内镜支架引流治疗肝细胞肝癌所致肝门部胆管恶性梗阻的疗效分析

目的　评估无法手术切除的肝细胞肝癌所致肝门部胆管恶性梗阻患者的内镜支架引流疗效。方法　回顾性分析2012年1月—2019年1月在海军军医大学第三附属医院因无法手术切除的肝细胞肝癌导致肝门部胆管恶性梗阻而行内镜支架引流的106例患者的临床资料。根据置入支架类型的不同，分为金属支架组（30例）和塑料支架组（76例）。观察指标包括临床成功率、并发症发生率、支架通畅期及总体生存时间。采用多因素Cox回归模型分析患者支架通畅期和总体生存时间的独立预测因素。结果　患者的总体临床成功率为67.9%（72/106），术后胆管炎发生率为29.2%（31/106）。金属支架组与塑料支架组的临床成功率分别为93.3%（28/30）和57.9%（44/76） （χ2=12.40，P<0.001），术后胆管炎发生率分别为13.3%（4/30）和35.5% （27/76）（χ2=5.12，P=0.024）。中位支架通畅期为5.2（95%CI：3.7~6.0）个月，中位总体生存时间为3.0（95%CI：2.5~3.7）个月。多因素Cox回归分析显示肝脏引流体积<30%是支架通畅期的独立预测因素（HR=2.12， 95%CI：1.01~4.46，P=0.048）。BismuthⅣ型（HR=2.06， 95%CI：1.12~3.77，P=0.020）、Child⁃Pugh C级（HR=4.09， 95%CI：2.00~8.39，P<0.001）、塑料支架（HR=1.87，95%CI：1.21~2.90，P=0.005）是总体生存时间的独立预测因素。结论　肝细胞肝癌一旦累及肝门部胆管预后不良。与塑料支架相比，金属支架引流在临床成功率、术后胆管炎发生率方面均具有一定优势。肝脏引流体积<30%是支架通畅期的独立预测因素，而Bismuth Ⅳ型、Child⁃Pugh C级、塑料支架为总体生存时间的独立预测因素。     

内镜支架引流治疗Bismuth Ⅳ型肝门部胆管癌的疗效分析：一项大型回顾性研究

目的探究内镜支架引流治疗Bismuth Ⅳ型肝门部胆管癌患者的疗效。方法回顾性分析2002年1月—2019年1月在海军军医大学第三附属医院内镜科治疗的无法手术切除且内镜支架成功置入的229例Bismuth Ⅳ型肝门部胆管癌患者资料。观察指标包括临床成功率、并发症发生率、支架通畅期和总体生存时间。使用Kaplan-Meier曲线估算支架通畅期和患者总体生存期。采用多因素Cox比例回归模型分析患者支架通畅期和总体生存期的独立预测因素。结果患者的临床成功率为78.2%(179/229)。内镜逆行胰胆管造影术后早期胆管炎发生率为20.5%(47/229)。患者的中位支架通畅时间和总体生存时间分别为5.7(95%CI:4.8～6.7)个月和5.1(95%CI:4.2～6.0)个月。进一步Cox回归分析显示金属支架(P<0.001, HR=0.452, 95%CI:0.307～0.666)和双边造影双边支架(P=0.036, HR=0.644, 95%CI:0.427～0.971)是患者支架通畅期的独立预测因素。总胆红素>200 μmol/L(P=0.001, HR=1.627, 95...     

