胰管狭窄的内镜下支架置入术发展历史及临床进展

胰管狭窄是胰腺疾病常见的病理生理改变，可导致胰液流出受阻、胰腺实质高压和局部缺血，诱发腹痛和加速胰腺内外分泌功能减退。扩张胰管、通畅引流为胰管狭窄的治疗核心。随着经内镜下逆行胰胆管造影术的不断完善，内镜治疗逐渐成为胰管狭窄的一线治疗方法，常用手段有括约肌切开术、狭窄扩张术和支架置入术。其中，括约肌切开术和狭窄扩张术效果不持久，常作为支架置入术的先导步骤。本文就胰管狭窄的内镜下支架置入术发展历史及临床进展进行了综述。     

内镜治疗慢性胰腺炎的探讨

目的 探讨内镜治疗慢性阻塞性胰腺炎疗效及并发症。方法 经内镜治疗２９例慢性胰腺炎中胰管括约肌切开术２７例（１９例为７内镜治疗前处置）,副乳头切开８例,乳头括约肌切开术５例,网篮邓胰石９例,胰管内引流７例,鼻胰管引流３例,辅助探条或球囊扩张共１４例。１３例治疗前、后检测胰腺内分泌功能。结果 ２９例中２６例（８９．７％）治疗后腹痛消失或明显减轻,９例胰腺结石患者中６例取出胰石;７例胰管内引流管未阻塞。     

十二指肠乳头括约肌小切开联合气囊扩张术治疗胆总管结石

经内镜乳头括约肌切开术（EST）取石用于治疗胆总管结石已得到广泛认可,但并发症发生率仍较高,经内镜乳头气囊扩张术（EPBD）取石具有与EST取石相近的成功率,出血、穿孔并发症相对较少,且保护了十二指肠乳头括约肌功能,但因球囊压迫胰管开口,术后胰腺炎的发生率相对较高。我们采用内镜下乳头括约肌小切开联合EPBD治疗了38例胆总管结石,现总结资料,探讨其有效性、安全性和在减少近期、远期并发症方面的作用。     

内镜逆行胰胆管造影在胰管结石诊治中的临床价值

目的：探讨内镜逆行胰胆管造影（ERCP）在胰管结石（PDS）诊断与治疗中的价值。方法：回顾分析1998年1月－2000年12月本院经ERCP诊治的18例PDS患者的治疗方式和结果。结果：18例PDS患者临床上均以上腹痛为主要首发症状且合并慢性胰腺炎,其中1例合并胰腺癌。经B超检查,10例患者检出有PDS或胰管扩张;全部病例经ERCP检查后均明确显著有PDS和胰管扩张。经ERCP＋乳头括约肌切开术（EST）／胰管括约肌切开术（EPST）成功取石4例;行EPST＋体外震波碎石（ESWL）及ESWL＋胰管内支架引流（ERPD）者各1例,半年后复查时胰石消失：行ERPD者12例。3例患者置管后3个月内因伴主胰管多发、巨大结石和胰腺癌而接受手术治疗。18例患者经1－11个月的随访,腹痛近期（＜3个月）缓解率为88．9％,远期（＞3个月）缓解率为75．0％,体重、脂肪泻、胰腺内、外分泌功能不足表现有不同程度的改善。ERCP术后早期并发症主要为一过性高淀粉酶血症,支架阻塞是其晚期并发症。结论：ERCP能清晰显示结石的位置、大小、形态及数量,是诊断PDS的主要手段。经ERCP取石具有安全可靠、创伤小、疗效满意及患者易于接受等优点,在PDS的治疗中亦具有较大临床应用价值。     

