门静脉高压与胆囊病变关系的探讨

本文总结了１９８８年至１９９５年因门静脉高压住院的３００例患者，经Ｂ型超声波、Ｘ线胆道造影（静脉胆道和口服胆囊造影）、ＣＴ检查所见胆囊的病理变化：如胆囊壁增厚（〉３ｍｍ）者１６６例，胆汁淤积和／或胆囊内见沉淀样物１０８例，胆囊收缩功能降低和排空迟缓１０４例，合并胆囊结石６２例，胆囊萎缩２８例，共发现有胆囊病变者１７５例，占５８．３％，很值得我们重视。     

肝胆管结石并发门静脉高压症外科治疗探讨

目的探讨肝胆管结石合并胆汁性肝硬化门静脉高压症的外科治疗方法。方法全面评估患者，积极术前准备，对大多数患者施行一次性胆道手术，治愈率为95．5％。结论胆汁性肝硬化门静脉高压症患者经去除胆道结石梗阻，建立有效引流后肝硬化门静脉高压症有可能逆转，故对大多数患者可行一次性胆道手术治疗。     

胆石症合并肝硬化门静脉高压症术中和术后出血的处理

目的总结胆道结石合并门静脉高压症的术中及术后出血的处理经验。方法对2000年1月至2005年7月收治的45例胆道结石合并门静脉高压症并手术的病人进行回顾性分析。结果本组45例病人，治愈38例，死亡7例，病死率为15．6％。发生肝肾功能衰竭，MODS5例，胆囊床大出血2例。死亡病例与肝功能分级有明显关系，肝功能A级死亡1例（5．6％），B级死亡3例（16．7％），C级死亡3例（33．3％）。术后出血9例（20％），包括腹腔内出血6例，消化道出血3例。术后出血病人中6例死亡（66．7％）。结论对合并有门静脉高压症的胆石症病人，加强围手术期处理，可降低死亡率。急诊手术先处理胆道疾病，Child A级病人行腹腔镜手术是安全的。合并有门静脉高压症的胆道疾病者，先行断流加分流手术，再行胆道手术，是最安全的方法。     

原发肝胆管结石并门脉高压的外科处理

原发肝内胆管结石合并门静脉高压是其严重并发症之一。外科处理非常棘手，且疗效不满意。我院1988．9～1996．7月共收治原发性肝内胆管结石558例，其中合并门静脉高压者46例，占同期肝内胆管结石8．24％。     

肝胆管结石的临床病理类型与手术方式的选择

肝胆管结石的外科治疗方法的选择依赖于此症的病理特点和临床类型。肝胆管结石的临床病理特点和类型1．肝胆管结石的临床病理特点肝胆管结石的主要临床病理特点有以下5点。（1）肝胆管结石沿肝内病变胆管树呈区域性分布现象。（2）肝胆管结石多并存不同程度的肝胆管狭窄，肝胆管狭窄所引起的胆汁淤积是结石形成和复发的基本因素。肝胆管结石合并二级分支以上肝管狭窄时易导致受累肝段或亚肝段萎缩；合并双侧肝门部肝管狭窄者，晚期常发生胆汁性肝硬化及胆源性门静脉高压症。（3）肝胆管结石其病变范围内的肝组织萎缩，而正常肝组织增生肥大…     

门静脉高压症合并胆囊结石

目的 探讨门静脉高压症合并胆囊结石的治疗方法。方法 对因门静脉高压症合并胆囊结石46例的手术方法、治疗结果予以回顾性分析。结果 我科1988-1998年收治肝硬化门静脉高压症患者286例,合并有胆囊结石者46例（16.1%,其中2例伴有继发性胆总管结石）;胆囊壁水肿增厚者145例（壁厚4-13mm),并发胆囊结石的46例患者的胆囊均增厚,本组在行脾切除和贲门周围血管离断术的同时一期切除胆囊者38例,治愈35例,死亡3例,另8例患者先行脾切除、贲门周围血管断术,3-6个月后二期行胆囊切除术,无1例死亡。结论 门静脉高压行脾切除、贲门周围血管离断术同时行胆囊切除术,可引起严重出血。故手术方式应根据病人肝硬化程度、肝门部血管扩张的程度、胆囊的炎症程度等进行选择。     

