胆道术后胆漏的原因分析和防治体会

目的探讨胆道术后胆漏的原因,治疗方法及预防措施。方法对我科在1999年7月至2006年4月施行收治556例胆道手术中发生10例术后胆漏进行分析。结果10例原因不同的胆漏患者采取相应的手术或非手术治疗,所有患者均获治愈,无严重并发症发生。结论周密的术前检查、个性化的治疗方案,通畅的术后引流是治疗和预防胆道术后胆漏的关键。     

Choledochal cyst following operation for idiopathic perforation of the biliary tract in childhood

Three patients with idiopathic perforation of the biliary tract who had been treated by a drainage procedure, had a choledochal cyst during 2–8 years of follow up. In all patients, anomaly of pancreaticobiliary duct was revealed by cholangiography and/or retrograde cholangiopancreaticography. It was strongly suggested that biliary perforation in childhood and congenital choledochal cyst are common in pathogenesis and that an anomalous arrangement may play an important causative role. Presented at the 15th Annual Meeting of the Pacific Association of Pediatric Surgeons, Vancouver, British Columbia, Canada, May 11–14, 1982.     

肝胆手术后胆漏的临床分析

目的探讨肝胆手术后胆瘘的原因及其诊断、治疗的方法。方法对10年来本院治疗的14例胆瘘病例进行分析。结果14例胆瘘病人均有肝胆手术史,10例行造影检查,其中7例经造影明确胆瘘位置及原因;11例行非手术治疗,3例行手术治疗,全部治愈出院。结论胆瘘多与肝胆手术损伤有关,造影检查有利明确胆瘘位置及了解胆道情况,绝大部分胆瘘病例可经非手术治愈。     

胆道支架植入加介入化疗方法治疗高位恶性胆道梗阻的体会

目的:评估胆道支架植入结合介入化疗在高位恶性胆道梗阻病人中的疗效。方法:对49例植入胆道支架并辅以选择性动脉插管化疗的病人,回顾性分析血清总胆红素(SB)和碱性磷酸酶(AKP)的变化,及支架阻塞发生率和存活时间。结果:术后2周,血清总胆红素和碱性磷酸酶水平较术前明显下降。在39例植入(33.3%)可膨式金属支架病人中,13例(33.3%)发生阻塞,中位阻塞时间为10个月;10例塑料支架均在术后4个月内出现阻塞。本组病人的中位生存时间为12个月,1年生存率为55%,2年生存率为20%。结论:对高位恶性胆道梗阻病人,植入胆道支架同时辅以选择性动脉化疗是合适的治疗方法。可膨式金属支架较塑料支架的效果更好。     

血清降钙素原检测对胆道梗阻合并感染者的预测价值

目的探讨胆道梗阻患者发生早期胆道感染时降钙素原变化的临床意义。 方法选取2015年8月至2016年7月四川大学华西医院行手术治疗的胆道梗阻患者63例。根据术后胆汁培养和症状体征分为非感染组（24例）和感染组（39例）。比较感染者和非感染者的降钙素原（PCT）、白细胞计数（WBC）和中性粒细胞比值（NE%）,分析PCT、WBC和NE%在胆道感染中的诊断价值,包括ROC曲线下面积、敏感度、特异性、约登指数,分析手术前后感染者的PCT、WBC和NE%变化。 结果感染组患者PCT、WBC和NE%显著高于非感染组患者[（1.35 ± 0.15）ng/ml、（9.48 ± 1.17）× 10⁹/L、（79.24 ± 7.83） vs.（0.16 ± 0.04）ng/ml、（8.14 ± 0.87）× 10⁹/L、（67.93 ± 6.09）]（t = 37.936、4.841、6.035,P均< 0.001）。感染组患者PCT、WBC和NE%的ROC曲线下面积分别为0.904、0.568和0.519,PCT作为检测指标的敏感度、特异性和约登指数显著高于WBC和NE%。感染组患者术后3 d PCT、WBC、NE%水平显著低于术前[（2.63 ± 0.21）ng/ml、（10.27 ± 1.35）×10⁹/L、（79.96 ± 7.23） vs. （0.86 ± 0.09）ng/ml、（8.23 ± 0.97）× 10⁹/L、（71.11 ± 6.36）]（t = 39.049、6.442、4.933,P均< 0.001）。 结论PCT对胆道梗阻患者发生早期胆道感染具有较高的诊断价值,敏感度和特异性均较为显著。     

