先天性胆总管囊肿手术治疗经验

目的：总结先天性胆总管囊肿的手术治疗经验。方法：对194例先天性胆总管囊肿的手术治疗经验进行回顾性分析。结果：194例均行囊肿切除,胆道重建术：（1）肝管十二指肠吻合术4例;（2）间置空肠肝管十二指肠吻合术（人工乳头）15例;（3）间置胆囊肝管十二指肠吻合术4例;（4）肝管空肠Roux-en-Y型吻合术171例。本组190例术后恢复顺利,手术死亡4例（2．06％）。结论：囊肿可使胆汁流入胰管内并发胰腺炎,囊肿易癌变,囊肿可形成盲袋和死腔易形成结石,故囊肿切除胆道重建术是治疗先天性胆总管囊肿的最佳选择。尽管胆道建术式较多,但以肝总管空肠Roux-en-Y型吻合术是胆道重建术的一种理想手术。     

腹腔镜胆囊切除术致胆瘘六例分析

临床资料男 1例 ,女 5例 ,术前术中诊断为慢性结石性胆囊炎。胆瘘部位及临床表现和治疗 :第 1例为胆囊管瘘 ,术中见胆囊管炎性改变增粗 ,约 1.5ｃｍ ,分离时离断 ,无法夹闭 ,则电凝胆囊管口 ,威氏孔置引流管 ,术后引流不畅 ,出现胆汁性腹膜炎 ,次日立即开腹结扎胆囊管 ,冲洗引流。第 2例为副肝管离断 ,右肝管端胆汁漏出 ,立即中转开腹证明为右则副肝管离断 ,予以结扎。第 3例剪断胆囊管后 ,发现胆囊管残端为双腔管 ,胆床有胆汁漏出 ,立即中转开腹 ,发现肝总管与胆囊管一次夹闭横断 ,断端漏胆汁 ,则行肝总管端端吻合 ,胆总管Ｔ管支架并引流。…     

犬肝管胆囊吻合和肝管空肠吻合术后胆汁成分变化的对比

目的　探讨犬肝管胆囊吻合和肝管空肠吻合术后胆汁成分的不同变化。方法　 2 9条犬被随机分为对照组 (5条 )和不全梗阻模型组 (2 4条 )分别实施假手术和左肝管不全梗阻 ,不全梗阻 7周后平均随机分为胆囊胆管吻合术 (HC组 ,12条 )和空肠胆管吻合术 (HJ组 ,12条 ) ,分别实施HC和HJ ,术中及术后 1个和 5个月分别引流胆管胆汁 ,进行成分 [胆汁酸 (TAB)、未结合胆红素(UCB)、钙离子、总胆红素 (TB)、胆固醇 (Ch)、磷脂 (PL)等 ]检测。结果　术后 1个和 5个月时 ,吻合口上方胆汁中总胆汁酸、胆固醇、总胆红素、磷脂浓度HC组均显著性高于同期HJ组 ,而游离胆红素、钙离子两组间差异均无显著性 ;术后 5个月时 ,HC组Ca2 ,UCB/TAB比值为 0 .0 8± 0 .0 1,显著性低于HJ组的 0 .2 3± 0 .0 7。结论　与HJ相比 ,HC术后肝管胆汁成分更有利于减少结石发生。     

皮下通道型胆囊肝胆管成形术后胆汁成分分析

目的 研究皮下通道型胆囊肝胆管成形术(STHG)后胆汁成分的变化及意义。方法26例择期手术的肝胆管结石患者分为皮下盲襻型肝胆管空肠吻合术组(SLCJ组)14例,STGH组12例,术中及术后第4周分别引流肝门部胆汁,各份胆汁行细菌培养、胆汁脂质成分定量分析以及黏蛋白、过氧化物歧化酶和过氧化脂质测定。结果 术后28d,STHG组和SLCJ组细菌培养阳性率分别为25％和86％;与SLCJ组相比,STHG组肝门部胆汁中总胆汁酸浓度明显升高,而Ca~(2 )和游离胆红素的浓度积差异无显著性,黏蛋白和过氧化脂质明显降低,而过氧化物歧化酶显著升高。结论 与SLCJ相比,STHG后胆汁成分的变化更有利于防止色素结石的复发。     

