腹腔镜胆囊切除术胆管损伤的因素及对策

目的　通过对腹腔镜胆囊切除术胆管损伤因素的探讨 ,探讨其预防对策 ,减少胆管损伤率。方法　回顾性分析本院 3 0 0 89例腹腔镜胆囊切除术中 2 7例胆管损伤的因素。结果　胆总管损伤 10例 ,汇合部分离性损伤 6例 ,穿孔性胆管损伤 9例 ,右侧副肝管损伤 2例。 2 7例全部治愈 ,无严重并发症。结论　腹腔镜胆囊切除术中要警惕胆管损伤因素 ,跨过“学习曲线”胆管损伤率可减少。     

THE PHYSIOLOGICAL VARIATIONS IN RESISTANCE TO BILE FLOW TO THE INTESTINE

Under specially controlled conditions in the healthy unanesthetized dog we have measured the resistance offered to the flow of bile through the lower common duct. The average resistance 4 to 12 hours after a feeding was found to correspond to the pressure of a column of bile 100 to 120 mm. in height. After a 24 to 72 hour fast the resistance was such as to support a much higher column of bile, one of 300 mm. at times. The exhibition of food to the fasting animal usually precipitated a reflex lessening in the resistance to the flow of bile to the intestine, the actual taking of food always brought it about. This was transient and was soon followed by a period of increased resistance lasting 10 to 30 minutes after food had entered the stomach. There succeeded a drop in resistance which was gradual and fluctuating. We have observed an increase in the resistance to the flow of bile into the intestine after alkali has entered the stomach, and a decrease after acid has been administered. We attribute the sudden changes chiefly to the activity of the sphincter of Oddi.     

肺癌剖胸的原因及对策

为了进一步提高肺癌外科手术切除率和治疗效果，本文对48例肺癌剖胸病人的本前X线、纤史镜、CT检查所见及剖胸探查结果和肺癌病理类型等进行了综合分析。着重指出传统的X线和纤支镜检查对来前判定中央型肺癌能否切除仍具有重要的价值，并指出高质量的CT检查对中央型肺癌是否适于外科手术具有指导意义。推荐才剖胸肺癌病人应用选择肺动脉括管、皮下埋藏化疗系技术，定期经肺动脉化疗，以弥补单纯开胸探查之不足，为晚期肺癌的治疗提供一个新途径。     

OBSERVATIONS ON SOME CAUSES OF GALL STONE FORMATION : III. THE RELATION OF THE REACTION OF THE BILE TO EXPERIMENTAL CHOLELITHIASIS.

As previous papers from our laboratory have shown, there exists a well defined tendency for calcium carbonate to come out of solution in the normal liver bile of the dog, and for it to be deposited on certain nuclei not infrequent in the secretion under pathological circumstances. Gall stones that had arisen in this fashion were a frequent occurrence in the intubated animals we studied. The present paper is concerned with the reasons for the absence of such stones from dogs with an intact biliary tract. The solubility of calcium carbonate is known to be markedly affected by the reaction of the fluid in which it is contained. The normal liver bile, out of which it tends to precipitate, is alkaline, with an average pH of 8.20 but in the gall bladder where conditions might otherwise seem especially favorable to precipitation, the secretion undergoes a change toward the acid side, becoming on long sojourn there, strongly acid to litmus (pH 5.18 to 6.00). From bile as thus altered, no carbonate precipitation takes place, even when it becomes greatly concentrated as in fasting animals or after obstruction of the common duct. Furthermore, carbonate which has precipitated out of liver bile on standing dissolves again in it when the fluid is rendered slightly acid in vitro, or, in some cases merely neutral to litmus. There are several obvious reasons for the absence of carbonate stones from the normal ducts under ordinary conditions,—notably the motility of these latter, the flushing that they undergo from an intermittently quickened bile stream, and the cleansing and possibly antagonistic action of the secretion elaborated by the duct mucosa. In the fasting animal, one at least of these influences is almost done away with, the rate of bile flow is so greatly cut down; while furthermore the calcium concentration of the secretion undergoes a considerable increase. But pari passu with these changes there occurs one in the bile reaction, a diminution in alkalinity so great that the pH often approximates that of the neutral point for litmus. That this change is not a direct consequence of the increase in calcium, may be inferred from the findings with stasis bile, the calcium content and reaction of which were observed to vary independently, if in general in the same direction. These adjustments within the organism, some of which may be thought to exhibit an element of the purposeful, when considered with the test-tube experiments, strongly suggest that the reaction of the bile plays a critical part in determining the occurrence of carbonate stones, as furthermore that their absence from the normal gall bladder is a consequence of the changes in the bile reaction there occurring. The changes come about through a functional activity of the bladder. This being the case, one might suppose that the failure to act would be followed by a formation of carbonate stones. There is sufficient evidence available in the literature to indicate that this happens, in rabbits at least. It is important to know whether changes in the bile reaction play any part in determining the cholelithiasis of man. To determine the matter will require a large material. But this much we have shown, that carbonate spheroliths not infrequently serve in human beings as centers in a formation of secondary stones of carbonate and cholesterol, as further that cholesterol precipitation out of human bladder bile can be induced or prevented by slightly altering the reaction of the fluid toward the alkaline and acid sides, respectively. The possibility that cholelithiasis may be a consequence of sins of omission on the part of the biliary channels and reservoir deserves to be considered.     

