Hem-o-lok clip found in common bile duct after laparoscopic cholecystectomy and common bile duct exploration: a clinical analysis of 8 cases

Currently laparoscopic cholecystectomy (LC) and common bile duct exploration (LCBDE) has become the standard surgical procedure for cholecystolithiasis and choledocholithiasis. During the operation cystic duct and vessels are usually controlled by Hem-o-lok clips. However, recently we found clips dropping into CBD in 8 patients during fiberoptic choledochoscope 2-3 months after operation. Therefore, there is risk that clip can migrate during postoperative period, which probably lead to hemorrhage and bile leakage after LC if this occurs within postoperative few days, or even cause recurrent stone in CBD. So, using of Hem-o-lok clips may be not a safe method to control vessels and cystic duct during LC. To our knowledge, this condition has not previously been reported. In our view, other more effective and safe method ligating cystic duct and gallbladder vessels, such as effective and convenient thread knotting method, should be investigated.     

Dissolution of bile duct stones by a hydrophilized glyceromonooctanoin-bile-acid-EDTA emulsion

Summary The clinical suitability of conventional glyceromonooctanoin (GMOC) and ethylenediaminetetraacetic acid (EDTA) containing solvents for the dissolution of common bile duct stones is questionable. To improve the solvent-stone contact and the miscibility with bile, GMOC was hydrophilized by the addition of polyethyleneglycol-caprylglyceride, polyethyleneglycol-sorbitan-etheroleyl-ester, and polyethyleneglycol-sorbitanlaurylester (PEG-GMOC). This product was mixed with a bile acid-EDTA (BA-EDTA) solution in a ratio of 12 (v/v) for cholesterol solubilizing and calcium complexing capacities. To determine clinical efficiency, the new solvent was infused via a nasobiliary tube in 16 patients with endoscopically nonextractable common bile duct stones and compared with a group of 16 patients treated with an alternating GMOC/BA-EDTA regimen. Continuous perfusion with PEG-GMOC-BA-EDTA led to a total (12 patients) or partial (3 patients) disappearance of the stones within 2–15 days. Similarly, alternating GMOC and BA-EDTA treatment dissolved the stones in 12 patients.The average volume of PEG-GMOC-BAEDTA infused contained only 27% of the GMOC applied during the alternating therapeutic regime. This reduction of the GMOC dose was associated with a significant reduction of adverse effects such as emesis, diarrhea and biliary pain. We concluded that GMOC is equally efficient in the new hydrophilized form but it is clearly superior as far as side effects are concerned. In all, this supports its clinical suitability for the dissolution treatment of common bile duct stones.Abkürzungsverzeichnis GMOC Glyceromonooctanoin - EDTA Ethylenediaminetetraacetic acid - PEG-GMOC Polyethyleneglycol-sorbitanlauryl-ester - BA-EDTA Bile acid ethylenediaminetetraacetic acid - EPT (EST) Endoscopic papillotomy (Endoscopie spincterotomy) - CBS Common Bile Duct Stones - MTBE Methyl-tert-Butyl Ether - CCE Cholecystectomy In memoriam Heinrich Baumgaertel     

猪胆总管脱细胞支架的制备及组织学评价

目的 用不同的脱细胞方法对猪胆总管进行处理,比较脱细胞前后的组织学变化,筛选适宜的脱细胞方法,为组织工程胆管支架材料的应用提供理论依据。 方法 30例猪胆总管随机分为5组：对照组（A组）：0.05% 胰蛋白酶+核酸酶（B组）：0.1%十二烷基硫酸钠（SDS）+核酸酶（C组）：1.0% Triton X-100+核酸酶（D组）：1.0% Triton X-100+0.1% SDS +核酸酶（E组）。通过HE染色光学显微镜下观察脱细胞基质的组织结构和细胞残留情况;用紫外分光光度法检测脱细胞基质的DNA含量,计算脱细胞率。结果 脱细胞B组有少量细胞残留,纤维有损伤;脱细胞C组、D组、E组的细胞均被去除,纤维无明显损伤。A组的DNA含量为（71.24 ± 2.56）μg /100 mg。B、C、Ｄ、Ｅ4个脱细胞组的DNA含量与A组的差异有统计学意义（F =15.29, P<0.01）,均有明显的脱细胞效果（P<0.01）。Ｂ组的脱细胞率为77.03%,比C组、Ｄ组、Ｅ组的脱细胞效果稍差（P<0.05）,Ｅ组的脱细胞率高达99.03%。 结论 应用1.0% Triton X-100+0.1% SDS +核酸酶的脱细胞效果好,能更好地降低胆总管的免疫原性,是一种比较理想的猪胆总管脱细胞方法。     

