家犬梗阻型胆道损伤外科修复时机的探讨

目的 探讨实验性梗阻性胆道损伤后手术修复的时机.方法 将60只健康家犬制成梗阻性胆管损伤的动物模型,随机分为5组(n=12),分别为梗阻5 d,梗阻10 d,梗阻15 d、梗阻20 d和梗阻30 d组,对照组为模型建立之前的正常犬.动态观察梗阻损伤后不同时间段的胆管形态学、局部组织病理学及肝脏功能变化指标,并于各组获得组织标本后即刻行胆肠Roux-en-Y吻合修复胆道,观察胆道梗阻性损伤修复术后犬并发症及生存情况.数据采用单因素方差分析进行分析.结果 胆管梗阻性损伤后,近端梗阻胆管持续扩张,第10天达(15.6±1.7)mm;损伤胆管局部组织出现急性炎症反应,以梗阻5 d时最严重(HE染色、WBC计数54±6个),梗阻第15天时炎症消退明显(HE染色、WBC计数42±7 vs 54±6个,P＜0.05),同时胆管壁由早期(第5天)的炎性水肿样增厚,改变成纤维增生性增厚(第15天);在梗阻性黄疸状态下肝功能发生规律性生理改变,血清TBIL、DBIL和ALP值在阻塞5 d组最高,至梗阻30 d时急剧上升(P＜0.05);而酶学指标ALT和AST在迅速升高后,在梗阻20 d后下降(P＜0.05),表现为"胆酶分离"现象;其中57只犬成功经受胆道修复手术,10只犬术后10 d内因胆漏死亡,其中损伤10 d内修复的胆漏7只,损伤10 d后修复的胆漏3只(P=0.025),术后观察发现,梗阻性损伤后3个月内营养及脏器衰竭死亡13例,其中梗阻5 d和梗阻10 d组各1例,梗阻15 d和20 d组各2例,梗阻30 d组7例(P＜0.05).结论 胆道梗阻后10～20 d机体处于代偿期,且炎性水肿减轻明显,手术操作难度较小,此时行手术修复,胆漏发生率和器官衰竭率较低,手术容易获得良好效果.

Abstract：

Objective To explore the optimal timing of operation for experimental obstructive jaundice in a dog model. Method A dog model of bile duct stricture (BDS) was established. Dogs were divided into (n = 12 in each group) 6 groups, ie control, BDS days 5, 10, 15, 20, and 30. In each dog,the morphology and local histopathology of the bile duct, and the liver function in different periods were observed. At the time of surgery biopsy was taken and Roux-en-Y hepaticojejunostomy performed. Surgical complications and survival were evaluated. Result After bile duct obstruction, the proximal bile duct dilated continuously. The diameter of bile duct was 15.6 ± 1.7 mm at the 10th day. The injury bile ductshowed the acute inflammation change. In the early time (in 10 days), inflammatory cells increased in the tissues, mucous edema aggravated, the wall was edematous thickening, it was most severe ( WBC counting 54 ±6) in the 5th day. In the later period (10 -30 days), inflammatory cells reduced, bile duct wall became fibrosis, which was most obvious in the 15th day (42 ± 7 vs 54 ± 6, P ＜ 0.05 ). During the development of jaundice, serum bilirubin reached the highest level in the early period ( BDS days 5 group),then presented a platform time, and then rised extremely at the last stage of the experiment ( BDS day 30 group) . Changes of ALT and AST paralleled that of bilirubin before the 20th day of obstruction and then plummeted. BDS was repaired successfully in 57 dogs. Ten dogs died postoperatively due to bile leakage within 10 days, 3 dogs in BDS days 5 group (3/11), 4 in BDS days 10 group (4/12), one each in other groups. Postoperatively 13 BDS dogs died of malnutrition and organ failure within 3 months, including one each in days 5 and days 10 group, two each in days 15 and days 20 group, and 7 in days 30 group (P＜0. 05). Conclusion Considering the changes of morphology, physical function and result of follow up.The period between 10 and 20 days after acute bile duct injury is optimal for surgical repair.     

