可生物降解肠吻合支架的动物实验研究

目的利用一种拥有自主研发的可降解肠吻合支架进行犬肠吻合术,观察该吻合支架的可操作性及对吻合口并发症预防的作用。方法实验犬分实验组和对照组,麻醉后分别进行手工缝合及利用该吻合器进行拟定肠段的全层吻合,术后第7、14天时分批处死实验犬,对吻合口爆破压、吻合口周径、肠管周径、吻合口部位羟脯氨酸含量等项目进行观测。结果利用吻合支架进行的肠吻合,其吻合口爆破压、羟脯氨酸含量等观测数据均优于对照组,吻合口周径、肠管周径两组无差异。结论该吻合器操作简单、快速、安全,可有效预防及降低术后吻合口并发症,值得继续深入研究。     

可降解吻合环应用于犬肠切除、肠吻合的实验研究

目的:探讨可降解吻合环应用于犬的肠切除、肠吻合的可行性及其临床应用价值。方法:用20只本地杂种犬行肠切除、肠吻合术,将其随机分为两组:单一缝合组(对照组,n=10),应用可降解吻合环吻合组(实验组,n=10)。观察两组手术前后肠道内径的变化,记录缝合时间和总手术时间,观察术后1~10d肠瘘的发生率、支架降解情况,术后12周取吻合口处部分肠管组织做病理学检查。结果:实验组术后胆漏的发生率(1/10)与对照组(0/10)比较,差异无统计学意义(P>0.05);对照组的缝合时间(10.20±2.88)min多于实验组(2.02±1.03)min。术后第12周肠道吻合口病理学显示,实验组肠壁各层较好,炎性反应轻,无明显肉芽肿形成,浆膜层无纤维瘢痕,明显优于对照;对照组与实验组术后吻合口内径变化比较,差异无统计学意义(P>0.05)。结论:可降解吻合环应用于肠切除、肠吻合在动物实验中是安全有效的,且优于线缝合组。     

CO2激光焊接辅以化学胶Ⅰ期修复犬内置可降解支架胆总管的可行性及全性

目的：探讨应用CO₂激光焊接辅以化学胶I期修复内置可降解支架胆总管切口的可行性和安全性。方法：本地杂交犬63只行胆总管横行切开后,依据对切口I期修复方法不同随机均分为缝合组、CO₂激光组（简称激光组）、CO₂激光+化学胶组（简称激光＋胶组）。每组均在胆总管切口吻合前置入聚乳酸（PLA）可降解支架,测试并记录胆总管吻合时间、吻合口破裂压和外径的变化,光镜下观察吻合口病理学改变及电镜下观察内支架的外形变化。结果：激光组和激光＋胶组胆总总管吻合时间均明显短于缝合组（P＜0.05）;术后1、4和12周时,吻合口破裂压缝合组与激光＋胶组比较差异均无显著性（P＞0.05）,而激光组均低于前两组（P＜0.05）;术后4和12周时,激光组和激光＋胶组胆管吻合口外径较吻合前均无明显扩张,而缝合组较吻合前均明显扩张;激光组和激光＋胶组胆总管黏膜下炎症反应较缝合组轻,无明显肉芽肿形成,纤维排列较缝合组整齐。电镜观察证实,每组胆总管内置支架表面随时间的延长由光滑变得粗糙,其截面由致密逐渐变得疏松。结论：CO₂激光焊接辅以化学胶I期修复内置可降解支架胆总管切口安全、可行,其效果优于单纯缝合及CO₂激光焊接。     

