The effect of decreased portal blood flow on the biliary system

A disturbance in the regional portal blood flow adjacent to the dilated bile duct in the liver is often observed in patients with hepatolithiasis. The effects of this disturbed portal blood flow on the biliary system, with or without cholangitis, were therefore investigated. Young rabbits were divided into the following four groups; (1) controls that had a laparotomy only (n=3), (2) those that had a ligation of the portal branch of the right posterior lobe (RP lobe) (PL) (n=10), (3) those that had tubing inserted into the bile duct through the duodenal papilla (BS) (n=10), and (4) PL+BS (n=10). Despite marked atrophy of the RP lobe, no distinct changes were seen in the biliary systems of groups 1 or 2. In groups 3 and 4, however, infiltration of inflammatory cells and glandular proliferation in the wall of the markedly dilated extrahepatic bile duct (proliferative cholangitis (PC), characteristic to hepatolithiasis) were seen. Findings of PC were also noted in the intrahepatic bile duct of the atrophied RP lobes of these 2 groups. The incidence of PC was 20 per cent in group 3 and 60 per cent in group 4, respectively, but the PC of the intrahepatic bile ducts in group 3 was more localized than in group 4. Goblet cell metaplasia was seen in the epithelial cells of PC. Bacteriologically, bile samples were aseptic in groups 1 and 2, however, samples of bile from groups 3 and 4 were all contaminated withEscherichia coli orStreptococcus Faecalis. The biliary contents of phospholipids, total cholesterol and total bile acid were significantly decreased in groups 3 and 4, when compared with groups 1 and 2. In conclusion, a disturbance in portal blood flow, accompanied by cholangitis and segmental liver atrophy, may play an important role in the clinical course of hepatolithiasis.     

肝胆管结石并发复发性胆管炎时择期手术处理的关键

目的 探讨提高肝胆管结石并发复发性胆管炎病人治疗水平的方法。方法 报告3例肝胆管结石并发复发性胆管炎病人的手术中发现及胆树的主要梗阻部位。结果 例1是右后肝管与右前肝管汇入左肝管横部的胆管变异致右肝管狭窄继以结石形成、右肝叶萎缩；例2胆树的主要梗阻部位是肝尾叶结石及右肝动脉对肝总管的压迫性狭窄；例3总肝管狭窄及嵌顿结石是主要的梗阻部位，并采用了相应的手术方式治疗。结论 掌握影像诊断如BUS、CT、ERCP、MRCP提供的资料，术中仔细探查胆道，加上术中胆道镜运用，消除与胆管炎密切相关的主要梗阻是手术处理肝胆管结石并发复发性胆管炎病人的关键。     

The practical value of applying chemical biliary duct embolization to chemical hepatectomy for treatment of hepatolithiasis

BACKGROUND: The high recurrence rate of hepatolithiasis, together with the high operative risk of hepatectomy for specifically located stones, has not been effectively settled until now. Thus, the aim of this study was to investigate the feasibility and effectiveness of using chemical biliary duct embolization (CBDE) to achieve chemical hepatectomy in a rabbit model of hepatolithiasis. MATERIALS AND METHODS: The animal model of hepatolithiasis was established using the methods of obstruction plus infection. Seven days later, the left hepatic ducts were embolized using phenol plus cyanoacrylate or absolute ethanol plus cyanoacrylate. Subsequently, the influence of CBDE on bile duct, liver, and stone formation was analyzed by histology, RT-PCR for procollagen, biochemistry, and enzymatic histochemistry for beta-glucuronidase (beta-G). RESULTS: CBDE resulted in the entire ablation of the diseased biliary duct mucosa and the complete occlusion of the diseased biliary duct lumen, thus effectively eradicating chronic proliferative cholangitis and preventing stone formation. More importantly, CBDE also resulted in the complete fibrosis and "self-cut" in the periphery of the embolized lobe, thus achieving chemical hepatectomy. Also of note, the embolized lobe exhibited a much lower level of endogenous beta-G than the nonembolized lobe, indicating an inhibitory effect of CBDE on beta-G. Besides, the mRNA level of procollagen I in the embolized bile duct wall of phenol embolization group was significantly higher than the ethanol embolization group. CONCLUSION: Chemical biliary duct embolization, especially using phenol plus cyanoacrylate, may prevent the recurrence of intrahepatic stone and concurrently achieve the effect of chemical hepatectomy.     

