老年胆石症手术治疗1450例临床报道

社会老龄化为一世界性问题 ,我院1991～ 2 0 0 1年共手术治疗 60岁以上老年胆石症病人 14 5 0例 ,由于老年人生理和病理特点 ,对老年人胆石症在治疗原则、手术时机及手术方法均与青壮年有所不同。1　临床资料1 1　一般资料　本组年龄 60～ 89岁 ,平均 68 4岁 ,男 676例 ,女 774例。合并症 :本组 14 5 0例中 1167例 (80 5 % )患有高血压、心脏病、糖尿病等。急诊入院 3 85例。主要临床表现为上腹痛 ,但也有仅表现为呕吐、发热等症状。术前均经Ｂ超证实。1 2　手术方法　本组病人均系手术治疗 ,单纯胆囊切除 10 15例 ,胆囊切除 +胆总管切开取…     

糖尿病患者胆囊切除术治疗效果的临床观察

目的观察分析糖尿病与非糖尿病患者治疗效果和糖尿病患者不同术式治疗效果。方法 2009年1月—2014年6月经笔者治疗的80例糖尿病(含应激性高血糖)患者行胆囊切除术,并选取同期具有可比性的80例非糖尿病行胆囊切除术患者为对照组,采用开腹和腹腔镜两种方式。结果糖尿病组术后水电解质紊乱、感染性并发症等发生率高于对照组(P0.05),糖尿病患者开腹手术的切口感染率和平均住院时间均高于腹腔镜手术(P0.05)。结论糖尿病病人行胆囊切除术时,必须严格控制围术期血糖,手术方式力求简单,若无禁忌症,首选腹腔镜胆囊切除术。     

胆囊腺肌增生症23例临床分析

目的探讨胆囊腺肌增生症的病因、诊断和治疗方法。方法在1046例胆囊切除术中,对病理检查确诊的23例胆囊腺肌增生症的临床资料进行回顾性分析,患者术前均行超声、CT或MRI检查。结果23例胆囊腺肌增生症临床表现与慢性胆囊炎胆石症类似。病变大体形态:局限型13例(均位于胆囊底部)、节段型7例和弥漫型3例。23例均行胆囊切除,合并胆囊结石6例,合并胆囊炎14例。结论胆囊腺肌增生症是一种好发于成年人的胆囊壁增生性病变,此病常与慢性胆囊炎、胆石症并存,临床诊断困难,确诊需依赖病理检查。联合超声、CT和MRI等影像学检查可提高术前诊断准确度。目前手术是治疗的最好方法。     

糖尿病患者胆囊切除术治疗效果的临床观察

目的观察分析糖尿病与非糖尿病患者治疗效果和糖尿病患者不同术式治疗效果。方法 2009年1月—2014年6月经笔者治疗的80例糖尿病（含应激性高血糖）患者行胆囊切除术,并选取同期具有可比性的80例非糖尿病行胆囊切除术患者为对照组,采用开腹和腹腔镜两种方式。结果糖尿病组术后水电解质紊乱、感染性并发症等发生率高于对照组（P〈0.05）,糖尿病患者开腹手术的切口感染率和平均住院时间均高于腹腔镜手术（P〈0.05）。结论糖尿病病人行胆囊切除术时,必须严格控制围术期血糖,手术方式力求简单,若无禁忌症,首选腹腔镜胆囊切除术。     

糖尿病与非糖尿病患者两种不同胆囊切除术治疗效果的临床分析

目的对比应用两种不同胆囊切除术对糖尿病与非糖尿病患者进行治疗的效果。方法随机选取2015年6月—2016年10月期间在该院接受治疗的44例伴有糖尿病(含应激高血糖)患者作为糖尿病组,44例未合并糖尿病患者作为非糖尿病组,分别行开腹、腹腔镜胆囊切除术治疗,对比组间及不同术式疗效。结果与非糖尿病组比较,糖尿病组患者术后感染性并发症、水电解质紊乱发生率均显著高于对照组(P0.05);在糖尿病组中,接受腹腔镜手术治疗患者,切口感染率显著低于开腹手术,平均住院时间显著短于开腹手术(P0.05)。结论对合并糖尿病患者行胆囊切除术治疗时,必须高度重视在围术期加强对患者血糖水平进行严格控制,在无禁忌证情况下,选用腹腔镜胆囊切除术对该类患者进行,可取得更加理想的治疗效果。     

