原发性肝内胆管结石的细菌学和电镜观察研究

目的 探讨原发性肝内胆管结石与胆道感染的关系。方法 手术过程中，在无菌条件下收集35例原发性肝内胆管结石病人的胆管胆汁35份，结石30份，进行需氧菌培养，并对部分结石行扫描电镜和透射电镜观察。结果 胆汁细菌培养阳性率为94.2%，结石细菌培养阳性率为96.7%。胆汁和胆石培养出的细菌种类相似，均以肠球菌属细菌占首位，其次为大肠杆菌和克雷伯菌属。对6例肝内胆管结石行扫描电镜观察，5例行透射电镜观察，均观察到结石内的有细菌存在，这11例病人的胆汁、胆石细菌培养均呈阳性。结论 原发性肝内胆管结石内有细菌存在，可能是引起胆道感染的重要感染源之一。     

肝切除术治疗肝内胆管结石

目的研究肝切除和不同范围肝切除术对肝内胆管结石的治疗效果。方法分析我院近14年择期手术治疗的肝内胆管结石病人498例，比较肝切除组和无肝切除组、不同范围肝切除组的术后残余结石率、治疗效果和手术并发症。结果本组63．7％的病人行肝切除术。2001年后肝切除术的比例（74．6％）明显高于1991-1995年（49．5％）和1996-2000年（51．1％），而胆肠吻合术和单纯胆管切开取石T管引流术的比例逐渐减少。肝切除组术后结石残余率明显低于无肝切除组（19．2％vs31．7％，X^2=9．996，P=0．002）；肝切除组的优良率明显优于无肝切除组（85．2％vs74．7％，X^2=7．251，P=0．007），但肝切除组术后的并发症（伤口并发症除外）发生率和死亡率与无肝切除者无统计学差异。局限在肝左外叶的结石，肝左外叶切除效果好，术后无一例有残余结石。对结石分布超过左外叶时，左外叶切除、左半肝切除、右半肝切除和肝段切除的结石残余率分别为51．2％，14．3％，6．25％和11．5％，左外叶切除术后结石残余率明显高于左半肝切除、右半肝切除和肝段切除（P〈0．001）。半肝切除和肝段切除的优良率明显高于左外叶切除（94．8％．US76．1％，X^2=15．454，P〈0．001）。结论肝切除是治疗肝内胆管结石最有效的方法，对于非局限在左外叶的肝内结石，半肝切除和肝段切除术优于左外叶切除。     

肝叶切除术治疗肝内胆管结石24例临床分析

目的 探讨防止肝内胆管结石术后高残余结石的有效方法。方法 5年来采用肝叶切除术治疗肝内胆管结石24例,其中行左外叶切除13例,左半肝切除5例,右后叶切除2例,右后叶加左外叶切除2例,右半肝切除2例。结果 术后残余结石4例（16．6％）,其中残留左内叶2例（8．3％）、右后叶2例（8．3％）。术后切口感染2例（8．3％）,右胸腔积液1例（4．2％）,胆漏1例（4．2％）。结论 肝叶切除术结合高位狭窄胆管切开整形胆肠吻合应是肝内胆管结石症治疗的最好和最主要的方法。     

T管胆汁细菌培养及对抗生素敏感性分析

目的：了解临床已无感染症状病人的T管引流胆汁的细菌感染情况及对抗生素的敏感性。方法：对2001年12月至2002年12月116例术后已无感染症状病人的T管引流胆汁的细菌培养和抗生素敏感性试验结果作统计分析。结果：T管胆汁细菌培养的阳性率为59．91％。158株微生物中包括23种细菌和3种真菌。肺炎克雷伯菌、铜绿假单胞菌、大肠埃希菌、表皮葡萄球菌、金黄色葡萄球菌、粪肠球菌和尿肠球菌占胆道细菌的72．75％，24例混合感染中13例感染铜绿假单胞菌，同时发现嗜麦芽窄食单胞菌和鲍曼不动杆菌等条件致病菌感染。细菌对头孢类抗生素具有较高的耐药率，对亚胺培南、万古霉素、阿米卡星有较高的敏感性。在不同病人相同菌种的药敏试验结果有较大差异，提示菌株不同。结论：临床无感染症状病人的T管引流胆汁具有较高的细菌感染率，二重感染和耐药菌株的增加是一旦发生胆汁性腹膜炎时严重感染的基础。     