胆囊良恶性病变ki-67和p27表达及其与细胞凋亡的研究

目的：研究胆囊良、恶性病变中ki-67和p27表达及其与细胞凋亡指数的关系。方法：采用病理组织学观察、免疫组化方法（S－P）和原位脱氧核糖核酸末端转移酶标记（TUNEL）技术,对57例胆囊良、恶性病变进行检测。结果：胆囊壁增厚者粘膜上皮部分或大部分脱失,形成代偿性区域性增生集中,伴有不同程度的异型性。ki-67在慢性单纯性胆囊炎中阳性细胞数占5．1％,胆囊壁肥厚者占21．25％,二者的阳性细胞数比较,差异有显著性（P＜0．01）。p27在慢性单纯性胆囊炎中阳性细胞数占9．4％,胆囊壁肥厚者45．2％,胆囊上皮癌变87．1％,三者之间的阳性细胞数比较,差异有显著性（P＜0．01）。细胞凋亡指数在慢性单纯性胆囊炎中出现较少,并且仅局限在粘膜表面上皮,胆囊壁肥厚者细胞凋亡指数增多,并呈灶性分布,在异型增生Ⅲ级和癌变的病例中细胞凋亡指数处于不稳定状态,但多数病例细胞凋亡指数明显增加。结果显示胆囊腺上皮增生、异型到癌变的过程ki-67、p27的表达和细胞凋亡指数显著相关。结论：胆囊壁肥厚是重要的癌前病变,胆囊壁肥厚或增厚的结节在1．5cm以上应采取外科切除。     

肝胆管结石合并门静脉高压症的外科治疗

肝胆管结石常合并胆管狭窄 ,长期的胆管梗阻必然演变为胆汁性肝硬变、门静脉高压症。肝胆管结石合并门静脉高压症(不含原发性硬化性胆管炎和医源性胆管狭窄胆汁性肝硬变 )的外科治疗存在许多难题。早在 1979年黄志强院士发表了胆管狭窄合并门静脉高压症的外科治疗问题〔1〕的经验至今还是非常重要的。现结合我院 1979年至 1999年 2 0年间 5 5例分期手术治疗经验介绍如下。1　临床资料本组 67例 ,男 3 9例 ,女 2 8例 ,平均年龄 3 9.2岁 ( ( 17～ 67岁 )。以往胆道手术次数平均为 2 .7次 ( 1～ 6次 )。有上消化道出血史 18例 ,其中胆道出血 4…     

肝胆管结石终末期病变与肝移植

肝内胆管结石合并反复发作的急性、慢性胆管炎 ,胆管狭窄、梗阻 ,胆汁淤滞 ,造成肝实质细胞损害 ,纤维组织增生 ,进一步发展为继发性胆汁性肝硬化、门静脉高压症。据报告 ,由胆管狭窄发展为胆汁性肝硬化的时间平均约 7年。此时病人在临床往往表现为黄疸、脾肿大、脾功能亢进、腹水、消化道出血、衰竭 ,并常伴胆道感染、发热。当肝内胆管结石合并胆汁性肝硬化、门静脉高压 ,已是胆管结石病发展的终末期病变。疾病发展到此阶段 ,治疗已十分困难 ,预后极差 ,我们认为这是肝脏移植的绝对适应证。1　病例报告肝移植治疗肝内胆管结石病在国际上只…     

胆囊壁内结石290例临床分析

胆囊壁内结石的临床分析。方法：7500例结石性胆囊手术（腹腔镜胆囊切除7418例，中转开腹82例）胆囊壁内结石290例。结果：胆囊壁内结石平均发病年龄在52岁，胆囊壁多发性结石230例（79．3％），胆囊壁单发性结石60例（20．7％），胆囊壁结石伴胆囊结石250例（86．2％）。结论；罗一阿氏窦变化是形成壁内结石的基本条件，胆囊切除是有效的治疗方法。     

