十二指肠乳头旁憩室与胆总管结石及复发结石的关系

目的 本文的目的是研究十二指肠乳头旁憩室是否与胆总管结石的发生及胆道术后胆总管复发结石有关。方法 1980年1月至1996年6月．我科共收治十二指肠乳头旁憩室38例，其中男25例，女13例．年龄21～80岁(57±12)。十二指肠憩室诊断均经X线造影片显示为据。结果 结果显示，十二指肠乳头旁憩室明显与胆总管结石的发生及胆道术后胆总管复发结石有关。结论 十二指肠乳头旁憩室可能是胆总管结石或复发结石的病因之一。因此，对胆囊或胆总管术后复发胆总结石者，应考虑合并有十二指肠乳头旁憩室的可能。     

顺行胆道造影胰管显影的临床意义及内镜治疗

目的 探讨顺行胆道造影胰管显影的临床意义与内镜治疗效果。方法 回顾性分析我院2012年1月至2014年12月行顺行胆道造影的384例患者临床资料。结果 顺行造影胰管显影68例,纳入51例,其中术前诊断为胆总管结石18例,胆囊结石14例,胆囊结石并胆总管结石19例,合并胰腺炎病史14例;造影发现胰管造影剂排泄延迟32例,造影剂排泄正常19例。经顺行胆道造影、胆道镜和（或）十二指肠镜等检查确定乳头旁憩室43例,胆胰合流异常35例,壶腹部隔膜缺失或功能缺陷7例,十二指肠乳头狭窄5例,Oddi括约肌功能障碍3例,原因不明2例。29例行内镜下胆胰分流术并置入一体式胰胆管引流管,未出现急性胰腺炎、胆道出血、胆漏等术后并发症,术后再次顺行胆道造影胰管未显影24例,胰管显影但造影剂排泄正常5例。随访1~3年,内镜治疗组复发胰腺炎1例、胆总管结石2例,非内镜治疗组复发胰腺炎6例、胆总管结石5例、胆囊结石4例,其中胰腺炎及胆囊结石发生率的差异具有统计学意义（P<0.05）。结论 顺行胆道造影胰管显影提示存在胆胰汇合部疾病,此类患者采取内镜下胆胰分流术可以降低胰腺炎及胆结石的发生率。     

十二指肠乳头旁憩室综合征13例误诊误治分析

目的: 探讨十二指肠乳头旁憩室诊治方法和分析误诊误治的原因及预防措施。临床资料:13例十二指肠乳头旁憩室中,1例保守治疗,12例单纯胆道手术,未处理憩室。其中5例术前确诊憩室,另7例术后通过ERCP检出憩室。术后复发Lemmel综合征12例,经选择内窥镜EST加支架治疗6例,胃-肠转流2例,胆-肠或胰内引流4例,术后均未复发Lemmel综合征。结论: 胆石症并存憩室,应开展ERCP、GI检查,确诊憩室及位置、大小。胆石症和憩室均需处理,处理遵循“个体化”原则。     

三种手术方法治疗胆囊结石并胆总管结石的临床疗效分析

目的 评价三种手术方法治疗胆囊结石并胆总管结石的临床效果.方法 将胆囊结石伴胆总管结石病例随机分为三组:A组:腹腔镜胆囊切除术+经十二指肠乳头切开取石组(LC+EST)(n=20);B组:腹腔镜胆囊切除术+胆总管切开取石(LC+LCBDE)+T管引流组(n=20);C组开腹胆囊切除术+胆总管切开取石+T管引流组(n=20);对比分析三组术后肛门通气时间、禁食时间、术后住院天数、住院费用及术后疼痛率等并发症指标.结果 LC+EST组的术后肛门通气时间、禁食时间、术后疼痛发生率、术后切口脂肪液化率均低于开腹组(P<0.01),术后疼痛发生率、胆漏率低于LC+LCBDE组(P<0.01),但术后血淀粉酶升高率高于LC+LCBDE组和开腹组;三组间术后结石残余率、住院费用、平均住院天数比较无统计学意义(P>0.05).结论 LC+EST术治疗胆囊结石并胆总管结石安全可靠、创伤小、术后恢复快.     