Routine vs ``on demand' postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography

Background: The detection of small and often asymptomatic gallbladder calculi within the bile duct at intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) frequently poses a management dilemma. Therefore, we set out to compare the outcomes and costs of two management strategies for small stones that remain in the bile duct after LC—routine postoperative endoscopic retrograde cholangiopancreatography (ERCP) vs observation alone with ``on-demand' ERCP. Methods: We studied 70 patients with bile duct stones among 922 consecutive patients who underwent LC between 1990 and 1997. Data were collected prospectively. Bile duct calculi were detected in 70 of 705 patients (9.9%) with successful IOC. Of these, 44 patients had large calculi (≥5 mm in diameter) and were subjected to a laparoscopic common bile duct exploration. The remaining 26 patients had small calculi (<5 mm in diameter); four of them had undergone preoperative endoscopic sphincterotomy and duct clearance and were therefore excluded from analysis. Patients with small duct calculi were assigned, according to individual surgeon policy, to either routine postoperative ERCP (group A, n= 8) or observation (group B, n= 14). ERCP was reserved for those who become symptomatic. The two groups were comparable for age and sex distribution. Results: No complications developed during the follow-up period in patients assigned to observation, although four became symptomatic and underwent ERCP. In group A, ERCP demonstrated a clear biliary tree in four patients and bile duct calculi in three patients; it failed in one patient. In group B, ERCP demonstrated a clear bile duct in one patient and bile duct calculi in two patients; it also failed in one patient. Endoscopic sphincterotomy and duct clearance were achieved in all patients with demonstrable bile duct calculi at ERCP. There was no morbidity or mortality associated with ERCP. The overall hospital stay was significantly longer in group A than in group B (median 5 vs 1.5 days; p= 0.011); however, the number of outpatient clinic visits was significantly greater in group b (median 3 vs 5.5, p= 0.011). The mean hospital costs, including the costs of hospital stay, readmissions, ERCP, and follow-up, were significantly greater in group A than in group B (mean ￡2669 vs ￡1508, p= 0.008). Conclusion: A ``wait and see' policy of observation alone for patients with small bile duct calculi detected at IOC during LC appears to be safe, and it is more cost-effective than routine postoperative ERCP. ERCP should be reserved for post-LC patients who become symptomatic. Received: 20 May 1999/Accepted: 24 September 1999/Online publication: 28 September 2000     

内镜乳头球囊扩张术治疗非扩张性肝外胆管结石的疗效分析

Objective To investigate the efficacy of endoscopic papillary balloon dilation (EPBD) and endoscopic sphincterotomy (EST) in the treatment of non-dilated extrahepatic biliary stones. Methods The clinical data of 317 patients with non-dilated extrahepatic biliary stones who were admitted to the Taiyuan Iron and Steel Corporation Hospital from January 1999 to April 2008 were retrospectively analyzed. Of all patients, 119 received EPBD treatment, and the remaining 198 received EST treatment. Sixty-two patients treated by EPBD (EPBD group) and 62 by EST (EST group) were selected to conduct the matched-pair analysis. In the EPBD group, a cylindrical balloon was inserted under the guidance of a guidewire after the conclusive diagnosis by endoscopic retrograde cholangiopancreatography. After the dilation, stones were extracted by a stone basket or a balloon, and then conventional endoscopic nasobiliary drainage was carried out. In the EST group, stones were extracted by a stone basket or a balloon under the monitor of the digital subtraction radiography after incision of the duodenal papilla. The efficacy of the two methods was compared using the chi-square test. Results The stonefree rate in one session was 92% (57/62) in the EPBD group and 94% (58/62) in the EST group, with no significant difference between the two groups ( χ 2 = 0.222, P > 0.05 ). The number of patients who were complicated with hyperamylasemia and pancreatitis was slightly greater, and the number of patients who were complicated with duodenal perforation was smaller in the EPBD group than those in the EST group, while there was no significant difference between the two groups ( χ 2 = 0. 286, 1. 000, 2.000, P > 0.05 ). The numbers of patients who were complicated with duodenal papilla bleeding or biliary infection in the EPBD group were significantly smaller thanthose in the EST group ( χ 2 = 4. 000, 7. 000, P < 0.05 ). All patients were followed up for 24 months. The recurrence rate of bile duct stone and the incidence of biliary infection in the EPBD group were significantly lower than those in the EST group at the end of 6, 12 and 24 months (χ2 =4. 000, 5. 000, 6.000; 6.000, 8.000,11. 000, P < 0.05 ). Conclusions Combined application of EPBD and ENBD has the advantages of minor trauma and quick recovery of patients. It can preserve the function of duodenal papilla, so it is the first choice for treating non-dilated extrahepatic biliary stones.     