急性结石性胆囊炎合并2型糖尿病患者的临床特点与手术治疗

目的探讨急性结石性胆囊炎合并2型糖尿病患者的临床特点与围术期血糖控制的意义。方法选择自2013年1月—2014年1月之间该科收治的急性胆囊炎合并糖尿病病人68例,对其手术期间血糖控制进行回顾性分析。结果 68例患者行腹腔镜下胆囊切除术55例,8例因胆囊与周围组织粘连严重转开腹手术切除,5例行胆囊造瘘术。术后切口感染10例,肺部感染5例,切口感染3例,心律失常2例,死亡1例。结论急性结石性胆囊炎合并2型糖尿病患者合并症多、感染几率大、手术风险高,尤其是老年体弱血糖控制不理想的患者,围术期血糖的控制是减少手术风险的保障。     

急性结石性胆囊炎合并2型糖尿病患者的临床特点与手术治疗

目的探讨急性结石性胆囊炎合并2型糖尿病患者的临床特点与围术期血糖控制的意义。方法选择自2013年1月—2014年1月之间该科收治的急性胆囊炎合并糖尿病病人68例,对其手术期间血糖控制进行回顾性分析。结果 68例患者行腹腔镜下胆囊切除术55例,8例因胆囊与周围组织粘连严重转开腹手术切除,5例行胆囊造瘘术。术后切口感染10例,肺部感染5例,切口感染3例,心律失常2例,死亡1例。结论急性结石性胆囊炎合并2型糖尿病患者合并症多、感染几率大、手术风险高,尤其是老年体弱血糖控制不理想的患者,围术期血糖的控制是减少手术风险的保障。     

兰州地区胆石症2180例诊治分析

目的了解兰州地区胆石症的发病特点。方法回顾分析2011年3月-2012年3月就诊的2180例胆石症患者临床资料。结果保守治疗335例,手术治疗1845例,治愈1844例。女性发病率高于男性,胆囊息肉与胆囊结石发病不相关。腹腔镜胆囊切除术1446例,其中常规腹腔镜胆囊切除术1371例;开腹胆囊切除399例。经统计分析,腹腔镜胆囊切除术手术时间、术中出血量、住院时间、术后胆瘘发生率均低于开腹胆囊切除术（P〈0.05）;其余各项均无统计学意义（P〉0.05）。结论兰州地区患胆石症人群在性别、年龄及饮食关系等方面有地区特点,且腹腔镜胆囊切除术在手术时间、术中出血量、住院时间及术后并发症等方面低于开腹胆囊切除术。     

老年患者胃大部切除术后并发胆囊炎,胆石症26例分析

２６例胃大部切除术后并发胆囊炎、胆石症，其中１７例作胆囊切除，４例作胆总管切开“Ｔ”型管引流术，３例因病人危重作胆囊造瘘术。对术后胆囊炎、胆石症的病因进行了探讨。结果表明，老年患者胃大部切除术后易发生胆石症，临床上应引起重视。对这类患者，应及早手术，以减少病死率。     

胆石症合并糖尿病围术期护理效果的临床探讨

目的探讨胆石症合并糖尿病病人围术期护理效果。方法选择该院2010年以来收治的72例胆石症合并糖尿病病人作为研究对象,并对其采取人性化的护理干预措施。结果本组患者手术后,6例发生切口感染,4例发生肺部感染,总的感染率为13.89%。其余患者的伤口拆线时间均在正常时间段内。感染患者进行对症治疗后,均痊愈出院。随访6个月~1年,期间无复发病例。结论人性化围术期护理胆石症合并糖尿病病人,能控制患者血糖,稳定其病情,促进手术顺利实施;术后护理能促进患者病情恢复,提高了护理满意度。     

The ultrasound survey of gallstone diseases of patients infected with Clonorchis sinensis in southern Taiwan

Ultrasonography was used to evaluate the relationship between the gallstone diseases and infection with Clonorchis sinensis. One thousand and ninety-one Hakkanese in southern Taiwan were examined in the past 2 years. Among the 947 cases infected with clonorchiasis, 89 cases were found to have gallstone diseases, which included gallbladder stones (85 cases), common bile duct stones (three cases) and one case of intrahepatic duct stone, indicating a prevalence of 8.97, 0.32 and 0.11% respectively. The overall prevalence of gallstones in the infected group was 9.39%. In the other 144 cases without clonorchiasis infection, eight patients were found to have gallstone disease, which included gallbladder stone (six cases) and intrahepatic duct stone (two cases), indicating an incidence of gallstone of 4.16 and 1.39% respectively. The overall prevalence of gallstones in the non-infected group was 5.56%. A comparison between the infected and non-infected groups was made and showed no significant relationship between gallstone disease and clonorchiasis.     