内镜支架引流治疗不可切除肝门胆管恶性梗阻临床成功影响因素的多中心研究

目的　探讨不可切除的肝门胆管恶性梗阻患者行内镜支架引流临床成功的影响因素。方法　回顾性分析2002年1月至2019年1月期间在3所内镜中心（海军军医大学第三附属医院502例、空军军医大学西京医院92例和上海交通大学附属第一人民医院39例）成功接受支架引流的肝门胆管恶性梗阻（Bismuth Ⅱ~Ⅳ型）的633例患者资料。主要观察指标为临床成功率,次要观察指标为支架通畅期和总体生存时间。临床成功患者和临床失败患者单因素比较中P<0.1的变量,纳入多因素logistic 回归,筛选出患者临床成功的独立影响因素。临床成功患者和临床失败患者支架通畅期和总体生存期使用Kaplan‑Meier曲线展示,两组间的差异比较使用log‑rank方法。结果　共有503例患者临床引流成功,有130例患者临床引流失败,总体患者的临床成功率为79.5%。单因素分析显示性别、疾病类型、Bismuth分型、肝硬化、支架类型、支架数量、支架跨越十二指肠乳头和肝脏引流体积可能是影响引流临床成功的因素（P<0.05）。进一步的多因素回归分析确定Bismuth分型（Bismuth Ⅱ~Ⅲ型比Bismuth Ⅳ型：OR=3.308,95%CI：1.772~6.176,P<0.001）、支架类型（金属比塑料：OR=3.297,95%CI：1.829~5.942,P<0.001）和支架数量（双边比单边：OR=2.335,95%CI：1.463~3.727,P<0.001）均为引流临床成功的独立预测因素。临床成功和临床失败患者的支架通畅期分别为6.5（95%CI：5.6~7.4）个月和1.2（95%CI：0.9~1.5）个月（P<0.001）,生存时间分别为5.1（95%CI：4.6~5.6）个月和1.2（95%CI：0.9~1.6）个月（P<0.001）。结论　内镜支架引流治疗不可切除的肝门胆管恶性梗阻患者时,Bismuth Ⅳ型的患者临床成功率较低; 使用金属支架或者双边引流的患者可以提高临床成功率。     

内镜下光动力治疗在胆管癌及壶腹癌治疗中的作用研究

目的 探讨内镜下光动力治疗（photodynamic therapy, PDT）联合支架置入治疗胆管癌及壶腹癌的临床疗效。方法 回顾性分析2013年9月—2016年12月东方肝胆外科医院收治的60例胆管癌及壶腹癌患者资料，支架组（n=36）单纯置入胆道支架，PDT组（n=24）行PDT联合胆道支架置入。记录临床资料及随访情况，统计分析2组临床成功率、并发症发生率、支架通畅期及生存期。结果 支架组和PDT组基线资料比较差异无统计学意义（P均＞0.05）。2组临床成功率[94.4%（34/36）比95.8%（23/24）， χ2=0.060, P=1.000]及术后并发症发生率比较[41.7%（15/36）比62.5%（15/24），χ2=2.50, P=0.187]差异无统计学意义。PDT组术后第1、3、6个月Karnofsky行为评分均较支架组高（P均<0.001）。支架组与PDT组支架中位通畅期分别为102.0 d（95%CI:73.9~130.1 d）与119.0 d（95%CI:96.8~141.2 d）（P=0. 634），中位生存期分别为162.0 d（95%CI:125.0~199.0 d）与327.0 d（95%CI:215.9~438.1 d）（P=0.006）。Cox回归多因素分析显示，PDT是患者生存时间的保护因素(P=0.012)，而胆总管癌(P=0.016)与更高TNM分期(P=0.001)是患者生存时间的危险因素。结论 内镜下PDT联合支架置入可有效延长胆管癌及壶腹癌患者的生存时间。PDT、病变部位与TNM分期是影响生存时间的独立预后因子。     