内镜诊治十二指肠乳头旁憩室合并胆胰疾病523例报告

目的探讨经内镜逆行胰胆管造影术(endoscopic retrograde choangiopancreatography,ERCP)及内镜下乳头括约肌切开术(endoscopic sphincterotomy,EST)对十二指肠乳头旁憩室合并胆胰疾病的诊治方法及价值。方法回顾性分析我院2007年7月~2009年6月1842例首次ERCP检查出523例十二指肠乳头旁憩室合并胆胰疾病的十二指肠乳头旁憩室与十二指肠乳头内镜下关系及其对ERCP成功率、EST及其并发症的影响。结果十二指肠乳头旁憩室合并胆胰疾病患者占ERCP总数的28.4%(523/1842),经ERCP明确十二指肠乳头旁憩室合并胆总管结石395例,占75.5%(395/523)。ERCP造影成功率97.5%(510/523)。实施EST482例全部成功,内镜取石成功率95.2%(376/395)。术后并发症16例(3.1%),包括出血5例,轻型急性胰腺炎5例,高淀粉酶血症4例,穿孔1例,诱发憩室炎1例,均经中西医结合非手术综合治疗痊愈,无死亡病例。术后315例随访1~24个月,平均10.5月,无胆道症状复发。结论只要严格执行内镜下治疗原则,熟练掌握操作技巧,内镜治疗是十二指肠乳头旁憩室合并部分胆胰疾病的微创、安全、有效的首选治疗手段。     

十二指肠乳头旁憩室对胆道疾病与ERCP插管的影响

目的 回顾性探究十二指肠乳头旁憩室对胆道疾病与ERCP插管的影响,以及探究胆总管结石复发的危险因素.方法 对我院行ERCP取石的970例胆石症患者的临床资料进行回顾性分析.按有无PAD分为PAD组和非PAD组,探究PAD对原发性胆总管结石、胆管炎、胆总管直径、结石的个数和大小、及ERCP插管成功率的影响;按有无结石复发...     

十二指肠乳头旁憩室合并胆胰疾病的诊治

十二指肠乳头旁憩室易诱发复发性胆管炎、胆道结石和胰腺炎等疾病。我院1982年1月至2002年1月共收治十二指肠乳头旁憩室合并胆胰疾病39例，临床分析如下。     

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目的探讨十二指肠乳头旁憩室伴胆胰疾病的诊断、手术治疗方法。方法回顾性分析1977～2002年手术治疗的50例十二指肠乳头旁憩室伴胆胰疾病者的临床表现、诊断及治疗方法。结果症状性十二指肠乳头旁憩室缺乏特异性临床表现，多以上腹病为首发症状，常伴有寒战、发热、黄疸、恶心、呕吐等消化道症状。上消化道钡餐造影、十二指肠镜、ERCP确诊率高。十二指肠乳头旁憩室一旦出现严重的临床症状及并发症首先考虑手术治疗。结论十二指肠镜、上消化道钡餐造影为诊断十二指肠乳头旁憩室的首选检查方法，强调根据病人具体情况制定“个体化手术治疗方案”，其中Billroth-Ⅱ式胃大部切除和(或)胆总管-空肠Roux-en-Y吻合术疗效满意。应重视乳头旁憩室与胆胰疾病的关系。对伴有胆胰疾病的乳头旁憩室的处理应持积极态度，手术是首选治疗方法。     