胆囊与胆管胆汁细菌培养及药敏分析的比较研究

目的探讨胆道感染者胆囊与胆管胆汁中的细菌分布、细菌培养阳性率及菌群对抗生素的敏感性。方法选择2005年6月至2007年10月住院手术的273例胆道感染患者的胆汁标本进行细菌培养及药敏试验分析，对培养结果阳性胆汁的细菌分布及药敏结果进行统计分析。结果273份胆汁标本中149例培养阳性，其中胆囊胆汁17例，培养阳性率为19．8％，胆管胆汁132例，培养阳性率为61．7％。共分离出G^-杆菌127株，G^＋球菌74株，真菌0株。引起胆道感染的病原菌依次为大肠埃希氏菌、肠球菌、铜绿假单胞菌和葡萄球菌。药敏结果显示，G^-杆菌对亚胺培南、美罗培南、头孢吡肟及丁胺卡那霉素耐药率最低，对氨苄西林、哌拉西林、头孢唑啉及复方新诺明高度耐药。G^＋球菌对替考拉宁、万古霉素及氯霉素耐药最低。结论胆道感染仍以G^-杆菌占主要地位，但G^＋球菌感染呈现出明显上升势头。胆管胆汁细菌感染率较胆囊胆汁高，且细菌对临床常用抗生素的耐药性明显增加。     

肝叶切除术治疗肝内结石254例临床分析

为探讨肝内切除术治疗肝内结石的效果，分析７年来采用肝切除术治疗２５４例肝内结石的术前检查、结石的部位和分布情况，手术方式、手术后并发症及结石残留等情况，加以归纳总结。结果表明，肝内结石以左肝较多（１５９例），全肝结石其次（７８例）；肝切除仍以左外叶及左半肝切除为主（９０％）；有１８．９％的病例有结石残留；４９例出现手术后并发症；手术死亡２例，占０．７９％；４例伴有胆管癌变；全组治疗效果良好。肝切除     

肝内胆管结石并胆管癌的临床病理和生化特征分析

目的探讨肝内胆管结石并胆管癌的临床病理和生化特征。方法选取我院收治的12例肝内胆管癌和同期良性病变（肝内胆管结石14例,肝外胆管结石30例,结石性胆囊炎40例）患者病例资料,通过多因素logistic回归分析模型探讨乙型肝炎病毒标志物检测,血清非特异性肿瘤标志物（CA19—9、CA125、CEA和AFP）检测,肝内胆管结石等10项影响因素对肝内胆管癌患病率的影响。结果本次研究所纳入病例,肝内胆管癌患者的乙肝病毒携带率或慢性乙肝患病率（33.3％）均明显高于同期的肝外胆管结石和结石性胆囊炎患者（P〈0．05）;多因素Logistic回归模型显示：肝内胆管结石（OR=1．05,CI为0．92～1．38,P=0．023）,乙肝病毒感染（OR=1．02,95％CI为0．78。1．31,P=0．02）;ICC患者血清高于参考值的CA19—9和黄疸指数对回归方程亦有贡献（P〈0．05）。结论乙型肝炎病毒感染,肝内胆管结石,高于参考值的CA19—9和黄疸指数可能作为提示诊断肝内胆管癌的辅助指标。     

966株尿路感染病原菌的分布

目的分析尿路感染的病原菌分布及耐药性特点,为临床选用抗菌药物提供依据。方法采用VITEK-32细菌鉴定仪鉴定菌种,对尿路感染患者的1978份尿液标本中分离的966株泌尿系感染病原菌进行鉴定及药物敏感试验。结果在分离的966株病原菌中,革兰阴性菌675株（占69．9％）,主要为大肠埃希菌;革兰阳性菌183株（占18．9％）,主要为粪肠球菌;真菌108株（占11．2％）,主要为白色念珠菌。分离数在前5位的病原菌依次为大肠埃希菌（占49．0％）、粪肠球菌（占9．6％）、肺炎克雷伯菌（占7．ooA）、白色念珠菌（占6．8％）、奇异变形杆菌（占3．9％）。大肠埃希菌产超广谱争内酰胺酶（ESBLs）检出率为47．3％,肺炎克雷伯菌产ESBLs检出率为33．8％。甲氧西林凝固酶阴性葡萄球菌（MRCNS）的检出率为44．8％,耐甲氧西林金黄色葡萄球菌（MRSA）的检出率为50％。结论引起尿路感染病原菌的分布广泛,大肠埃希菌为尿路感染的主要病原菌。有些菌株产生多重耐药性,大肠埃希菌产ESBLs检出率较高。应尽量根据药物敏感试验选用抗菌药物,减少耐药菌株的产生和医院感染的爆发流行。     

