Endotoxemia after relief of biliary obstruction by internal and external drainage in rats

Systemic and portal endotoxemia were studied in rats with biliary obstruction and after relief of the obstruction by internal and external drainage. Endotoxemia was increased after bile duct ligation (p less than 0.001) compared with control values. The incidence of systemic and portal endotoxemia was significantly reduced after internal drainage (p less than 0.001). A significantly higher incidence of portal (86 percent) and systemic (57 percent) endotoxemia, however, was found after external drainage. The persistence of endotoxemia after external drainage, when serum bilirubin levels returned to normal units, indicates that bile flow is important in controlling endotoxemia during preoperative biliary drainage. These results suggest that the systemic endotoxemia observed after relief of obstruction by external drainage may contribute to the increased mortality, as found in previous rat studies. This observation may contribute to an understanding of why patients with preoperative external drainage of biliary obstruction have a higher incidence of septic complications.     

Endotoxemia in human obstructive jaundice. Effect of polymyxin B

A clinical trial was undertaken to study endotoxemia in 14 patients with obstructive jaundice given the antiendotoxin polymyxin B, 13 patients with obstructive jaundice who were not given the antiendotoxin , and 13 nonjaundiced control patients undergoing comparable surgery. Endotoxins were detected by the limulus assay. Endotoxemia did not occur in the nonjaundiced patients but was common before (68 percent), during (70 percent), and after (81 percent) surgery in the jaundice patients. Thirty-six percent of the jaundiced patients had postoperative oliguria. Endotoxemia before surgery was associated with death after surgery, all deaths occurring in patients who were endotoxemic before operation (p less than 0.05). Polymyxin B infusion had no effect on endotoxemia or outcome. Measurement of indicators of fibrinolysis, soluble fibrin, and fibrin degradation products showed no prognostic significance. We conclude that preoperative endotoxemia is an important predictor of outcome in patients who undergo surgery for jaundice.     

肝门部胆管癌术后胆红素的动态变化规律及影响因素分析

目的分析肝门部胆管癌(HCCA)术后胆红素的动态变化规律及影响因素。方法回顾性分析2011年2月至2016年2月我院275例HCCA患者的临床资料,均行HCCA根治术,根据术后血清总胆红素(TBIL)变化趋势分为观察组(胆红素逐渐下降,n=165)、对照组(胆红素一过性升高,n=110),分析两组术后2周内血清,TBIL变化情况,比较其术前白蛋白(Alb)、碱性磷酸酶(ALP)、谷氨酰转肽酶(GGT)、TBIL、甲胎蛋白(AFP)、糖类抗原199(CA199),分析术后1~6d平均TBIL与上述指标的相关性,对比两组手术资料、预后情况,分析引起术后胆红素升高的独立危险因素。结果观察组术后2周内胆红素逐渐下降,在术后第13~14d复常,对照组术后第1~6d胆红素升高,第4~6d达高峰后下降,复常时间14d;观察组术前ALP(405.12±1.88)U/L、GGT(654.23±1.35)U/L与对照组比较明显较高(P0.05),观察组CA199水平(110.23±1.47)kU/L低于对照组(P0.05);相关分析显示术后1~6d平均TBIL与患者ALP、GGT水平呈负相关(P0.05),与CA199呈正相关(P0.05);观察组术前减黄比例23.64%、输血率38.79%、肝切除率56.36%、肝硬化比例4.85%明显低于对照组70.91%、62.73%、78.18%、14.55%(P0.05),观察组住院时间(25.04±1.23)d短于对照组,观察组术后1个月内并发症发生率9.05%低于对照组20.91%(P0.05),两组生存时间比较无显著差异(P0.05);Logistic回归分析显示ALP、GGT、CA199水平及术前减黄、输血、肝切除是导致胆红素一过性升高的独立危险因素(P0.05)。结论 ALP、GGT、CA199水平及术前减黄、输血、肝切除是引起肝门部胆管癌术后胆红素一过性升高的独立危险因素,并增加并发症发生率,延长住院时间,临床需加以监测。     