A METHOD FOR THE PHYSIOLOGICAL STUDY OF TISSUES IN VITRO

1. A method has been developed which allows the continuous growth of pure strains of fibroblasts, epithelium, and leucocytes in a medium which undergoes but slight spontaneous deterioration. 2. The principle of the method is to leave the tissues undisturbed while the medium is changed. This was realized by special containers allowing the change of the medium without bacterial contamination and by the simultaneous use of a solid and a fluid medium. 3. The curve of growth of pure cultures of fibroblasts and epithelial cells in a nutrient medium is a parabola; in a non-nutrient medium, it is S-shaped and expresses the residual activity of the tissues. Leucocytes invade the culture medium progressively, as do bacteria, but never aggregate in a tissue. 4. The method is used for the study of the morphological and dynamic changes occurring in tissues under the influence of chemical and physical factors.     

THE INFLUENCE OF INFLAMMATION ON THE ABSORPTION OF SUBSTANCES OF VARIED DIFFUSIBILITY

1. Inflammation retards the absorption of horse serum globulin and crystalline egg albumin from the peritoneal cavity and subcutaneous tissue, but retardation of the absorption of crystalline egg albumin is less than that of globulin, which is less diffusible. 2. Inflammation retards the absorption of the specific polysaccharide of pneumococcus Type I from the peritoneal cavity; inflammation may accelerate, but does not hinder, the absorption of glucose from the peritoneal cavity. 3. Inflammation retards the spread of trypan blue in the skin, but accelerates absorption from the skin of the more diffusible dye, brom phenol blue. 4. Phenol red is excreted in the urine with equal rapidity after injection into normal and into inflamed subcutaneous tissue or into normal and into inflamed peritoneal cavities. Direct extractions of phenol red from inflamed subcutaneous sites indicate that inflammation accelerates the absorption of the dye from these areas. 5. Inflammation retards the absorption of the indiffusible proteins, carbohydrates and dyes; it tends to accelerate the absorption of the diffusible carbohydrates and dyes.     

EFFECT OF THE INJECTION OF BILE ON THE CIRCULATION

1. We have confirmed previous work which shows that the injection of bile increases the tone of the vagus nerve, and that this action can be abolished after the administration of atropine. 2. We have found that the amount of bile salts in a lethal dose of pig''s bile for dog''s will, if inejcted alone, produce neither a fall in blood pressure nor a slowing in rate. 3. We have found that the amount of pigment in a lethal dose of the bile will, if injected alone, cause death with slowing of the heart and lowering of blood pressure. 4. We have found that the bile pigment in combination with calcium or sodium is less toxic than uncombined pigment. 5. We have found that in experimentally produced jaundice the calcium content of the blood is increased, while that of the liver, muscle and brain are decreased. 6. We are of the opinion that increase in calcium in the blood is a protective mechanism against the circulating pigments of obstructive jaundice.     