胆道良性疾病老年患者的治疗分析

目的探讨老年胆道良性疾病的治疗方式选择。方法回顾性分析了1999年5月-2005年4月218例60岁以上老年人胆道良性疾病的治疗情况，分为手术组和非手术组，分析了疾病种类分布、合并症类型、治疗方式选择和治疗结果。结果75．2％的患者存在不同类型的合并症。206例行手术治疗，其中急诊95例，手术并发症33例。总死亡率2．29％。结论针对老年患者并存病多和术后并发症多的特点，强化围手术期处理是提高手术成功率，降低并发症和病死率的关键。     

经胆道镜治疗胆道残余结石19年回顾

目的　介绍纤维胆道镜治疗胆道残石的经验体会。　方法　回顾分析 19年来纤维胆道镜诊治 110 5例胆道残余结石的临床资料。　结果　 10 6 7例残石中 ,镜检取石 14 83例次 ,结石取净 10 35例 ,残石取净率 97% ;未能取净残石 32例 ,全组无死亡。　结论　纤维胆道镜治疗胆管残余结石不仅能降低结石残留 ,避免病人多次手术 ,而且具有安全性高、创伤小、费用低、术后恢复快等优点。     

Management of biliary tract disease during pregnancy: a decision analysis

Background The appropriate management of biliary tract disease during pregnancy is uncertain. Although laparoscopic cholecystectomy can be performed safely during pregnancy, the timing and indications for this surgical intervention have not been firmly established. Methods We constructed a Markov decision analytic model that incorporates maternal well-being and fetal outcome into a choice between nonoperative management (NM) and laparoscopic cholecystectomy (LC) for pregnant women with biliary tract disease (BTD). Our model cycles through weeks of pregnancy for a cohort of 200 gravid women presenting with biliary tract disease in both the first and second trimesters. Weekly state probabilities and utilities for fetal outcome were derived from the literature, while weekly utilities for disease and operative states were estimated in consultation with obstetricians. We cycled the model from 6 to 42 weeks and from 19 to 42 weeks to simulate first and second trimester presentations. Outcomes are expressed in quality pregnancy weeks (QPWs). One QPW is the utility of a normal healthy week of pregnancy. Results A comprehensive search of the literature yielded a fetal death rate following LC for biliary tract disease of 2.2% and following NM of 7%. Relapse rates were found to be trimester dependent and estimated to be 55%, 55%, and 40% in the first, second, and third trimester, respectively. For a hypothetical cohort of 100 women presenting with biliary tract disease in their first trimester, LC generated 12,800 QPWs compared with 12,400 QPWs for NM, an average gain of 4 QPWs per woman. For the cohort of women entering the model in the second trimester, 11,600 QPWs were accrued by the LC group and 11,400 QPWs by the NM group, an average gain of 2 QPWs per woman. These findings were sensitive only to changes in fetal death rates under the two treatment arms. Conclusions Laparoscopic cholecystectomy is superior to nonoperative management for pregnant women presenting in the first or second trimester with biliary tract disease.     