胆囊壁增厚的CT强化分型对胆囊炎病因的鉴别诊断意义

目的运用对胆囊壁增厚CT强化分层分型的方法,总结不同病因急性胆囊炎胆囊壁水肿与囊周积液的影像学特征及其临床意义。方法选取2009年1月至2012年12月期间,佛山市禅城区中心医院及顺德区新容奇医院临床诊断为急性胆囊炎或确诊为肝病并行上腹部CT增强扫描的患者169例作为研究对象,同时选取同期行上腹部CT增强扫描且诊断胆囊正常者5例作为对照组。研究组中,系非肝病性胆囊炎者146例,肝病性胆囊炎者23例。胆囊壁按囊壁强化及分层的不同分为5型,观察各组胆囊壁强化分型情况,测量胆囊壁黏膜层厚度;比较非肝病组和肝病组的各型发生率及胆囊壁黏膜层厚度之间的差异。结果非肝病组Ⅱ型102例（69.9%）,Ⅲ型5例（3.4%）,Ⅳ型30例（20.5%）,Ⅴ型9例（6.2%）;肝病组Ⅱ型2例（8.7%）,Ⅲ型11例（47.9%）,Ⅳ型5例（21.7%）,Ⅴ型5例（21.7%）。Ⅱ型在非肝病组的发生率高于肝病组（P〈0.005）,而Ⅲ型和Ⅴ型在非肝病组的发生率却低于肝病组（P〈0.005,P〈0.05）,Ⅳ型在2组的发生率之间的差异无统计学意义（P〉0.05）。Ⅰ型仅出现在对照组。非肝病组胆囊壁黏膜层厚度为（2.61±1.30）mm,大于肝病组的（2.02±0.52）mm（t=2.22,P〈0.05）。结论胆囊壁CT强化分层分型的方法,有利于非肝病性与肝病性胆囊炎的鉴别诊断,对胆囊炎有无穿孔也具有鉴别诊断意义。     

肝硬化、门静脉高压合并胆囊病变一期贲门周围血管离断术及胆囊切除术的可行性探讨

目的 :探讨肝硬化、门静脉高压合并胆囊结石、胆囊炎病人一期贲门周围血管断流术及胆囊切除术的可行性。方法 :对 33例肝硬化、门静脉高压合并胆囊结石、胆囊炎行断流术及胆囊切除术病人的临床资料与同期 30例肝硬化、门静脉高压不合并胆囊病变行贲门血管离断术的临床资料对比分析。结果 :两组病人术前、术中、术后临床资料均无显著性差异 (P >0 .0 5 )。结论 :肝硬化、门静脉高压合并胆囊结石、胆囊炎行一期胆囊切除术和贲门周围血管离断术是安全可行的     

Significance of wall thickness in symptomatic gallbladder disease.

One hundred cases of patients who underwent urgent cholecystectomy after presenting with symptoms of acute or subacute gallbladder disease were retrospectively reviewed. Sixty patients had pathologically proved acute cholecystitis, and 40 had chronic cholecystitis alone. One patient had an incidental gallbladder carcinoma, and four had global gangrene of the gallbladder. Focal ischemia, transmural hemorrhage, or focal necrosis (indicating more severe disease) was present in 19 patients. Fifty-four percent of patients had thin-walled gallbladders. Among patients with more severe acute disease, 56% had thin walls. Conversely, 24% of thin-walled gallbladders and 22% of thick-walled gallbladders had evidence of focal necrosis or gangrene. We conclude that gallbladder wall thickness, although demonstrable on preoperative ultrasound examination in all patients, does not correlate directly with severity of disease or pathologic findings.     

Liver transplantation in precirrhotic biliary tract disease: Portal hypertension is frequently associated with nodular regenerative hyperplasia and obliterative portal venopathy