壶腹周围憩室与胆胰疾病

壶腹周围憩室 (periampullary diverticula,PAD)是发生在Vater壶腹 2～ 3cm范围内的十二指肠向腔外膨出。近些年来的研究表明 ,PAD与某些胆胰疾病有关。1　概念与历史回顾PAD也称乳头周围憩室 ,是起源于邻近或包含 Vater壶腹(主乳头 )或胆总管 (CBD)壁内段的十二指肠粘膜向腔外的突出 [1 ]。有些 PAD可穿透到胰头。发生在壶腹周围 2～ 3cm但不包含壶腹的憩室 ,称为乳头旁 (壶腹旁 )憩室 (Juxtapapillary di-verticula,JPD) ,发生在憩室内的乳头称之为憩室内乳头。1710年 Chomel首次报道含有 2 2枚结石 (可能为胆源性的 )的十二指肠…     

十二指肠乳头周围憩室与胆道疾病关系的探讨

目的探讨十二指肠乳头周围憩室（periampullary diverticula,PAD）与胆道疾病的关系。方法选择经内镜逆行胰胆管造影（ERCP）检查确诊合并有PAD的125例（PAD组）与同期经ERCP检查无PAD的125例（对照组）作对照研究。胆道疾病通过B型超声、CT及ERCP等检查确诊。结果PAD组合并胆囊结石、胆总管结石、胆总管下端括约肌功能不良的病人明显多于对照组,尤以胆总管结石增多为主,两组相比较有非常显著性差异（P〈0．01）。结论PAD与胆道疾病尤其是胆管结石存在着密切关系,可能是导致胆道疾病发生的一个重要因素。     

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目的 探讨壶腹周围憩室（PAD）与胆道疾病的关系以及内镜诊断PAD铁应用价值。方法 选择284例经内镜逆行胰胆管造影（ERCP）检查确诊合并有PAD的病人（PAD组）与同期经ERCP检查无PAD的病人（对照组）作为对照研究。胆道疾病根据病史，体征，结合实验室检查，B超，CT以及ERCP等确诊。结果 PAD组合并胆囊结石，胆总管结石，胆总管下端括约肌功能不良病人明显多于对照组，尤以胆总管结石增多为著（P＜0．01）。结论 PAD与胆道疾病，尤其是胆管结石存在着密切关系，PAD可能是胆道疾病发生或复发的一个重要因素，对胆道疾病病人行ERCP检查以了解PAD与胆道的关系，从而选择合适的治疗方案，对提高胆道疾病的治愈率有重要意义。     

血浆五聚素3水平在血液透析患者外周动脉疾病中的意义

目的 通过检测血液透析（血透）患者血浆五聚素3（PTX3）水平和踝臂指数（ABI）,探讨PTX3在血透患者外周动脉疾病（PAD）发生发展中的可能作用。 方法 选取接受规律性血透3个月以上患者。根据ABI将血透患者分为PAD组（ABI＜0.9）和非PAD组（ABI≥0.9）。收集血透患者临床资料、相关生化指标和炎性反应指标。选取体检健康人为对照组。用ELISA方法测定各组血浆PTX3水平。用Logistic回归方法分析PAD与PTX3及其它因素间的关系。 结果 本中心116例血透患者入选。PAD的发生率为18.1%（21/116）。血透患者血浆PTX3水平显著高于对照组[（2.90±1.03） μg/L比（1.70±0.85） μg/L,P ＜ 0.01];PAD组血浆PTX3水平显著高于非PAD组[（5.55±2.63） μg/L比（2.32±1.29） μg/L,P ＜ 0.01]。单变量分析显示ABI 与PTX3水平（r = -0.548,P ＜ 0.01）、超敏C反应蛋白（hsCRP）水平（r = -0.495,P ＜ 0.01）均呈负相关。PAD的ROC曲线分析显示,PTX3曲线下面积为0.901（P ＜ 0.01）,当以4.06 μg/L为检测截点时,其敏感性和特异性分别为81.0%和91.5%;hsCRP曲线下面积为0.640（P ＜ 0.05）,当检测的截点为3.33 mg/L时,其敏感性和特异性分别为57.1%和56.8%。Logistic回归分析显示,PTX3血浆浓度上升对PAD的优势比（OR）值为9.755 （95%CI：2.359～19.354,P = 0.001）。 结论 本中心规律性血透患者PAD发生率为18.1％。血透患者血浆PTX3水平显著高于健康对照组。PAD与血浆PTX3水平升高相关。PTX3作为诊断PAD的参考指标,其特异性和敏感性均优于hsCRP。     