肝胆管结石640例外科治疗及随访结果分析

探讨肝内胆管结石手术及疗效及其影响因素。方法总结了１９８４年６月至１９９８年１２月手术治疗的肝内胆管结石６４０例。其中左肝管、右肝管和左右肝管结石分别为２６９例（４２．１％）１２４例（１９．３％）和２４７例（３８．５％）。３５７例合并胆管狭窄,占５６．０％,２７６例行肝叶或肝段切除术治疗,占４３．１％。结果手术死亡１４例,手术病死率为２．２％,术后残石率２９．８％。肝切除术后残石率（７．８％）明显     

肝胆管结石病的成因诊断和分类

1　肝胆管结石的成因肝胆管结石即原发性肝内胆管结石 ,有关其成因 ,以往的研究较多 ,也形成了各具特色的几个学说。这些学说之间有所区别也有所交叉且互为补充。但总的来讲 ,直至现在 ,人们对结石的形成仍没有一个清晰的认识。1 1　传统的观点及以往的研究　传统观点认为 ,肝内胆管结石的形成主要与胆道细菌感染、胆汁淤滞和胆道寄生虫病等因素相关 ,诸多事实也支持这个观点。早在 195 4年侯宝璋等就报道肝内胆管结石源于细菌感染 ,可伴肝管狭窄 ,致病情反复难愈。邹声泉等[1] 报道 ,胆汁细菌培养阳性者依次为 :大肠埃希菌、嗜麦芽窄食单…     

Bile leakage after hepatectomy for hepatolithiasis: risk factors and management

BACKGROUND: Bile leakage remains a major postoperative complication after liver resection. Bile leakage after hepatectomy for liver neoplasms has been well studied. However, the risk factors and management of this complication after liver resection for intrahepatic lithiasis has not been investigated. METHODS: From January 1992 to June 2004, 312 consecutive patients with intrahepatic lithiasis underwent hepatic resections Sun Yet-san University. Perioperative risk factors pertaining to the development of bile leakage were identified using univariate and multivariate analysis. The management and outcome of these patients with bile leakage were evaluated. RESULTS: Bile leakage developed in 23 (7.4%) of 312 patients. The multivariate logistic regression analysis identified that left hepatectomy (P=.024, odds ratio [OR]=3.695, 95% confidence interval [CI]: 1.185 to 11.517) and the period greater than 1 month between operative time and the latest acute cholangitis attack (P=.02, OR=4.144, 95% CI: 1.248 to 13.757) were the independent risk factors for development of bile leakage after hepatectomy for hepatolithiasis. The septic complications were higher in the patients with bile leakage than in those without bile leakage (ie, wound infection: 56.5% vs 13.5%, P=.001; subphrenic abscess: 21.7% vs 4.8%, P=.01; septicemia: 8.7% vs 0.7%, P=.029). Percutaneous drainage or combined endoscopic naso-biliary drainage was the first choice of treatment for bile leakage; 20 (87.0%) of 23 patients were treated by this method. One patient underwent re-operation for diffuse peritonitis due to withdrawal of T tube inadvertently at postoperative day 1. Two patients with bile leakage were re-operated due to uncontrollable hemobilia at postoperative day 5 and 12, respectively. CONCLUSIONS: Patients who underwent hepatectomy at the period less than 1 month after the latest attack of acute cholangitis carry high risk for the development of bile leakage. Preoperative cholangiography to identify the aberrant hepatic duct for high risk patients and avoidance of hepatectomy at the acute phase of cholangitis are of critical importance to prevent bile leakage after hepatectomy. Percutaneous drainage is the primary and effective treatment for bile leakage.     