Intrahepatic Segmental Primary Sclerosing Cholangitis: Report of a Case

A 67-year-old woman was referred to our hospital for investigation of epigastric discomfort. Computed tomography (CT) showed dilatation of the intrahepatic bile duct in the left lobe of the liver, endoscopic cholangiography showed complete stenosis of the left main branch of intrahepatic bile duct, and CT during angiography showed decreased portal blood flow to segment 3 of the liver. Based on these findings, we suspected intrahepatic cholangiocarcinoma and performed left lobectomy of the liver. However, pathological examination revealed fibrosis and infiltration of inflammatory lymphoid cells around the stenotic bile duct and periportal area, without any evidence of malignancy. Since these findings were compatible with sclerosing cholangitis and the patient did not have a disorder that would cause secondary sclerosing cholangitis, the final diagnosis was primary sclerosing cholangitis (PSC). It is difficult to distinguish segmental PSC from cholangiocarcinoma; thus we think surgical resection is an appropriate therapeutic and diagnostic procedure for segmental intrahepatic bile duct stenosis.     

肝胆管结石的微创手术治疗进展

肝胆管结石(hepatolithiasis)是指位于左、右肝管分叉以上的胆管结石。肝胆管结石常合并反复发作的胆管炎,导致肝胆管狭窄、肝实质萎缩,继发性胆汁性肝硬化甚至胆管癌。肝胆管结石病变复杂,术后并发症多、结石残余率及复发率均较高,其治疗一直是肝胆外科的难题。手术微创化是当今国际外科学发展的一大趋势,肝胆管结石的微创手术治疗方法及疗效也有了很大的进步。本文将近年来肝胆管结石的微创手术治疗进展作简要综述。     

肝胆管结石合并胆管癌的临床特点及防治

目的 探讨肝内胆管结石合并肝内胆管癌的临床特点及其防治.方法 对1990-2009年肝内胆管结石伴肝内胆管癌84例的临床资料进行回顾性研究.结果 肝内胆管结石合并肝内胆管癌的发生率占同期肝内胆管结石病例的4.6%(84/1840),术前明确诊断47例;肿瘤均发生于含结石的胆管处,以左肝多见;病程1～40年,平均18年.20例迟发性肝内胆管癌发生于取石后6-16年,平均9年.临床表现为久治不愈的肝脓肿、难以控制的肝内感染、肝内阻塞性进行性黄疸和影像学提示结石部位的肿瘤性改变.84例中晚期病例65例(65/84,77.4%).行根治性切除者仅35例,姑息性切除26例,射频消融4例,单纯活检19例.结论 (1)肝内胆管结石并发肝内胆管癌的概率较高.(2)对所有肝内占位性病变行术前、术中活检是避免误漏诊的重要方法.(3)早期诊断者行根治性切除可获得良好疗效.(4)对肝内结石伴胆管狭窄、肝段萎缩纤维化者行病灶肝段切除对继发胆管癌有预防作用.     

腹腔镜肝切除术治疗左肝内胆管结石的临床应用

目的 探讨腹腔镜肝切除术治疗左肝内胆管结石的技术与疗效。 方法 回顾性分析2011年1月至2016年12月完成67例腹腔镜肝切除术治疗左肝内胆管结石临床及随访资料。 结果 全部67例患者合并左半肝或左外叶肝萎缩,腔镜手术方式包括左外叶肝切除48例、左半肝切除19例。其他腹腔镜下联合术式包括：胆囊切除术52例、胆总管探查术43例、T管引流术39例,胆总管一期修补术4例。手术切口长度（4.67±1.26）cm。术后发生胆漏3例,均经引流观察后自愈;1例因术后腹腔大出血合并胆瘘再手术治愈;肝脓肿1例,膈下脓肿1例,均经穿刺引流治愈。 结论 腹腔镜肝切除术治疗左肝内胆管结石安全可靠,术中应尽量取净其他胆道残余结石并连续紧密缝合左肝管残端。如结石已被取净胆总管的探查和T管引流并非必需。     