腹腔镜胆囊管残端部分开放联合胆道造影在胆囊管结石治疗中的应用

目的探讨胆囊管残端部分开放联合胆道造影在胆囊管结石治疗中的临床应用价值。方法2010年2月～2012年12月,对55例胆囊管结石行四孔法腹腔镜胆囊切除术。全麻,术中明确“三管”关系后夹闭胆囊管近侧端,剪开远侧部分胆囊管管壁,钝性挤压远端,挤出可能残留结石直至清亮胆汁流出,自胆囊管开放口置管行术中胆道造影,判断有无结石残留。术后观察腹部症状体征、肝功能指标,常规行B超复查,必要时行MRCP检查,明确有无胆囊管结石残留或继发胆总管结石残留。结果55例手术均获成功。术中经胆囊管残端开放钝性挤压,15例有残留小结石挤出。术中胆道造影,1例发现继发胆总管结石残留,多次反复挤压取石失败,术后第3日行ERCP＋EST取石成功,余54例无结石残留。术后2例不明原因上腹疼痛,肝功能、B超及MRCP检查均无异常,予以对症解痉治疗后腹痛缓解,余均顺利康复。结论对胆囊管结石行腹腔镜胆囊切除术时,采用胆囊管残端开放法,通过钝性挤压胆汁溢出,冲出可能残留结石,辅以经胆囊管残端插管胆道造影,及早发现胆囊管结石残留或继发胆总管结石残留,增加腹腔镜胆囊切除术的安全性。     

拔T管后胆汁性腹膜炎5例报告

１９９５年１月至２０００年５月，我院收治５例拔Ｔ管后胆汁性腹膜炎患者，男２例，女３例，年龄３８～７１岁，平均５３．２岁。２例患胆囊结石并胆总管结石，２例患肝内外胆管结石，均行胆囊切除、胆总管切开取石及Ｔ管引流术；１例患恶性胰岛细胞瘤，行Ｗｈｉｐｐｌｅ术及Ｔ管引流术。置管时间分别为１９、２１、９２、１３２及１５天，拔管前均行Ｔ管造影证实胆道通畅，Ｔ管材料均为乳胶管。其中４例于拔管当天出现腹痛、发热、腹部压痛、反跳痛，１例于拔管后３８天出现上述症状。处理：２例经原Ｔ管窦道插入一导尿管行引流，并配合抗…     

保胆取石术后胆囊泥沙样结石发生原因的临床分析及应对策略

目的探讨保胆取石术后胆囊泥沙样结石的形成原因及应对策略。方法回顾性分析2008年12月至2014年12月期间大连大学附属中山医院胆道微创外科诊治的内镜保胆取石术后反复出现胆囊泥沙样结石的62例患者的临床资料。结果 62例患者中为无症状性胆囊泥沙样结石43例,为胆囊泥沙样结石伴急性胆囊炎19例。结石发生原因:近胆囊管开口处胆囊分隔4例,胆囊管迂曲过长6例,胆囊管结石3例,胆总管结石4例,十二指肠乳头旁憩室39例,胆胰合流异常18例,十二指肠乳头狭窄6例,十二指肠乳头炎29例,十二指肠乳头腺癌3例。行腹腔镜胆囊切除术(LC)2例,行内镜下乳头括约肌切开术(EST)/内镜下乳头括约肌球囊扩张术(EPBD)+LC 1例,行经皮经肝胆囊穿刺置管引流术(PTGD)+开腹胆囊切除术1例,行PTGD+EST/EPBD 14例,行PTGD+胆囊肝胆管成形术(HG)1例,行EST/EPBD 34例,行EST/EPBD+经内镜胆道金属支架置入术(EBMSD)3例,行HG 5例,行EST/EPBD+HG 1例。术后成功保留胆囊的55例患者的胆囊泥沙样结石均消失,脂餐后1 h胆囊收缩率上升至(59±16)%。术后53例患者获访,随访时间为0.5~6.0年(中位随访时间为3.6年),随访率为85.5%。随访期间胆囊结石复发3例,发生胆总管结石2例,发生肝内外胆管结石2例。结论胆囊胆汁流出不畅是引起保胆术后胆囊泥沙样结石形成的重要原因,HG、EST及内镜下球囊扩张是保持胆囊胆汁流出通畅的有效方法。     