内镜引导下逆行胰胆管造影术胆道引流治疗恶性肝外胆道梗阻回顾性研究

目的分析内镜引导下逆行胰胆管造影术(ERCP)胆道引流对恶性肝外胆道梗阻的姑息性治疗效果。方法回顾分析吉林大学中日联谊医院内镜中心2012年4月至2014年5月纳入本研究的86例肝外胆道系统恶性梗阻患者的临床资料,其中男52例,女34例,年龄42~87岁[平均(67.8±11.4)岁]。将86例患者分为三组:鼻胆管引流(ENBD)组46例、胆道塑料支架(ERBD)组36例、金属胆道支架(EMBE)组25例,分析三组患者引流效果、实施引流后1周内肝功能变化,比较长期引流支架通畅时间及生存时间。计量资料均以均数±标准差表示,胆道引流前后肝功变化资料采用配对t检验进行统计学分析;累计生存时间采用Kaplan-Meier法进行预估及制图,用Log-rank检验进行对比分析;支架通畅时间采用Kaplan-Meier法进行预估及制图,用非配对t检验进行统计分析,P0.05为差异有统计学意义。结果 86例恶性肝外胆道梗阻患者共进行112次ERCP操作,其中成功插管及治疗107次,插管成功率95.5%(107/112),引流有效率为92.5%(99/107)。对比内镜下胆道引流前后肝脏功能,ERBD组和EMBE组均有改善。ERBD和EMBE组的患者生存时间分别为(208.1±96.8)d和(274.1±98.5)d(P=8.167),两组支架通畅时间分别为(83.9±36.4)d和(262.7±98.7)d(t=8.167,P0.001)。结论 ERCP胆道引流用于恶性胆道梗阻姑息治疗效果切实可靠,值得临床应用。     

ERCP放置胆管内支架姑息治疗难以切除的恶性胆管梗阻

目的探讨ERCP放置胆管内支架对难以切除的恶性胆管梗阻的临床治疗效果。方法对54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP将导丝插入胆管并超过梗阻部位,扩张狭窄处,用推送导管将已经选择合适的引流支架置于胆管适当部位,其两端均超过梗阻段2cm以上。结果54例患者中51例插管成功,3例插管不成功的患者中1例乳头开口于憩室内,另2例肿瘤完全阻塞导丝无法通过。成功率为94.44%(51/54)。34例胆管内放置8FZ型自膨胀式金属支架,其余20例行8～10F塑料内支架引流。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。其中39例2周内血清总胆红素下降50%以上,血清总胆红素退至34μmol/L以下。放置胆管内支架1周后,患者血清总胆红素由术前235.45±56.67μmol/L降至78.36±37.58μmol/L,肝功能较术前显著改善(P<0.05,P<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆管内支架引流治疗1周、2周后,其胆红素下降明显优于肝门部胆管梗阻患者(P<0.01)。34例放置胆管金属支架患者中,有12例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第10个月出现支架阻塞予以再次植入金属支架。另外20例放置塑料内支架者,有3例于术后1～4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和阻塞,予以更换内支架,其中1例植入塑料双支架。结论经ERCP内镜下胆管放置内支架,对解除恶性胆管梗阻性黄疸、缓解症状、提高患者生存质量具有满意疗效,对胆总管下段梗阻性黄疸的疗效优于肝门部胆管梗阻。     

金属支架置入治疗胆道恶性梗阻性疾病的临床应用与价值

目的探讨金属胆道支架引流术对恶性胆道梗阻的引流效果。方法对33例经ERCP诊断的恶性胆道梗阻患者行经内镜金属胆道支架置入术。结果33例恶性胆道梗阻患者,支架置入成功率为100%,引流有效率为93.93%,支架置入术后1周时STB,γ-GT、AKP平均下降率分别为69.3%、37.9%和37.3%。3、6、9个月有效引流比率分别为90.32%、61.29和35.48%。支架平均通畅时间为7.8±3.7月,平均生存时间8.5±4.3月。结论内窥镜金属支架是治疗胆道恶性梗阻安全有效的姑息治疗方法,可以有效地解除梗阻、消退黄疸、恢复肝功能,起到与外科手术相媲美的治疗效果。     