左肝外侧叶切除术在肝内胆管结石治疗中的作用

目的 了解左肝外侧叶切除术在胆道结石中的治疗作用。方法 总结分析过去14年行左肝外侧叶切除治疗肝内胆管结石51例。结果 疗效优良率87.5％。结论 左肝外侧叶切除不但能切除病灶,而且可经左肝断面的扩张胆管为“借路”,取除其他部位肝内、外胆管的结石,以及便于肝门部狭窄胆管的整形。该手术操作简便、可行,在肝内胆管结石的治疗中可广泛应用。     

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。     

Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines

Unusual cases of acute cholecystitis and cholangitis include (1) pediatric biliary tract infections, (2) geriatric biliary tract infections, (3) acalculous cholecystitis, (4) acute and intrahepatic cholangitis accompanying hepatolithiasis (5) acute biliary tract infection accompanying malignant pancreatic-biliary tumor, (6) postoperative biliary tract infection, (7) acute biliary tract infection accompanying congenital biliary dilatation and pancreaticobiliary maljunction, and (8) primary sclerosing cholangitis. Pediatric biliary tract infection is characterized by great differences in causes from those of adult acute biliary tract infection, and severe cases should be immediately referred to a specialist pediatric surgical unit. Because biliary tract infection in elderly patients, who often have serious systemic conditions and complications, is likely to progress to a serious form, early surgery or biliary drainage is necessary. Acalculous cholangitis, which often occurs in patients with serious concomitant conditions, such as those in intensive care units (ICUs) and those with disturbed cardiac, pulmonary, and nephric function, has a high mortality and poor prognosis. Cholangitis accompanying hepatolithiasis includes recurrent pyogenic cholangitis, an epidemic disease in Southeast Asia. Biliary tract infections, which often occur after a biliary tract operation and treatment of the biliary tract, may have a fatal outcome, and should be carefully observed. The causes of acute cholangitis associated with pancreaticobiliary maljunction differ before and after operation. Direct cholangiography is most useful in the diagnosis of primary sclerosing cholangitis. If cholangiography visualizes a typical bile duct, differentiation from acute pyogenic cholangitis is easy. This article discusses the individual characteristics, diagnostic criteria, treatment guidelines, and prognosis of these unusual types of biliary tract infection.     

应用胆道化学性栓塞治疗肝内胆管结石的实验和临床研究

目的探讨胆道化学性栓塞在肝内胆管结石治疗中的应用价值。方法应用肝内胆管结石动物模型评估胆道化学性栓塞能否达预防结石复发和化学性肝切除的效果。结果栓塞胆管的粘膜上皮完全消失,被增生的胶原纤维取代,从而有效的根除了慢性增生性胆管炎;各级靶胆管腔均被栓塞剂填充,因而也无结石产生。在栓塞肝叶的周边部可见完全纤维化区域,达到了化学性肝切除的效果,并有效的解决肝内胆管狭窄和结石复发的问题。结论胆道化学性栓塞有可能达到预防结石产生的目的,同时也可能达到化学性肝切除的效果。     

肝门胆管良性狭窄个体化治疗的临床研究

目的 前瞻性地评价肝门胆管良性狭窄的处理方式与近远期疗效的关系。方法 前瞻性观察了按病因不同分为4组的25例患者,分别以不同方式治疗所取得的近远期疗效。结果 肝门胆管空肠吻合术治疗良性医源性肝门胆管狭窄疗效确切,随访期间返流性胆管炎1例,发生率较低,仅为10%,肝门胆管原位整形保持了胆管生理学的完整性,惟需可用的良好的自体修补组织及合理的手术设计两个因素;含石的萎缩右半肝切除加肝门胆管整形既达到了清除病灶的目的,又保持了胆管的通畅性及生理功能的完整性;气囊扩张虽对轻度环形狭窄有良效,但继发性硬化性胆管炎伴肝门管状狭窄气囊扩张疗效欠佳。结论 根据不同病因选择各异的治疗方案（个体化）,处理肝门胆管良性狭窄可获近远期良效。     