Chronic biliary tract disease is the third most common indication for orthotopic liver transplantation (OLT) in the United States. Most patients undergoing OLT for chronic biliary tract disease have end-stage liver disease associated with cirrhosis, but a minority are transplanted in the precirrhotic stage for indications that can include poor quality of life (eg, intractable pruritis or fatigue), recurrent ascending cholangitis, or cholangiocarcinoma. A smaller subset of these patients suffer from severe noncirrhotic portal hypertension that can be associated with histologic features of nodular regenerative hyperplasia (NRH) and/or obliterative portal venopathy. We reviewed 306 liver explants performed for chronic biliary tract disease at 2 institutions during 1995 to 2003 to identify patients who were transplanted in the precirrhotic stage. The following clinical data were recorded: age, sex, type of biliary tract disease, radiology, clinical symptoms, signs of portal hypertension, pretransplant shunting procedures, time between diagnosis and OLT, and primary indication for OLT. Histopathologic data included: explant weight, gross appearance, fibrosis stage (1 to 4), cholangitis, bile duct dysplasia, malignancy, portal vein thrombi, presence of NRH, and presence of obliterative portal venopathy. Twenty-six of 306 (8.5%) patients underwent OLT in the precirrhotic stage (12 females: 14 males, mean age of 46 y, age range 12 to 68 y). At explant, fibrosis stage ranged from 1 to 2 (portal and periportal fibrosis) to 3 (multiple bridging fibrosis). Underlying biliary tract disease included primary sclerosing cholangitis (18 cases), primary biliary cirrhosis (5 cases), autoimmune cholangitis (2 cases), and secondary sclerosing cholangitis (1 case). Primary indications for OLT were recurrent cholangitis and/or decreased quality of life (11 cases), complications of portal hypertension (6 cases), portal hypertension plus cholangitis/decreased quality of life (5 cases), and malignancy (4 cases). Of the 11 patients with portal hypertension as a major indication for transplant, 2 had undergone transjugular intrahepatic portal-systemic shunting and 3 others had portal vein thrombi. Histopathologically, NRH was prominent in 8 of these 11 patients (73%) and obliterative portal venopathy in 6 (55%). NRH was also present in 4 of the 15 (27%) patients who were transplanted for other indications. These results indicate that precirrhotic portal hypertension is a predominant or major contributing factor to OLT in a significant minority (11 of 306, 3.3%) of patients with chronic biliary tract disease. The occurrence of NRH in some patients transplanted for other indications suggests it is a histologic pattern that can precede the development of clinically significant portal hypertension.     

Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis

An easy, safe, and definitive operation for the "difficult gallbladder" is described and has been termed subtotal cholecystectomy. Eighteen patients underwent subtotal cholecystectomy during a 30-month period, which constitutes approximately 7% of cholecystectomies performed at our institution. The indications were cholecystitis with severe fibrosis or inflammatory changes that prevented safe dissection in Calot's triangle in 11 patients and portal hypertension in seven patients (liver cirrhosis [two patients] and segmental portal hypertension caused by chronic pancreatitis [five patients]) to prevent massive blood loss from the gallbladder bed. The operation entails leaving the posterior wall of the gallbladder attached to the liver and securing the cystic duct at its origin from within the gallbladder with a purse string technique. The latter obviates the need for dangerous dissection in Calot's triangle. Control of bleeding from the remaining gallbladder edge is greatly facilitated by the use of a running suture after each stage of piecemeal excision of the gallbladder. All patients survived the operation and wound infection occurred in only two patients (11%). One patient required a laparotomy 1 month after surgery for adhesive small bowel obstruction related to the remaining gallbladder wall and site of a liver biopsy. No patients have so far developed postcholecystectomy symptoms (median follow-up 12.2 months; range 3 to 31 months). Subtotal cholecystectomy is a definitive operation that prevents recurrent gallstone formation, as no residual diseased gallbladder mucosa is left in continuity with the biliary system. It provides a simple, safe option in patients in whom cholecystectomy could be hazardous.     

Intraportal endovascular ultrasonography in the diagnosis of portal vein invasion by pancreatobiliary carcinoma.