THE INFLUENCE OF BILE ON METABOLISM

1. Bile increases the digestion of fat when given by the mouth in pill form. The percentage of fat lost in the stools of our patient with a complete biliary fistula was 63 per cent in the first period and 57 per cent in the third. This closely corresponds to the results that Müller obtained in human beings and dogs with complete obstruction of the common duct. Under bile medication the stools contained 23 per cent less fat than in the first period, and 17 per cent less than in the third. This represents an actual diminution of the amount of fat lost in the stools. Looking at the result in another way, it may be said that the average digestion of fat in the periods without bile was 40 per cent; in the periods with bile, 60 per cent, i. e., bile increased the digestion of fat relatively by 50 per cent. 2. The digestion of nitrogenous food is improved by the use of bile pills when the amount of fat in the stools is large. Instead of an average of 15 per cent being lost in the fæces, but 7 per cent escaped digestion during the four days the patient took bile. The reason for this, perhaps, lies in the better digestion of fat at this time, in consequence of which the proteid elements of the food were more thoroughly exposed to the digestive juices. 3. Ox bile is a cholagogue. The amount of bile-solids secreted in the bile period was 47 per cent greater than in the periods before and after. This confirms the work of Pfaff and Balch, here in Boston, on a human being, and that of Stadelmann and his pupils, in Germany, on dogs. 4. The effect of the bile on the bowels in this case was not remarkable, although they moved more satisfactorily during the bile period. In my experiments with dogs I usually obtained diarrhœa when giving bile. I do not feel sure, however, that this should be attributed wholly to the medication, for the diarrhœas as a rule appeared six or more days after the beginning of the experiment and the animals were then in poor condition. Dr. Pfaff, who has had more experience with the administration of bile than I, tells me that he has found its action variable in patients. In some cases it is a laxative; in others, in which there is diarrhœa, due apparently to large amounts of fat in the food, it has the opposite effect. 5. As to the general effect of bile on body metabolism, it was observed that the urea and nitrogen were excreted in greater amount in the bile period than in either of the others. No definite conclusions can be drawn from this fact, because more nitrogen was ingested during these four days; moreover, it must be borne in mind that in these results the salol may have been a factor. 6. The amount of urine was increased by more than 50 per cent in the bile period. It is interesting to note that the amount was about the same during this bile period as in the second experiment when the bile was again taking its natural course. Von Noorden has recorded a similar increase in the amount of urine following the removal of the obstruction in acute catarrhal jaundice. The salol coating of the bile pills, which amounted to one and a quarter grammes a day, is not sufficient to account for this effect. This is evident from the work of Kumagawa, who gave two grammes of sodium salicylate daily to a dog of 25 kilos without essentially changing the amount of urine secreted. On the other hand, in taking the 30 pills daily the patient drank several extra glasses of water, and in the second experiment her general condition was naturally better than at any other time.     

经内镜胆道内支撑术解除恶性梗阻性黄疸的临床应用评价

目的 :探讨经内镜内支撑术解除恶性梗阻性黄疸的疗效。方法 :对恶性胆道梗阻引起的黄疸病人 10 8例采用内镜胆道内支撑术作胆汁引流 12 4例次 ,其中ENBD 39例次、ERBD 4 7例次、EMBE 38例次。结果 :引流总的有效率 (引流满意 +引流效果一般 ) 90 %～ 95 % ,并发症发生率为 14 .6 % ,没有操作相关的死亡发生。比较ERBD与EMBE患者的支架通畅时间 ,结果金属支架的通畅时间 (135± 14d)明显长于塑料支架 (49±5d) (P <0 .0 1)。结论 :以上资料表明经内镜内支撑术能有效解除恶性梗阻性黄疸病人的胆道梗阻 ,有良好的临床疗效 ,ENBD、ERBD和EMBE各有其适应症 ,可在临床中进一步推广应用。     

MECHANISM OF THE REACTION BETWEEN BILE SALTS AND BLOOD SERUM AND THE EFFECT OF CONJUGATION IN THE FORMATION OF BILE SALTS

These experiments suggest the following conclusions concerning hemolytic action: 1. It is probably the proteid part of the serum which inhibits the bile salts. 2. The cholalic acid group is the active part of the bile salt molecule. 3. The protection afforded by bile salts against serum is of especial interest from the following considerations: (a) The protective action is a property apparently peculiar to proteids obtained from blood serum. It is not given satisfactorily by egg albumen. (b) The conjugation of cholalic acid with glycocoll in the formation of the bile salts is of some advantage to the organism. Although the toxicity of the cholalate for red corpuscles, when free from serum, is at most only slightly diminished by conjugation, yet the blood serum possesses a greater inhibiting action for the resulting glycocholate than for the original cholalate. 4. As compared with its inhibition of sodium glycocholate, normal serum possesses relatively little inhibiting action against certain foreign hemolytic agents, such as tetanus toxin, sodium benzoate, phenol and ethyl alcohol. 5. Hemolytic experiments afford a fairly general method for studying, in vitro, certain syntheses occurring in the body. They avoid, largely, the complications, such as rapid chemical alteration, which might occur in animal experimentation. Contrary to the results obtained with bile salts, the conjugation of benzoic acid and of phenol results in an effective reduction of their hemolytic action independently of the presence or absence of serum.     