阻塞性黄疸术前经皮肝穿刺胆管引流对围手术期的影响

【Abstract】〓Objective〓To summarize the experience in treatment of the obstructive jaundice by preoperative percutaneous puncture of liver bile duct drainage. Methods〓Eight-six patients with obstructive jaundice were included and divided into two groups according to the operation procedure, 44 cases were given preoperative percutaneous transhepatic cholangial drainage(observation group) and then,.underwent internal or external drainage or radical operation,.42 cases were served as control group without preoperative percutaneous transhepatic cholangial drainage..Intraoperative blood loss, operative time,..hospital stay and complications were compared between two groups. The preoperative and postoperative liver function tests,such as total bilirubin(TB),.serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) were evaluated and compared in two groups. Results〓The operation time,.blood loss,.length of hospital stay and complication rates between observation group were lower than that in control group (P<0.05). The levels of TB, ALT, AST in 14 days after operation reduced in two groups, but were significantly decreased in observation group,.as compared to control group (P<0.05). Conclusion〓For patients with obstructive jaundice, preoperative percutaneous transhepatic cholangial drainage would shorten the length of hospital stay,.reduce complications occurrence,.and improve liver function.     

Topical nitrate drip infusion using cystic duct tube for retained bile duct stone:A six patients case series

A retained bile duct stone after operation for cholelithiasis still occurs and causes symptoms such as biliary colic and obstructive jaundice.An endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy(EST),followed by stone extraction,are usually an effective treatment for this condition.However,these procedures are associated with severe complications including pancreatitis,bleeding,and duodenal perforation.Nitrates such as glyceryl trinitrate(GTN) and isosorbide dinitrate(ISDN) are known to relax the sphincter of Oddi.In 6 cases in which a retained stone was detected following cholecystectomy,topical nitrate drip infusion via cystic duct tube(C-tube) was carried out.Retained stones of 2-3 mm diameter and no dilated common bile duct in 3 patients were removed by drip infusion of 50 mg GTN or 10 mg ISDN,which was the regular dose of intravenous injection.Three other cases failed,and EST in 2 cases and endoscopic biliary balloon dilatation in 1 case were performed.One patient developed an adverse event of nausea.Severe complications were not observed.We consider the topical nitrate drip infusion via C-tube to be old but safe,easy,and inexpensive procedure for retained bile duct stone following cholecystectomy,inasmuch as removal rate was about 50% in our cases.     

应用磁压榨吻合术行肠漏一期修补的实验研究

目的 应用磁压榨吻合的原理,探索一种新的肠漏一期修补的方法.方法 将24只犬在距Treitz韧带50、100 cm处空肠分别横行切开肠壁约1 cm,建立犬高位、多处肠漏模型,按随机数字表法分为实验组和对照组,每组12只,观察犬肠漏模型的建立情况.肠漏形成48 h后,实验组采用磁通量为2500 G的钕铁硼磁环原位压榨修补漏口,对照组采用丝线缝合修补漏口.观察犬的一般情况,测吻合口渗漏压,肉眼观察吻合口情况并切取吻合口组织行HE和Masson染色,实验组加行X线检查观察磁环位置并记录磁环排出体外的时间.采用两样本t检验分析检测结果.结果 肠漏模型建立48 h后出现严重的腹腔感染.实验组犬肠漏修补全部获得成功,动物能长期存活,磁环在肠漏修补术后6～7 d排出体外;对照组犬存活8只.肠漏修补术后7 d,实验组与对照组犬吻合口渗漏压分别为(134±23)mm Hg(1 mm Hg=0.133 kPa)和(91±18)mm Hg,两组比较,差异有统计学意义(t=3.225,P＜0.05);肠漏修补术后14 d,实验组与对照组犬吻合口渗漏压分别为(281±7)mm Hg和(271±21)mm Hg,两组比较,差异无统计学意义(t=0.988,P＞0.05).磁环原位压榨修补后肠道的浆肌层和黏膜层愈合良好,吻合口周围炎症反应轻微,胶原纤维含量少,瘢痕增生不明显.结论 在腹腔感染状态下,应用磁通量为2500 G的磁环对犬肠漏进行一期修补是安全可靠的.

