Biliary fibrosis in microsurgical extrahepatic cholestasis in the rat

A new model of extrahepatic cholestasis, using a microsurgical technique, is performed as an alternative to the traditional model of the bile duct ligated-rat, in order to study the stage of fibrosis in the long-term. Male Wistar rats were divided into two groups: I (Sham-operated, n = 9) and II [Microsurgical Cholestasis (MC), n = 10]. After 4 weeks, portal pressure, types of portosystemic collateral circulation, mesenteric venous vasculopathy, hepatic function test, and liver histopathology were studied by using the Knodell index and fibrosis was determined by reticulin and Sirius red stains. The animals with MC presented portal hypertension with extrahepatic portosistemic collateral circulation, associated with mesenteric venous vasculopathy and increased plasma levels of bilirubin (6.30 +/- 1.80 vs. 0.22 +/- 0.37 mg/dL; P = 0.0001), alkaline phosphatase (293.00 +/- 82.40 vs. 126.30 +/- 33.42 U/L; P = 0.001), AST (380.00 +/- 78.50 vs. 68.33 +/- 11.74 IU/L; P = 0.0001), ALT (87.60 +/- 22.32 vs. 42.22 +/- 7.89 IU/L; P = 0.0001), and LDH (697.76 +/- 75.13 vs. 384.80 +/- 100.03 IU/L; P = 0.0001). On the contrary, plasma levels of albumin decreased (2.72 +/- 0.12 mg/dl vs. 2.99 +/- 0.10; P = 0.001). The microsurgical resection of the extrahepatic biliary tract in the rat produces an experimental model of hepatic inflammation, characterized by a high Knodell hepatic activity index (4), bile proliferation, and fibrosis.     

Sclerosing cholangitis. Anatomical distribution of obstructive lesions.

The cholangiograms of 36 patients with sclerosing cholangitis were reviewed. The mean age of the patient group was 43 years, and the mean disease duration was 4.5 years. Seventeen of the patients had associated inflammatory bowel disease. The mean serum bilirubin was 6.8 mg/dl, the mean SGOT was 105 IU/L, the mean SGPT was 108 IU/L, and the mean serum alkaline phosphatase was 534 IU/L. The cholangiograms demonstrated involvement of the extrahepatic bile ducts in 33 patients, involvement of the hepatic duct bifurcation in 33 patients, and involvement of the intrahepatic bile ducts in 35 patients. The cholangiograms were graded as to the areas of the most severe obstructive involvement. In 24 patients the area of most severe involvement was the hepatic duct bifurcation. In eight additional patients the hepatic duct bifurcation, along with the extrahepatic ducts and/or the intrahepatic ducts, were felt to be the areas most severely affected. This predilection for severe obstructive disease at the hepatic duct bifurcation in sclerosing cholangitis held for both patients with and without inflammatory bowel disease. Thus, most patients with sclerosing cholangitis have cholangiographic evidence of diffuse extrahepatic and intrahepatic biliary tract disease, with the hepatic duct bifurcation being the area generally most severely affected.     