Impact of bactibilia on the development of postoperative abdominal septic complications in patients with malignant biliary obstruction.

This study was intended to clarify the role of bile bacteria in the development of postoperative septic complications in patients with malignant biliary obstruction. A total of 116 patients with malignant biliary obstruction underwent surgical intervention after biliary decompression. The relation between contaminated ductal bile and postoperative abdominal septic complications was analyzed retrospectively. Such complications developed in 49 patients (42%). Bile-contaminated operations (n = 93) resulted in a higher incidence of septic complications than non-bile-contaminated operations (n = 23; P = 0.009). Patients with pre-operative positive bile culture had a higher incidence of septic complications than those with negative bile culture (P = 0.06). There was a positive correlation between the presence of pre-operative cholangitis and the occurrence of septic complications (P = 0.007). Bacteria found in pre-operative ductal bile were also detected in infected sites of 80% of patients with septic complications. Intra-operative contamination from infected ductal bile plays a critical role in the development of postoperative abdominal septic complications.     

Bile leakage after hepatic resection

OBJECTIVE: To identify the perioperative risk factors for postoperative bile leakage after hepatic resection, to evaluate the intraoperative bile leakage test as a preventive measure, and to propose a treatment strategy for postoperative bile leakage according to the outcome of these patients. SUMMARY BACKGROUND DATA: Bile leakage remains a common cause of major complications after hepatic resection. METHODS: Between January 1985 and June 1999, 781 hepatic resections without bilioenteric anastomosis were performed at the authors' institution. Perioperative risk factors related to postoperative bile leakage were identified using univariate and multivariate analysis. The characteristics of patients with intractable bile leakage and the effect of intraoperative bile leakage test were also examined. Management was evaluated in relation to the outcomes and the clinical characteristics of the patients with bile leakage. RESULTS: Bile leakage developed in 31 (4.0%) of 781 hepatic resections. This complication carried high risks for surgical death (two patients [6.5%] died). The stepwise logistic regression analysis identified high-risk surgical procedure, in which the cut surface exposed the major Glisson's sheath and included the hepatic hilum (i.e., anterior segmentectomy, central bisegmentectomy, or total caudate lobectomy), as the independent predictor of the development of postoperative bile leakage. None of the 102 cases in which an intraoperative bile leakage test was performed were subsequently complicated by postoperative bile leakage, and the preventive effect of the test was statistically significant. Patients with fisterographically demonstrable leakage from the hepatic hilum and with postoperative uncontrollable ascites had poor outcomes. CONCLUSION: Patients with bile leakage from the hepatic hilum and postoperative uncontrollable ascites tend to have a poor prognosis. Therefore, especially when a high-risk surgical procedure is performed in patients with liver cirrhosis, more careful surgical procedures and use of an intraoperative bile leakage test are recommended.     

肝门部胆管癌术后医院感染的预测因素:一项回顾性分析

目的 探讨肝门部胆管癌术后医院感染的预测因素.方法 回顾性分析2013年1月至2019年12月于福建医科大学附属第一医院手术治疗的243例肝门部胆管癌病人的临床资料,根据术后是否出现感染分为感染组和非感染组,对比两组病人的一般临床资料、治疗、手术及术后并发症等情况.观察术后感染病人病原学特点,采用单因素分析及多因素Lo...     

Bacteriological investigation of bile in patients with cholelithiasis

The microflora in bile from the gallbladder and common bile duct was investigated in 303 patients who underwent surgery for cholelithiasis. The purpose of this study was to identify current bacteria and bacterial casts in the biliary tract and also to analyze the relationship between bactericholia at the time of operation and postoperative infection. Bile cultures were positive in 38% of all patients, although a higher incidence of positive bile cultures occurred in patients over 70 years of age (77%), those with common duct stones (83%), those with pigment stones (65%), and those who underwent gastrectomy (71%). The predominant organisms were Escherichia coli (22%), Klebsiella (18%), and Enterococcus (15%). Obligate anaerobes were less frequently seen (4%), being found only in patients with pigment stones and always mixed with aerobes. Four patients developed postoperative infections (1.3%) which were all caused by biliary bacteria. The following two factors may contribute to this low incidence of postoperative infections: our policy of operating electively whenever possible, and the prophylactic use of antibiotics to which the organisms cultured from bile are sensitive.     

