自体腹膜管修复胆总管缺失的实验研究

目的探讨自体腹膜管修复胆总管缺失的可行性。方法取健康雄性成年普通家兔20只,分为A、B两组,两组都建立胆总管缺损模型,切取壁层腹膜制成腹膜管,分别与胆管上、下断端行端端吻合,腹膜管外包带蒂大网膜。术后观察实验动物活动、饮食、巩膜有无黄染及二便等一般情况。A组和B组分别于修复术后4周和12周再次开腹,切取修复区胆管行HE光镜检查及免疫组化检查,观察局部组织的愈合、胆管上皮的爬行情况。结果动物存活情况:2只实验兔分别于修复术后第9 d和第15 d死亡,其余18只实验兔均健康存活至再次手术。大体标本观察:修复段胆管质地柔韧,管腔无狭窄。探查肝脏表面光滑,质韧。光镜观察:腹膜管大部分腔面覆盖着单层柱状上皮,中外层为增生纤维组织,散在淋巴细胞、浆细胞、成纤维细胞和巨噬细胞,并见较完整的毛细血管。结论自体腹膜管修复缺损胆总管后,使用带蒂大网膜包裹,腹膜管的成活率高,胆管上皮可逐渐由两端向对侧移行覆盖腹膜管腔面。     

壁层腹膜加带蒂大网膜覆盖术修复胆总管缺损的实验研究

为了解决修补胆管后的腹膜重新获取血供，我们用自体壁层腹膜加带蒂大网膜覆盖术修复胆管缺损的方法进行了实验研究，并做了光镜和扫描电镜（简称ＳＥＭ）的观察。１．材料与方法：采用杂种犬６只（体重１５～２０ｋｇ），１只为对照组，５只为实验组。在胆总管前壁造一个...     

不同组织替代输尿管黏膜重建输尿管的组织病理学观察

目的观察腹膜和膀胱黏膜重建犬黏膜剥脱输尿管的组织病理学变化。方法成年杂种犬18条，随机分3组，制作输尿管黏膜剥脱模型后，重建组黏膜缺损处分别予膀胱黏膜或腹膜植入，对照组仅留置输尿管支架管，术后10周将犬处死，取重建段输尿管作病理学检查。结果对照组损伤段输尿管腔明显狭窄或闭锁，未见黏膜生长。膀胱黏膜替代组黏膜生长良好，其中1条犬重建段输尿管上段轻度扩张，重建段狭窄不明显。腹膜替代组腹膜组织消失，重建段见新生移行上皮，输尿管腔均无狭窄。结论腹膜或膀胱黏膜可作为输尿管黏膜剥脱后重建的理想修复材料。     

带腹壁下血管腹膜瓣修复输尿管长段缺损的实验研究

目的:探讨带腹壁下血管腹膜瓣修复输尿管长段缺损的可行性。方法:18只健康成年杂种犬随机分为三组,每组6只,建立长段输尿管缺损动物模型。分别用游离腹膜、带腹壁下血管腹膜瓣修复缺损输尿管,对照组仅留置支架管。术后12周行静脉肾盂造影和组织病理检查。结果:对照组及游离腹膜组输尿管未恢复连续性,带腹壁下血管腹膜瓣组输尿管恢复连续性。结论:带腹壁下血管腹膜瓣可作为长段输尿管缺损修复的选择材料。     

自体组织修复肝门部胆管良性狭窄

目的 总结应用自体组织修复肝门部胆管良性狭窄的经验。方法 回顾分析我院自1989～2002年应用带蒂胆囊壁瓣修复肝门部胆管良性狭窄33例，应用肝圆韧带修复肝总管狭窄2例。结果 35例术后无明显胆瘘、出血等并发症，无手术死亡。术后T管造影显示无狭窄。术后30例(30/35)随访2个月至12年，仅有2例因术后胆管炎发作，经非手术治愈，收到良好效果。结论 应用自体组织带蒂胆囊壁瓣及肝圆韧带修复肝门部胆管良性狭窄符合生理性，取材方便，操作简便，效果良好。     

