胆石症对心血管疾病发病的影响

目的 探讨胆石症对心血管疾病（cardiovascular disease,CVD）发病的影响。方法 采用前瞻性队列研究方法分析2006、2008年度首次参加开滦总医院健康体检的共计126 847名职工,收集其体检资料。最终纳入118 516例观察对象,分为胆石症组（n=2 901）和非胆石症组（n=115 615）,随访并收集两组人群CVD发病情况。用寿命表法计算各组CVD的累积发病率,并用Log-rank检验比较两组中CVD累积发病率的差异,采用Cox比例风险模型分析胆石症对CVD发病风险的影响。按性别进行分层,分析不同性别CVD的风险比和95%可信区间。结果 与非胆石症组相比,胆石症组年龄、男性比例、体质指数（BMI）、甘油三酯（TG）、体育锻炼率、吸烟率、饮酒率、高血压率,组间差异具有统计学意义（P＜0.05）。在平均10.03年的随访期间内,共发生CVD 7 205例,其中心肌梗死1 674例,脑卒中5 695例,脑卒中合并心肌梗死164例;其中缺血性脑卒中4 772例,出血性脑卒中1 101例,出血性脑卒中合并发生缺血性脑卒中的178例。胆石症组CVD、心肌梗死、脑卒中、缺血性脑卒中、出血性脑卒中累积发病率分别为7.98%、1.96%、6.24%、5.01%、1.46%;非胆石症组CVD、心肌梗死、脑卒中、缺血性脑卒中、出血性脑卒中累积发病率分别为5.48%、1.32%、4.28%、3.54%、0.8%,经Log-rank检验,两组间差异均有统计学意义（P＜0.05）。Cox比例风险模型结果显示,校正了混杂因素后,胆石症组发生CVD的HR值（95%CI）为1.31（1.15～1.49）,发生心肌梗死的HR值（95%CI）为1.25（0.95～1.64）,发生脑卒中的HR值（95%CI）为1.32（1.14～1.52）,发生缺血性脑卒中的HR值（95%CI）为1.28（1.09～1.51）,发生出血性脑卒中的HR值（95%CI）为1.43（1.05～1.96）。男性胆石症患者CVD、脑卒中、缺血性脑卒中的发病风险要低于女性胆石症患者。结论 胆石症是心血管疾病发病的独立危险因素。     

胃肠外科手术治疗肥胖症及2型糖尿病

肥胖症是现今社会所面临的最严重的公共健康问题之一,手术治疗是使肥胖症患者获得长期而稳定的减重效果的唯一方法。自从1954年报道第1例减肥手术以来,外科手术治疗肥胖症在全球范围内获得了很大的发展,逐渐成为治疗病态性肥胖的＂金标准＂。随着研究的不断深入,越来越多的证据表明,胃肠外科手术不仅能减重,同时可以改善甚至治愈肥胖症相关的多种代谢性疾病,尤其是2型糖尿病。目前国内外的胃肠外科医师们正致力于将手术推广到2型糖尿病的治疗中去。外科手术治疗肥胖症及2型糖尿病将有巨大的发展空间。     

肥胖症与2型糖尿病外科治疗的规范和推广

外科治疗肥胖症和2型糖尿病的临床疗效已得到国际公认。中国大陆地区的微创胃减容手术总例数已由2008年的110余例迅速增至2012年的2000余例，但由于治疗缺乏统一规范的治疗准则，致使部分患者出现疗效不佳或术后发生严重并发症等情况。由于缺乏权威的统计机构，也一直未形成属于中国的临床数据库。因此，规范和推广中国的肥胖症和2型糖尿病外科治疗势在必行。     

手术治疗2型糖尿病合并肥胖症26例

目的：探讨胃肠外科手术在治疗2型糖尿病（T2DM）合并肥胖症中的意义。方法：对26例T2DM合并肥胖症的患者行胃减容和胃肠短路手术,观察术后血糖、体质指数（BMI）等指标的变化。结果：术后1年空腹血糖4.9-8.8 mmol/L,平均6.3 mmol/L。治疗T2DM有效率100%,治愈率42.3%。体质量降低5-42 kg,平均降低17.5 kg。BMI降至20.8-32.0,平均25.5。结论：胃减容和胃肠短路手术是治疗T2DM合并肥胖症可行、有效的方法。     