经乳头内镜胰腺假性囊肿引流术

文章报告了３０例接受经乳头内镜胰腺假性囊肿引流术（ｅｎｄｕｓｃｏｐｉｃｔｒａｎｓｐａｐｉｌｌａｒｙｃｙｓｔｄｒａｉｎａｇｅ，ＥＴＣＤ）治疗的胰腺假性囊肿病人。２例病因为胆源性急性胰腺炎，２８例为慢性胰腺炎引起，平均主胰管最大直径４．２ｍｍ（３～１２ｍｍ），１１例存在胰管狭窄。本方法为通过主或副乳头置入假体管以引流与胰管系统相通的胰腺假性囊肿。施行诊断性ＥＲＣＰ后，进行短距（５ｍｍ）胰管括约肌切开术，可能的话事先行胆管括约肌切开术，扩张胰管狭窄后，置入胰管支架管，将导丝插入胰管并尽可能接近胰腺假性…     

内镜下乳头气囊扩张对胆总管结石的治疗价值

经内镜乳头括约肌切开术（EST）是治疗性经内镜逆行胰胆管造影术（ERCP）的基础,尤其在胆总管结石的治疗中EST是运用最广泛最成功的内镜下技术.尽管如此,EST仍然有不少短期、长期并发症,如出血、穿孔、胰腺炎及乳头狭窄、胆管炎等[1].1983年,Staritz等[2]介绍了一项可以替代EST的新技术--内镜下乳头气囊扩张术（EPBD）,与EST相比,EPBD的并发症如出血、穿孔发生率明显降低.     

内镜超声引导下胰管引流

通常,胰管高压的患者以腹痛为主要症状,常见于慢性胰腺炎、胰管结石、胰空肠吻合口狭窄及胰腺导管内乳头状黏液性肿瘤（IPMN）的患者,主要解决方式为外科手术或内镜下减压,如括约肌切开术、逆行胰管支架置入术、胰管狭窄扩张术等。一项随机试验显示,慢性胰腺炎导致胰管阻塞的治疗中外科介入的有效性优于内镜介入,然而并未考虑患者主观接受程度与创伤大小。一些由于一般条件不允许行外科手术或拒绝行手术治疗的患者会选择内镜介入治疗,但对于有解剖结构改变者,如Whipple术后患者,经典的ERCP术往往不能成功。     

慢性胰腺炎内镜治疗的临床研究

目的探讨内镜治疗慢性胰腺炎（CP）的治疗效果。方法研究自1997年1月至2004年12月期间在上海长海医院确诊为CP，并住院行内镜治疗的患者，随访观察其临床疗效。结果符合CP诊断标准并进行内镜下治疗的患者共296例。其中胰管括约肌单纯切开23例，胰头部胰管气囊扩张11例，胰管取石86例。138例放置主胰管支架，26例放置副胰管支架。EUS下经胃壁假性囊肿引流12例，EUS下腹腔神经节阻滞30例。224例患者腹痛症状均有不同程度缓解（P〈0．05），1周后148例患者腹痛症状缓解，其中34例（15．2％）腹痛缓解持续时间达7年。患者内镜治疗成功率100％，无严重并发症发生，体质量均有一定程度增加（P〈0．05）结论内镜治疗能有效缓解CP患者的腹痛症状，增加患者的体质量，是治疗CP的一种安全有效的手段。     

儿童慢性胰腺炎内镜治疗的研究进展

儿童慢性胰腺炎是一种慢性、不可逆性炎症性疾病,可出现顽固性腹痛和胰腺内外分泌功能异常,严重影响儿童生长发育和生活质量。经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography, ERCP）于20世纪70年代末开始用于儿童患者,主要用于治疗胰管结石、胰管狭窄、胰腺假性囊肿等,常见方法有胰管括约肌切开术、结石取出术、胰管支架置入术。ERCP治疗慢性胰腺炎因疗效好、创伤小等优点已逐渐替代传统外科手术,成为首选治疗方案。     

猪作为胰胆管造影操作模型的实验研究

内镜下逆行性胰胆管造影（endoscopic retrograde cholangiopancreotography．ERCP）是在十二指肠镜直视下经十二指肠乳头注入造影剂作X线胰胆管造影检查，是胰腺、胆道等疾病的重要诊治手段之一。通过ERCP．可以进行乳头括约肌切开术、胆胰管取石、支架植入和狭窄扩张。此项微创技术需要经验丰富的内镜医师操作，初学者操作有一定风险.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.