膨体聚四氟乙烯补片修复胆管缺损的实验研究

目的 探讨膨体聚四氟乙烯（ePTFE)修复胆管缺损的可能性。方法 36条重庆地区成年犬,通过切除部分胆管壁（A组,14条）、整段切除2－4cm胆总管（B组,10条）和完全结扎胆总管（C组,5条;D组,7条）的方式建立胆管损伤模型,分别采用ePTFE补片修补胆管缺损,管形材料替代胆管,间置材料在胆囊、十二脂肠或空肠吻合修复胆管。观察动物在手术前后的活动状况,结合胆道造影了解胆通畅情况,并在术后3天,2、4、8、12及52周切取胆管修复处的组织,观察胆管组织的变化,不同手术方式对肝脏形态结构的影响。结果 A组采用ePTFE补片修补胆管,胆管上皮能覆盖材料表面,通畅率达75％（9／12）,胆汁引流通畅,肝脏无损害;B组通畅率为40％（4／10）,伴有不同程度的肝脏形态结构改变;C组和D组的材料均被排除,形成胆囊十二指肠或胆囊空肠瘘。结论 ePTFE补片具有操作简便、通畅率高的特点,可作为修补胆管缺损的材料。     

游离腹膜管重建黏膜剥脱输尿管的实验研究

目的探讨腹膜重建黏膜剥脱输尿管的可行性，探索治疗输尿管黏膜袖状剥脱的新方法。方法成年杂种犬12条，随机分为重建组和对照组，每组6条。首先制作输尿管黏膜剥脱模型，黏膜剥脱3—5cm。重建组采用游离腹膜管植入黏膜缺损段，并留置输尿管支架管；对照组仅留置支架管。术后10周行IVU和组织病理学检查。结果术后10周重建组IUV示术侧肾脏形态大小正常，无肾积水，输尿管均可全程显影，腹膜替代部分输尿管无明显狭窄；对照组IVU示术侧肾脏均不显影或仅显示增大模糊轮廓，输尿管均未显影。对照组犬输尿管腔均严重狭窄或闭锁。重建组犬腹膜组织被完整成熟的移行上皮替代，输尿管无明显狭窄，上皮下可见丰富的新生血管。结论输尿管黏膜剥脱〉3cm时，仅留置支架管将导致输尿管狭窄或闭锁；利用游离腹膜管替代输尿管黏膜是一种有效的治疗方法。     

自体膀胱黏膜移植于浆肌层肠段重建输尿管的实验研究

目的长段输尿管狭窄或缺损的修复是泌尿外科棘手问题,将犬自体膀胱黏膜移植于浆肌层肠段重建输尿管,探讨其作为尿路替代材料重建输尿管的可行性。方法成年比格犬12条,体重6.5～9.3kg,雌雄不限,根据重建输尿管部位不同将其随机分成A、B、C组(n=4)。A组:自体膀胱黏膜移植于浆肌层肠段后包缝于人工输尿管支架制备人工输尿管,重建8cm长下段输尿管,将人工输尿管近端与上段输尿管断端吻合,远端与膀胱吻合。B组:同A组方法重建8cm长上段输尿管,将人工输尿管近端与肾盂吻合,远端与下段输尿管断端吻合。C组:同A组方法重建全段16cm长输尿管,将人工输尿管近端与肾盂吻合,远端与膀胱吻合。术前各组犬取血行肾功及电解质检测;术后观察犬的一般情况及支架管和造瘘管的引流、手术切口的愈合、并发症的发生等情况。术后第6周行生化指标复查及静脉尿路造影(intravenous urography,IVU)检查后,对人工输尿管行大体及组织学观察。结果B组1条犬术后2d因输尿管支架脱出,术后发生尿瘘及伤口感染,排除实验;其余犬术后均无并发症发生。术后第6周各组犬肾功和电解质检测与术前比较,差异均无统计学意义(P0.05)。IVU显示:A组1条犬术侧肾脏积水、上段输尿管扩张,B组1条犬人工输尿管与下段输尿管吻合口狭窄、同侧肾脏积水;其余各组犬术侧肾脏功能良好,人工输尿管有蠕动功能。组织病理学观察示术后第6周3组人工输尿管组织结构与正常输尿管相似,其中A、C组各1条犬出现人工输尿管炎症。结论自体膀胱黏膜移植于浆肌层肠段重建犬输尿管,可形成组织结构与正常输尿管相似的人工输尿管,且功能良好。     