胆囊结石与急性胰腺炎的关系

目的 探讨胆囊结石患者发生急性胰腺炎（AP）的影响因素.方法 选取武汉大学人民医院消化内科收治的诊断为胆囊结石的患者118例,通过影像学检查,测量胆囊大小、胆囊结石大小及数量,判断是否伴有胆总管结石.根据有无并发AP进行分组,比较各相关因素对AP发生率的影响.结果 118例胆囊结石患者中并发AP 61例.74例的胆囊大小正常,其中49例（66.2％）发生AP;44例胆囊增大或缩小,其中12例（27.3％）发生AP.31例为单发结石,其中11例（35.5％）发生AP;87例为多发结石,其中50例（57.5％）发生AP.发生AP的11例单发结石患者,其中8例（72.7％）结石≥10mm;50例多发结石患者中41例（82.0％）结石＜10 mm.19例伴有胆总管结石,其中17例（89.5％）发生AP;99例无胆总管结石,其中44例（44.4％）发生AP.各因素的两组间差异均有统计学意义（Х^2=16.758,P=0.000;Х^2 =4.425,P=0.029;Х^2=13.434,P=0.001;Х^2 =12.994,P=0.000）.结论 急性胆源性胰腺炎的发生与胆囊结石相关,胆囊是否正常、胆囊结石大小及数量、是否伴有胆总管结石均是影响AP发生的相关因素.     

Risk factors for symptomatic gallstones in patients with liver cirrhosis: a case-control study

OBJECTIVES: Liver cirrhosis is a well-documented risk factor for the formation of gallstones. In cirrhotic patients, gallstones are almost always "silent," and surgery is rarely required. When indicated (symptoms or complications), cholecystectomy implies a high morbidity risk in these patients, especially in the advanced stages of cirrhosis. The aim of this study was to estimate the risk factors for symptom development in cirrhotic patients with gallstones to identify the subgroup of patients at risk of undergoing surgery. METHODS: A total of 140 patients with liver cirrhosis and gallstones were studied: 97 with asymptomatic and 43 with symptomatic gallstone disease. The risk factors for gallstone formation (age, gender, family history, parity, obesity, diabetes mellitus, hyperlipoproteinemia) and the characteristics of liver cirrhosis (etiology, duration, Child class, hypersplenism), gallstones (duration, number, size), and gallbladder (size, wall thickness) were assessed in all patients. In 12 patients (four symptomatic, eight asymptomatic), gallbladder emptying was also evaluated by ultrasound. The association of asymptomatic and symptomatic gallstones with all these parameters was statistically evaluated by Student's t, Mann-Whitney, and chi(2) tests, as well as by means of multiple logistic regression. The causal relationship between these characteristics and gallstone symptoms was also examined by means of the KDD (knowledge discovery from databases) method, with an algorithm for learning Bayesian networks. RESULTS: Advanced age, female gender, viral etiology of cirrhosis, family history of gallstones, and duration of gallstone disease were significantly associated with symptomatic gallstone disease. The number or size of gallstones and the size or emptying of the gallbladder did not differ in symptomatic versus asymptomatic patients. Male gender and alcoholic cirrhosis were inversely correlated with symptom presence. In the multivariate analysis, family history (p = 0.0098) and advanced age (p = 0.0422) were positively correlated and male gender (p = 0.0049) and alcoholic etiology of cirrhosis (p = 0.0116) negatively correlated with symptom presence. These relationships (except for age) were also evidenced by the KDD method. CONCLUSIONS: The risk of gallstones becoming symptomatic is significantly lower in men and in alcoholic cirrhosis. In cirrhotic women, and especially in the presence of a positive family history and of advanced age, the risk of developing symptoms and undergoing surgery was significantly greater.     

Gallstones play a significant role in Salmonella spp. gallbladder colonization and carriage

Salmonella enterica serovar Typhi can colonize the gallbladder and persist in an asymptomatic carrier state that is frequently associated with the presence of gallstones. We have shown that salmonellae form bile-mediated biofilms on human gallstones and cholesterol-coated surfaces in vitro. Here, we test the hypothesis that biofilms on cholesterol gallbladder stones facilitate typhoid carriage in mice and men. Naturally resistant (Nramp1^+/+) mice fed a lithogenic diet developed cholesterol gallstones that supported biofilm formation during persistent serovar Typhimurium infection and, as a result, demonstrated enhanced fecal shedding and enhanced colonization of gallbladder tissue and bile. In typhoid endemic Mexico City, 5% of enrolled cholelithiasis patients carried serovar Typhi, and bacterial biofilms could be visualized on gallstones from these carriers whereas significant biofilms were not detected on gallstones from Escherichia coli infected gallbladders. These findings offer direct evidence that gallstone biofilms occur in humans and mice, which facilitate gallbladder colonization and shedding.     