壶腹周围憩室和胆道结石的关系探讨

目的 探讨壶腹周围憩室（PAD）与胆道结石的关系以及内镜诊断PAD的应用价值。方法选择284例经内窥镜逆行胰胆管造影（ERCP）检查确诊合并有PAD的患者（PAD组）与同期经ERCP检查无PAD的患者（对照组）作为对照研究。胆道疾病根据病史、体征、给合实验室检查上超、CT以及ERCP等确诊。结果PAD组合并胆囊结石、胆总管结石、胆总管下端括约肌功能不良患者明显多于对照组,尤以胆总管结石增多为主（P<0.01）。结论PAD与胆道结石有着密切关系,PAD可能是胆道结石发生或复发的一个重要因素。     

Platelet activation increases with the severity of peripheral arterial disease: implications for clinical management

INTRODUCTION: Patients with peripheral arterial disease (PAD) have increased mortality from cardiovascular events compared with age and sex matched controls Platelets play a major role in atherosclerosis and thrombotic vascular events. Platelet reactivity is increased in patients with PAD compared with healthy controls. We aimed to determine the relationship, if any, between platelet activation and severity of disease. METHODS AND RESULTS: One hundred eighty-two patients with intermittent claudication (IC) or subcritical limb ischemia (SLI), defined as the presence of rest pain or ulceration, had the following investigations performed: platelet P-selectin expression and bound fibrinogen by flow cytometric analysis and platelet aggregation using the rapid platelet function assay with arachidonic acid (AA) and thrombin receptor activation peptide (TRAP) as agonists. Patients with SLI compared with IC had significantly enhanced ADP stimulated P-selectin expression (median 42.45% [inter-quartile range 33.32% to 58.5%] vs 35.2% [26.07% to 46.32%], P = .002) and bound fibrinogen (73.7% [54.3% to 83.2%] vs 63.7% [43.8% to 76.5%], P = .001). TRAP stimulated aggregation was higher (207 [153 to 238] PAU vs 183[155 to 199] PAU, P = .04) but AA mediated aggregation was not significantly different. An ankle-brachial pressure index (ABPI) of less than 0.6 was associated with increased ADP stimulated P-selectin and bound fibrinogen (P < .05). ABPI correlated inversely with ADP stimulated P-selectin expression (r = -0.228, P = .003), ADP stimulated fibrinogen binding (r = -0.156, P = .043) and TRAP stimulated aggregation (r = -0.179, P = .04). CONCLUSION: We have demonstrated for the first time that progression of severity of PAD is not only reflected by symptoms, signs, and ABPI but also by increased platelet activity as assessed by both flow cytometry and aggregation. As patients with more severe PAD have increased cardiovascular mortality, our findings suggest that new strategies for platelet inhibitory therapy are indicated in these patients.     

Association between nutrition and peripheral artery disease in continuous ambulatory peritoneal dialysis patients