SIS修复重建兔气管缺损的实验研究

目的 探讨SIS覆盖的聚丙烯补片(polypropylene mesh,PPM)修复重建兔气管缺损的可行性,及SIS在促进气管纤毛柱状上皮再生、减少术后并发症等方面的作用.方法 取12只新西兰大白兔,体重1.8～2.0 kg,制备大小为1.2 cm×0.6 cm的气管前壁、侧壁4～6环全层缺损模型.根据修复材料不同,随机分为两组,每组6只.PPM修复组采用大小为1.4 cm×0.8 cm的单纯PPM修复缺损;SIS-PPM修复组采用预先紧密缝合的大小为1.4 cm×0.8 cm的SIS和PPM修复缺损.术后观察动物一般情况,于4、8、12周取材进行大体观察、HE染色及扫描电镜观察重建区域情况.结果 术后SIS-PPM修复组动物均存活至实验完成,无感染、皮下气肿、呼吸困难发生.PPM修复组分别于术后6 d及18 d因气道感染及气道分泌物潴留死亡1只兔,其余动物均出现不同程度的颈部皮下气肿.两组动物重建气管均无塌陷、狭窄.组织学观察:术后各时间点两组动物气管腔内均未见明显肉芽及瘢痕,8、12周时重建气管表面有气管黏膜覆盖,SIS-PPM修复组纤毛组织和杯状细胞多于PPM修复组.扫描电镜观察:术后8周SIS-PPM修复组重建气管中心区域大部分被较成熟的纤毛覆盖,PPM修复组重建中心区域大部分为幼稚纤毛覆盖;12周时SIS-PPM修复组纤毛方向性好,纤毛无明显分泌物附着;PPM修复组纤毛凌乱,纤毛表面有大量分泌物附着.结论 SIS和PPM修复重建气管缺损能充分维持修复重建后的气道形态和生理功能,并能获得良好的上皮化.SIS具有促进气管黏膜修复愈合,减少术后皮下气肿、气管狭窄的作用,有望用于临床修复重建气管组织缺损.     

自体组织修复胆管良性狭窄

目的总结应用自体组织修复肝外胆管良性狭窄的经验。方法回顾性分析2007-2011年应用带蒂胆囊壁瓣、肝圆韧带脐静脉片修复6例肝外胆管良性狭窄的临床资料。结果 6例病人术后均无胆漏、出血等并发症,术后T管造影显示胆道通畅无狭窄,随访6个月至4年,无胆管炎症状及胆道梗阻发生。结论应用自体组织带蒂胆囊壁瓣,肝圆韧带脐静脉片修复肝外胆管良性狭窄符合生理,取材方便,操作简便,效果良好。     