电视腹腔镜胆囊切除术200例体会

在１９９３年３月至１９９４年５月，作者共行电视腹腔镜胆囊切除术２００例。手术成功１９０例，失败病例包括：胆囊三角区致密必另分离困难５例；损伤胃十二指肠２例；因胆囊动脉出血及探查中发现肝癌而中转开腹手术各１例和严重心律失常中止手术１例。术后发生严重并发症３例，分别是总胆管横断性损伤，总胆管侧壁破损作胆囊管钛夹脱落漏胆。此外，还发生肝下积液、腹壁气肿各２例。全组病例无一死亡。文内讨论了手术适应和手术技     

单纯胆囊切除术失误六例报告

单纯胆囊切除术是普外科常见手术之一,手术失误可增加病人的痛苦,甚至造成死亡。我院自１９９０年来共行胆囊切除术１０５６例,手术失误６例,现报道如下。１　临床资料１．１　一般资料　本组６例均为胆囊结石病人,术式为单纯胆囊切除术。男３例,女３例,年龄３８～７０岁。１．２　失误情况　肝外胆道损伤５例,胆囊管残留过长并遗漏结石１例。１．３　处理方法　肝外胆管损伤５例中４例在术中发现,其中２例行修补加Ｔ管支撑引流术,２例行胆管空肠ＲｏｕｘＹ吻合术;另１例术后胆汁性腹膜炎３天后第二次进腹发现胆总管有一小破口…     

间置胆囊肝管十二指肠内引流术治疗肝门胆管癌二例

我院利用间置胆囊肝管十二指肠内引流术治疗肝门胆管癌2例，现将手术方式作一介绍。临床资料例1：男，67岁。因进行性无痛性黄疸2月入院，经B超、CT诊断为肝门胆管瘤。于1994年5月17日在全麻下行间置胆囊肝管十二指肠内引流术，术中见癌肿位于肝总管，体积Zcm×2．5cm×3cm并侵犯门静脉及肝固有动脉，肝十二指肠韧带内淋巴结肿大，质硬，左右肝管从交叉部扩张，直径达2．8cm。肝肿大，质韧，呈淤胆性硬化，胆囊空虚，胆总管直径0．5cm，行胆囊底部同左右肝管交叉部吻合，胆囊颈部（Hartmann袋）同十二指肠球部后壁吻合。手术140分钟，未输…     

瘦素对血脂及胆汁成分的调节在胆囊胆固醇结石形成中的作用

目的:分析胆囊胆固醇结石患者瘦素与血脂及胆囊内胆汁成分的关系,探讨瘦素在胆囊胆固醇结石形成中的作用。方法:选择胆囊胆固醇结石接受腹腔镜胆囊切除术的患者30例(结石组)与同期因胆囊息肉行腹腔镜胆囊切除术的患者22例(息肉组),检测患者血清总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)、瘦素、胆囊胆汁中的TC与总胆汁酸(TBA)水平,以及胆囊壁组织瘦素受体mRNA水平。结果:与息肉组比较,结石组血清TC、TG、LDL、瘦素水平以及胆囊内胆汁TC/TBA含量比率与胆囊组织瘦素受体mRNA水平均明显升高,而血清HDL明显降低(均P0.05)。结石组的血清瘦素水平与血清TG、TC及胆汁TC均呈正相关(r=0.633,P=0.002;r=0.224,P=0.025;r=0.384,P=0.000),与HDL和TBA呈负相关(r=-0.205,P=0.014;r=-0.548,P=0.024)呈负相关,而息肉组血清瘦素与以上指标间均无关(均P0.05)。结论:瘦素参与了胆囊胆固醇结石的形成,瘦素及其受体水平的升高可能与胆囊胆固醇结石患者胆固醇代谢异常、胆囊胆汁成分失调密切相关。     