Objective To investigate the association between nutrition and peripheral artery disease (PAD) in continuous ambulatory peritoneal dialysis (CAPD) patients. Methods One hundred and two stable CAPD patients from a single center were enrolled in this cross-sectional study. Automatic ankle-brachial index (ABI) measuring system was applied to examine ABI. Patients were divided into PAD group (ABI＜0.9) and non-PAD group (ABI≥0.9). Clinical data were collected. Biochemical parameters were detected. Nutritional status was evaluated by serum albumin, handgrip strength (HGS) and subjective global assessment (SGA). Logistic regression analysis was performed to estimate the association of PAD with each nutritional marker as well as other potential risk factors. Results The incidence of PAD was 23.53% (24/102). ABI was significantly lower in patients with malnutrition as compared to those without malnutrition [(0.72±0.21) vs (1.04±0.14), P＜0.01]. Compared with non-PAD patients, serum albumin (P＜0.01), HGS (P＜0.01), diastolic blood pressure (P＜0.05), serum creatine (P＜0.05)、blood urine nitrogen (P＜0.01) were significantly decreased, but age (P＜0.01), the incidence of malnutrition [SGA, P＜0.01], diabetic status (P＜0.01), cardiovascular disease history (P＜0.01) were significantly increased in PAD patients. Logistic regression analysis showed that serum albumin (OR=0.762, 95％CI：0.611-0.948, P=0.015), HGS (OR=0.988, 95％CI：0.979-0.997, P=0.013) were independent protective factors for PAD, malnutrition [(SGA), OR=21.101, 95％CI：5.008-88.901, P＜0.01] was independent risk factor for PAD in CAPD patients. Conclusions The PAD incidence of CAPD patients in our center is 23.53%. Nutrition is independent factor associated with PAD in CAPD patients.     

Peripheral arterial disease in patients with stages IV and V chronic renal failure.

BACKGROUND: Cardiovascular disorders are frequently found among chronic renal failure (CRF) patients due to their higher susceptibility to develop atherosclerosis. However, peripheral arterial disease (PAD), that is associated with a high mortality rate, is not usually assessed in these patients. The aims of this study are to find out the prevalence of PAD affecting lower limbs in a population of CRF patients in stages IV/V, and to assess how much PAD determines the 5-year patient survival. METHODS: The study population (44 males and 29 females) was aged 58 +/- 15 years. They suffered from advanced CRF (18.6 +/- 6.1 ml/min creatinine clearance), but they were not on dialysis. These patients were sequentially referred initially to the predialysis unit over a period of 14 months. The vascular lesions were assessed by carotid and transcranial ultrasound, as well as by ankle-brachial index test (ABI). Routine 24 h blood and urine laboratory tests were performed for each patient. Cardiovascular morbidity and cardiovascular disease risk factors were evaluated through personal interview. RESULTS: Fourteen patients had an ABI index of less than 0.91 (PAD indicative), 11 of them also suffered from intermittent claudication. PAD affected significantly more males (P = 0.001) and diabetics (P = 0.001). Also, PAD prevalence was significantly higher in patients with a previous clinical record of coronary heart disease (P = 0.001), increased clinical record of cerebrovascular disease (P = 0.005), a thickness of the left ventricular posterior wall (P = 0.03) and lower cardiac ejection fraction (P = 0.02). PAD patients had a significantly different protein intake (P = 0.003), calcium-phosphorus product (P = 0.001), risk of coronary heart disease based on the Framingham score (P = 0.001) and 5-year survival rate (P = 0.004). There were no significant differences for PAD patients in terms of body mass index, creatinine clearance, lipid profile, Ca and P. Multivariate risk factor analysis revealed that a previous clinical record of coronary heart disease and diabetes increased the risk of developing PAD, as defined by ABI < 0.91. After 5 years, 21 patients (29%) had died: 64% of patients that suffered PAD (9/14) and 20% of the non-PAD population (12/59). The Cox proportional hazards model demonstrated that older age and a lower ABI increased the risk of death. CONCLUSIONS: The present study, conducted on CRF patients in stages IV and V not undergoing dialysis, showed; (a) that a high percentage of these patients developed PAD (19%) or other vascular pathologies; (b) that there was an associated high mortality rate (29%) after 5 years; (c) that the 5-year mortality rate was significantly higher (P = 0.004) in PAD patients (64 vs 20%).     

Increased platelet aggregation and activation in peripheral arterial disease.