腹腔镜与开腹胆总管探查术144例对比研究

目的 探讨胆囊结石合并胆总管结石行胆总管探查术的术式选择。方法 回顾性分析144例胆囊结石合并胆总管结石患者行腹腔镜与开腹胆总管探查术的临床资料。根据手术方式分为腔镜组（n=78）和开腹组（n=66）。结果 腔镜组一期缝合39例,T管引流32例,经胆囊管探查2例,中转开腹5例;术后胆漏7例,胆管炎4例,残余结石2例,肠穿孔1例,MODS 1例,电解质紊乱5例,伤口感染2例。开腹组术后胆漏合并胸、腹腔积液1例,胆管炎1例,残余结石2例,术后出血再次手术1例,电解质紊乱4例,伤口感染4例,肝肾功能不全2例,死亡1例。两组在术后并发症发生率方面比较差别无统计学意义（P＞0.05）。结论 与开腹手术比较,腹腔镜胆总管探查取石术具有微创、术中失血少、术后恢复快、术后住院时间短等优点,但尚不能完全替代传统开腹手术。     

规则性肝段切除结合胆道镜治疗肝内胆管结石

目的 研究规则性肝段切除结合胆道镜治疗肝内胆管结石的优越性及有效性。方法 根据289例患者肝内胆管结石的分布情况(左外叶138例．左肝叶96例,右前叶6例,右后叶12例,右肝叶25例。双侧肝叶12例;合并有显著肝段或肝叶萎缩98例,肝脓肿8例,胆瘘3例,胆管癌5例)行肝段或联合肝段切除。其中S2～S3切除181例,S2～4切除56例．S6～S7切除18例,S5～8切除12例,双侧肝叶切除12例。附加术式包括经肝门部胆管切开取石186例,经肝实质胆管切开取石8例,胆管空肠Roux-en-Y吻合196例(10例输出空肠拌皮下埋植)。术中胆道镜经胆总管途径186例,肝断面胆管途径103例,术后胆道镜经T管途径186例,皮下输出空肠袢途径10例。结果 随访10个月至10年,89．5％(259／289)症状消失,7．9％(23／289)偶有轻度胆管炎发作,2．6％(7／289)仍反复发作严重胆道感染。术后并发症有胆漏8例(2．8％)．膈下感染12例(4．2％)．腹腔脓肿1例(0．35％)．3例(1．03％)术后死于肝衰竭。结论 规则性肝段切除术结合胆道镜技术是治疗肝内胆管结石的最有效手段。     

靶向PCNA的反义基因治疗对慢性增生性胆管炎的实验疗效

目的 近年的研究证实胆结石的术后高复发率和胆道再狭窄率均与术后遗留的慢性增生性胆管炎(PC)密切相关,鉴于PC是一种过度增殖疾病,本研究拟探讨应用PCNA shRNA抑制PC的过度增殖行为和成石潜力的可行性和疗效,以期为预防结石的术后复发和胆道再狭窄探讨新的治疗途径.方法 建立慢性增生性胆管炎的实验动物模型,胆总管内注入0.5 ml的PCNA shRNA,探讨其对PC的过度增殖行为和成石潜力的影响.结果 PCNA shRNA可通过抑制PCNA和Procollagen Ⅲ mRNA和蛋白的表达,有效抑制胆道黏膜上皮、黏膜下腺体和胶原纤维的过度增殖,有望达到控制或逆转慢性增生性胆管炎及其所继发的胆道狭窄的目的 .此外,该治疗还可抑制黏蛋白基因Mucin 5AC的激活和表达,有助于降低PC的成石潜力.结论 PCNA shRNA治疗可能在达到控制或逆转慢性增生性胆管炎及其所继发的胆道狭窄的目的 同时,亦有助于降低病变胆管的成石潜力.     