Liver failure after hepatic resection

Pathophysiology of hepatic resection in 89 cases was investigated from the point of endotoxemia and phagocytic function in order to clarify the mechanism of postoperative liver failure. In the control group (n = 44) and the bile stasis group (n = 9) plasma endotoxin increased to 22 to 160pg/ml early after operation and decreased thereafter: but in the liver failure group (n = 10) it increased higher corresponding to high risk operation and the massive bleeding or anastomosis leakage. In control and bile stasis groups phagocytic K value, serum CH50, plasma fibronectin decreased to half of the preoperative level on the first postoperative day, and later improved. In liver failure group these levels decreased but never improved. Liver failure group was characterized by an irreversible platelets count decrease corresponding to the increase of serum bilirubin level. It was concluded that endotoxemia in the presence of a self defence system dysfunction is thought to be a trigger for organ failure.     

血清新喋呤与烧伤病人内毒素血症及脓毒症的关系

为探讨血清新喋呤与大面积烧伤后内毒素血症及脓毒症的关系，对３５例烧伤面积大于３０％，（３０％～９８％）患者的血清新喋呤，血浆内毒素的变化进行了动态观察，结果表明，烧伤后第３天大多数患者新喋呤升高（Ｐ〈０．０５），但与烧伤面积无显著相关（Ｐ〉０．０５），严重烧伤第２周以后内毒素血症患者新喋呤水平显著高于无内毒素的血症患者（Ｐ〈０．０５～０．０１），同时，伤后第１４，２１天内毒素血症患者的循环内毒素与     

Sexual function in women after proctocolectomy.

One hundred women who had undergone proctocolectomy with a continence-preserving procedure (50 Kock pouches, 50 ileoanal anastomoses) for ulcerative colitis or polyposis coli were interviewed regarding their preoperative and postoperative sexual function. Frequency of intercourse increased and the incidence of dyspareunia decreased after operation in both groups. Patients who had a Kock pouch had a greater incidence of persistent postoperative dyspareunia than patients who underwent an ileoanal procedure (38% vs. 18%, p less than 0.02). Only one patient in each group reported a postoperative disturbance in ability to achieve orgasm. Most women reported no change in their menstrual cycle, but patients with a Kock pouch had more episodic vaginal discharge than patients with an ileoanal anastomosis (18% vs. 0%, p less than 0.001). Postoperative fertility was minimally impaired. Overall, the majority of women in this study who underwent proctocolectomy for benign diseases experienced enhanced sexual function after operation, which they attributed mainly to improved health.     

Hypophosphatemia after major hepatic resection.

METHODS. We performed a retrospective study of 44 patients who underwent right or extended right hepatic lobectomy to determine the incidence and significance of hypophosphatemia after major hepatic resection. RESULTS. The postoperative serum phosphate level (measured as inorganic phosphorus) dropped in all 44 patients studied. Profound hypophosphatemia (less than 1.0 mg/dl) was significantly (p less than 0.001) associated with the frequent development of major postoperative complications (cardiorespiratory, five cases; infections, four cases; hemorrhage, one case; and liver failure, one case). Factors such as extent of liver resection, blood loss, blood or plasma transfusion, postoperative bilirubin level, and preexisting liver diseases showed no significant correlation with the nadir inorganic phosphorous level. Use of aluminum-containing antacids caused a further drop of the serum values (p less than 0.05). Early phosphorous replacement showed a significant protective effect (p less than 0.05), with higher serum levels and fewer major complications. CONCLUSIONS. These observations affirm the importance of frequent monitoring and replacement of phosphate after major hepatic resection.     