T型管支撑法在胆肠吻合术中的应用价值

目的：探讨一种T型管支撑法在胆肠吻合术中的价值。方法：回顾性分析41例胆肠吻合术患者的临床资料。按随机分组原则分成T型管支撑胆肠吻合口组（研究组）及直接胆肠吻合组（对照组）两组,并随访1～2年,比较两组的减黄效果、胆漏及胆肠吻合口狭窄的发生率。结果：两组具有相同的减黄效果;术后胆漏发生率研究组明显低于对照组;术后第1年随访研究组胆肠吻合口狭窄率低于对照组（P〈0.05）,第2年随访两组无明显统计学意义（0.1〉P〉0.05）。结论：T型管支撑胆肠吻合口法能有效预防胆肠吻合术早期胆漏的发生,对远期胆肠吻合口狭窄的预防尚缺乏证据。     

胆总管十二指肠后段大口径吻合术远期疗效分析（附248例临床报告）

目的：评价胆总管十二指肠后段大口径吻合术远期疗效。方法：回顾性分析248例临床胆总管十二指肠后段大口径吻合术临床资料,进一步总结胆总管十二指肠后段大口径吻合术手术适应证及手术应遵循的原则。结果：本组248例,近期全部治愈,无胆瘘及肠瘘发生。受访224例,随访率为90%,随访时间3～15年。仅有5例反复出现逆性感染症状,均系研究初期病例,手术指征掌握不当所致。其中3例经对症处理后症状消失,另2例再手术改行胆肠吻合术。结论：胆总管十二指肠后吻合术是一种操作简便易行、安全度大、手术死亡率低的手术方式。只要正确掌握指征,遵循手术原则,吻合口尽量做得低,做得大,疗效是满意的。     

犬胆总管内置可降解支架并行激光焊接的安全性及胆总管组织学变化

目的：探讨犬胆总管(CBD)探查后内置可降解支架并行激光焊接的可行性及其临床应用价值。方法：用30条本地杂种犬模拟胆总管探查术（CBDE）,将其随机分为3组:单一激光焊接组（对照组Ⅰ,n=10）,CBD内置可降解支架后行I期缝合组（对照组Ⅱ,n=10）,以及CBD内置可降解支架后行激光焊接组（实验组,n=10）。观察各组手术前后CBD内径的变化,记录缝合时间和总手术时间, 观察术后1～3 d胆漏的发生率、支架降解情况,术后6周取胆总管及肝组织做病理学检查。结果：对照组Ⅰ术后胆漏的发生率（6/10）显著高于实验组（0/10）和对照组Ⅱ（0/10）;对照组Ⅱ的缝合时间［(7.20±2.88)min］多于实验组［(2.02±1.03)min］。术后第6周胆总管及肝组织病理学显示,实验组胆总管的内膜已修复,炎症反应轻,无明显肉芽肿形成,部分焊接区域几乎无纤维瘢痕,明显优于对照组Ⅱ;对照组Ⅱ与实验组术后均无肝损伤表现,CBD内径均无增宽或变窄。结论：胆总管探查术后内置可降解支架并行激光焊接的方法在动物实验中是安全有效的,且优于线缝合组。     

碱性成纤维细胞生长因子预防胆肠吻合口狭窄的实验研究

目的 观察碱性成纤维细胞生长因子（bFGF）对胆肠吻合愈合过程的影响，预防术后胆肠吻合口狭窄。方法 通过制作犬胆总管十二指肠吻合模型，术后一周内吻合口局部应用bFGF（实验组），并与生理盐水组对照。两组术后不同时期分别取材行光镜，电镜观察及羟脯氨酸含量分析。结果 bFGF能显著促进胆肠吻合口粘膜上皮愈合过程，促进肉芽组织生长及伤口收缩，减少瘢痕形成。结论 吻合口局部应用bFGF是预防术后胆肠吻合口狭窄的一种有效措施，其机制与bFGF能够（1）促进创面巨噬细胞增生，活化；（2）促进肉芽组织生长；（3）促进伤口收缩，（4）促进释放胶原酶以及引流吻合口粘膜下少量渗出胆汁等多种因素有关。     