非流行区华支睾吸虫感染致胆道急症诊治研究

目的探讨非流行区华支睾吸虫感染导致胆道外科急症的临床特点及诊治方法。方法对1998年1月至2007年4月中国医科大学附属盛京医院普外科收治的华支睾吸虫感染导致胆道外科急症21例临床资料进行回顾性分析。结果5例直接确诊,行经内镜下鼻胆管引流(ENBD)或内镜乳头括约肌切开术(EST),未行外科手术。其余的手术中或术后确诊,7例行胆囊切除术,6例行胆囊切除、胆总管切开取石、T管引流术,2例行胆总管空肠Roux-en-Y吻合术,1例行胰十二指肠切除术。全部手术病人术中或术后均发现胆汁内有华支睾吸虫成虫和(或)虫卵。结论非流行区胆道外科急症的病人应注意病因诊断。华支睾吸虫感染病人常具有典型的病史和辅助检查改变,一经确诊,除必要的外科治疗外均应进行驱虫治疗。     

MSCT在胃肠道穿孔中的诊断价值

【摘要】〓目的〓探讨多层螺旋CT(MSCT)在胃肠道穿孔中的诊断价值。方法〓回顾性分析25例经手术和病理证实胃肠道穿孔患者的术前MSCT影像资料,进行多平面重建(multiplanar reformation,MPR),分析穿孔征象,定性及定位的诊断准确性。结果〓25例患者中,胃、十二指肠穿孔18例,空、回肠穿孔2例,结肠穿孔3例,阑尾穿孔2例。MSCT术前诊断穿孔的正确率为100%(25/25),定位诊断正确率为96%(24/25)。CT诊断胃肠道穿孔的直接征象为肠壁连续性中断12例(48%)。间接征象包括腹腔内游离气体23例(92%),穿孔部位周围的炎症渗出改变25例(100%),腹腔积液12例(48%),局部胃肠道管壁增厚13例(52%),小网膜囊积液3例(12%),阑尾周围脓肿2例(8%),弥漫性腹膜炎2例(8%)。结论〓MSCT对胃肠道穿孔的定性和定位具有很高的诊断价值,有助于外科手术治疗。     

Use of an opened umbilical vein patch for the reconstruction of the injured biliary tract

Background/Purpose When iatrogenic biliary tract injury occurs, there is the risk of complications such as bile leak and biliary stricture, and hepaticojejunostomy is the conventional procedure used for injury repair. However, this procedure can be complicated by retrograde biliary tract infection and the procedure can destroy the normal anatomical structure. Methods We report here a method of end-to-end biliary tract reconstruction that uses an opened umbilical vein (OUV) patch and two stents to reduce bile leakage and biliary stricture formation following injury to the common bile duct or right main bile duct. The postoperative courses of four patients are reviewed. Results In two of the patients, there was a small amount of postoperative bile drainage (for 3 days in the first patient and 2 days in the second patient). Of the two stents, the first stent was removed 1 month postoperatively, and the second stent at 2 to 3 months postoperatively. Three patients have returned to normal activity without symptoms after 44, 62, and 93 months, respectively. One patient died of a liver tumor recurrence in the fifth postoperative month, without a biliary problem. Conclusions An OUV patch for end-to-end biliary reconstruction reduced the volume and duration of bile leakage. Further research is needed to accurately evaluate the stenting period so as to reduce its duration.     

急诊胆道手术围术期心率变异性观察

目的 探讨全麻下急诊胆道手术对心脏自主神经反射的影响。方法 15例急诊胆总管结石手术患者,行全身麻醉。测定麻醉前(T0)、气管插管后5分(T1)、胆道探查时(T2)、术中1小时(T3)、2小时(T4)、术毕拔气管导管前(T5)和拔气管导管后15分(T6)的血压、心率和心率变异性。结果 与T0比较,T1血压显著下降(P<0.01),T4、T5和T6血压升高(P<0.05和0.01)。总功率谱(TP)和低频谱(LF)在T1、T5和T6降低(P<0.05);LF在T3、T4升高(P<0.05);高频谱(HF)在T4显著升高(P<0.05),T5、T6显著降低(P<0.01);标化LF(LFnorm)和LF/HF从T1到T4显著下降(P<0.01),而同期标化HF(HFnorm)却显著升高(P<0.01)。结论 急诊胆道病人心率变异性增高;全麻下手术TP稳定,麻醉前异常兴奋的交感神经被抑制;拔管前后心脏自主神经兴奋性下降,交感神经兴奋性占优势。     