老年性胆囊炎胆石症并发糖尿病的围手术期处理

我院自1995年10月～2004年9月共收治并发糖尿病的老年性胆囊炎胆石症共56例，进行手术治疗54例。本文分析其围手术期的处理，并对手术时机、手术方式进行探讨。     

手术治疗肥胖症及糖尿病——在共识与争议中发展

肥胖症已经成为现今社会所面临的最严重的公共健康问题之一,手术治疗是使肥胖症病人获得长期而稳定的减重效果的唯一手段。自从20世纪50年代出现第一例减肥手术的报道以来,胃肠外科手术治疗肥胖症在全球范围内获得了很大的发展,已经成为治疗病态肥胖的“金标准”。在2000 年开展国内第一例腹腔镜下垂直绑带式胃减容术之后,笔者单位还开展了腹腔镜下可调节胃绑带术、“Y”型胃肠短路术、改良简易型胃肠短路术、管状胃胃切除术等,并且所有手术均在腹腔镜的条件下完成,取得了非常好的效果。随着研究的不断深入,越来越多的证据表明,胃肠外科手术不仅能减重,同时可能改善甚至治愈肥胖症相关的多种代谢性疾病,尤其是2型糖尿病。目前国内外的胃肠外科医师们正致力于将手术推广到2型糖尿病的治疗中去。外科手术治疗代谢性疾病仍有巨大的发展空间。     

代谢手术治疗肥胖症和2型糖尿病的相关问题

代谢手术治疗肥胖症和2型糖尿病在国际上越来越受到重视。在我国经过10余年的发展，目前已经广泛开展。随着这一新的外科领域的发展，许多相关问题不断产生。临床医师既要吸取国外的相关经验，又要根据我国患者和学科发展的实际情况逐步形成自己的实践经验。因此，笔者对代谢手术治疗肥胖症和2型糖尿病的相关问题进行探讨，以期促进代谢手术在我国的健康发展。     

手术与多学科综合治疗肥胖症及2型糖尿病

单纯性肥胖症及2型糖尿病的治疗应是多学科的综合治疗,包括饮食结构调整、增加身体活动量、行为纠正和药物治疗。一些病态肥胖患者还需要进行微创减肥手术治疗。尽管近年来微创减肥手术对于治疗单纯性肥胖症及2型糖尿病的疗效明显,但存在的问题是：缺乏相关科室的协作与多学科综合治疗以及患者随访率低,这是手术风险增加、疗效差和并发症增多的主要原因。因此,单纯性肥胖症和2型糖尿病及其合并症应该予以微创胃肠外科与相关多学科的综合治疗并进行长期随诊。     

多学科综合治疗肥胖症合并2型糖尿病

2型糖尿病常合并肥胖症、高血压、高血脂等代谢综合征症候群。对于此类难以控制的2型糖尿病合并肥胖症的诊断和治疗，内科常用非手术如控制饮食、运动、药物方式治疗；外科则可采用手术方式，改善2型糖尿病及其代谢综合征症候群，达到“治愈”糖尿病和高脂血症的目的。中南大学湘雅三医院对1例肥胖症合并2型糖尿病患者采用多学科协作综合治疗模式，取得了较好疗效。     

The effects of ethinylestradiol,a glucose diet and streptozotocin induced diabetes mellitus on gallstone formation and biliary lipid composition in the hamster

Possible risk factors for gallstone formation were examined and the concentrations of biliary lipids and each bile acid in the hepatic and gallbladder bile of hamsters were quantified. Forty female golden Syrian hamsters were divided into 4 groups according to diet; Group I, given control chow, Group II, given an ethinylestradiol and cholesterol supplemented diet, Group III, given a glucose rich diet without induced diabetes mellitus, and Group IV, given a glucose rich diet with diabetes mellitus induced by streptozotocin injection. The formation of cholesterol crystals but not gallstones was induced in Group II associated with a significantly decreased total bile acid concentration in the gallbladder bile but not in the hepatic bile. The formation of cholesterol gallstones and crystals with significantly higher concentrations of cholesterol and phospholipid was observed in Group III, while neither the formation of gallstones nor lithogenicity was enhanced by diabetes mellitus. However, a quite different lithogenicity was evident between the hepatic and gallbladder bile of the Group IV animals. These results suggest that neither the consumption of oral contraceptives nor diabetes mellitus induces gallstone formation, but that these factors can be responsible for dysfunction of the gallbladder.     

Complications of gallstone disease in kidney transplantation patients.