Small intestinal submucosa as a bioscaffold for biliary tract regeneration

BACKGROUND: Porcine small intestinal submucosa (SIS) biograft is used as a bioscaffold for regeneration of a variety of tissues. To date, SIS has not been used as a biliary tract graft. The purpose of this study was to evaluate the feasibility of using SIS as a scaffold for bile duct tissue regeneration in a canine model. METHODS: Fifteen, 25- to 35-kg mongrel dogs underwent midline laparotomy and exposure of the common bile duct. Nine dogs had a longitudinal choledochotomy and a 2- x 1-cm elliptical patch of 4-ply SIS placed using 6-0 polypropylene suture. Six dogs had the anterior two thirds of the bile duct resected and a 2- to 3-cm tubularized 4-ply SIS interposition graft placed. Dogs were killed at intervals ranging from 2 weeks to 5 months. Before killing, liver function tests (alkaline phosphatase [U/L] and total bilirubin [mg/dL]) were evaluated, cholangiograms were performed, and the bile duct was examined histologically. RESULTS: Fourteen out of 15 dogs survived and were healthy at the time of killing. The one failure was a result of a bile leak in a patched animal. The SIS showed signs of incorporation with infiltration of native fibroblasts, blood vessels, and biliary mucosa within 2 weeks. Within 3 months the SIS graft was replaced with native collagen covered with a biliary epithelium. No changes occurred at 5-month follow-up. One animal with an interposition graft developed a stricture at the proximal anastomosis within 2 months. In the remaining dogs, liver enzymes were normal, and the caliber of the common bile duct remained normal. CONCLUSIONS: SIS can be used for regeneration of bile duct tissue in a canine model. In 13 of 15 dogs SIS resulted in regeneration of canine common bile duct when used as a patch or as an interposition graft. The potential for the use of SIS as a patch for biliary stricturoplasty, or as an interposition graft for repair of complex biliary injuries is encouraging.     

小肠黏膜下基质用于胆管重建的研究

目的 探讨在肝外胆管节段性缺失时,小肠黏膜下基质(SIS)用于重建胆管的可行性及相关机制,为胆道重建寻找新的思路.方法 SIS制成管状,实验犬6条,胆总管节段性切除12～15 mm,以SIS管桥接.分别于术后3、9周取材,通过胆道造影、病理等方法观察胆道重建过程和组织重构效果.结果存活率100％,胆瘘、胆道闭塞发生率为0.胆管收缩、狭窄现象普遍,长度收缩约(13.5±4.1)％.病理检查见胆管内膜细胞覆盖植入SIS段胆管,管壁由成纤维细胞构成,新生血管丰富.结论 SIS材料制成管状用于替代胆管节段性缺失是可行的,可以避免胆漏,无管腔塌陷、闭塞.     

Repair of Extrahepatic Bile Duct Defect Using a Collagen Patch in a Swine Model

Extrahepatic bile duct (EBD) injury can happen during surgery. To repair a defect of the EBD and prevent postoperative biliary complications, a collagen membrane was designed. The collagen material was porous, biocompatible, and degradable and could maintain its shape in bile soaking for about 4 weeks. The goal was to induce rapid bile duct tissue regeneration. Twenty Chinese experimental hybrid pigs were used in this study and divided into a patch group and a control group. A spindle‐shaped defect (20 mm × 6 mm) was made in the anterior wall of the lower EBD in the swine model, and then the defect was reconstructed using a collagen patch with a drainage tube and wrapped with greater omentum. Ultrasound was performed at 2, 4, 8, and 12 weeks postoperatively. Liver function tests and white blood cell count (WBC) were measured. Hematoxylin–eosin staining, cytokeratin 7 immunohistochemical staining, and Van Gieson's staining of EBD were used. The diameter and thickness of the EBD at the graft site were measured. There was no significant difference in liver function tests or WBC in the patch group compared with the control group. No evidence of leakage or stricture was observed, but some pigs developed biliary sludge or stone at 4 and 8 weeks. The drainage tube was lost within 12 weeks. The neo‐EBD could withstand normal biliary pressure 2 weeks after surgery. Histological study showed the accessory glands and epithelial cells gradually regenerated at graft sites from 4 weeks, with increasing vessel infiltration and decreasing inflammation. The collagen fibers became regular with full coverage of epithelial cells. The statistical analysis of diameter and thickness showed no stricture formation at the graft site, but the EBD wall was slightly thicker than in the normal bile duct due to collagen fiber deposition. The structure of the neo‐EBD was similar to that of the normal EBD. The collagen membrane patch associated with a drainage tube and wrapped with greater omentum effectively induced the regeneration of the EBD defect within 12 weeks.     