Immunohistochemistry of carcinoembryonic antigen,secretory component and lysozyme in benign and malignant common bile duct tissues

Summary An immunoperoxidase technique has been utilized for the localization of carcinoembryonic antigen (CEA), Secretory component (SC) and lysozyme (LZ) in normal and cancerous common bile duct tissues. Little or no CEA was found in the non-cancerous common bile duct tissues. SC was found in the surface epithelium and accessory gland epithelium and LZ was demonstrated only in the accessory glands. Some inflammatory cells were also positively stained for LZ. In adenocarcinoma, CEA was always present on the luminar border of the carcinoma cells, occasionally with intercellular and intracellular localization. LZ was absent, or only faintly detected in carcinoma. SC was generally distributed in well-differentiated adenocarcinoma cells, but showed a reduced intensity of staining with progressive dedifferentiation. These findings suggest that CEA, SC and LZ could be useful markers providing valuable information in the pathological diagnosis of bile duct carcinoma.     

The fine structure and histochemistry of human bile duct in obstruction and choledocholithiasis

Biopsies from the common bile ducts from seven patients undergoing surgery for biliary obstruction due to stones or malignancy were studied histochemically and electron microscopically. The surface of the bile duct is lined by a tall epithelium which extends into diverticula. Apically, they contain some neutral and sialated mucosubstances. Fucosyl residues were found in the Golgi apparatus and along the apical cell membrane. The latter is lined by microvilli. There was a well-developed rough endoplasmic reticulum and Golgi apparatus and a small number of apical secretory droplets. Large numbers of lipid droplets were present basally in some cells. Lipid-containing macrophages were also seen intra-epithelially and in the lamina propria. This suggests a possible pathway for lipid transport. The glands were lined by cuboidal cells, some containing much mucus--sulphated, sialated, and neutral with a basal nucleus. A well-developed endoplasmic reticulum and Golgi apparatus were found with abundant secretory droplets. The glandular epithelium contained lysozyme, alpha-1-antitrypsin, and alpha-1-antichymotrypsin. These may play a protective role. The lamina propria contained scattered smooth muscle cells amongst the fibroblasts and inflammatory cells.     

The role of bile duct reactive change in the pathogenesis of liver fibrosis due to hepatitis C

The question addressed here is: does the bile duct reactive component of hepatitis C disease progress during the progression of the disease to cirrhosis? The question is important because if the answer to the question is yes, then an important correllated question is: does the bile duct reactive component contribute to the fibrotic change which leads to cirrhosis? The first question is addressed in the present study of a series of liver biopsies taken at the four stages of liver fibrosis in patients with hepatitis C. Sixty-four patients with hepatitis who had been biopsied for staging purposes were reviewed retrospectively. The liver biopsies were routinely stained with antibodies for liver cells, bile duct cells, activated stellate cells and cells in S phase of the cell cycle and histochemical stains for collagen and basement membrane. Selective biopsies were stained for stem cells and oval cells. There was a progressive increase in metaplastic bile ductules but the increase did not reach a significant level until stages III and IV of fibrosis. There was a positive correlation between the number of ductules formed and the stage of liver fibrosis. The incidence of proliferating metaplastic ductules was low and did not change significantly during the progression of the stage of the fibrosis. Stains for oval cells and stem cells were negative. It is concluded that the answer to the question posed is: bile ductule reaction does increase during the development of cirrhosis caused by hepatitis C but the increase is due to bile ductular metaplasia, not due to proliferation.     

