梗阻而无扩张：在估计黄疸中的重要性

用经肝胆道造影的方法,可能显示外科黄疸患者的肝内胆管不扩张,胆总管可以扩张或不扩张。作者为150例患者进行了经皮肝穿刺胆道造影,16例有部分或完全性胆汁流通障碍,但无肝内胆管扩张,其中5例的胆总管呈现扩张。这16例的黄疸原因是肝门转移癌,良性狭窄和结石。上述的矛盾现象,即胆道梗阻而无肝内胆管扩张,可用 Laplace 定律来解释,     

表皮生长因子受体在梗阻性黄疸肝内胆管上皮细胞的表达及意义

目的:观察表皮生长因子受体在梗阻性黄疸肝内胆管上皮细胞的表达.方法:通过大白鼠胆总管结扎模型,观察胆道梗阻时肝内胆管增生在肝纤维化中的作用;表皮生长因子(EGF)与肝内胆管增生的关系.结果:胆总管结扎2周后肝小叶汇管区有明显的胆管增生和肝纤维化,胆总管结扎4周导致肝硬变形成;透射电镜显示胆总管结扎2周时胆管上皮细胞基底侧可见大量的胶原纤维和增厚的基底膜物质.胶原纤维与胆管上皮细胞紧贴:肝脏EGF受体免疫组化染色显示胆总管结扎2周时肝内胆管上皮细胞胞浆、胞膜及胞核出现阳性染色反应.结论:胆道梗阻时增生的胆管通过破坏肝小叶结构和产生胶原纤维及基底膜物质,参与肝纤维化过程;EGF在胆道梗阻肝内胆管增生过程中起重要作用     

改良Oddi括约肌成形术30例

1994年至 2 0 0 2年对胆总管远端狭窄的病人应用改良Oddi括约肌成形术 ,以解除狭窄扩大胆道引流口径 ,经临床观察效果满意 ,报告如下。1　资料和方法一般资料 :本组 30例中男 8例 ,女 2 2例。年龄 32～ 6 7岁。 30例均有胆总管结石并扩张及远端狭窄 ,胆总管扩张程度直径 1.5～ 3cm。左右肝管有不同程度的扩张。合并肝内胆管结石 12例 ,胆囊结石 5例 ,胆总管切开取石术后再发结石 9例。术前有阻性黄疸 11例。手术适证 :①Oddi括约肌乳头开口直径小于 3mm。②胆总管远端狭窄段不超过 2cm。③胆总管扩张直径大于 1.5cm。④胆肠内引流术后盲端…     

经内镜鼻胆管引流联合腹腔镜、胆道镜完成胆总管探查后一期缝合的探讨

目的探讨术前经内镜鼻胆管引流(endoscopic nasobiliary drainage,ENBD)在腹腔镜胆囊切除、胆总管切开、胆道镜取石后一期缝合胆总管代替术后T形管引流的可行性. 方法对18例胆囊结石合并胆总管结石(不伴有完全性胆道梗阻)腹腔镜手术之前行鼻胆管引流,术中一期缝合胆总管. 结果手术时间70～120 min,平均85 min.术后住院7～10 d,平均8 d.术后5 d经鼻胆引流管行胆道造影显示胆总管愈合良好,全组病人无胆漏、胆总管狭窄、肝内外胆总管残余结石、引流管脱落、胆汁性胰腺炎等并发症.18例随访6个月,1例胆总管内小结石经内镜括约肌切开取石,余17例未见胆总管明显扩张或狭窄. 结论腹腔镜胆囊切除、胆总管探查、胆道镜取石网取石手术之前行鼻胆管引流,完全可以替代T形管体外引流,缩短了住院时间.     

腹腔镜胆总管探查术后一期缝合与置T管引流的比较

传统的胆总管探查术(common bile duct exploration,CBDE)强调放置T管引流,防止术后出现胆漏及胆总管狭窄,已成为胆道外科治疗常规之一.但腹腔镜胆总管探查术后放置胆管引流管增加了住院时间和拔除T管后并发症的发生率,并且增加了患者长期带T管的痛苦,严重影响了生活质量.而胆管一期缝合却因术后胆漏等原因未能得到推广.胆管一期缝合术后引起胆漏的常见原因有:粗针大线缝合,在针眼处渗漏胆汁;胆管内结石未取干净,引起胆管梗阻,胆道内压力升高,缝合口处渗漏胆汁;胆道探查和取石的过程中造成医源性胆管内壁损伤,术后胆管黏膜水肿,胆道内压力升高而出现胆漏.     