多层CT在肝移植术后胆道并发症中的诊断价值

目的 探讨多层CT在肝移植术后胆道并发症中的诊断价值.方法 44例肝移植术后胆道并发症病人接受多层CT动态增强扫描,并于1周内行胆道造影检查(cholangiography,CP).以CP结果为对照,分析多层CT诊断肝移植术后胆道并发症的能力.CT对胆道系统的评价以动态增强门静脉晚期图像为基础,并结合胆道系统多平面重建进行分析.结果 CP证实肝外胆管(胆总管和肝总管)狭窄23例,左、右肝管狭窄24例,肝内胆管狭窄27例.CT诊断肝外胆管狭窄的敏感度、特异度、正确率、阳性预测值、阴性预测值分别为91.3%、83.3%、87.8%、87.5%、88.2%;诊断左、右肝管狭窄的敏感度、特异度、正确率、阳性预测值、阴性预测值分别为83.3%、88.2%、85.4%、90.9%、78.9%;诊断肝内胆管狭窄的敏感度、特异度、正确率、阳性预测值、阴性预测值分别为74.1%、92.7%、80.5%、95.2%、65.0%.CT发现4例肝内胆汁瘤及2例肝脓肿,而CP仅发现其中2例胆汁瘤,另4例因严重胆管狭窄和胆泥阻塞在CP上未能显影.CP证实3例吻合口胆漏,CT仅显示肝门区和腹腔积液,对漏口位置不能显示.CP证实33例肝内外胆管结石或胆泥,CT诊断的敏感度、特异度、正确率、阳性预测值、阴性预测值分别为72.7%、100.0%、78.1%、100.0%、47.6%.此外,CT检查正确诊断1例弥漫性肝内胆管狭窄病人的急性活动性胆道出血.结论 多层CT可作为诊断肝移植术后胆道并发症的常用检查方法,对诊断胆管狭窄、胆漏、胆管结石或胆泥以及肝实质病变、急性胆道出血具有重要价值.     

The development of a pyogenic liver abscess following radical resection of cholangiocellular carcinoma with ligation of the right hepatic artery: Report of a case

We present herein the case of a pyogenic liver abscess developing from hepatic ischemia caused by resection of the right hepatic artery when a left hemihepatectomy with caudate lobectomy and extrahepatic bile duct resection was performed for cholangiocellular carcinoma. Postoperative cholangiography revealed communication between the abscess cavity and the intrahepatic bile duct. The liver abscess was successfully treated by percutaneous transhepatic drainage. Thus, breakdown of the intrahepatic bile duct due to ischemia may play an important role in the development of a pyogenic liver abscess following hepatic arterial occlusion.     

Surgical treatment of congenital dilatation of the bile duct with special reference to late complications after total excisional operation

The surgical treatment of 100 cases with congenital dilatation of bile duct with special reference to late complications was analyzed. There were no deaths nor occurrences of malignancy. Among 91 patients who had undergone the standard operation, namely total excision of the dilated extrahepatic bile duct and reconstruction after Roux-en-Y hepaticojejunostomy, there were one early complication (pancreatic juice leakage) and five late complications (four intrahepatic gallstones and one liver abscess). The cause of intrahepatic gallstone formation after a total excisional operation was attributed to the remaining intrahepatic bile duct dilatation and the stenosis located between the intrahepatic bile duct dilatation and the common hepatic duct. Accordingly, these results support the total excisional procedure for this condition; however, with regard to the cases associated with cystic dilatation of intrahepatic bile ducts, completely free bile drainage from the dilated intrahepatic biliary system should be performed at the radical operation.     

肝动脉栓塞术后的肝内外胆道损毁性病变

目的 探讨经导管肝动态栓塞术后对胆道损伤的病因、治疗及预防。方法 总结５例因肝动脉栓塞引起的胆道损伤患者,其中４例为肝血管瘤经导管动脉栓塞术后,１例为手术时结扎肝动脉注射ＴＨ胶后。动物实验观察向大鼠肝动脉内注射乙醇复制血管栓塞剂对肝脏的损伤。结果 ５例患者均有胆道毁坏性病变,甚至造成胆汁性肝硬化,４例进行胆管空肠吻合及胆道支撑。实验结果证实肝动脉注射血管硬化剂无水乙醇后可以引起邻近汇管区肝脏局部坏     

Clinicopathological review of 18 cases of liver allografts lost due to bile duct necrosis