BACKGROUND: We studied the complications of gallstone disease in kidney transplantation patients and evaluated whether the screening and treatment of gallstones before acceptance to the kidney waiting list is relevant. METHODS: Complications of gallstone disease were evaluated in 1608 kidney transplantation patients on cyclosporine and long-term steroid treatment with median age 45.5 years, transplanted between 1990 and 2000. To evaluate the prevalence of cholecystolithiasis after kidney transplantation an abdominal ultrasound examination was cross-sectionally performed to a subgroup of 304 patients and the results were correlated to their serum lipid values, changes in BMI and use of statins. RESULTS: Pre-transplant cholecystectomy due to cholecystolithiasis (prerequisite for acceptance to kidney waiting list) had been performed on 71 (4%) of the patients. Thirty (15%) patients with diagnosed post-transplant gallstones and four without gallstones developed biliary complications. There were 25 cases of cholecystitis of which three resulted in gallbladder perforations. Seventeen patients (50%) with biliary complications required urgent surgery and one (3%) patient died of post-operative complications. In the subgroup of ultrasound examination patients (median 7 years post-transplant follow-up) 81% of the patients had no gallstones and 9% of the patients had gallstones had developed after transplantation. Patients with pre-transplant gallstones were older (P < 0.01) and patients with post-transplant gallstones gained the most weight during the follow-up. No differences in lipid values were found. CONCLUSION: In transplantation patients, the complications of gallstone disease may be severe. Screening and treatment of pre- and post-transplantation gallstone disease are recommended.     

Baseline anxiety disorders are associated with progression of diabetic kidney disease in type 2 diabetes

BackgroundDiabetic kidney disease (DKD) is a leading cause of kidney failure worldwide. Anxiety has been associated with disease progression in non-diabetes patients. We aimed to examine the prospective association between anxiety and progression of DKD in type 2 diabetes.MethodsWe conducted a prospective cohort study of 2040 participants with type 2 diabetes at the Diabetes Center of Shanghai General Hospital between May 2017 and June 2020. Anxiety disorders at baseline were diagnosed by a structured clinical interview based on the 10th Revision of International Classification of Disease (ICD). Progression of DKD was identified as the transition from one urinary albumin excretion rate (AER) stage to the next or the development of kidney failure during the follow-up period.ResultsAt baseline, 403 (19.8%) had a diagnosis of anxiety disorders, of whom 107 (26.6%) also received a depression diagnosis. During a median follow-up time of 3.2 years, deterioration of the kidney status occurred in 340 (16.7%) individuals. After adjustment for potential confounders including depression or an anxiety × depression interaction term, anxiety disorders were independently related to an increased risk of progression of DKD (HR 1.539, 95% CI 1.130–2.095, p = 0.006; HR 1.536, 95% CI 1.111–2.122, p = 0.009, respectively).ConclusionsAnxiety disorders at baseline, independent of possible confounders, were associated with the progression of DKD in type 2 diabetes. Whether therapeutic interventions for anxiety reduce the risk needs to be investigated.     

Mirizzi syndrome and gallstone ileus: An unusual presentation of gallstone disease

We discuss the case of a man with an unusual complication of gallstone disease. An 85-year-old patient presented to the emergency department with a 3-week history of abdominal pain in the right upper abdominal quadrant. Thoracoabdominal radiography demonstrated that the whole extrahepatic biliary tree, including the common bile duct, common hepatic duct, gallbladder, and left and right hepatic ducts, were visibly delineated by air. The operative findings revealed a small shrunken gallbladder, a fistula between the gallbladder fundus and the gastric antrum, and a cholecystohepatic fistula, corresponding to Mirizzi syndrome, type II. A large gallstone was found impacted in the jejunum. This patient seems to have developed initially a cholecystohepatic fistula. Due to the acute infiammatory process, the stone eroded through the gallbladder wall and into the gastric antrum, passing from the antrum into the small bowel, where it became impacted. We suggest that the natural history of Mirizzi syndrome does not end with a cholecystobiliary fistula but that the continuous infiammation in the triangle of Calot may result in a complex fistula involving not only the biliary tract but also the adjacent viscera.     