显微外科技术建立稳定的大鼠梗阻性黄疸内引流模型

目的:利用显微外科技术建立一个稳定的大鼠梗阻性黄疸内引流模型。方法:所有操作均在手术显微镜下进行。第1次开腹结扎近端胆总管,往胰腺端胆总管插入引流管约3 mm长,引流管远端封闭,建立黄疸模型;7天后第2次开腹,引流管开放后置入近端扩张的胆总管,实现近端胆管和胰胆管架桥。检测引流前后大鼠营养状况、肝重、肝脏和胰腺生化、肝脏病理和超声弹性成像等,评估新型模型的稳定性。结果:未见肠道返流、胆管堵塞等并发症。建立黄疸模型后第1天,有2例大鼠血清淀粉酶和脂肪酶升高,第4天及以后均未发现胰腺酶谱升高。胆道内引流后血糖和血清白蛋白较快恢复到正常水平;肝重/体重上升;各项生化指标、肝脏超声弹性模量值、肝脏病理改变逐渐恢复到正常水平。结论:采用显微外科技术,成功建立了一个新型稳定的大鼠梗阻性黄疸内引流模型。     

右肝管误认为胆总管一例报告

患者：女性,55岁,于2010年12月以胆总管结石收住入院.术前检查：一般情况正常,肝功能无异常,无梗阻黄疸体征,彩超示：胆囊结石,胆总管扩张并多发结石,右肝管扩张并结石.术中见：胆囊增大,与肝脏、网膜有轻微粘连,内有多枚结石,Calot三角尚清楚,胆囊管解剖清楚,胆囊管直径约0.4 cm、长约2 cm,自扩张胆总管发出,胆总管直径约2 cm,长5 cm,内有泥砂样结石数枚,纵行切开扩张胆管2 cm,取出结石,用胆道探子探清十二指肠及胆管上段关系,探查胆管上段,未见左、右肝管分叉及开口,常规行T管引流术,胆囊切除术.术后无特殊异常,9 d痊愈出院.术后15 d,间断夹闭T管,患者有轻微腹胀、恶心,偶有疼痛,但无黄疸,T管引流胆汁量400 ml/d左右.经T管造影后报告：胆总管、左、右肝管均轻微扩张,T管自右肝管引出,距胆总管约2 cm,十二指肠通畅,无残留结石.术后4周拔T管后无异常.患者病情康复,随访至今无特殊异常.     

胆囊颈管汇入部微切开免T管的胆道探查

胆道探查是肝胆外科的常见手术方式,常规胆道探查的指征包括术前患者的黄疸病史,B超检查中发现胆总管有可疑结石或胆管扩张,术中发现胆总管扩张或扪及异常等。以上均是胆总管的探查指征。但临床上常有一部分具有探查指征的病例探查为阴性而所有的探查胆管均需常规安放T管引流,安放T管后患者可能出现胆道狭窄,胆汁引流造成消化功能减弱、水电解质紊乱等;为此笔者于2000年起对部分需要胆总管探查的病例行胆囊颈管汇入部微切开,插入德国产Storz4．8m／n纤维胆道镜探查胆道,对部分病例免安T管取得成功,现报告如下。     

婴儿胆道扩张症伴胆道发育不良的手术治疗

目的 探讨巨大胆总管囊肿伴胆道发育不良症患儿的诊断和手术难点.方法 回顾性分析胆道扩张症患儿278例,其中3例伴有肝外巨大囊肿的胆道发育不良症患儿.本组患儿术中都进行胆道造影检查,了解肝内、外胆管通畅情况以及肝内胆管扩张情况;术中行肝脏活检,行囊肿切除术,术中放置肝总管支架管,并行肝总管-空肠Roux-en-Y吻合手术. 结果 3例患儿手术年龄在1～2个月之间,术中造影显示囊肿较巨大,左、右肝管发育较细且与肝内相通,有黄色胆汁流出.切开囊肿时有1例损伤肝总管,行肝总管修补手术,并行肝总管部位囊肿成型术,再行肝门-空肠吻合术.3例患儿术后无吻合口狭窄和结石形成;肝活检病理证实有通畅胆管,但胆管数量减少,未见类似胆道闭锁的胆管增生以及胆栓形成.术后随访1～5年,未见黄疸发生,超声显示无肝内胆管扩张.结论 术中胆道造影检查非常必要,如遇囊肿巨大,左、右肝管较细,切开囊肿时应小心,切口位置选择在胆囊管水平以下,勿损伤肝管,造成吻合困难,吻合时放置支架管对于早期胆汁引流意义重大.     