医源性胆管狭窄的手术治疗

目的 探讨医源性胆管狭窄的手术治疗方法.方法 回顾性总结1989年1月至2006年12月收治的235例医源性胆管损伤及胆管狭窄患者的临床资料.对损伤或狭窄患者采用胆肠通路重建术、保留和利用乳头括约肌的修复术、肝移植术等进行修复.结果 本组182例患者行胆肠Roux-en-Y吻合术,12例行胆总管对端吻合术,34例行自体带蒂组织瓣吻合术,6例行胆总管切开成形T管引流术,1例行肝移植术.随访时间1～10年,189例获随访.手术优良率为94.7%(179/189).狭窄复发率为5.3%(10/189),复发原因主要为合并结石、硬化性胆管炎、胆汁性肝硬化等.1例因严重胆汁性肝硬化、门静脉高压症,术后死于肝功能衰竭.结论 胆肠Roux-en-Y吻合术是可靠的治疗方法.利用自体带蒂组织瓣修复胆管能保留胆管下端Oddi括约肌的功能,效果良好,但远期疗效有待进一步评估.胆管内不需要常规放置支撑管.肝移植是治疗胆管狭窄引起的终末期胆病的有效方法.     

Human amnion as a bioprosthesis for bile duct reconstruction in the pig

Despite technical advances in management, the complication of late stricture formation and biliary sepsis still occur in bile duct reconstruction. In an attempt to avoid bilioenteric anastomosis, which bypasses the biliary sphincter mechanism, various biologic and artificial materials have been employed clinically and experimentally to replace the damaged bile duct. No satisfactory biliary replacement material has yet been found. In the experimental model of bile duct stricture that has been presented, human amnion bile duct injuries mimicking those seen in clinical practice were repaired using human amnion as a free graft. Noncircumferential duct loss appeared to be satisfactorily repaired using amnion, and the amnion repair was found to be as good as or superior to plastic repair; however, circumferential duct loss was not adequately repaired with the amnion graft.     

可降解聚乳酸支架在胆管损伤治疗中作用的实验研究

目的评价一种新型的可降解聚乳酸支架在胆管损伤胆管修复中的支撑作用和其安全性以及可行性。方法选择4条犬作为实验动物，麻醉后行胆囊切除，横断胆总管，造成胆管损伤模型。行胆管对端吻合，并放置可降解聚乳酸支架支撑。分别于10周、11周、13周和15周行胆道造影，并切取胆总管组织和肝组织做组织学检查。结果所有犬血胆红素正常。胆道造影检查显示胆管支架通畅，没有胆管狭窄。支架膨胀，完好支撑在胆管内，没有移位。支架内没有胆泥形成。组织学检查显示胆管黏膜未见异常，没有明显炎症反应和上皮增生。结论可降解聚乳酸支架能有效支撑胆管，安全，可行，为胆管损伤的支撑治疗提供了一个新的材料。但尚需要对其进行进一步观察和研究。     

内镜逆行胰胆管造影在肝移植后胆系并发症诊断和治疗中的作用

目的：评价内镜逆行胰胆管造影(ERCP)在肝移植术后胆系并发症诊治中的临床价值。方法：11例肝移植术后并发胆系并发症，其中吻合口狭窄4例，吻合口及供肝肝总管均狭窄2例，胆漏2例，多发性硬化性胆管炎样狭窄2例，移植肝胆总管与受者胆总管分离1例，分别行ERCP检查及治疗。结果：4例吻合口狭窄者，放置胆管塑料支架，2例吻合口和供肝肝总管均狭窄者放置Wallstenl，金属支架，上述6例近期黄疸均消退；2例胆漏者中，1例放置胆道塑料内支架，另1例行乳头括约肌切开术，均于2周内胆漏愈合；2例移植肝多发性硬化性胆管炎样狭窄者，1例行乳头括约肌切开后取出少量坏死胆管上皮样组织，另1例未行内镜治疗；1例移植肝胆总管与受者胆总管分离者再次手术行胆管吻合术。结论：内镜逆行胰胆管造影可用于肝移植术后的常见胆系并发症的诊断与治疗，可获得较好的近期疗效。     