Clinical significance of hyperbilirubinemia in patients with pulmonary hypertension undergoing heart-lung transplantation

Hyperbilirubinemia is commonly observed in long-standing pulmonary hypertension and is thought to be the result of chronic right ventricular failure and subsequent liver congestion. To evaluate the clinical significance of preoperative hyperbilirubinemia, we reviewed the cases of 62 patients with pulmonary hypertension (31 primary and 31 Eisenmenger's syndrome) who underwent heart-lung transplantation between 1981 and 1990 at Stanford. Bilirubin levels higher than 1.0 mg/dl were noted in 58% of patients, and bilirubin levels higher than 2.0 mg/dl were noted in 23% of patients. Indirect hyperbilirubinemia accounted for 66% to 87% of the total bilirubin and tended to fluctuate with diuretic therapy. It was associated with polycythemia, reticulocytosis, and mild elevations of liver enzymes. Early postoperative mortality in patients with total bilirubin levels greater than 2.1 mg/dl, bilirubin levels greater than 1 mg/dl but less than 2.0 mg/dl, and levels less than 1 mg/dl was 58%, 27%, and 16%, respectively (p less than 0.05). In those with high bilirubin levels, four patients had severe hemorrhage as part of their terminal event. Cardiac cirrhosis was found at autopsy in 75% of the early deaths of patients with high bilirubin. We conclude that hyperbilirubinemia is a late manifestation of pulmonary hypertension. The mechanism of hyperbilirubinemia is probably the result of the combination of increased hemolysis and decreased uptake by the chronically congested liver. Patients with pulmonary hypertension and hyperbilirubinemia appear to be at greater surgical risk during heart-lung transplantation.     

胰十二指肠切除术后胰瘘相关危险因素分析

目的 探讨胰十二指肠切除术后胰瘘发生的相关危险因素.方法 回顾性分析2001年6月至2006年6月间97例采用标准胰腺十二指肠切除术(PD)和传统Child法消化道重建患者的临床资料,分别对围手术期可能与胰瘘发生相关的因素进行分析比较.通过单因素分析与多因素分析筛选出与PD术后胰瘘发生相关的因素. 结果 97例PD术后患者中,发生胰瘘13例.单因素分析结果显示,术前血清胆红素水平≥170 mmol/L(P=0.038)、手术时间(P=0.003)、胃肠吻合口下方输入段与输出段之间加做Braun吻合(P=0.034)及术后预防性应用生长抑素(P=0.003)与PD术后胰瘘的发生相关;多因素分析结果显示,术前血清胆红素水平≥170 mmol/L(OR=11.687,P=0.021)是术后胰瘘发生的独立危险因素,而术后预防性应用生长抑素(OR=0.056,P=0.016)是胰瘘发生的保护因素. 结论 术前血清胆红素水平≥170 mmol/L是PD术后胰瘘发生的危险因素,术后预防性应用生长抑素可以减少胰瘘的发生.     

Predictive value of preoperative serum albumin levels on outcomes in patients undergoing LVAD implantation

Background

We performed a single‐center retrospective analysis to determine whether preoperative serum albumin levels were associated with postoperative adverse events and short‐ and long‐term survival in patients who underwent continuous‐flow left ventricular assist device (CF‐LVAD) implantation.

Methods

From November 2003 through March 2016, 526 patients underwent CF‐LVAD implantation. Patients whose preoperative serum albumin level was normal (≥3.5 g/dL) were compared to patients with preoperative hypoalbuminemia (<3.5 g/dL), which was further categorized as moderate (2.5‐3.5 g/dL) or severe (<2.5 g/dL). These groups were compared regarding preoperative demographics, incidence of postoperative complications, and long‐term survival.

Results

Patients with hypoalbuminemia had higher serum levels of liver enzymes (P < 0.05) and total bilirubin (P < 0.001) and significantly lower platelet counts (P = 0.02) and prealbumin levels (P < 0.001) than patients with normal preoperative albumin levels. Survival in patients with moderate and severe preoperative hypoalbuminemia was significantly decreased compared with patients with normal preoperative serum albumin levels (P < 0.001). Preoperative hypoalbuminemia was also associated with higher incidences of postoperative infection, gastrointestinal bleeding, neurological dysfunction, and acute kidney injury (P ≤ 0.01 for all) but did not affect the success of bridge to transplantation or survival after transplantation.

