,建立通畅的胆流。不论采用何种术式 ,成功的修复必需具备以下基本原则[1]:①胆管与胆管或胆管与肠管的吻合应做到粘膜对粘膜 ;②吻合口足够大且无张力 ;③吻合的组织血供良好 ;④应用好的可吸收缝合材料减少异物反应 ,吻合口间断一层缝合 ;⑤有足…