OBJECTIVE: The purpose of this study was to determine the value of intraportal endovascular ultrasonography (IPEUS) in the diagnosis of portal vein invasion by pancreatobiliary carcinoma. The authors reported their experiences with this new technique and compared it with conventional imaging technologies, such as portography and computed tomography (CT). SUMMARY BACKGROUND DATA: Pancreatobiliary carcinoma often invades the portal vein. Observation of the echogenic band of the portal vein wall by means of a high-frequency, high-resolution intravascular ultrasound catheter allows for the accurate diagnosis of the portal vein invasion. METHODS: A prospective study of 30 consecutive patients with pancreatobiliary carcinoma (16 pancreatic carcinomas, 8 bile duct carcinomas and 6 gallbladder carcinomas) was performed. In 23 cases IPEUS was performed intraoperatively from the superior mesenteric venous route with an 8 French, 20 MHz intravascular ultrasound catheter. In 7 cases IPEUS was performed before surgery from the percutaneous transhepatic route with a 6 French, 20 MHz intravascular ultrasound catheter. The finding of IPEUS was confirmed by pathologic examination of resected specimens and surgical exploration. The results of IPEUS were compared to those of portography and CT. RESULTS: Intraportal endovascular ultrasonography visualized the portal vein wall as an echogenic band with a thickness of 0.5 mm to 1.0 mm. The diagnostic criterion of portal vein invasion was destruction of this echogenic band. Portal vein invasion was found in 15 of 30 cases. Vascular invasion was confirmed by pathologic examination of resected specimens in 10 patients and operative findings in 5. The sensitivity, specificity, and overall accuracy of IPEUS for diagnosis of portal vein invasion was 100%, 93.3%, and 96.7%, respectively. The values were 80%, 67.7%, and 73.3% for portography and 53.3%, 80%, and 66.7%, respectively, for CT. CONCLUSIONS: Intraportal endovascular ultrasonography provided precise information about the relationship between the pancreatobiliary tumor and the portal vein wall. It was capable of accurately detecting or excluding early invasion of the portal vein wall by pancreatobiliary carcinoma.     

胆结石对胆囊粘膜的病理损害及其与胆囊癌关系的研究

研究结石对胆囊粘膜的病理损害及这一过程中细胞DNA和AgNOR含量的改变,以探讨各型病理改变在胆囊癌发病中的作用。方法:对165例连续切除的胆囊标本进行病理及组化研究。结果:合并结石时胆囊粘膜的单纯增生、不典型增生、胆囊癌发生率分别为75.2％、19.33％和5.4％;结石引起的化生率为38.8％;胆囊粘膜从单纯增生到轻、中、重度不典型增生及胆囊癌的AgNOR颗粒及面积与DNA倍体含量逐步增高;50岁以上结石患者的化生、不典型增生、DNA及AgNOR含量均明显增加。结论:胆囊结石病例的不典型增生明显增多,推测不典型增生是胆囊癌的重要癌前病变,50岁以上的结石患者胆囊癌风险明显增加。     

胆囊疾患合并肝硬变行腹腔镜胆囊切除术的体会

目的:总结胆囊疾患合并肝硬变行腹腔镜胆囊切除术(LC)的经验。方法:切胆囊疾患合并肝硬变ll例行LC,观察肝硬变对手术的影响和术后恢复过程。结果:11例术后均恢复顺利,随访至2000年12月无并发症发生。结论:无症状的轻度肝硬变患者行LC治疗安全可靠;伴有门静脉高压症的患者,是LC的相对适应证。行LC治疗应慎重,并须认真做好围手术期处理。     

经皮经肝胆囊穿刺置管引流治疗合并肝硬化的急性胆囊炎

【摘要】〓目的〓探讨经皮经肝胆囊穿刺置管引流治疗对合并肝硬化门静脉高压症的急性胆囊炎患者的安全性及疗效。方法〓回顾性分析于2013年9月到2014年12月进行经皮经肝胆囊穿刺置管引流术治疗的合并肝硬化高压症急性胆囊炎患者12例。其中,肝功能Child-pugh A级7例,Child-pugh B级5例,分析12例患者经皮经肝穿刺胆囊置管引流术后并发症发生情况、术后炎症消退情况、术前后肝功能变化情况。结果〓12例患者均通过皮经肝胆囊穿刺置管引流术治疗后胆囊炎症消退,并择期成功行腹腔镜下胆囊切除术。其中,有2例患者因穿刺出现腹腔内出血,后经保守治疗后出血停止。无胆瘘发生。术后部分患者肝功能有所改善。结论〓经皮经肝穿刺胆囊置管引流治疗对合并肝硬化的急性胆囊炎是一种安全的治疗方法,可作为后续安全地施行腹腔镜下胆囊切除术的过渡。