Clinical, radiographic, and pathological features of 18 patients with biliary necrosis in their explanted liver allografts were reviewed. Twelve patients were men and ages ranged from 27 to 72 years. Indications for initial liver transplant (LT) were viral hepatitis (n = 7), steatohepatitic cirrhosis (n = 3), cryptogenic cirrhosis (n = 3), secondary sclerosing cholangitis (n = 2), primary sclerosing cholangitis (n = 1), biliary atresia (n = 1), and nodular regenerative hyperplasia (n = 1). Donor age ranged from 16 to 75 years. Duct-to-duct biliary anastomoses were fashioned in 13 cases; warm and cold ischemia times were not significantly different from general LT population. Seventeen allograft biopsies after recirculation had no significant findings. Post-LT, clinical and radiographic evaluation indicated biliary strictures (n = 7), bile leak (n = 7), intrahepatic abscess (n = 1), and duodenal perforation (n = 1). Radiographic vascular studies suggested hepatic arterial thrombosis or stenosis in 11 cases. Biopsies prior to retransplantation were performed on 17 patients and showed acute rejection (n = 10), biliary outflow impairment (n = 4), normal histology (n = 2), and centrilobular necrosis (n = 1). Retransplantation was performed 14 to 334 days after initial LT. Pathological examination of explants revealed perihilar duct necrosis in all cases, with bacterial colonies (n = 10) and fungal organisms (n = 2). Arterial thrombi were seen in 10 cases, and two had prominent arteriosclerosis. Infarction and centrilobular necrosis were seen in 9 and 13 cases, respectively. Four explants showed features of biliary outflow impairment. Twelve patients were alive 6 to 18 months following retransplantation. We conclude that post-LT biliary necrosis is associated with ischemia, and such a complication is rarely evident in allograft biopsies. Biliary and vascular imaging studies are essential in evaluating patients for this complication.     

内镜逆行胰胆管造影术治疗肝移植术后并发胆管结石受者临床分析

目的探讨肝移植术后并发胆管结石受者行内镜逆行胰胆管造影术(ERCP)治疗的安全性和有效性。 方法回顾性分析南京军区福州总医院肝胆外科2005年1月至2015年12月肝移植术后并发胆管结石受者的临床资料。24例受者胆管结石确诊主要依据T管造影、MRCP或ERCP。确诊胆管结石受者均采用ERCP下行球囊扩张联合胆道塑料支架置入治疗,术中采用地西泮镇静,同时密切监测生命体征。观察肝移植术后并发胆管结石受者结石类型、狭窄情况、ERCP治疗情况及其治疗前后肝功能指标变化。采用Wilcoxon符号秩和检验比较ERCP治疗前后受者血清总胆红素(TBil)、碱性磷酸酶(ALP)、谷氨酰转肽酶(GGT)、ALT和AST水平变化。P<0.05为差异有统计学意义。 结果24例受者中胆总管结石20例(包括单纯胆总管结石11例、胆总管结石合并胆管狭窄9例),肝内、外胆管结石4例。肝移植至并发胆管结石平均间隔时间(604±215)d。19例发生在术后12～66个月,余5例发生在术后3个月内。11例胆总管结石受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架引流治疗,治疗有效。9例胆总管结石合并胆管狭窄受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架＋鼻胆管引流治疗,其中8例治疗有效;1例因重度胆管狭窄,反复内镜取石不能取尽,继发感染再次行肝移植。4例肝内、外胆管结石受者均采用柱状球囊扩张＋取石篮取石＋左、右肝管置入内支架＋鼻胆管引流治疗,治疗有效。受者内镜治疗后血清TBil、ALP和GGT分别为31、179和247 mmol/L,均低于内镜治疗前水平(43、273和385 mmol/L),差异均有统计学意义(z＝0.042、0.001、0.004,P均<0.05)。截至2017年12月,24例受者随访时间为1～2年,4例因原发性肝癌复发分别于肝移植术后9、5、34、25个月死亡,1例因上消化道出血于肝移植术后34个月死亡,1例因重度胆管狭窄行二次肝移植并于2014年4月因肝脓肿继发感染性休克死亡,1例因感染性休克于肝移植术后33个月死亡,其余17例随访期间未见结石再发。 结论内镜下行球囊扩张联合塑料支架置入治疗原位肝移植术后并发胆管结石安全、有效,可作为目前原位肝移植术后并发胆管结石的首选治疗方案。     