胆固醇结石病人肝脏胆小管侧膜ATP基因表达差异的研究

目的:本研究旨在测定比较胆石病人与对照组肝脏胆小管侧膜转运蛋白表达差异,以探讨胆石病发生的分子生物学机制。方法:研究包括20例胆囊胆固醇结石病人和11例无胆石症的对照。测定血清胆固醇和甘油三酯、胆汁胆固醇、胆汁酸和磷脂含量,采用Carey表计算胆汁胆固醇饱和指数。实时定量PCR法测定肝脏胆小管侧膜转运蛋白(ABCG5、ABCG8、ABCBll和ABCB4)mRNA的表达量。结果:胆石组血清胆固醇低于对照组(P<0.05)。胆石组胆汁胆固醇摩尔百分比和胆固醇饱和指数较对照组显著升高(P<0.01)。胆石组肝脏胆小管侧膜胆固醇转运蛋白ABCG5和ABCG8表达高于对照组,且后者差异具有统计学显著性(ABCG5:31.44±3.17Vs25.72±3.27,ABCG8:27.53±3.06vs17.81±2.23)。ABCBll和ABCB4表达在两组间差异无显著性。结论:本研究显示,胆石病主要病理生理异常为胆汁胆固醇过饱和,与肝脏胆小管侧膜胆固醇转运蛋白ABCG5和ABCG8的mRNA表达增加有关。     

胆宁片对胆囊胆固醇结石的防治作用

目的：研究胆宁片对胆囊胆固醇结石有无防治作用并初步探讨其机制。方法：豚鼠120只随机均分为4组：胆宁片组建立胆囊胆固醇结石模型后给予胆宁片,同时与熊去氧胆酸(UDCA)组及空白组、致石组对照,测定血、胆汁生化及肝、胆囊病理。结果：胆宁片组成石率为17％显著低于致石组的73％．其致石指数(LI)及血甘油三酯(TG)与肝脂肪变性显著低于致石组。结论：胆宁片对胆囊胆固醇结石有良好的防治作用并可缓解肝脂肪变性。     

Impact of metabolic syndrome on the incidence of chronic kidney disease: a Chinese cohort study

Aim: Metabolic syndrome (MetS) is a major culprit in cardiovascular disease and chronic kidney disease (CKD) in Western populations. We studied the longitudinal association between MetS and incident CKD in Chinese adults. Methods: A cohort study was conducted in a nationally representative sample of 4248 Chinese adults in Taiwan. The MetS was defined according to a unified criteria set by several major organizations and CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m². Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) adjusted for sex, age, body mass index (BMI) and serum levels of total cholesterol. Results: The prevalence of MetS among participants at baseline recruitment was 15.0% (637/4248). During a median follow‐up period of 5.40 years, 208 subjects (4.9%) developed CKD. The multivariate‐adjusted HR of CKD in participants with MetS compared with those without was 1.42 (95% CI = 1.03, 1.73). Additionally, there was a significantly graded relationship between the number of the MetS components and risk of CKD. Further, the relation between MetS and incident CKD was more robust in subjects with BMI >27.5 kg/m² than in those with lower BMI. Conclusion: The results suggest that the presence of MetS was significantly associated with increased risk of incident CKD in a Chinese population. These findings warrant future studies to test the impact of preventing and treating MetS on the reduction of the occurrence of CKD.     

The relationship of obesity to the complications of diverticular disease

OBJECTIVE: Diverticular disease is common in our community. Most patients remain asymptomatic and the development of diverticular complications is rare. A common clinical observation is that patients presenting with complications of diverticular disease are obese. The aim of this study was to examine the relationship of obesity to the complications of diverticular disease. METHODS: The study was based on a retrospective case note review conducted at the Flinders Medical Centre between 1/7/1998 and 30/6/2003. Patients were identified using ICD codes and their body mass index (BMI) calculated. Controls were taken randomly from the colonoscopy database at The Flinders Medical Centre. Patients were divided into four groups, those admitted with diverticular perforation or abscess, recurrent diverticulitis, a single episode of diverticulitis and a control group of patients with uncomplicated diverticulosis. The mean BMI for each group was calculated. Statistical analysis was performed by one way anova test with significance set at P < 0.05. RESULTS: Sixty-one patients were studied, including 16 patients with perforated diverticular disease, 11 randomly selected with recurrent diverticulitis, 16 patients with a single episode of diverticulitis and 18 controls. The control group had a significantly lower BMI than patients presenting with perforation (P = 0.001) or recurrent diverticulitis (P = 0.002). There was no significant difference between the control group and patients with a single episode of diverticulitis (P = 1.0). CONCLUSION: The study showed that patients with perforations and recurrent diverticulitis are significantly more obese than those who remain asymptomatic or have one episode. The aetiological relationship between obesity and diverticular complications remain unclear.