阻塞性黄疸大鼠法尼酯衍生物X受体表达及加味大柴胡汤作用的研究

目的:研究法尼酯衍生物X受体(FXR)对胆汁酸代谢的作用,以及加味大柴胡汤对FXR的表达的影响.方法:制作急性阻塞性黄疸大鼠模型,分为7、14、21 d 3个时段,每个时段又分为胆总管结扎 加味大柴胡汤组、胆总管结扎 TUDCA、胆总管结扎组 生理盐水组、假手术 生理盐水组等4组,每组6只.生化检测ALT、TB、TBA、ALP;免疫组化法检测FXR蛋白表达.结果:胆道梗阻后,随梗阻时间的延长,FXR表达减弱.血清TBA、ALT、ALP、TB含量明显增加.加味大柴胡汤使FXR表达上调,血清TBA、ALT、ALP、TB明显下降,肝脏病变减轻.结论:阻塞性黄疸时FXR表达可调节胆汁酸代谢.加味大柴胡汤可以上调FXR蛋白表达,促进胆汁酸代谢,从而减轻肝脏损害.     

Some observations on gallstones and bile composition.

A series of 31 consecutive patients undergoing surgery for gallstone disease has been studied and the composition of the gallstones and bile from the gallbladder and common duct determined. As a result of the stone analysis by the X-ray powder diffraction method, the patients were classified according to whether their stones consisted of cholesterol, calcium salts or a mixture of the two. The mean composition of the common duct bile for the groups with cholesterol and mixed stones was just outside the micellar region of cholesterol solubility. The gallbladder bile from the cholesterol group of stone-formers was also supersaturated, but the gallblader bile from the group of mixed stone-formers was undersaturated with respect to cholesterol. None of the patients forming gallstones of calcium salts showed any abnormality in the cholesterol content of their bile.     

Effect of sphincteroplasty on gallbladder function and bile composition.

The effect of sphincteroplasty on bile concentration and composition and on gallbladder function was investigated in the dog. Gallbladder and hepatic bile samples were analyzed for cholesterol, phospholipid (lecithin), bile salt concentration and individual bile salt content. Motor function was studied by cholecystokinin-cholecystography with changes in gallbladder volume computed from the radiographs. All bile samples were cultured and at the conclusion of the experiments, the gallbladders were histologically examined. Sphincteroplasty did not alter biliary cholesterol concentration but the concentration of lecithin and bile salts decreased in gallbladder bile and increased in hepatic bile (p less than .001). These changes depict a trend toward greater lithogenicity for gallbladder bile and lesser lithogenicity for hepatic bile. Postoperative analysis of individual bile salts in gallbladder bile showed an increase in monohydroxy and dihydroxy bile salts and a decrease in trihydroxy bile salts (p less than .001). This tendency has been shown to be conducive to gallstone formation. The concentrating ability of the gallbladder was partially eliminated by sphincteroplasty but gallbladder filling and motor response to stimulation by cholecystokinin was not affected. All gallbladders demonstrated histologic changes of chronic inflammation and all developed a significant bacterial flora following sphincteroplasty. It is concluded that cholecystectomy should always be performed following transduodenal sphincteroplasty not because of any resultant abnormality of motor function, as has previously been held, but because of the resultant abnormality of gallbladder pathophysiology.     

Transport of fluid and biliary lipids in the canine gallbladder in experimental cholecystitis