结肠液囊管一期修复结肠吻合口漏的动物实验研究

摘要：目的研制结肠液囊管作为一种安全可靠的新技术对结直肠吻合口漏进行有效的一期修复。方法将西藏小型猪随
机分为2组,处理组与对照组,每组15头,处理组采用结肠液囊管对结肠吻合口漏进行一期修补,对照组以传统一期吻合
口漏缝合近段结肠造瘘,二期结肠回纳手术。在修补术后第7、14、21天检测吻合口漏愈合情况：吻合口漏部位的愈合强
度——爆破压、愈合部位组织中微血管密度及羟脯氨酸含量。结果结肠液囊管能够修复结肠吻合口漏,两组均无动物死
亡,无肠管狭窄及坏死。术后第7、14天处理组爆破压、羟脯氨酸含量、微血管密度均高于对照组,但术后第21天两组无显
著性差别。结论应用结肠液囊管技术一期修复结肠吻合口漏是安全、可靠且有效。特别是在结直肠吻合口漏48~72 h以
上,腹腔严重感染的环境下能有效修复结直肠吻合口漏。     

胆管-空肠侧侧吻合术的临床试验研究

目的：比较胆肠Roux-en-y侧侧吻合术与端端吻合术两种术式，指导临床医师选择合理的术式。方法：将符合条件的病人随机分成两组。每组70人，用单盲法对两组病人分别流行端端和侧侧吻合术，测量胆道空肠压力差及pH值，并行t检验，同时对术后吻合口漏和狭窄的发生率进行X^2检验。结果：侧侧吻合较端端吻合压力差大（＞5mmHg),pH值变化及两组漏的发生率无统计学意义。吻合口狭窄1，3，5年的发生率组间差异显，P＜0．05，且呈逐年增加的趋势。结论：胆肠侧侧吻合术的长期效果优于端端吻合术，值得临床推广应用。     

预防胰十二指肠切除术后并发胰胆瘘的体会

总结预防壶腹部周围癌行胰十二指肠切除术并发胰胆瘘的体会。方法对我院１９８４年１月～１９９５年１０月３８例胰十二指肠切除术病例进行回顾性分析。结果全组术后胰瘘３例（７．７％），非手术治愈。无胆瘘发生，无手术死亡率。结论胰漏的预防关键在于胰腺残端常规楔形切除与合掌式缝合，胰空肠端端套入吻合，吻合层次精确，吻合口无张力，胰管内置多侧孔引流管，胰液输出通畅。胆肠胰肠吻合口相距５ｃｍ～６ｃｍ。胆肠吻合口的胆总管周围组织游离长度以１ｃｍ为宜，保证胆肠吻合血供。胆肠胰肠吻合口附近各置质软腔大的硅胶管充分引流。消化道重建以Ｃｈｉｌｄ术式为佳。     

Sutureless choledochoduodenostomy with an intraluminal degradable stent in dog model

Background  It is difficult and time-consuming for carrying out conventional hand-sewn bilioenteric anastomosis, especially for small bile duct anastomosis and laparoscopic procedure. In order to simplify it, we have developed a novel procedure of sutureless bilioenteric anastomosis with an intraluminal degradable stent. This study aimed to evaluate the feasibility and safety of this technique with cholangioduodenostomy in dog model.

Methods  A patent intraluminal degradable stent tube for sutureless choledochoduodenostomy in dog model was made with polylactic acid in diameter of 3 mm or 4 mm. Thirty-eight dogs were randomly divided into to a stent group (SG, n=20) and a control group (CG, n=18). Dogs in the SG underwent sutureless choledochoduodenostomy with intraluminal stent, while the CG underwent conventional choledochoduodenostomy (single layer discontinuous anastomosis with absorbable suture). Dogs of each group were divided into 4 subgroups according to time of death (1, 3, 6, and 12 months postoperatively) to evaluate the healing of anastomosis. Operation time, intraoperative tolerance pressure of anastomosis, rate of postoperative bile leakage, bursting pressure of anastomosis were compared between the two groups. Anastomosis tissue was observed afterwards by pathology evaluation, hydroxyproline content, serum bilirubin, liver enzyme level and magnetic resonance cholangio-pancreatography (MRCP) to assess the stricture.