Common presence of Helicobacter DNA in the gallbladder of patients with gallstone diseases and controls

BACKGROUND: Several species of Helicobacter colonise the biliary tract of animals and cause hepatobiliary diseases. Helicobacter species have also been identified in the gallbladder of a high proportion of Chilean patients with gallbladder cancer. AIM: To determine the presence of Helicobacter species, particularly Helicobacter pylori and Helicobacter bilis, in the gallbladder of patients with non-malignant gallbladder diseases and control patients. PATIENTS AND METHODS: DNA was extracted from gallbladder samples from 122 consecutive patients undergoing cholecystectomy. The presence of Helicobacter genus-specific or Helicobacter pylori and Helicobacter bilis species-specific DNA was determined by polymerase chain reaction and sequence analysis. The presence of Helicobacter pylori-specific immunoglobulin G in the serum (n=84) and bile (n=104) samples was determined by enzyme linked immunosorbent assay. RESULTS: Helicobacter DNA was detected in 61 (50.0%) gallbladder samples: 29 of 60 (48.3%) patients with symptomatic gallstone, six of 10 (60.0%) patients with asymptomatic gallstones, 11 of 15 (73.3%) patients with other biliary diseases, and 15 of 37 (40.5%) control patients, respectively. Among them, 39 samples were positive for Helicobacter pylori but none were positive for Helicobacter bilis. Sequence analysis of Helicobacter genus-positive samples showed that 56 samples were Helicobacter pylori and five were Helicobacter species 'Liver 3' strain. Overall, there was no significant difference in the detection rate of Helicobacter DNA or the levels of serum and bile Helicobacter pylori-specific immunoglobulin G in the various biliary disease groups compared with control patients. Neither was there any significant difference in the blood biochemistry and liver function tests between patients with positive and negative Helicobacter DNA detection. CONCLUSION: Helicobacter species' DNA are commonly present in the gallbladder of patients with gallstone diseases and in controls, implying that Helicobacter infection alone may not play a significant role in the formation of gallstones. However, our results do not exclude the possibility of Helicobacter infection as a cofactor in the development of gallstones.     

Effect of NSAIDs on gallbladder bile composition

Secretion of gallbladder mucin is an important step in gallstone pathogenesis. Previous studies have demonstrated that aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) can both inhibit gallbladder mucin secretion and prevent gallstone formation in animal models of cholesterol gallstone disease. The present study was performed to determine if chronic NSAID use was associated with a reduction in the mucin content or affected the lipid components of human gallbladder bile. Four groups of patients were identified retrospectively from a cohort of 230 morbidly obese patients who underwent gastric bypass surgery. The index group consisted of 18 patients who were found to have gallstones at gastric bypass surgery and had a history of chronic NSAID use. Three other patient groups were identified from the cohort by matching this index population for sex, race, and age according to the following criteria: (1) patients with gallstones who had not utilized NSAIDs, (2) patients without gallstones but with chronic NSAID use, and (3) patients without gallstones and without a history of NSAID use. Gallbladder bile was obtained from all patients by direct aspiration from the gallbladder at the time of surgery. Patients with gallstones had a significantly (P<0.02) greater concentration of gallbladder mucin in their gallbladder bile compared to patients without gallstones (0.897±0.226 vs 0.173±0.039 mg/ml). Among gallstone patients, gallbladder mucin was reduced in those patients with a history of chronic NSAID use (1.18±0.43 vs 0.74±0.19 mg/ml). Chronic NSAID use was also associated with a reduction in the cholesterol/phospholipid ratio of gallbladder bile in patients with and without gallstones. These data suggest that chronic NSAID use may later the mucin and lipid content of gallbladder bile in a manner that could reduce the risk for gallstone formation.Supported by NIH-FIRST award DK43264 (M.L.S.) and NIH grant DK47628 (E.W.M.) from the National Institutes of Digestive and Kidney Diseases.     