In acute cholecystitis the cystic duct is usually obstructed by a gallstone and the gallbladder is often tensely distended with clear fluid. Because these findings suggest that fluid absorption in the gallbladder may be reversed in cholecystitis, we examined the effect of inflammation on the gallbladder mucosal function in dogs. In 20 dogs cholecystitis was induced by ligating the cystic duct and allowing inflammation to develop from bile stasis and the presence of a chronic indwelling cannula in the gallbladder. Every morning an aliquot of normal hepatic bile was infused into the gallbladder through a cannula in the gallbladder fundus. After either 4 or 24 hr the gallbladder contents were aspirated, the volume was measured, and the concentrations of bile acids, cholesterol, phospholipids, and protein were determined. Changes in volume were checked using [14C]PEG as a nonabsorbable tracer. A net absorption of fluid, bile acids, cholesterol, and phospholipids occurred during the first 24 to 48 hr after ligation of the cystic duct. Thereafter, fluid, cholesterol, and protein were secreted into the lumen, but absorption of bile acids continued. The lithogenic index of bile placed in the inflamed gallbladder was always greater when the bile was removed 24 hr later. The rate of fluid secretion into the lumen of the inflamed gallbladder increased after a meal and decreased after indomethacin. These findings demonstrate that inflammation can stimulate the gallbladder mucosa to secrete fluid, a process that may be important in the pathophysiology of acute cholecystitis in man. Since inflammation also resulted in an increased cholesterol saturation of gallbladder bile, cholecystitis per se may contribute to the formation of cholesterol gallstones.     

Why does somatostatin cause gallstones?

Long-term administration of the somatostatin analogue, octreotide, is complicated by gallstone formation. Somatostatin is known to inhibit hepatic bile secretion and gallbladder emptying. However, the effect of octreotide on gallbladder bile composition remains unknown. Therefore, we tested the hypothesis that octretide would alter hepatic bile composition and cause gallbladder stasis, thereby increasing gallbladder bile solute concentrations. Fourteen control prairie dogs received daily saline injections, whereas 10 animals received 1 micrograms of octreotide subcutaneously three times per day for 5 days. Cholecystectomy and common bile duct cannulation were then performed. Octreotide increased hepatic bile concentrations of bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.05), and total protein (p less than 0.01). Rsa, an index of gallbladder stasis, was decreased (p less than 0.01) in the octreotide group. Gallbladder bile total calcium (p less than 0.05), bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.01), total protein (p less than 0.05), and total lipids (p less than 0.05) were increased in the octreotide group. Animals receiving octreotide also had decreased hepatic (p less than 0.05) and gallbladder (p less than 0.001) bile pH. No differences in cholesterol saturation index were observed. These data suggest that in the prairie dog, octreotide (1) alters hepatic bile composition, (2) causes gallbladder stasis, and (3) increases gallbladder bile calcium, bilirubin, protein, lipid, and hydrogen ion concentrations. We conclude that octreotide causes alterations in gallbladder bile composition that increase the likelihood of cholesterol and calcium bilirubinate precipitation.     

蛋白酶体抑制剂bortezomib对胆道梗阻大鼠肝脏的保护作用

目的探讨蛋白酶体抑制剂bortezomib对胆道梗阻大鼠肝脏的保护作用.方法将30只大鼠随机分为假手术组(SO组)、胆道梗阻对照组(Con组)和bortezomib实验组(Bor组).Con组通过胆总管结扎建立大鼠胆道梗阻模型,Bor组同法结扎胆总管并于术前1 d、术后第3天腹腔注射bortezomib,假手术组仅行剖腹和胆总管游离.所有大鼠均于术后7 d处死,处死前采集血清测定血清丙氨酸转氨酶(ALT),总胆红素(TB)和总胆汁酸(TBA)水平.免疫组化染色测定肝组织NF-κBp65含量.逆转录-聚合酶联反应测定肝脏组织中TNF-α mRNA水平.结果Con组与Bor组的TB和TBA水平并差异无统计学意义(P＞0.05),而Bor组的ALT水平[(92.4±21.4)μmo1/L]明显低于Con组[(145.7±33.5)μmol/L],P＜0.05.Bor组的NF-κB p65亚基阳性染色率(11.6%±2.7%)明显低于Con组(15.5%±4.3%),P＜0.05.而逆转录-聚合酶联反应发现,Bor组TNF-αmRNA相对表达量(1.0±0.2)明显低于Con组(1.3±0.4),P＜0.05.结论bortezomib可以通过抑制NF-κB的活化减少炎症反应的发生,从而减轻因胆道梗阻引起的肝脏损害.     