Surgical complications accompanying liver transplantation in Estonia

The purpose of this study was to evaluate surgical complications accompanying the introduction of orthotopic liver transplantation (OLT) in Estonia. Between 1999 and 2009, we performed the first 12 liver transplantations. Eight patients were males and four were females of age range 12 to 67 years. Their diagnoses were cholestatic disease (n = 5); tumor (n = 3); hepatitis C virus cirrhosis (n = 2); Budd-Chiari syndrome (n = 1); and cystic fibrosis (n = 1). Technical complications occurred in 7/12 patients. The early vascular complications in two patients were a suprahepatic vena cava lesion occurring at liver extraction, which resulted in uncontrolled suprahepatic bleeding after liver perfusion; the recipient died during transplantation. The other case displayed a right intrahepatic portal venous thrombosis, which was treated successfully with thrombolysis and anticoagulant therapy. Early biliary complications of biliary leaks occurred in three patients: two had undergone duct-to-duct reconstructions, which were treated by endoscopic retrograde cholangiography that successfully managed the anastomotic and recipient cystic duct leaks with a papillotomy and stenting. In one patient with a duct-to-jejunum anastomosis, a bile leak stopped at 3 weeks but he needed surgical therapy 2 years later due to an anastomotic stricture. Severe decubitus occurred in the lumbosacral region of the subjects with operating times of 14 hours. They required necretectomy and plastic surgery. One of them with postoperative intra-abdominal hypertension also displayed wound eventration requiring reoperations. The rate of hepatic (5/12) and extrahepatic (3/12) surgical complications, as well as of 1-year survival (9/12), in our period of implementation of OLT were satisfactory to continue OLT development in Estonia.     

Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation

OBJECTIVE: To evaluate anatomic variations of the biliary tree as applied to living donor liver transplantation. SUMMARY BACKGROUND DATA: Anatomic variability is the rule rather than the exception in liver surgery. However, few studies have focused on the anatomic variations of the biliary tree in living donor liver transplantation in relation to biliary reconstruction. METHODS: From November 1992 to June 2002, 165 patients underwent major hepatectomy with extrahepatic bile duct resection; right-sided hepatectomy in 110 patients and left-sided hepatectomy in 55. Confluence patterns of the intrahepatic bile ducts at the hepatic hilum in the surgical specimens were studied. RESULTS: Confluence patterns of the right intrahepatic bile ducts were classified into 7 types. The right hepatic duct was absent in 4 of the 7 types and in 29 (26%) of the 110 livers. Confluence patterns of the left intrahepatic bile ducts were classified into 4 types. The left hepatic duct was absent in 1 of the 4 types and in 1 (2%) of the 55 livers. CONCLUSIONS: In harvesting the right liver from a donor without a right hepatic duct, 2 or more bile duct stumps will be present in the plane of transection in the graft in 3 patterns based on their relation to the portal vein. Accurate knowledge of the variations in the hepatic confluence is essential for successful living donor liver transplantation.     

Spontaneous biliary peritonitis,or delayed bile leak?

Introduction

Spontaneous biliary peritonitis is a rare cause of acute abdominal pain. Whilst usually of extrahepatic origin, here we describe an even rarer perforation of an intrahepatic duct.

Presentation of Case

A 31 year old woman presented with acute onset epigastric abdominal pain on a background of cholecystectomy four years prior. Laparoscopy demonstrated bilious fluid but failed to identify the site of bile leak. Subsequent ERCP localised the leak to an anomalous radical of the right hepatic duct.

Discussion

Spontaneous biliary peritonitis is a rare diagnosis. Most cases are extrahepatic and the pathogenesis of intrahepatic ductal rupture has been difficult to define. Whilst acute bile leak is a recognised complication of cholecystectomy, bile leak four years following operation has not been described previously.