鲨鱼软骨制剂辅助治疗晚期胆道恶性肿瘤的初步临床观察

目的：评价鲨鱼软骨制剂辅助治疗胆道晚期肿瘤的临床应用价值。方法：以寿命表法统计分析２９例应用鲨鱼软骨制剂的胆道恶性肿瘤患者与对照组的生存率。结果：鲨鱼软骨制剂治疗组的平均生存时间为２６个月,而对照组仅为８．５个月,治疗组明显长与对照组。结论：鲨鱼软骨制剂在辅助治疗晚期胆道恶性肿瘤中有一定的临床应用价值。     

围肝门胆道手术方式方法的探讨附79例报告

目的探讨围肝门胆道手术的术式选择及手术技巧。方法2003年6月至2007年6月进行的围肝门胆道手术79例，其中肝门胆管癌22例（按Bismuth分型，Ⅳ型16例，Ⅲ型6例）；肝癌侵犯肝门7例；胆囊癌侵及肝门20例；肝移植术后肝门胆管狭窄4例；伴左右肝管起始部病变的肝内胆管结石22例。Ⅲ型Mirrizzi综合征4例。手术中将肝门部分为三个区域：门口、门外和门内，分别使用肝门显露技术、肝十二指肠韧带骨骼化技术和肝门拆开技术来处理，联合应用可显露病灶并切除之。然后通过肝管成形、胆肠吻合等技术完成胆道引流。结果79例患者均顺利完成手术，9例BismuthⅣ肝门部胆管癌获得根治性切除（56．3％）。本组患者均恢复良好，无重大并发症发生，无围手术期死亡病例。平均手术时间3．5h，平均出血量为450ml，大部分患者不需要输血即可以完成手术。切口感染4／79例；肺部感染、肺不张10／79例；胆瘘6／79例，经保守治疗，通畅引流10～28d后治愈。结论围肝门胆管是围肝门手术的核心，门口、门外和门内三技术的联合应用大大地提高了围肝门病灶的切除率，是成功手术的关键之所在。     

腹腔镜治疗小儿胆道穿孔12例临床体会

目的:总结腹腔镜手术治疗小儿胆道穿孔的临床体会。方法:2008年12月至2015年12月收治12例胆道穿孔患儿,均经腹腔镜探查证实为胆道穿孔,根据病情分别行胆总管囊肿T管引流+腹腔引流、胆囊造瘘术+腹腔引流、单纯腹腔引流。结果:12例患儿均成功完成手术,术后未出现胆道出血、胆漏等并发症。胆汁引流及腹腔引流24~72 h后,临床症状缓解,腹痛显著减轻,体温降至正常,黄疸逐步消退。8例胆总管囊肿穿孔患者术后6个月行二期胆总管囊肿切除、肝总管空肠Roux-Y吻合术,其中5例在腹腔镜下完成二期手术,3例因胆总管周围粘连重、分离困难中转开腹。结论:腹腔镜用于小儿自发性胆道穿孔的诊断与治疗避免了盲目开腹探查的缺点,创伤小,手术视野广,对腹腔及肠管干扰小,手术时间短,胆总管囊肿穿孔不影响二次腹腔镜手术。     

莫西沙星在胆道疾病手术中应用的前瞻性研究

目的 1.评价莫西沙星对胆道疾病手术病人的临床及细菌学疗效.2.观察莫西沙星治疗胆道疾病的安全性.方法 选取2008年6～ 10月确诊为胆道疾病行手术治疗的52例病人,随机分为实验组(莫西沙星治疗组,32例)和对照组(头孢哌酮/舒巴坦治疗组,20例).术中留取胆汁作细菌培养和药敏试验,并观察临床疗效.结果 41例病人胆汁共培养出48株细菌,另11例胆汁培养无菌生长,胆汁细菌培养阳性率为78.8％(41/52).菌株药敏结果和临床疗效两组间比较无显著差异(P＞0.05).莫西沙星治疗组有1例病人发生胸闷和气促.结论 莫西沙星是胆道疾病手术治疗病人一种可供选择的抗生素.