STUDIES ON THE TOTAL BILE : IV. THE ENTEROHEPATIC CIRCULATION OF BILE PIGMENT.

In dogs fed the green bile or the liver tissue of herbivora, the bile later secreted frequently becomes green, changing from the previous yellow-brown. When they are fed sheep bile that contains cholohematin, their bile comes to contain this pigment. When they are fed dog bile in quantity a well marked increase in the output of bilirubin by the liver frequently follows. Taken together, these facts indicate the existence of an enterohepatic circulation of bile pigment.     

STUDIES ON THE TOTAL BILE : II. THE RELATION OF CARBOHYDRATES TO THE OUTPUT OF BILE PIGMENT.

Carbohydrate feeding or injection produces often a temporary increase in the rate at which bilirubin is put forth in the bile, but none in the amount of the pigment secreted from day to day. There would appear to be no ground for the supposition that bilirubin is normally derived in part from the carbohydrates of the food.     

STUDIES ON THE TOTAL BILE : VII. CONDITIONS INFLUENCING THE CALCIUM CONTENT OF THE BILE.

A day to day study has been made of the calcium content of the total liver bile of dogs intubated under sterile conditions. The concentration of this element in the bile is fairly constant under physiological conditions which do not involve wide fluctuations in the secretory output. It follows that the calcium yield for each 24 hour period in general varies directly with the amount of the bile. But when this amount becomes greatly lessened, as the result of fasting, the concentration of calcium becomes markedly increased, though not sufficiently so to compensate for the lessened volume. When the bile amount rises much above the average after the ingestion of food in quantity, the calcium content, unlike that of pigment, does not become correspondingly diminished, but tends to remain the same as ordinarily. Hence when great amounts of bile are put out, so too are relatively great amounts of calcium. This is not because of the increased ingestion of the element. For neither feedings with bone meal, nor the administration of large quantities of calcium salts intravenously or by mouth has any effect to alter the biliary output of calcium. The normal gall bladder, far from secreting calcium into the bile, as some have supposed, acts to remove this element from the secretion, and removes carbon dioxide as well. The "white bile," which is a specific secretion of the bile ducts, contains but little calcium, like the mucous secretions from elsewhere in the body. The concentration is only slightly greater than that in the blood plasma, and contrasts significantly with the high concentration to be noted in true bile of the fasting animal. Evidently the greater portion of the bile calcium must be secreted, not by the duct walls, but by the liver itself. The findings have an evident bearing on the problem of cholelithiasis.     

STUDIES ON THE TOTAL BILE : VI. THE INFLUENCE OF DIET UPON THE OUTPUT OF CHOLESTEROL IN THE BILE.

The development of a method for the collection of total bile from dogs in a sterile state and uninfluenced by the gall bladder, day after day for weeks, has rendered possible an accurate study of the influence of diet upon the cholesterol output of the secretion. When a diet rich in cholesterol is given the amount of the substance in the bile greatly increases. Not only this but the concentration per cc. is, in almost every instance, greater. An increase in the total food intake, by the addition to the ordinary ration of a bone mash diet containing only a slight additional amount of cholesterol (200 mg.) produces a similar, though lesser, increase. In the fasting dog, the cholesterol yield is greatly cut down. The increase in the cholesterol after food rich in the substance does not depend on the cholagogue action of this latter, though it is true that the concentration of cholesterol in the bile usually increases with the bile volume. Though fasting cuts down the cholesterol of bile, the concentration of the substance per cc. is greatly increased. On an ordinary diet the yield of it fluctuates abruptly and considerably from day to day. In general the rule holds that an animal eating largely puts out not only much more bile but much more cholesterol. The relation between bile quantity and cholesterol yield is anything but a fixed one, however. The cholesterol yield of the bile does not parallel that of bilirubin. The pigment output from day to day remains relatively constant as compared with that of cholesterol.     

ON THE ABSORPTION OF BILE PIGMENTS FROM THE INTESTINE

Bilirubin as such is not reabsorbed from the intestine by way of the portal vein in healthy animals. Bilirubin may be absorbed from the intestine by the lymphatics but only in minute amounts. Urobilin is reabsorbed from the intestine by way of the portal vein and by way of the lymphatics.