Conclusion

Spontaneous biliary peritonitis remains as a rare cause of acute abdominal pain. Within the context of cholecystectomy, the surgeon should always be alert to the possibility of delayed bile leak.     

Biliary complications and outcomes of liver transplantation from donors after cardiac death.

Biliary complications after liver transplantation (LT) using organs retrieved from donors after cardiac death are not well characterized. The aim of this study was to evaluate the severity of biliary complications and outcomes after donation after cardiac death liver transplantation (DCD-LT). A retrospective evaluation of 20 DCD-LTs from 1997-2006 was performed. The recipient age was 53+/-8.7, and the donor age was 35+/-11 years. The warm ischemia time, cold ischemia time, peak alanine aminotransferase level, and peak aspartate aminotransferase level were 33+/-12 minutes, 8.7+/-2.7 hours, 1757+/-1477 U/L, and 4020+/-3693 U/L, respectively. The bilirubin and alkaline phosphatase levels at hospital discharge after LT were 3.2+/-5.4 mg/dL and 248+/-200 U/L, respectively. During a median follow-up of 7.5 months (range: 1-73), 5 patients (25%; 1 death after re-LT) died (3 from sepsis, 1 from recurrent hepatocellular carcinoma at 4 months, and 1 from a cardiac event at 46 months), and additionally, 4 patients (20%) required re-LT (1 because of hepatic artery thrombosis, 1 because of primary graft nonfunction, and 2 because of biliary strictures). Twelve (60%) developed biliary complications, and of these, 11 (55%) had serious biliary complications. The biliary complications were as follows: a major bile leak for 2 patients (10%; both eventually underwent retransplantation), anastomotic strictures for 5 patients (25%), hilar strictures for 7 patients (35%), extrahepatic donor duct strictures for 9 patients (45%), intrahepatic strictures for 10 patients (50%), stones for 1 patients (5%), casts for 7 patients (35%), and debris for 2 patients (10%). More than 1 biliary complication was seen in most patients, and these were unpredictable and required multiple diagnostic or therapeutic procedures. Serious biliary complications are common after DCD-LT, and research should focus on identifying donor and recipient factors that predict and prevent serious biliary complications.     

Resection of hepatic duct bifurcation and transhepatic stenting for sclerosing cholangitis.

Thirty-one patients with sclerosing cholangitis underwent reconstruction of their hepatic duct bifurcation and long-term stenting between 1980 and 1987. Indications for surgery were persistent jaundice in 29 and recurrent cholangitis in two. The mean serum bilirubin level before surgery was 10.4 mg/dl. Liver biopsy revealed that 26 patients had varying degrees of hepatic fibrosis, and five patients had progressed to secondary biliary cirrhosis. In 29 patients the major obstructive duct disease was at or near the hepatic duct bifurcation, and in two patients it was in the distal common duct. The operative procedure consisted of: (1) excision of the hepatic duct bifurcation and extrahepatic biliary tree, (2) dilatation of the intrahepatic ducts, (3) insertion of Silastic transhepatic biliary stents, and (4) bilateral hepaticojejunostomies. Two of the five patients (40%) with cirrhosis died after surgery. In contrast, only one of 26 patients (3.9%) with hepatic fibrosis died after operation. The 1-, 3-, and 5-year actuarial survival rates for patients with cirrhosis were 20%, 20%, and 20%, respectively. The only long-term survivor underwent a liver transplant. The 1-, 3-, and 5-year actuarial survival rates for patients with hepatic fibrosis were 92%, 87%, and 71%, respectively. In addition, the mean serum bilirubin levels of patients with hepatic fibrosis at 1, 2, 3, 4, and 5 years were 3.4 mg/dl, 2.9 mg/dl, 4.0 mg/dl, 5.4 mg/dl, and 4.3 mg/dl, respectively. Two of the long-term survivors subsequently underwent a liver transplant. Patients with sclerosing cholangitis, persistent jaundice, and biliary cirrhosis should be referred for consideration of liver transplantation. However, in the absence of biliary cirrhosis, if the major obstructive disease is at the hepatic duct bifurcation, primary biliary reconstruction and long-term stenting should be considered.     