Conclusions

Our data demonstrated that there is a significant association of preoperative low serum albumin levels with postoperative adverse outcomes and lower survival rates. This highlights the importance of a patient's preoperative nutritional status on postoperative outcomes after CF‐LVAD implantation.     

Preoperative characteristics predicting intraoperative hypotension and hypertension among hypertensives and diabetics undergoing noncardiac surgery.

We prospectively studied patients with hypertension and diabetes undergoing elective noncardiac surgery with general anesthesia to test the hypothesis that patients at high risk for prognostically significant intraoperative hemodynamic instability could be identified by their preoperative characteristics. Specifically we hypothesized that patients with a low functional capacity, decreased plasma volume, or significant cardiac comorbidity would be at high risk for intraoperative hypotension and those with a history of severe hypertension would be at risk for intraoperative hypertension. Patients who had a preoperative mean arterial pressure (MAP) greater than or equal to 110, a walking distance of less than 400 m, or a plasma volume less than 3000 cc were at increased risk of intraoperative hypotension (i.e., more than 1 hour of greater than or equal to 20 mmHg decreases in the MAP). Hypotension was also more common among patients having intra-abdominal or vascular surgery, and among those who had operations longer than 2 hours. Patients older than 70 years or with a decreased plasma volume were at increased risk of having more than 15 minutes of intraoperative elevations of greater than or equal to 20 mmHg over the preoperative MAP in combination with intraoperative hypotension; this was also more common when surgery lasted more than 2 hours. Patients who had intraoperative hypotension tended to have an immediate decrease in MAP at the onset of anesthesia and were often purposefully maintained at MAPs less than their usual level during surgery with fentanyl and neuromuscular blocking agents. Patients who had intraoperative hyper/hypotension tended to have repeated elevations in MAP above their preoperative levels during the course of surgery, and such elevations precipitated interventions with neuromuscular blocking agents and/or fentanyl. Neither pattern was more common among patients who developed net intraoperative negative fluid balances. Both hypotension and hyper/hypotension were associated with increased renal and cardiac complications after operation. Patients with cardiac disease, especially diabetics, and those with negative fluid balances also had increased complications. Preoperative characteristics influence the susceptibility to intraoperative hypotension and hypertension, which are related to postoperative complications.     

Effect of biliary decompression on morbidity and mortality of pancreatoduodenectomy

To evaluate the effect of levels of serum bilirubin on morbidity and mortality after pancreatoduodenectomy, a prospective study was designed to compare patients who underwent preoperative biliary decompression to those who did not. Preoperative biliary decompression decreased the mean serum bilirubin level from 15.8 to 5.8 mg/dl in one group of 10 patients (Group A). The only statistical differences between this group and the two other groups of patients (Groups B and C) who were not treated with preoperative biliary decompression was the level of serum bilirubin before pancreatoduodenectomy (5.8, 22, and 1.3 mg/dl in Groups A, B, and C, respectively). Only one death occurred in each group of patients. The numbers of nonfatal complications were comparable. These results suggest that there is no decrease in morbidity or mortality after pancreatoduodenectomy when the serum bilirubin level is decreased by preoperative biliary drainage.     

Risk of biliary surgery in patients with hyperbilirubinemia

Previous studies have suggested a direct relationship between the serum bilirubin level and the risk of operation. However, patients with high bilirubin levels are usually older and have associated conditions unrelated to jaundice that may contribute to the development of postoperative complications. We studied the courses of 98 consecutive patients who were admitted with biliary obstruction and a serum bilirubin level of 10 mg/dl or greater and underwent operation. Sixty-one had neoplastic obstructions, 26 had benign biliary strictures, 8 had choledocholithiasis, and 3 had other obstructive lesions. Comorbid factors were evaluated and assigned a score to reflect their severity. Neither age nor advanced local cancer was considered to be a comorbid factor. Biliary obstruction was treated by resection of the bile duct, the pancreas, or both in 28 patients, by bilioenteric bypass in 55 patients, and by other operations in 15 patients. Postoperatively, complications developed in 30 patients and 8 died. There was no correlation between the admission serum bilirubin level, hematocrit value, or serum albumin level and the development of complications or death. There was a strong correlation between the presence of severe associated disease and the risk of postoperative complications or death. Nineteen of 81 patients with a comorbid score below 4 had a complication compared with 11 of 17 patients with scores of 4 or higher (p less than 0.01). Two of the 81 patients with scores below 4 died compared with 6 of 17 patients with a score of 4 or higher. These findings show that postoperative deaths and serious complications in patients with severe jaundice are principally the result of uncontrolled associated disease and that jaundice per se does not contribute substantially to an undesirable outcome.     