快速康复外科在老年患者传统开腹与腹腔镜下胆囊切除加胆总管探查术围手术期中的应用

目的探讨快速康复外科(ERAS)理念在老年患者传统开腹与腹腔镜下胆囊切除加胆总管探查术围手术期的应用及其在临床中的使用价值。 方法选取2012年1月至2016年4月在内蒙古自治区人民医院肝胆胰脾外科择期行胆囊切除加胆总管探查术的老年患者共113例,按随机数字表法将113例患者分为行开腹胆囊切除加胆总管探查术患者60例(O-组)和腹腔镜下胆囊切除加胆总管探查术患者53例(L-组),再用随机数字表法将两大组分为4个亚组,分别实施ERAS措施和传统措施,即分为O-ERAS组(30例)、O-Control组(30例)和L-ERAS组(27例)、L-Control组(26例)。O-组实施开腹胆囊切除术加胆总管探查术,L-组实施腹腔镜下胆囊切除术加胆总管探查术。而O-ERAS组和L-ERAS组采取ERAS相关措施进行处理,O-Control组和L-Control组应用传统方法处理,对不同组别病例的手术时间、术中出血量、术后排气时间、术后住院时间、住院费用等情况进行观察。对数据行t检验。 结果O-Control组手术时间为(2.3±0.7) h、术中出血量为(81.0±77.7) mL、术后排气时间为(3.4±1.0) d、术后住院时间为(12.9±4.0) d,与O-ERAS组的手术时间[(1.9±0.5) h]、术中出血量[(48.0±24.1) mL]、术后排气时间[(2.8±0.9) d]、术后住院时间[(10.5±4.1) d]相比,后者术中出血量减少,手术时间、术后排气时间、术后住院时间缩短,差异均有统计学意义(t＝－2.008、－2.099、－2.734、－2.233, P值均小于0.05);而2组住院费用分别为(22 246.9±13 344.3)元、(20 194.4±2 828.2),差异无统计学意义(P>0.05)。 L-Control组手术时间为(2.2±0.6) h、术中出血量为(54.0±32.1) mL、术后排气时间为(2.9±0.9) d、术后住院时间为(7.0±2.0) d,与L-ERAS组的手术时间[(1.8±0.5) h]、术中出血量[(37.0±26.3) mL]、术后排气时间[(2.4±0.8) d]、术后住院时间[(5.7±1.1) d]相比,后者术中出血量减少,手术时间、术后排气时间、术后住院时间缩短,差异均有统计学意义(t＝－2.179、－2.214、-2.197、－2.660,P值均小于0.05);而2组住院费用分别为(22 672.6±5 446.9) 、(22 404.4±8 482.4)元,差异无统计学意义(P>0.05)。与O-ERAS组相比,L-ERAS组术中出血量减少,手术时间、术后排气时间和术后住院时间缩短,2组差异均有统计学意义(P值均小于0.05);但2组住院费用差异无统计学意义(P>0.05)。 结论快速康复外科理念在老年患者胆囊切除加胆总管探查术中能促进老年患者术后康复,且腹腔镜胆囊切除术加胆总管探查术更有利于患者术后快速康复,临床应用效果明显,可在临床推广。     

The relationships of the bile duct and the retroduodenal arteries and their importance in the surgical treatment of hemorrhagic duodenal ulcer

Summary The anatomic relationships of the gastroduodenal artery (GDA) and the posterior superior pancreaticoduodenal artery (PSPD) with the bile duct in their retroduodenal courses were studied in 35 bloc specimens from normal cadavers, injected after removal. The distances between the GDA, the pylorus, and the bile duct were measured in the sagittal plane. The origin and course of the PSPD in relation to the bile duct were studied. The relation of the GDA and the bile duct were divisable into four types: in Type 1 (n=22) the two structures separated progressively, the artery being on the left of the bile ducts; in Type 2: (n=7) the structures approached each other without crossing, Type 3: (n=5) the GDA crossed in front of the bile duct at the level of the first part of the duodenum (D1), Type 4: (n=1) the GDA crossed the bile duct below D1 and ran along its right border. The PSPD originated at the posterior face of D1 in 20% of cases (n=7) and crossed the anterior surface of the bile duct at the posterior surface of D1. In four cases there was no pancreatic tissue between the PSPD and the bile ducs. It follows that the risk of injury to the bile duct when securing hemostasis by transfixing a bleeding duodenal ulcer in the D1 segment is great when the arterial structures (GDA and PSPD) cross the bile duct. This risk is increased when there is no pancreatic tissue between them.

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Rapports du conduit cholédoque et des artères rétroduodénales. Incidences sur le traitement chirurgical de l'ulcère duodénal hémorragique