胆总管囊肿自发性破裂

日本Nagoya大学医院外科在过去24年中共收治123例胆总管囊肿,其中5例(4.1%)发生自发性穿孔,病因不清,可能与胆道内蛋白塞子和胰胆管连接异常有关.该5例的年龄为9月～8岁,均有腹胀、疼痛、恶心和呕吐症状,4例有发热,2例有黄疸,均未能扪及胆总管囊肿的块物.术前化验检查示血清胆红素值增高5例、血清淀粉酶增高1例、GOT增高3例和GPT增高1例.术前确诊3例,依据腹腔穿刺所得的胆汁和超声扫描提示胆总管扩张的结果.均行急症剖腹探查,见穿孔均在胆总管与胆囊管交接处的前方,穿孔自针尖至6mm直径不等,在穿孔处置入T管,并作腹腔引流.胆总管均呈梭形,伴胆胰管连接异常.术后恢复顺利.第一次术后1～4月再施行根治术,切除扩张的胆总管以及胰内狭窄的胆管远端,作空肠肝管Roux-Y型吻合,术后良好.组织学检查示胆总管穿孔壁增厚,复盖有肉芽组织,后者的范围局限,穿孔处以外的胆管粘膜完整良好,近穿孔处的纤维肌层含有大而活跃核的成纤维细胞,血管丰富.讨论 1932年Dijkstra报道首例胆管自发性穿孔,此后陆续有病案报道.病理机制不明,推测可能与胆管壁先天性薄弱、胆管壁存有憩室或异常腺体,胆管内反流的胰液刺激其粘膜以及胆管病毒感染有关.胆管自发性穿孔与穿孔性胆总管囊肿是不同的疾     

An unusual case of jaundice: Biliary tumor thrombus in fibrolamellar hepatocellular carcinoma

BackgroundFibrolamellar hepatocellular carcinoma (FL-HCC) is a rare and unique variant of hepatocellular carcinoma (HCC) whose presentation remains inadequately described. We present a resectable case of FL-HCC which involved tumor thrombus of the common bile duct.PresentationA 27 year-old male presenting with jaundice, abdominal pain, vomiting, hepatic dysfunction and hyperbilirubinemia was found to have a large liver mass and lymphadenopathy on preoperative imaging. A right hepatectomy with perihepatic lymph node dissection and cholecystectomy was performed. Intraoperative cholangiogram demonstrated common bile duct (CBD) obstruction. CBD exploration revealed biliary tumor thrombus relieved with biliary thrombectomy.DiscussionFL-HCC can initially present with invading obstructing biliary tumor thrombus of the CBD causing jaundice.ConclusionPreoperative surgical approach should consider CBD exploration on an individual basis for underlying obstructive biliary tumor thrombus.     

豚鼠不全性胆道梗阻早期Oddi括约肌功能的变化

目的:观察豚鼠胆道不全性梗阻后早期Oddi括约肌(SO)肌电活动及压力的变化。方法:16只英国短毛豚鼠随机均分假手术组与模型组,分别行假手术与制作胆总管不全性梗阻模型,期间测定胆总管直径;术后1周,再次检测两组胆总管直径、肝功能指标、SO肌电活动与动力学指标。结果:术后假手术组胆总管直径无明显改变(P0.05),而模型组较术前明显增大(P0.05)。与假手术组比较,模型组血清胆红素、肝酶水平明显升高(均P0.05);SO快波幅度和慢波振幅显著降低(均P0.05),但快波和慢波频率无统计学差异(均P0.05);SO基础压明显升高,但SO峰压明显降低(均P0.05),而SO收缩频率无统计学差异(P0.05)。结论:不全性胆总管梗阻可使豚鼠SO快、慢波振幅降低,SO基础压升高、收缩峰压降低,这可能是胆道不全性梗阻时易诱发急性胆源性胰腺炎的重要机制之一。     

Biliary stricture due to neuroma after an innocent blunt abdominal trauma

A traumatic neuroma of the biliary tract is rarely associated with biliary obstruction. However, when it arises in the common bile duct (CBD) and is associated with obstructive jaundice, it is difficult to distinguish it from bile duct cancer. We describe a patient who developed obstructive jaundice and itching, due to CBD stricture, 8 years after innocent blunt abdominal trauma. The stricture was resected and hepatico-jejunal anastomosis was performed. Histological examination revealed a traumatic neuroma and a fibrous scar around the common bile duct. Symptoms disappeared following surgical removal of the lesion. Blunt abdominal injury may cause the late onset of a fibrous scar and traumatic neuroma in the common bile duct. To our knowledge, a traumatic neuroma of the biliary tract after blunt abdominal trauma has not been reported previously. We review the clinical picture of this relatively rare problem, along with its diagnosis, pathogenesis and treatment.     