Partial hepatectomy on cirrhotic liver with a right lateral tumor

A total of 24 patients with cirrhotic liver and solitary, small hepatocellular carcinoma (HCC) located at the lateral part of the right lobe underwent surgery with our technique of hepatic clamping and finger dissection. There were no operative mortality or acute or chronic hepatic failure. Total operating time was 129 +/- 20 minutes; actual resection time was only 22.7 +/- 4.9 minutes. The average amount of blood transfused during this procedure was 1552 +/- 909 ml. The preoperative serum bromsulphalein retention rate proportionately reflected the postoperative peak serum conjugated bilirubin concentration if the weight of the resected specimen was less than 310 gm (p less than 0.001). An evaluation of the enzymes (SGOT, SGPT, and lactate dehydrogenase) released from liver cells on the first postoperative day found that more prominent elevation was observed in the group of patients with hypotension than in those without hypotension (all p less than 0.001). Although all enzyme levels returned to the preoperative level on the fourteenth postoperative day, the excretory capacity of liver cells as measured by serum bromsulphalein retention rate on day 14 time was still abnormally high (p less than 0.001) and took 2 to 3 months to decline to a level that still exceeded preoperative levels (p less than 0.05). In conclusion, partial hepatectomy on cirrhotic liver by hepatic clamping and finger dissection was a simple, rapid technique without any serious side effects.     

Prognostic value of carcinoembryonic antigen and CYFRA21-1 in patients with pathological stage I non-small cell lung cancer.

BACKGROUND: The aim of this retrospective study was to assess the prognostic value of serum tumor markers (carcinoembryonic antigen (CEA) and CYFRA21-1) in patients with pathologic (p-) stage I non-small cell lung cancer (NSCLC) undergoing complete resection. METHODS: Two hundred and seventy-five patients (163 males, 112 females, mean age 67.1 years) with p-stage I NSCLC who underwent complete resection at our institution between April 1999 and October 2004 were examined. Patients who had received preoperative chemotherapy or radiotherapy were excluded, as were patients who had multiple malignancies including multiple lung cancer. The serum levels of tumor markers were measured using commercially available immunoassays within 1 month before surgical resection. Serum levels of CEA and CYFRA21-1 higher than 5.0 and 2.8 ng/ml, respectively, were considered as positive according to the manufacture's instructions. RESULTS: The histological classification was adenocarcinoma in 193 patients, squamous cell carcinoma in 71, large cell carcinoma in 5, and other histological type in 6. One hundred and fifty-seven patients had T1 disease and 118 patients had T2 disease. The positive ratio of CEA and CYFRA21-1 was 25.7% and 13.7%, respectively, and in relation to histological type was 27.8% and 7.8% in adenocarcinoma, and 20.6% and 28.4% in squamous cell carcinoma. The overall 5-year survival rate was 79.3%. With a median follow-up of 35.5 month for surviving patients, those with initial CYFRA21-1 serum levels higher than 2.8 ng/ml had a significantly worse prognosis (p=0.0041). Patients with an elevated preoperative CEA level exceeding 5.0 ng/ml had a shorter disease-free survival period (p=0.0003). In patients with adenocarcinoma, a CEA level above 5.0 ng/ml was associated with shorter survival and early recurrence, whereas CYFRA21-1 showed no such association. In patients with squamous cell carcinoma, elevated preoperative CEA was not related to survival and recurrence. In these patients, preoperative CYFRA21-1 level exceeding 2.8 ng/ml was associated with a poorer outcome, whereas preoperative CYFRA21-1 level was not associated with cancer recurrence. CONCLUSION: The patients with p-stage I adenocarcinoma whose preoperative CEA level was high might be considered as good candidates for adjuvant chemotherapy. The prognostic value of CYFRA21-1 could not be confirmed for stage I NSCLC, and preoperative CYFRA21-1 level was not useful in selecting the candidates for adjuvant chemotherapy.     