塑料胆管支架置入方式对不可切除肝门部胆管癌伴梗阻性黄疸治疗效果的影响

目的对比塑料胆管支架3种末端开口留置方式在解除不可切除肝门部胆管癌梗阻性黄疸方面的临床应用效果。方法回顾性分析2014年4月—2020年12月在中国医学科学院肿瘤医院内镜科行塑料胆管支架置入减黄治疗的不可切肝门部除胆管癌患者61例, 其中胆管支架末端开口胃内留置18例(胃内留置组), 十二指肠乳头留置31例(十二指肠乳头留置组), 十二指肠水平部留置12例(十二指肠水平部留置组)。对随访2周发热率、围手术期死亡率、术后90 d支架梗阻率、支架中位通畅时间进行分析。结果胃内留置组、十二指肠乳头留置组和十二指肠水平部留置组3组患者术后2周内发热率比较[66.7%(12/18), 58.1%(18/31)和16.7%(2/12), χ2=7.30, P=0.026]差异有统计学意义, 围手术期死亡率[0(0/16), 3.2%(1/31)和0(0/10), χ2=1.09, P=1.000]、术后90 d内支架梗阻率[52.9%(9/17), 48.3%(14/29)和40.0%(4/10), χ2=1.91, P=0.589]和支架中位通畅时间(66.0 d, 91.5 d和94.0 d,...     

内镜下光动力治疗在不可切除肝门部胆管癌梗阻性黄疸治疗中的作用研究

目的　探讨内镜下光动力治疗（photodynamic therapy, PDT）联合胆管支架置入在不可切除肝门部胆管癌梗阻性黄疸中的临床疗效。方法　回顾性分析2020年1月至2023年1月中科大附一院（40例）和铜陵市人民医院（3例）收治的共43例不可切除肝门部胆管癌发生梗阻性黄疸的患者临床资料,支架组（n=23）单纯置入胆管支架,联合组（n=20）行PDT联合胆管支架置入。对比两组患者的胆红素下降程度、支架通畅期、术后卡氏行为评分、并发症发生情况及预后情况。采用Cox回归分析患者生存期的影响因素。结果　支架组和联合组一般资料比较差异无统计学意义（P>0.05）。术后联合组的支架通畅时间为204.53 d（95%CI：143.75~265.32 d）,长于支架组的138.36 d（95%CI：95.38~181.34 d）,差异无统计学意义（P=0.091）。支架组和联合组术后1周中位胆红素下降值分别为30.10 μmol/L和9.40 μmol/L,差异无统计学意义（Z=-0.243,P=0.808）。支架组和联合组术后1个月［（69.09±12.69）分和（73.16±13.36）分,t=-0.999,P=0.324］和3个月卡氏行为评分［（67.14±9.94）分和（70.67±10.33）分,t=-0.935,P=0.358］差异无统计学意义。联合组的总体生存期为267.38 d（95%CI：186.93~347.83 d）,显著长于支架组的140.41 d（95%CI：97.38~183.45 d）（P=0.017）。Cox回归多因素分析显示,PDT联合胆管支架置入（HR=0.457,95%CI：0.212~0.986,P=0.046）是患者生存期的独立保护因素。结论　内镜下PDT联合胆管支架置入可有效缓解不可切除肝门部胆管癌的梗阻性黄疸,改善患者的生活质量,延长患者的生存时间。     

原发性硬化性胆管炎的内镜治疗及预后分析

目的探讨原发性硬化性胆管炎(primary sclerosing cholangitis, PSC)患者行经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography, ERCP)的诊疗效果及预后相关因素。方法纳入2009年5月—2020年5月西京医院接诊的PSC病例。回顾性收集人口学、临床症状、实验室和影像学检查、ERCP诊疗等数据, 探讨ERCP治疗人群特点及临床疗效, 随访观察疾病进展、无移植生存期和总体生存期等。结果共纳入74例PSC患者, 中位年龄53岁, 男性占54.1%(40/74), 合并胆管显性狭窄、炎症性肠病和其他自身免疫性肝病患者分别占32.4%(24/74)、18.9%(14/74)和17.6%(13/74), 接受ERCP患者占36.5%(27/74)。Logistic回归分析显示, 高总胆红素(OR=12.33, 95%CI:1.24～122.63, P=0.032)和合并胆管显性狭窄(OR=24.67, 95%CI:3.40～178.88, P=0.002)是ERCP诊疗的独立危险因素。ERCP操作和...     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.