Results  All procedures were completed successfully. The surgical time of the SG was significantly less than the CG (SG: (19.2±4.3) minutes, vs. CG: (29.2±7.1) minutes, P=0.000). One bile leakage was occurred in either group. No significant difference of intraoperative tolerance pressure of anastomosis, rate of bile leakage and postoperative bursting pressure of anastomosis, anastomotic stricture, hydroxyproline content, serum bilirubin and liver enzyme level was found between the two groups. MRCP showed no anastomosis stricture and obstruction during months of follow-up.

Conclusion  The technique of sutureless choledochoduodenostomy with a degradable intraluminal stent is feasible and a safe procedure in this dog model.

     

Application of a new-type sutureless anastomosis stent to the primary reconstruction of the bilioenteric continuity after acute bile duct injury in dogs

Objective： To evaluate the effect of a new-type sutureless magnetic bilioenteric anastomosis stent that was used to reconstruct the bilioenteric continuity （primarily under the circumstances of severe inflammation after acute bile duct injury in dogs ）. Methods： Establishing an animal model of acute bile duct injury with severe inflammation and bile peritonitis in dogs. The newtype sutureless magnetic bilioenteric anastomosis stent was used to reconstruct the bilioenteric continuity primarily. Results： The experiment group anastomosis healed well with a mild local inflammation reaction, and the collagen lined up in order without the occurrence of observable bile leakage and infection. Conclusion： It was safe and feasible to use the new-type anastomosis stent to reconstruct the bilioenteric continuity primarily under the circumstances of severe inflammation after acute bile duct injury in dogs.     

支架法胃肠吻合术的猪动物模型实验研究

Background  Gastrojejunostomy is one of the most frequently used procedures for general surgeons. The creation of anastomosis between various parts of the gastrointestinal tract is a basic technical component and major task in the daily practice of almost all gastrointestinal procedures. This research evaluated a new procedure of making gastrointestinal anastomosis with stent.

Methods  Twenty experimental mini-pigs were randomized into two groups. In stent anastomosis group (SA), the anastomoses were constructed with a poly-levolactic acid stent. In hand-sewn group (HA), the anastomoses were performed with a single-layer continuous suture. Abdominal X-ray with intraluminal contrast was performed on the 10th postoperative day. Five pigs of each group were sacrificed on the postoperative days 3 and 14 to determine anastomotic bursting pressure in situ, hydroxyproline concentration, and histopathological evaluation of the anastomotic sites.

Results  There was no intraoperative morbidity or mortality. The median time needed for the sutured anastomosis was (21.7±2.3) minutes and for the stent anastomosis was (11.9±1.9) minutes (P <0.001). Abdominal X-ray with intraluminal contrast demonstrated normal gas distribution and showed no evidence of leakage or obstruction. Macroscopic appearance at the longitudinal opening of anastomosis was always good in both groups. The median anastomotic bursting pressure was (18.2±1.6) kPa in SA group on postoperative day 3, compared with (11.7±3.2) kPa in HA group (P=0.003). The anastomotic bursting pressure on day 14 was not significantly different between SA group ((27.1±2.6) kPa) and HA group ((28.3±1.7) kPa) (P=0.388). The hydroxyproline concentrations were not significantly different.

Conclusions  The stent anastomosis was not considered to be more difficult than a sutured anastomosis. This method is proved to be safe and feasible compared with the traditional hand-sewn method in the porcine model. The method increases early anastomotic strength in this study.