上尿路结石围手术期尿细菌检测的临床意义

目的 分析上尿路结石患者围手术期尿细菌谱及其药敏结果,指导抗生素治疗,减少术后发热和感染并发症.方法 2009年1月至2010年9月,148例上尿路结石患者行经皮肾镜取石术,对患者术前中段尿、术中感染性结石、术后肾造瘘管末端进行细菌培养,选择敏感药物行抗感染治疗,并对细菌谱、术后发热及感染并发症进行总结分析.结果 148例患者中段尿细菌培养阳性38例(25.7%),其中大肠埃希菌17例(44.7%)、表皮葡萄球菌4例、奇异变形杆菌3例、肺炎克雷伯杆菌3例、铜绿假单胞菌2例、屎肠球菌2例、溶血葡萄球菌2例、鲁氏不动杆菌1例、弗氏柠檬杆菌1例、酵母样菌1例、摩氏摩根菌1例、腐生葡萄球菌1例;感染性结石10例,细菌培养阳性8例,其中大肠埃希菌和奇异变形杆菌各3例,酵母样菌和铜绿假单胞菌各1例;肾造瘘管细菌培养阳性25例(16.9%),其中表皮葡萄球菌5例、溶血葡萄球菌5例、铜绿假单胞菌5例、屎肠球菌3例、科氏葡萄球菌2例、沃氏葡萄球菌2例、蜡样芽孢杆菌1例、产气肠杆菌1例、粪肠球杆菌1例.3种标本共培养344例次,阳性71例次,总阳性率20.6%.培养阳性者常用敏感药物包括亚胺培南、头孢吡肟、万古霉素、呋喃妥因等.术后发热患者41例(27.7%),包括术前中段尿培养阳性10例和肾造瘘管培养阳性患者9例;术后出现感染性休克1例.结论上尿路结石术前尿细菌以革兰阴性杆菌为主,术后末期革兰染色阳性球菌常见;术前中段尿培养能指导抗生素应用,有效控制围手术期尿路感染,减少并发症.

Abstract：

Objective To analyze the bacterial distribution and resistance in upper urinary tract stone patients, then choose suitable antibiotics and reduce infectious complications accordingly.Methods Middle flow urine, infectious stone and the end of kidney drainage tube were taken for culture in 148 patients who underwent percutaneous nephrolithotomy between January 2009 to September 2010. Antibiotics were used according to the culture results and the complications secondary to infection were analyzed. Results Urinary pathogens presented in 38 (25.7%) patients before operation.There were 112 strains of bacteria. The predominant strains included: Escherichia coli (17 cases,11.5%), Staphylococcus epidermidis (4 cases) and Proteus mirabillis (4 cases). Escherichia coli and Proteus mirabillis were common in stone culture. Staphylococcus epidermidis (5 cases),Pseudomonas aeruginosa (5 cases) and Staphylococcus haemolytcus (5 cases) were found in renal drainage tube culture which were positive in 25 patients. Imipenem, cefepime, vacomycin, nitrofurinton were sensitive and commonly used antibiotics. Forty-one patients (27.7 %) had fever postoperatively, including 10 positive for middle urine culture and 9 positive for drainage tube culture. One infective shock was diagnosed postoperatively. Conclusions Gram-negative bacilli are predominant in the upper urinary tract stone patients preoperatively. Gram-positive ones are common postoperatively.Suitable antibiotics, based on middle flow urine culture, could reduce urinary infective complications.     