不同年龄患者甲状腺腺叶切除术后甲状腺功能变化的研究

目的：探讨不同年龄甲状腺良性肿瘤患者行单侧腺叶切除术后甲状腺功能的变化及激素替代治疗的必要性。 方法：将120例因甲状腺良性肿瘤行单侧腺叶切除术的患者根据年龄不同分为青年组（≤30岁,23例）、中年组（<30~<60岁,69例）、老年组（≥60岁,28例）,检测各组患者术前及术后1周,1、3、6个月,1、2年游离三碘甲状腺原氨酸（FT3）、游离甲状腺素（FT4）和促甲状腺激素（TSH）水平。 结果：青年组FT3水平在术后1周、1个月时较术前明显降低（P<0.05）,后期各时间点则与术前无统计学差异（P>0.05）;FT4水平术后各时间较术前均无明显变化（P>0.05）;TSH水平在术后1周,1、3个月时较术前比明显升高（均P<0.05）,后期各时间点则与术前无统计学差异（P>0.05）。中年组术后各时间点FT3、FT4、TSH与术前比较均无统计学差异（P>0.05）。老年组患者FT3水平在术后1周,1、3个月时较术前明显降低（P>0.05）,后期各时间点则术前无统计学差异（P>0.05）;FT4水平在术后1、3、6个月时较术前明显降低（P<0.05）,其余各时间点则与术前无统计学差异（P>0.05）;TSH水平在术后1周,1、3、6个月时均较术前比升高（P<0.05）,后期各时间点则与术前无统计学差异（P>0.05）。3组患者均未出现临床甲状腺功能减退症状。 结论：不同年龄甲状腺良性肿瘤患者行单侧腺叶切除术后甲状腺功能恢复情况不同。中年患者术后代偿能力强,可不予激素替代治疗;青年对甲状腺激素需求量相对较大而老年患者代偿能力较差,故青年患者术后半年内、老年患者术后1年内给予激素替代治疗较合适。     

Primary isolated aortic valve replacement. Early and late results

A total of 1689 consecutive patients underwent isolated aortic valve replacement at the Cleveland Clinic Foundation from 1972 through 1986. There were 57 (3.4%) in-hospital deaths. Multivariate analysis identified advanced age (p = 0.0014), preoperative blood urea nitrogen level greater than 25 mg/100 ml (p = 0.008), New York Heart Association function class (p = 0.015), and preoperative atrial fibrillation (p = 0.04) as independent variables associated with increased in-hospital mortality and the use of cardioplegia for myocardial protection (p = 0.006) as a factor decreasing mortality. Follow-up documented survival rates of 85% and 66% and event-free survival rates of 71% and 43% at 5 and 10 postoperative years, respectively. Advanced age, moderate or severe impairment of left ventricular function, coronary artery disease, and preoperative blood urea nitrogen level greater than 25 mg/100 ml were associated with decreased late survival and event-free survival (all p less than 0.05). Patients with bioprostheses had better survival (p = 0.003) and event-free survival (p = 0.0007) rates than patients with mechanical valves. Patients with bioprostheses had superior results only if not receiving warfarin, and they experienced more reoperations and endocarditis; those with mechanical prostheses had more strokes, myocardial infarctions, bleeding complications, and thromboembolic events. Analysis of patients grouped according to age at operation showed that bioprostheses were associated with improved survival and event-free survival for patients 40 years older or older. Younger patients experienced more reoperations and episodes of endocarditis, and older patients more thromboembolic complications. We conclude that 10-year results after isolated aortic valve replacement are influenced by both patient-related and management-related variables, and the impact of these factors is different for patients of different ages.     