Long-term results of hepaticojejunostomy for hepatolithiasis

The results of a hepaticojejunostomy as a biliary-enteric bypass for benign disease are usually excellent. On the other hand, hepatolithiasis features a high rate of residual and recurrent stones with cholangitis after surgery. This study aims to evaluate the long-term results of a hepaticojejunostomy for hepatolithiasis regarding both the degree of the occurrence of postoperative cholangitis and the outcome. The clinical records of 159 patients with hepatolithiasis who underwent surgical treatment over a 23-year period were also retrospectively reviewed. Ninety-four of 159 patients underwent a hepatecetomy and 65 patients were subjected to liver-preserving surgery by means of intra- and postoperative endoscopic lithotripsy. In addition 72 patients underwent a hepaticojejunostomy. The rate of residual or recurrent stones was 31.4 per cent after complete stone removal. Twenty-two (30.6%) of the 72 patients developed some kind of cholangitis. This rate was significantly higher than that (three of 87 patients) of the non-biliary-enteric anastomosis group regarding the occurrence of biliary complications. We conclude that the use of a hepaticojejunostomy for patients with possible residual stones or intrahepatic bile duct lesions remains controversial.     

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目的 分析胆肠吻合术治疗肝内胆管结石并胆道狭窄的选择和疗效。方法 对１９９１年９月至１９９８年１２月６９例行胆肠吻合术的肝内胆管结石并胆道狭窄病例进行总结,包括临床表现、结石部位、狭窄情况、手术方式和治疗效果等。结果 胆管狭窄主要位于１￣２级胆管内。５１例（７３．９％）行肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,１８例（２６．１％）采用胆总管十二指肠吻合术,随访结果表明,肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合     

Pathological study of hepatolithiasis with special reference to unusual cases

Morphological survey was performed in 140 liver specimens of hepatolithiasis which were collected from several pathological and surgical Departments in Japan. Among them there were 19 cases with unusual features suggestive of presumed lithogenic processes. They consisted of association of congenital dilatation of biliary tree (5 cases), association of stenosis or obstruction of biliary tree occurring prior to lithiasis (4 cases), association of anomalous communication between biliary tree (1 case), presence of serous glands simulating to pancreatic exocrine glands in biliary tree (1 case), association of non-biliary hepatic cirrhosis (4 cases), association of chronic ulcerative colitis (1 case), intrahepatic cholesterol stone (2 cases) and association of granulomatous cholangitis (1 case). Chronic proliferative cholangitis which is consistently seen in a common type of hepatolithiasis was found in about a half of these unusual cases and not in the remaining cases. Based on the observations of these unusual cases, the following suggestions were obtained: dilatation, bile stasis or cholangitis may be a lithogenic factor of hepatolithiasis, and chronic proliferative cholangitis associated with a numerous amount of mucinous glands is not always a prerequisite lesion and exerts a promoting and accelerating effect in hepatolithiasis.     

经肝圆韧带肝膈面径路施行肝内胆肠吻合术治疗肝胆管结石21例临床观察

报告采用经肝圆韧带肝膈面径路施行肝内胆管空肠吻合治疗肝胆管结石２１例，其中伴医源性胆管损伤５例，左肝管结石８例（伴狭窄７例），肝内泥沙状结石并急性化脓性胆管炎２例，胆总管Ｔ管引流术后左肝管残余结石伴囊状扩张３例，胆管外伤、多次胆管手术后及左肝管结石并出血各１例。患者年龄３２～５０岁占７５．９％。２１例经临床观察，效果尚属满意。作者认为，该手术具有操作具有简便易行，术野暴露满意；创伤性小、保存肝组织、勿须切肝；术后能迅速降压减黄等优点。另外，对手术适应证、吻合方法及操作细节、术中注意事项等问题进行了讨论。