Incidence and management of bile leakage after partial liver resection

Background/Aims: Bile leakage after partial liver resection still is a common complication and is associated with substantial morbidity and even mortality. Methods: A total of 234 consecutive liver resections without biliary reconstruction, performed between January 1992 and December 2004, were analyzed for postoperative bile leakage. Results: Postoperative bile leakage occurred in 6.8% of patients (16/234). In univariate analysis, male gender (p = 0.037), major liver resection (p = 0.004), right-sided hepatectomy (p = 0.005), prolonged operation time (p = 0.001), intraoperative blood loss >500 ml (p = 0.009), red cell transfusion (p = 0.02), tumor size (p = 0.026), duration of vascular occlusion (p = 0.03) and surgical irradicality (p = 0.001) were risk factors. No independent risk factors were associated with bile leakage after liver resection. Bile leakage originated from the resection plane in 10 patients (63%). Endoscopic biliary decompression was performed in 9 patients as initial treatment, and percutaneous drainage of the bile collection was used in 4 patients. Bile leakage resolved spontaneously in 3 patients. Conclusions: Bile leakage is a persisting complication and in this study occurred in 6.8% of patients after partial liver resection. Percutaneous drainage of bile collection with or without endoscopic biliary decompression are effective interventions in the management of most cases of bile leakage.     

复杂性肝内胆管结石的外科治疗

目的　总结复杂性肝内胆管结石的外科治疗方法及效果。 方法　 总结分析１９９２ ～１９９８ 年外科治疗复杂性肝内多段胆管结石并多处胆管狭窄３５ 例的手术方法,总结显露与切开肝内狭窄段胆管、取出结石、解除狭窄的经验和体会。 结果　３５ 例无手术死亡,术后近期并发感染、胆漏、肝功能不全或消化道出血共７ 例,均治愈;残留结石９ 例,术后经胆道镜取净结石７ 例。随访６ 个月至５ 年６ 个月２４ 例,优良２１ 例（８８ ％ ） ,好转２ 例（８ ％ ） ,无效１ 例（４ ％ ） 。 结论　复杂肝内胆管结石外科治疗的关键是显露和切开肝内各叶段胆管的狭窄段,取出结石、建立通畅的胆流通道。经肝门区或肝方叶可以显露和切开肝门胆管、左右肝管和左内叶、右前叶胆管,经肝膈面切开肝实质进路,可以显露和切开右肝内各叶段胆管。     

肝部分切除治疗肝胆管结石414例

目的总结肝部分切除治疗原发性肝胆管结石的经验。方法回顾性分析1981年1月至2001年12月肝部分切除治疗原发性肝胆管结石414例的临床资料,统计结石的分布、术式的选择、术后并发症情况及治疗效果。结果414例中发生术后并发症72例(17·4%),手术死亡3例(0·7%),305例获得2~22年随访,随访率73·7%,疗效优良率88·9%,残石率15·7%,结石复发率4·6%。结论正确掌握肝部分切除是治疗原发性肝胆管结石的有效方法之一。     

解剖性肝切除术治疗复杂肝内胆管结石体会

目的探讨解剖性肝切除术治疗复杂肝内胆管结石的价值。方法回顾性分析2012年1月至2017年3月行肝切除术的98例复杂肝内胆管结石病人的临床资料,男性42例,女性56例,年龄28~69岁,平均47.2岁。其中行解剖性肝切除术51例(AR组),非解剖性肝切除术47例(NAR组)。对比两种手术方式病人的术中出血量、手术时间、肝功能恢复情况、住院时间、术后并发症、术后残石率和结石复发率。比较两种手术方式的治疗效果。结果 AR组病人术中出血量为(466.0±52.1)ml、术后并发症8例(17.65%)、术后残石率为0和结石复发1例(2.04%),明显优于NAR组的(741.0±46.3)ml、15例(29.79%)、3例(6.67%)和4例(8.89%)。而手术时间、肝功能恢复情况、住院时间差异均无统计学意义。术后2个月至5年获随访94例,其中AR组49例,NAR组45例,失访4例。均行B超、CT、MRCP等检查,AR组无结石残留,术后胆总管结石复发1例,行内镜下十二脂肠乳头括约肌切开术(EST)取石治愈。NAR组结石残留3例,结石复发4例。在术后8个月至3年内再次行解剖性肝叶肝段切除3例,1例行EST取石成功,1例长期服用熊去氧胆酸等药物治疗未手术,另2例因经济原因放弃治疗。结论解剖性肝切除术治疗复杂肝内胆管结石,具有术中出血少、术后并发症少、术后残石率和复发率低的优势,是一种可选择的手术方式。