Periodic gallbladder contraction maintains bile acid circulation during the fasting period: a canine study

Using a canine model we have studied the relationship between the interdigestive cycle in the small intestine, motility changes in the biliary tract and bile acid output into the duodenum from direct hepatic secretion and gallbladder emptying. Under anaesthesia catheters were inserted into the gallbladder, common bile duct and duodenum, and electrodes were attached to the small intestine in five dogs. These animals were subsequently studied conscious and fasting. A double marker technique was used to measure bile acid output from the gallbladder and liver while pressure in the gallbladder and common bile duct and electrical activity in the small intestine were monitored. Four complete interdigestive cycles were recorded in each dog. Output of bile acids from the gallbladder fluctuated with the phases of the cycle: being lowest in phase I (3.9 +/- 0.7 mumol/min); increasing significantly (P less than 0.005) in phase II (9.8 +/- 1.0 mumol/min); remaining elevated in phase III (13.9 +/- 1.7 mumol/min); and falling significantly (P less than 0.05) in phase IV (8.4 +/- 1.8 mumol/min). In contrast, hepatic secretion of bile acids directly into the duodenum remained fairly constant. Intraluminal pressure in the biliary tract paralleled the fluctuation in gallbladder bile acid output, being significantly increased (P less than 0.05) in phases II and III. Periodic contraction of the gallbladder would, therefore, appear to be the principal mechanism for the phasic output of bile during fasting.     

Primary "brown pigment" bile duct stones

Bile duct stones from 42 patients were morphologically and chemically analysed. The calculi from 27 patients had important primary bile duct stone (PBDS) features, consisting of a general ovoid shape and fragile structure, with alternating light and dark brown pigmented layers on cross-section. Chemically these stones contained low levels of cholesterol, with high levels of bilirubin and calcium. Subsequent infrared spectroscopy analysis showed that calcium bilirubinate and calcium palmitate were the only calcium salts present. Calcium palmitate was prominent in the light brown layers. A morphological and chemical comparison with gallbladder stones showed that bile duct "stasis stones" were similar in morphological and chemical composition to the brown pigment gallbladder calculi. However, they were distinct from most gallbladder stones, indicating that primary bile duct calculi have an aetiology that is different to 90% of gallbladder calculi. Primary bile duct calculi were observed to occur with or without the presence of a gallbladder, and more interestingly, in the bile duct of two patients with cholesterol gallbladder stones. Bile duct bile of patients with primary choledocholithiasis were always moderately to profusely infected and with abundant calcium bilirubinate precipitation. Moreover, this study has shown that PBDS chemical analyses profiles were consistent and correlated well with their defined morphology. Consequently, PBDS may be accurately identified at the time of operation by morphology. An important aetiological factor would appear to be infection, which would seem to promote bile duct bile stasis and eventual stone growth.     

胆囊黏膜ABCA1的表达和胆囊胆固醇息肉发病关系的研究

目的：研究ABCA1在胆囊黏膜的表达及其表达与胆囊胆固醇息肉发病的关系。方法：收集因胆囊疾患而行腹腔镜胆囊切除术病人的胆石、胆汁、胆囊黏膜及胆囊壁全层组织共计42例,其中胆囊胆固醇息肉15例,胆囊胆固醇结石15例,对照组12例（胆囊腺瘤5例,非胆固醇胆囊结石7例）。分别测定胆石胆固醇含量、胆汁胆固醇、胆汁酸、磷脂的浓度;实时PCR定量检测胆囊黏膜ABCA1、LXRα、RXRα的mRNA表达：胆囊壁全层组织做病理切片;免疫组化显示ABCAl蛋白在胆囊黏膜的表达．结果：胆固醇息肉组胆汁胆固醇饱和指数为1．0±0．2,较对照组胆固醇饱和指数0．6±0．3明显增高,其差别有统计学显著性（P〈0．01）。免疫组化显示ABCA1在胆囊黏膜上皮细胞有明显表达。息肉组、结石组和对照组胆囊黏膜ABCAI、LXRa、RXRα mRNA相对表达量比较,各组之间差异无统计学意义。结论：胆囊黏膜ABCA1的表达可能并不是导致胆囊胆固醇息肉发病的重要原因。