Long-term outcome after extracorporeal shock wave lithotripsy for gallstones]

We retrospectively reviewed 289 cases followed for a long time after extracorporeal shock wave lithotripy (ESWL) for gallstones. Follow-up periods ranged from 0.5 years to 9.2 years, with a median of 4.1 years. The complete resolution rate was 45.6%. A solitary gallstone, non-calcified gallstones on CT, and Tsuchiya's sonographic type Ia and Ib gallstones were found to be statistically significant variable for resolution of the disease. With a maximum follow-up period of 9 years, the cumulative recurrence rate was 30.7%. Among the 156 patients whose gallstones did not resolve, 70 were symptomatic and the other 86 were asymptomatic. Thirty-eight of the symptomatic patients (54.3%) became symptom-free, while 23 asymptomatic patients (29.1%) became symptomatic. The cumulative rate of occurrence of colic attacks and/or acute cholecystitis was significantly higher in the cases with lithotripsy fragments 4 mm or more in size than in the cases wih fragments 3 mm or less in size (51.8% vs. 16.7%; p < 0.05). ESWL was followed by surgery in 23.1% because symptoms developed or became aggravated after ESWL in 58.3% of them. Gallbladder cancer was discovered in one case. Patients undergoing ESWL should be followed by focusing on postoperative recurrence, symptoms, and gallbladder cancer.     

Relation of gallbladder function and Helicobacter pylori infection to gastric mucosa inflammation in patients with symptomatic cholecystolithiasis

BACKGROUND: Inflammatory alterations of the gastric mucosa are commonly caused by Helicobacter pylori (Hp) infection in patients with symptomatic gallstone disease. However, the additional pathogenetic role of an impaired gallbladder function leading to an increased alkaline duodenogastric reflux is controversially discussed. AIM: To investigate the relation of gallbladder function and Hp infection to gastric mucosa inflammation in patients with symptomatic gallstones prior to cholecystectomy. PATIENTS: Seventy-three patients with symptomatic gallstones were studied by endoscopy and Hp testing. Methods: Gastritis classification was performed according to the updated Sydney System and gallbladder function was determined by total lipid concentration of gallbladder bile collected during mainly laparoscopic cholecystectomy. RESULTS: Fifteen patients revealed no, 39 patients mild, and 19 moderate to marked gastritis. No significant differences for bile salts, phospholipids, cholesterol, or total lipids in gallbladder bile were found between these three groups of patients. However, while only 1 out of 54 (<2%) patients with mild or no gastritis was found histologically positive for Hp, this infection could be detected in 14 (74%) out of 19 patients with moderate to marked gastritis. CONCLUSION: Moderate to marked gastric mucosa inflammation in gallstone patients is mainly caused by Hp infection, whereas gallbladder function is not related to the degree of gastritis. Thus, an increased alkaline duodenogastric reflux in gallstone patients seems to be of limited pathophysiological relevance.     

Gallstone recurrence after successful percutaneous cholecystolithotomy:a 10-year follow-up of 439 cases

BACKGROUND: Stone recurrence is a major problem in the medication of gallstones with gallbladder preservation. The aim of this study was to determine the long-term recurrence rate of gallstones and the clinical outcome after successful percutaneous cholecystolithotomy (PCCL) treatment, and to investigate the possible risk factors for gallstone recurrence. METHODS: After successful PCCL for gallstones, 439 patients were followed up during a 10-year period. The long-term gallstone recurrence rate and clinical outcome were evaluated. Risk factors associated with stone recurrence were identified. RESULTS: Gallstone recurrence was detected in 182 of 439 PCCL patients, giving an overall recurrence rate of 41.46%. The cumulative gallstone recurrence rate for each of the 10 post-operative years was 9.57%, 18.91%, 27.33%, 34.14%, 37.59%, 39.86%, 41.90%, 42.73%, 42.85%, and 43.21%, respectively. Among these recurrent patients, 94 were asymptomatic, 80 suffered from nonspecific upper gastrointestinal symptoms and 8 suffered from abdominal pain or biliary colic. Thirty-eight of the 182 patients were retreated with cholecystectomy. The risk factors for stone recurrence included a family history of gallstones, preference for fatty food, accompanying liver disease, multiple stones and poor gallbladder function pre-PCCL. CONCLUSIONS: In this study, the overall recurrence rate of gallstone was 41.46% during a 10-year period. The highest frequency of gallstone recurrence was during the 5th to 6th postoperative years and then continued to slowly increase. Risk factors for stone recurrence varied.We suggest that the use of PCCL in patients with gallstones should be considered carefully because of stone recurrence.     

Infectious diseases and the gallbladder

Infections of the gastrointestinal tract can often involve the gallbladder. Infection probably plays a role in the formation of gallstones but is more commonly thought to contribute to acute illness in patients. Acute calculous cholecystitis caused by an impacted gallstone is often complicated by secondary bacterial infection and is a major cause of morbidity and even mortality in patients. A wide variety of organisms can be associated with acute acalculous cholecystitis, a less common but potentially more severe form of acute cholecystitis. This review focuses on infections and their role in the above-mentioned processes involving the gallbladder.