选择性左肝动脉结扎在腹腔镜肝切除术中的应用

目的:探讨选择性左肝动脉结扎用于腹腔镜肝切除术的可行性。方法:回顾分析2008年10月至2009年7月我院为19例左肝内外胆管结石、血管瘤患者行腹腔镜肝切除术中行选择性左肝动脉结扎的临床资料。结果:19例手术均获成功,术中出血20~200ml,平均80ml,手术时间90~420min,平均240min,术后住院4~9d,平均5.9d,术后病理示无恶变,无肝脏衰竭、出血、胆漏及膈下脓肿等并发症发生。结论:腹腔镜左肝切除术中选择性左肝动脉结扎术能减少术中出血,安全可行。     

磁共振成像在肝移植术后并发症诊断中的应用

目的探讨磁共振成像在肝移植并发症诊断中的价值。方法回顾分析11例肝移植术后发生并发症者的磁共振检查影像资料。结果11例患者术后出现皮肤和巩膜黄染、发热以及尿黄等症状，丙氨酸转氨酶、天冬氨酸转氨酶、γ-谷氨酰转移酶和胆红素升高．经B型超声波检查不能明确原因，采用磁共振（MRI、MRA和MRCP）检查，明确肝动脉吻合口狭窄1例；肝动脉闭塞2例；下腔静脉吻合口狭窄及血栓形成各1例；胆管吻合口狭窄4例，其中1例伴胆汁瘤形成；肝门水平非吻合口狭窄6例；肝坏死2例；肝包膜下血肿及右肾上腺出血各1例；均显示不等量的右侧胸腔积液、腹腔积液及肝门部水肿。结论磁共振一次检查可显示肝内外的多种结构，能为肝移植术后并发症的诊断提供丰富的肝脏、血管、胆道以及肝外结构的图像信息。     

不同浓度盐酸消融兔胆管的实验研究

目的：了解不同浓度盐酸消融胆管后兔的肝功及胆管组织改变,为临床应用消融栓塞胆管治疗肝内胆管结石提供实验依据。方法：观察20%、15%、10%和5%的盐酸消融右外叶胆管后兔的存活情况、肝脏功能和胆管组织病理改变。结果：胆管消融术后所有动物均未死亡,存活率100%。20%盐酸及15%盐酸胆管消融造成兔右外叶肝脏几近坏死。10%盐酸胆管消融导致兔右外叶近肝门部肝实质完全坏死,肝叶中部及边缘组织以汇管区为中心的大片坏死。5%盐酸胆管消融后兔右外叶近肝门部及中部肝实质以汇管区为中心的坏死,肝叶边缘仅胆管坏死。与20%、15%和10%盐酸组兔相比,5%盐酸组的肝功能损害最轻。结论：盐酸作为胆管消融剂,能够导致胆管组织凝固性坏死,破坏胆管上皮,终止胆管上皮及胆管周围腺体的分泌;5%为盐酸消融胆管的较理想浓度。     

肝胆管外科入路的应用解剖

目的探讨在不同肝门解剖结构条件下，肝内及肝门胆管的暴露途径。方法选用成人肝脏标本３０例，沿肝十二指肠韧带向肝门及肝内解剖，观察肝内外胆管的行径特点及其毗邻关系。结果肝管汇合的常见方式有３型，本组左右肝管正常汇合型１８例、二级肝管直接汇合型和右侧胆管变异支异常汇合型分别为６例。肝管行出肝门的水平有较大差异。肝门区管道结构的相互毗邻关系及Ｇｌｉｓｏｎ束在肝内的行径相对恒定。结论在正常的肝门解剖结构条件下，通过解剖肝门的方法可以暴露肝总管及左右肝管，在解剖变异或需要暴露更高位胆管时，可以借助肝正中裂切开法或肝方叶切开法达到暴露目的。     