Résumé Les auteurs ont analysé les rapports anatomiques de l'artère gastroduodénale (AGD) et de l'artère pancréatico-duodénale postérieure et supérieure (APDPS) avec le conduit cholédoque dans leur trajet rétroduodénal à partir de 35 blocs duodéno-pancréatiques sains et injectés après prélèvement. Les distances entre l'AGD, le pylore et le conduit cholédoque ont été mesurées dans le plan frontal. Les distances entre l'AGD et le conduit cholédoque ont également été mesurées dans le plan sagittal. L'origine et le trajet de l'APDPS par rapport au conduit cholédoque ont été étudiés. Les rapports de l'AGD et du conduit cholédoque ont été classés en 4 types : Type 1 (n=22) ces deux éléments s'éloignaient progressivement, l'artère se situant à gauche du conduit cholédoque; Type 2: (n=7) ils se rapprochaient sans se croiser; Type 3 : (n=5) l'AGD croisait le conduit cholédoque par en avant à la face dorsale de la partie supérieure du duodénum (D1) ; Type 4 : (n=1) l'AGD croisait le conduit cholédoque au dessus de D1 et cheminait le long de son bord droit. L'APDPS naissait à la face dorsale de D1 dans 20 % des cas (n=7) et croisait la face ventrale du conduit cholédoque à la face dorsale de D1. Dans 4 cas il n'existait pas d'interposition de tissu pancréatique entre l'APDPS et le conduit cholédoque. Il en résulte que le risque de plaie cholédocienne lors de l'hémostase d'un ulcère hémorragique de D1 par des points transfixiants est important lors d'un croisement des éléments artériels (AGD ou APDPS) et du conduit cholédoque. Ce risque est majoré en l'absence d'interposition de tissu pancréatique.

     

经皮内镜下胃造口术在脑卒中患者康复期的应用

目的总结经皮内镜下胃造口术(PEG)应用于25例脑卒中伴意识障碍患者康复期的经验。方法 在静脉麻醉及心电监测下,对25例脑卒中伴意识障碍康复期的患者行PEG,加强围手术期处理,特别注意相关肺部感染的治疗及观察。结果 PEG成功率100%、操作时间平均(10±3)min;无手术相关死亡、出血、腹膜炎等并发症,术中及术毕时发生2例心肺并发症,经及时治疗后好转;术后随访6～18月,术后肺部感染得到有效控制。结论 对脑卒中伴意识障碍康复期的患者行PEG治疗是安全的,它有利于肺部感染的控制,但需加强围手术期处理。     

比较纤维支气管镜和经皮肺穿刺活检在肺占位性病变中的诊断价值

目的　探讨纤维支气管镜和CT引导下经皮肺穿刺两种肺活检方法在肺占位性病变中的诊断价值。  方法　严格选择我院及南方医院呼吸科2011年6月至2013年6月期间经胸片或CT诊断为肺部占位性病变患者192例。其中126例行纤维支气管镜检查并行活检取组织,另66例CT引导下经皮肺穿刺活检。观察胸片、CT及纤支镜下肺占位病变大小形态,同时比较两种肺活检方法的确诊阳性率。  结果　采用纤维支气管镜可直接观察到病变部位大小形态;纤支镜肺活检和经皮肺穿刺活检两种方法肺部病变确诊阳性率分别为83.1%和88.7%,两者比较无显著差异（P＞0.05）。纤支镜和经皮肺穿刺并发症发生率分别为1.51%和12.12%,后者显著高于前者,差异具有统计学意义（P＜0.05）。  结论　纤维支气管镜肺活检和CT引导下经皮肺穿刺活检均对肺占位病变有诊断价值,但纤支镜检查相对安全。     

The nature of the immune response (Ir) gene defect for pigeon cytochrome c in [B10.A(4R) x B10.PL]F1 mice: A Comparison Between Thymic Selection and Antigen Presentation

[B10.A(4R) x B10.PL]F₁ mice are low responders to pigeon cytochromec, while [B10.A(2R) x B10.PL]F₁ and B10.A mice are high responders.The in vivo site at which the different aliomorphs of the E_aIa molecule exert their Ir gene effect on the immune responseto pigeon cytochrome c was examined by creating two differentsets of radiation-induced bone marrow chimeras. [B10.A(4R) xB10.PL]F₁(b.m.) B10.A(lrr.) chimeras, which possess antigen-presentingcells (APC) of the low responder, but whose T cells are educatedin a high responder environment, were found to be low respondersto pigeon cytochromec. In contrast, B10.A(b.m.) [B10.A(4R)x B10.PL]F₁(lrr.) chimeras, which possess APC of the high respondertype, but whose T cells are educated in a low responder environment,responded to pigeon cytochrome c Addition of B10.A APC to thefirst type of chimera, both prior to antigen priming and atthe time of the secondary challenge in vitro, converted 50%of the animals to responders Furthermore, [B10.A(4R) x B10.PL]F₁mice responded to pigeon cytochrome c If they were primed witha 10-fold greater antigen dose and restimulated in vitro Inthe presence of B10.A APC. These results suggest that the primarysite of the Ir gene defect in this system is at the level ofantigen presentation and not in the T cell repertoire.