超声引导下经皮经肝胆管穿刺置管引流186例经验总结

目的探讨超声下经皮经肝胆管穿刺置管引流术在梗阻性黄疸的临床应用价值。方法应用彩色多普勒超声引导对186例梗阻性黄疸患者进行经皮经肝胆管穿刺置管引流术,并将治疗结果进行分析。结果186例梗阻性黄疸患者总成功率为97.3%(181/186),一针穿刺成功率达72.0%(134/186)。穿刺胆管直径范围为4～11mm。平均直径为5.3mm,术后胆汁引流量平均为420ml/d,带管时间为7～97d,平均为18.3d,并发症发生率为0.5%。结论彩色多普勒超声引导下的经皮经肝胆管引流术穿刺置管简便、安全、成功率高的优点,能够使患者得到持续性胆汁引流的机会,因此将成为治疗梗阻性黄疸的重要方法。     

正常直径胆总管行腹腔镜下胆总管探查一期缝合的安全性及可行性

目的探讨正常直径胆总管行腹腔镜下胆总管探查一期缝合的安全性与可行性。方法回顾性分析盛京医院2014年1月1日至2019年11月30日收治的行腹腔镜下胆总管探查一期缝合的120例患者资料,其中男性44例,女性76例,平均年龄57.2(22.0~88.0)岁。根据胆总管直径大小将患者分为扩张组(>8 mm)和正常组(≤8 mm)。比较两组患者手术时间、术中出血量、术后住院时间、术后腹腔引流管拔除时间与术后并发症的发生情况。结果扩张组纳入76例患者,其中男性25例,女性51例,中位年龄62.5岁;正常组纳入44例,其中男性19例,女性25例,中位年龄57.5岁。两组患者性别、年龄、白蛋白水平、总胆红素等基线资料差异无统计学意义(P>0.05)。两组患者手术时间[正常组106.0(87.3,146.3)min比扩张组112.0(90.5,134.5)min]、术中出血量[正常组20(10,30)ml比扩张组20(10,20)ml]、术后住院时间[正常组7.0(5.3,9.0)d比扩张组7.0(5.0,7.0)d]、术后腹腔引流管拔除时间[正常组6(4,7)d比扩张组5(4,6)d]差异均无统计学意义(P>0.05)。两组患者术后胆漏、胆道狭窄、结石复发等并发症的发生率差异无统计学意义(P>0.05)。结论在正常直径(≤8 mm)胆总管的患者中行腹腔镜下胆总管探查联合一期缝合术安全有效。     

Obstructive jaundice due to a textiloma mimicking a common bile duct stone

A foreign body is a rare cause of obstructive jaundice. We report a 19-year-old woman with jaundice caused by a surgical gauze in the common bile duct (CBD). Four yours earlier, she had undergone a cholecystectomy and drainage for hydatid disease of the liver. Her postoperative course was complicated by a biliary fistula that healed after 50 days. She now presented with obstructive jaundice of 2 weeks' duration. Magnetic resonance cholangiopancreatography (MRCP) showed a signal-void mass, consistent with a CBD stone. Surgical exploration of the CBD revealed a surgical gauze as the cause of the obstruction. To the best of our knowledge, this is the first case of a surgical gauze obstructing the CBD requiring surgical removal.     