Randomized trial of the usefulness of a bile leakage test during hepatic resection

HYPOTHESIS: An intraoperative bile leakage test will assist in decreasing postoperative bile leakage in patients undergoing hepatic resection. DESIGN: Randomized controlled trial. SETTING: University hospital. PATIENTS: One hundred three consecutive patients who were scheduled for hepatic resection without biliary reconstruction. Associated cirrhosis was present in 49 patients (48%), and only 24 (23%) had normal livers. Patients were randomized to undergo (n = 51) or to not undergo (n = 52) a bile leakage test, according to age, liver function, and hepatectomy method. The 2 groups were similar in baseline demographics. INTERVENTION: A bile leakage test was carried out by injecting isotonic sodium chloride solution through the cystic duct, and interrupted suturing was taken for a bile leak on the transected liver surface. MAIN OUTCOME MEASURES: The incidence of postoperative bile leakage and the length of the postoperative hospital stay. Bile leakage was defined as continuous drainage, with a bilirubin level of 86 micromol/L or more (> or =5 mg/dL), beyond 1 week. RESULTS: Twenty-one patients (41%) in the test group showed a bile leak, and a median of 1 site (range, 1-6 sites) was closed during the test. Postoperative bile leakage was observed in 3 patients (6%) in the test group and in 2 (4%) in the control group (P = .99). The odds ratio of the event was 1.53 (95% confidence interval, 0.25-9.44). The median postoperative hospital stay lasted 17 (range, 13-47) and 18 (range, 12-41) days for the test and control groups, respectively (P =.98). CONCLUSION: This randomized trial suggested no advantage in using a bile leakage test during hepatic resection.     

Congenital cystic dilatation of the intrahepatic bile ducts (Caroli's disease): report of a case and review of the literature.

A case of congenital cystic dilatation of the intrahepatic bile ducts (Caroli's disease) followed for more than 7 years is reported. This patient presented also with congenital hepatic fibrosis, gallstones, and biliary hypersecretion of more than 3,000 ml in 24 hours. An analysis of the literature relating to Caroli's disease disclosed 46 well-documented cases of both hepatic histopathology and biliary tree studies. Six cases (13%) were found to be isolated forms of intrahepatic cystic dilatations; 16 (34.7%) were associated with congenital hepatic fibrosis; 10 (21.7%) presented with either a choledochal cyst or nonobstructive extrahepatic biliary tree dilatation; and in 14 cases (30%) the three anomalies were found together in the same patient. After these findings, we think that congenital hepatic fibrosis, congenital cystic dilatations of the intrahepatic bile ducts (Caroli's disease), choledochal cyst and other nonobstructive dilatations of the extrahepatic biliary tree are possibly the same congenital disease with different levels of involvement.     

腹腔镜胆总管切开取石T管引流术210例报告

目的 探讨腹腔镜治疗肝内外胆管结石效果。方法 在腹腔镜下切开胆总管用纤维胆道镜取石,胆总管内置入T管,缝合胆总管切口。结果 210例腹腔镜手术全部成功,手术时间80～230min。术后腹腔引流管引流出胆汁6例,十二指肠损伤1例,腹腔残石致引流管口形成脓肿1例,胆道残石10例,术后经T管窦道纤维胆道镜取石后治愈,从T管引流出钛夹2例。术后第2天进流质饮食并下床活动,平均住院5天,带T管出院。结论 该手术扩大了腹腔镜胆囊切除术适应证,具有创伤小、恢复快、住院短等优点,是治疗胆囊结石并胆总管结石尤其是胆总管大结石的有效方法。