     

经内镜逆行胆管支架置入在恶性胆管狭窄姑息性减黄 治疗中的有效性和安全性分析

目的探讨经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）置入胆管支架治疗恶性胆管狭窄所致梗阻性黄疸的有效性及安全性,筛选胆管支架引流效果预测指标。方法采用ERCP技术对106例不能手术切除的恶性胆管狭窄病人行胆管支架置入治疗。根据分析目的不同分为:恶性胆管狭窄肝门部与远端组;恶性肝门部胆管狭窄BismuthⅠ型与Ⅱ~Ⅳ型组;恶性肝门部胆管狭窄BismuthⅡ~Ⅳ型中单侧支架与双侧支架组;恶性远端胆管狭窄中塑料支架与金属支架组;支架引流有效与无效组。记录术前、术中及术后相关指标,比较术前术后及各组引流效果、术后并发症发生情况,分析筛选可能影响支架引流效果的相关指标。结果106例病人术后1周内血清总胆红素水平较术前明显下降（P < 0.05）,引流有效率70.8%。Bismuth Ⅰ型组、金属支架组引流有效率分别明显高于BismuthⅡ~Ⅳ型组、塑料支架组（P < 0.05）。恶性肝门部胆管狭窄较远端胆管狭窄的术后急性胰腺炎及急性胆管炎的发生率明显升高（P < 0.05）。术前血清白蛋白水平及术中回抽淤积胆汁量与引流效果呈明显正相关（P < 0.05）。结论经ERCP置入胆管支架的姑息性减黄治疗安全有效,但对于引流效果及术后并发症相对风险较高之BismuthⅡ~Ⅳ型组应谨慎对待。术前血清白蛋白水平及术中回抽胆汁量可预测支架引流效果。     

移行吻合术治疗肝门部良性胆管狭窄的实验研究

目的探索“移行吻合术”治疗肝门部胆管良性狭窄的新术式,探讨肝门部胆管良性狭窄进行“移行吻合术”的理论基础与实际应用可行性．方法小型猪30头随机分为：A、B、C3组．A组（对照组）于十二指肠上缘分离出一段长约2cm的胆总管;B组分离胆总管同A组,然后以钳夹、电热等方法制造胆管组织物理损伤;C组制造胆管损伤同B组,术后监测小型猪的饮食二便,ALT,AST和胆红素等指标,待狭窄形成后再次开腹行移行吻合术．术后观察饮食、精神状态及尿液颜色,术前和术后1d及术后每7d测ALT、AST、T—BIL、D—BIL,全部手术完成3个月后处死,取部分肝组织,并用液氮保存,待做病理检查．结果从术前到术后30d,A组ALT、AST、T—BIL、D—BIL等指标无明显变化,B组、C组相关指标均有明显变化（P〈0．05）．B组术后21d的ALT、AST、T—BIL、D—BIL较术前及术后14d明显升高（P〈0．05）．C组行移行吻合术后,各项指标在移行吻合术后14、21d较移行吻合前明显减低（P〈0．05）．结论“移行吻合术”治疗小型猪肝门部胆管良性狭窄是切实可行的,为临床以“移行吻合术”治疗肝门部胆管狭窄提供了实验基础．     

103钯放射性支架对平滑肌肌动蛋白在犬胆管损伤愈合过程中的表达影响及意义

目的观察胆管内放射对平滑肌肌动蛋白(SMA)在犬胆管损伤愈合过程中的表达影响,探讨^103钯(^103Pd)放射性支架抑制胆管损伤后狭窄的作用及意义。方法通过犬肝外胆管损伤模型将^103Pd放射性支架和普通支架分别植入犬肝外胆管内,分别于手术后30d取材行SMA免疫组织化学SP染色观察。结果^103Pd放射性支架组犬胆管SMA表达较弱,而普通支架组却较强,但是^103Pd放射性支架组犬胆管腔狭窄程度比普通支架组轻。结论^103Pd放射性支架犬胆管内放射可以减弱SMA在胆管愈合过程中的表达,从而可以抑制胆管损伤后因胆管瘢痕性挛缩导致的胆管狭窄。