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??Laparoscopic transcystic bile duct exploration??An analysis of 32 cases FAN Xiong-wei*, YANG Hai-tao, GUO Wei, et al.*Department of General Surgery, Wuzhong People's Hospital Affiliated to Ningxia Medical University, Wuzhong 751100, China
Corresponding author: GUO Wei, E-mail??guoweibfh@163.com
Abstract Objective To investigate the feasibility of laparoscopic transcystic biliary duct exploration (LTCBDE) for the treatment of common bile duct (CBD) stones by using 5 mm conventional choledochoscope in the basic-level hospital. Methods The clinical data and outcomes of 32 cases of gallstone and CBD stones treated by LTCBDE in Wuzhong People's Hospital Affiliated to Ningxia Medical University from June 2015 to April 2016 were analyzed retrospectively. All the cases were diagnosed with gallstone accompanying CBD stones preoperatively by ultrasonography, CT and (or) MRCP. Results The diameter of CBDs were 8 to 15 mm. CT or MRCP showed the diameter of the cystic ducts were more than 3 mm. The number of CBD stones were 1 to 3, and the diameter were 3 to 8 mm. Thirty of 32 cases of LTCBDE were successfully performed with the success rate of 93.8% (30/32). The average operation time was (96.2±32.5) min, and the average postoperative hospital stay was (3.5±2.1) d, and the incidence of complications was 6.3% (2/32). There were 8 cases of large stones during the operation, and the microincision technique was used to complete the stone removal. After 10 to 22 months of out-hospital follow-up, no biliary stricture, residual stones and recurrence were found. Conclusion It is feasible that the LTCBDE using conventional 5 mm choledochoscope can be applied in basic-level hospital when the patients are well selected and the surgeons are well trained. Thus, the technique is worthy to be popularized in the basic-level hospitals.     

Changes in liver blood flow with development of biliary obstruction in the rat.

As well as causing retention of biliary secretory products, bile duct obstruction is associated with other hepatic and systemic effects which are poorly understood. These latter changes contribute to the increased morbidity and mortality associated with surgery for biliary obstruction. This study examines the changes in liver blood flow occurring after common bile duct (CBD) ligation in the belief that relative hepatic ischaemia may contribute to dysfunction. A new method for measuring liver blood flow (LBF) based on the clearance of 133Xe from the liver following injection into the portal vein is described. With this new development, serial measurements of LBF can be performed in the conscious, unfasted rat. With the development of jaundice, a highly significant reduction in LBF is seen which is first evident 36 hours after CBD ligation. By the third day after ligation, LBF is only 54% of the control value. No fall in LBF is seen in rats subjected to sham ligation. The mechanism for the reduction in LBF is uncertain, but the delayed onset makes any relfex autonomic reaction unlikely.     

局部胆管内压大小及持续时间对犬胆管壁的影响

目的探讨局部胆管内压大小及持续时间对犬胆管壁的影响。方法设计并自制一内置入式胆管扩张器,体外测试扩张气囊内压力与注水容积及囊径的关系。将20只杂交犬随机分为五组,A组为假手术组仅在胆总管内放置胆管扩张器;B、C组分别向扩张气囊内注水0.1ml、0.2ml（球囊压力分别为0.24Kpa、0.58Kpa）扩张胆总管10min后抽空气囊并留置胆管扩张器作胆汁引流;D、E组分别向扩张气囊内注水0.1ml、0.2ml扩张胆总管后,不抽空气囊并留置作胆汁引流。各组分别术后7天再次剖腹。观察各组扩张前后血清总胆红素（TB）、丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）值及胆管直径（BD）变化、胆管壁及肝组织学改变。结果与A组比较,C组扩张后BD增宽（P〈0.05）。D组扩张后BD显著增宽（P〈0.01）,E组扩张后TB、ALT、AST均增高（P〈0.01）。A、B组胆管壁组织学无明显变化,C组胆管壁粘膜充血水肿,部分粘膜脱落,D组胆管直径增粗及胆管壁增厚,E组胆管壁部分坏死,与网膜或十二指肠粘连。结论局部胆管内压大小及持续时间对犬胆管壁的影响存在双向互变关系,正常胆管壁在一定的时间内可承受一定的局部胆管内压而不致发生胆管壁的病理变化,适宜的局部胆管内压可引起局部胆管及其上游胆管壁扩张,反之,胆管壁可出现破坏性改变。     

Ectopic hepatocellular carcinoma arising in the bile duct

We report a case of ectopic hepatocellular carcinoma arising in the bile duct. A 72-year-old woman was transferred to our hospital with fever, abdominal pain, and jaundice. Contrast-enhanced computed tomography revealed a round mass, measuring 25 mm in diameter, in the bile duct. The mass was causing obstructive jaundice. Endoscopic retrograde cholangiography showed a 27 mm × 21-mm round defect in the superior bile duct. These findings led to a diagnosis of bile duct tumor, and the patient underwent extrahepatic bile duct resection and biliary reconstruction. Gross examination of the tumor showed a fibrous capsule and a stalk arising from the bile duct mucosa. The tumor was diagnosed histopathologically as well-differentiated hepatocellular carcinoma arising in the bile duct.