Perioperative change of plasma endotoxin levels in early infants

As a preliminary study to elucidate the relationship of endotoxemia to postoperative morbidity, the plasma endotoxin levels in 64 surgical neonates were quantitated by the chromogenic limulus test (Toxicolor test; Seikagaku Kogyo, Tokyo, Japan). The preoperative levels of plasma endotoxin were 64 +/- 59 pg/mL in the group of infants with perforated peritonitis (n = 9), 63 +/- 51 pg/mL in the group of infants with gastroschisis (n = 7), and 15 +/- 16 pg/mL in the group of infants with ileus (n = 28), while the mean level was 6 +/- 5 pg/mL in the remaining 20 surgical neonates who had no signs of ileus or peritonitis. In the serial determination of plasma endotoxin in 28 neonates, the levels on the first postoperative day increased significantly compared with the preoperative levels (16 +/- 18 pg/mL to 46 +/- 25 pg/mL, P less than .01). They decreased gradually to 8 +/- 5 pg/mL within a week in 15 neonates who had no postoperative complications. However, in 13 neonates who had postoperative complications such as wound infection or postoperative ileus, the postoperative levels of plasma endotoxin increased to a much higher level and remained there. In this article the relationship of clinical endotoxemia to postoperative thrombocytopenia and hyperbilirubinemia is analyzed, and the usefulness of evaluating endotoxemia in surgical neonates is discussed.     

壶腹部癌合并急性胆管炎的治疗选择

目的　探讨壶腹部癌合并急性胆管炎的治疗方法。方法　对比分析 12年间收治的壶腹部癌合并急性胆管炎的临床资料。其中采用一期切除手术 2 5例 ,先作胆道引流二期行切除手术 12例。结果　一期手术组通过非手术治疗 ,术前的体温和白细胞均比入院时明显降低 (P <0 .0 5 ) ,基本达到二期手术组二期切除的术前水平 ( P >0 .0 5 ) ,而总胆红素和清蛋白水平无明显变化 ;与二期组比较 ,一期组切除术前准备期明显缩短 (P <0 .0 5 ) ,手术时间和术中出血量减少 ,虽然术后感染性并发症发生率和术后住院天数增加 ,但再手术率和手术死亡率相似。结论　壶腹部癌合并急性胆管炎可先给予非手术治疗 ,待胆道感染控制后一期行胰十二指肠切除术     

Post-traumatic jaundice--its mechanism from a view point of hepatic mitochondrial function

It has been proposed that post-traumatic jaundice was the result of increased hemolysis, absorption of hematoma, effects of drugs, and so on. We considered that hepatic impairment in the bilirubin metabolism as a result of hepatic hypoperfusion might also be an important factor of the jaundice. Patients who developed jaundice after trauma were divided into two groups according to the maximum total bilirubin level; groups H (greater than 8 mg/dl) and L (less than 5 mg/dl). Severity of shock, levels of serum hepatic enzyme, and blood ketone body ratio were compared between the groups. Minimum systolic pressure, H 58, L 82 mmHg (p = 0.003); duration of shock (less than 80 mmHg), H 225, L 20 min (p less than 0.001); blood transfusion, H 9188, L 2914 ml (p less than 0.001); direct/total bilirubin, H 0.66, L 0.43 (p less than 0.001). Although no significant difference was noted in serum hepatic enzyme levels, blood ketone body ratios were significantly lower in group H throughout the first week. From these facts, it is considered that an impairment in the most energy requiring process of bilirubin metabolism, excretion of conjugated bilirubin from cytosol to capillary bile duct, due to post-traumatic hepatic mitochondrial dysfunction, followed by the reabsorption of conjugated bilirubin into the blood stream, would be one of factors of post-traumatic jaundice.