OBJECTIVES: patients with peripheral arterial disease (PAD) have a threefold increase in cardiovascular mortality. Standard antiplatelet treatment may not confer uniform benefit in different patient groups. This study aimed to compare platelet function in patients with lower limb PAD, carotid disease and abdominal aortic aneurysm (AAA) with age- and sex-matched healthy controls. METHODS: patients with lower limb PAD (n = 20), carotid disease (n = 40), AAA (n = 13) and age/sex matched healthy controls (n= 20) were studied. Whole blood methods to detect spontaneous platelet aggregation (SPA), and adenosine diphosphate (ADP) and collagen-induced aggregation were used. The detection of platelet P-selectin and the PAC-1 antigen by flow cytometry were also used as markers of platelet activation and aggregation. RESULTS: patients with lower limb PAD or AAA had higher baseline SPA compared to normal controls (p < 0.01). There was significantly higher collagen-induced aggregation in IC patients compared to normal controls (p < 0.01). However, there was no difference in ADP-induced aggregation between lower limb PAD and control patients. There was no difference in PAC-1 binding between control patients and the patients with lower limb PAD, carotid disease or AAA. Patients with carotid disease had a higher expression of P-selectin compared to normal controls (p < 0.05). CONCLUSIONS: this study provides further evidence that platelet hyperactivity is present in patients with PAD despite the use of antiplatelet therapy. Further antiplatelet strategies may be indicated to protect these patients.     

Platelet Monocyte Aggregates and Monocyte Chemoattractant Protein-1 are not Inhibited by Aspirin in Critical Limb Ischaemia

OBJECTIVES: Platelet monocyte aggregates (PMA) and monocyte chemoattractant protein-1 (MCP-1) play a significant role in atherosclerotic disease but the effect of aspirin and their role in peripheral arterial disease (PAD) requires further investigation. We have compared p-selectin, PMA and MCP-1 in patients with PAD treated with aspirin (75 mgs daily), with age matched controls not treated with aspirin. MATERIALS AND METHODS: Using flow cytometry and ELISA, P-selectin, PMA and MCP-1 were compared in 3 populations; healthy controls (n=12), intermittent claudication (n=19) and critical limb ischaemia (CLI), (n=10). RESULTS: P-selectin was significantly higher in CLI patients (3.48% positive) compared to the claudicants (1. 36% positive) and the controls (1.76% positive). PMA levels were significantly higher for CLI population (44.5% positive) compared to the claudicants (20.48% positive) and the controls (28.33% positive). MCP-1 levels expression was significantly higher for the CLI patients (175.4 pg/mL) compared to the claudicants (76.1 pg/mL) and the controls (117.0 pg/mL). CONCLUSION: Despite aspirin treatment CLI patients have higher platelet activation and MCP-1 expression than controls and claudicants. With increasing severity of disease aspirin is unable to suppress markers of platelet activation and pro-atherosclerotic chemokine expression which may represent another form of aspirin resistance.     

Periampullary diverticula and pancreaticobiliary disease.

BACKGROUND: Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients. METHODS: The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed. RESULTS: The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with beta-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres. CONCLUSION: With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.     

High density lipoprotein cholesterol and arteriography in intermittent claudication

Overnight fasting plasma lipoprotein and lipid concentrations were measured in a group of 76 patients with peripheral arterial disease (PAD)--main symptom: intermittent claudication--and compared to those of 21 controls, matched with the patients according to age, sex, body-mass index, alcohol and tobacco consumption, but without any signs of peripheral arterial disease. Significantly lower median values of high density lipoprotein cholesterols (HDL-C) (P less than 0.01), and significantly higher median values of low density lipoprotein cholesterols (LDL-C) (P less than 0.05) were found in the PAD group. The results also showed significantly lower ratios of HDL-C/LDL-C and HDL-C/total cholesterol in the PAD group when compared to the controls (both P less than 0.005). No significant differences were demonstrated concerning very low density lipoprotein, total cholesterol, or triglyceride plasma concentrations. Evaluation of arteriograms showed a significant negative correlation between HDL-C concentrations and the extent of arteriosclerotic lesions in the lower extremities (P less than 0.05). Thus, not only were the HDL-C and LDL-C levels different in the PAD group, but we also found a correlation between HDL-C and the severity of vascular disease.