活体肝移植的胆道重建技术及并发症分析

目的 探讨活体肝移植的胆道重建方法及并发症防治措施.方法 回顾性分析77例活体肝移植临床资料,其中74例行右半肝移植(带肝中静脉29例,不带肝中静脉45例),左半肝带肝中静脉1例,左外叶切取2例.胆道重建采用胆肠吻合或供肝肝管与受体肝管端端吻合.结果 供肝断面1个胆管开口为54例,多个胆管开口为23例;胆肠吻合2例,胆管端端吻合75例,63例留置T管;术后总体胆道并发症发生率为36.4%(28/77),其中胆漏为10.4%(8/77),胆道狭窄为26.0%(20/77).供肝单支胆道以及单个吻合口术后胆道狭窄的发生率明显低于多支胆道及多个吻合口(P<0.05).8例胆漏病人经过B超指引穿刺引流全部治愈,20例吻合口狭窄病人经T管窦道放置支撑管或通过ERCP进行扩张,肝功能全部或部分好转.结论 活体肝移植供肝切取术中注意对断面胆管血供的保护以及尽可能获得单一的肝管开口可有效减少术后胆道并发症的发生;内镜和放射介入技术是治疗胆道并发症的有效手段.     

肝移植术后胆道并发症的内镜治疗

目的:探讨内镜下逆行胰胆管造影术(ERCP)在治疗肝移植术后胆道并发症方面的临床疗效.方法:回顾性分析2002年8月-2012年12月采用ERCP治疗8例肝移植术后胆道并发症患者的临床资料,其中胆道狭窄5例(吻合口狭窄4例,肝内型胆道狭窄1例),胆瘘1例,胆石和胆泥形成2例.8例患者共行ERCP治疗21次,对胆道狭窄患者行括约肌切开、胆管扩张、鼻胆管引流和内支架置放术等治疗;对胆瘘患者行鼻胆管引流及塑料内支架置放术等治疗;对结石患者行括约肌切开、鼻胆管冲洗引流术及取石网篮取石等治疗.结果:ERCP手术成功率为100％ (21/21);4例吻合口狭窄、1例胆瘘和2例结石患者均治愈,1例肝内型胆道狭窄治疗未成功,建议再次肝移植;术后胆道感染的发生率为14.3％(3/21),胰腺炎发生率为19.0％ (4/21),经对症治疗后均痊愈.结论:ERCP是治疗肝移植术后胆道并发症微创、安全和有效的方法.     

经内镜逆行胆管造影在肝移植术后胆管并发症中的应用价值

目的探讨经内镜逆行胆管造影在肝移植术后胆管并发症中的应用价值。方法回顾分析本中心2003年10月至2006年3月经内镜逆行胆管造影诊断及治疗的71例肝移植术后胆管并发症的资料。71例胆管并发症包括52例胆管狭窄、6例胆漏和13例胆管结石。结果经内镜逆行胆管造影诊断胆管狭窄、胆漏和胆管结石的成功率分别为98．1％（51／52）、100％和100％（13／13）。经内镜逆行胆管造影介入治疗胆管吻合口狭窄、肝外型、肝门型、肝内型和弥漫型胆管狭窄的治愈率分别均为66．7％、66．7％、0、0和0,治疗胆漏的治愈率为66,7％,治疗胆总管结石和肝内胆管结石的治愈率分别为77．8％和0。结论经内镜逆行胆管造影是肝移植术后胆管并发症的有效诊断方法。不同类型的胆管并发症经内镜逆行胆管造影介入治疗的疗效不同。经内镜逆行胆管造影介入治疗仅能治愈部分胆管并发症（如胆管吻合口狭窄、肝外型胆管狭窄、轻中度胆漏及胆总管结石）。