Abstract：

Objective To explore a new method for one-stage repair of the intestinal leakage based on the principle of magnetic compression anastomosis. Methods Twenty-four dogs were randomly divided into experimental group (n = 12) and control group (n = 12) according to random number table. The model of upper and multiple intestinal leakages was established by making transverse incisions of 1 cm in length on the jejunum wall about 50 cm and 100 cm away from the Treitz ligament. Forty-eight hours later, two NdFeB magnetic rings with the magnetic flux of 2500 G were put into the intestine from the leak sites. The leak sites were pressed between the two rings. The ventages in the control group were sutured. The condition of the dogs was observed after the repair of the leakage. The excreting time was recorded, and the leakage pressures of the anastomotic stoma were detected.The positions of the magnetic rings in the experimental group were detected by X ray. Tissues of the anastomotic stoma were processed by hematoxylin eosin and Masson staining. All data were analyzed using the two-sample t test. Results Severe abdominal infection occurred 48 hours after the establishment of the model. All the intestinal leakages in the experimental group were successfully repaired and the dogs survived for a long time. The magnetic rings were excreted six or seven days after the repair. Eight dogs of the control group survived. The leakage pressure of the anastomotic stoma seven days after the repair was (134 ±23)mm Hg (1 mm Hg =0. 133 kPa) in the experimental group and (91 ± 18)mm Hg in the control group, respectively, with a significant difference between the two groups (t = 3.225, P ＜ 0.05). The leakage pressure of the anastomotic stoma 14 days after the repair was (281 ±7)mm Hg in the experimental group and (271 ±21) mm Hg in the control group, respectively, with no significant difference between the two groups (t =0. 988, P ＞ 0.05). Histological observation showed that after the magnetic compression anastomosis, the intestinal muscle and mucosa recovered well, inflammatory reaction was slight and less collagen fiber and scar was formed. Conclusions Application of magnetic ring with the magnetic flux of 2500 G in one-stage repair of the intestinal leakage in the state of severe abdominal infection is safe and reliable.     

大鼠肝脏胆管及门静脉铸型扫描图像分析

目的 建立大鼠去胆管肝叶和去门静脉肝叶自身对照模型,观察两肝叶之间胆管及门静脉是否存在交通支及其大体形态变化.方法 SD大鼠40只,分为S、BL、PL和BPL共4组,分别应用氰基丙烯酸酯对肝右叶胆管进行栓塞结扎制备去胆管肝叶;对肝方叶行门静脉结扎制备去门静脉肝叶.通过测量肝重/体重和方叶重/右叶重及对各组大鼠胆管和门静脉分别灌注硫酸钡明胶混悬液制备铸型标本,并运用Micro-CT扫描来观察两叶肝脏胆道和门静脉形态变化.结果 (1)大鼠手术后在本观察期内存活率达到100%,无黄疸表现.肝叶大体形态观察和两叶肝重量比指标显示,S、BL、PL组肝重/体重为3.5%,与BPL组比较差异有统计学意义(P<0.01).S、BL组方叶/右叶重量比为60%～70%,PL及BPL组则为20%左右,提示去胆管和去门脉肝叶之间的重量比差异有统计学意义(P<0.05或P<0.01).(2)Micro-CT铸型扫描可以直观地显示胆管和门静脉形态变化,未发现两个肝叶之间存在交通支或侧枝循环.结论 去胆管肝叶无明显萎缩.胆管及门静脉灌注造影显示两叶胆管及门静脉无明显的侧枝循环.Micro-CT扫描可以直观地显示胆管及门静脉形态变化,硫酸钡明胶灌注铸型为小动物肝脏Glissons系统形态学研究提供了一种借鉴方法.

Abstract：

Objective To establish a rat self-control model with the bile duct deprived (BDD) and the portal vein deprived (PVD) hepatic lobe and to observe whether there were communicated branches between the two lobes.Methods Forty SD rats were divided into four groups: group S with sham operation as an undisposed blank control, group BL with the right lobe bile duct embolized and ligated, group PL with the quadrate lobe portal vein ligated, and group BPL with the right lobe bile duct embolized and ligated and meanwhile the quadrate lobe portal vein ligated. The right hepatic bile ducts were embolized with cyanoacrylate and then ligated to prepare the BDD lobe. The portal vein of quadrate hepatic lobes was ligated as the PVD lobes. The observation period was 1 month after the bile duct or portal vein ligated. The values of liver weight/body weight and the quadrate lobe weight/the right lobe weight were recorded. The bile duct and portal vein casting specimens of these four groups were prepared by a perfusion with barium and gelatin solution. Three-dimensional micro-computerized tomography (Micro-CT) data sets were acquired to observe the morphological changes of bile duct and portal vein of the livers and whether there were communicated branches between the right and quadrate lobes in order to estimate the feasibility of the model.Results (1) The survival rate of rats after operation was 100%. No jaundice was observed. The ratio of liver/body weight in groups S, BL and PL was about 3.5%, significantly lower than that in group BPL (P<0.01). The ratio of quadrate/right lobe weight in groups S and BL was about 60%-70%, while that was about 20% in groups PL and BPL (P<0.05, or P<0.01); (2) Micro-CT images exhibited directly the morphological changes of the hepatic bile duct and portal vein, and no communicated branches or side circulation situation were observed between the two lobes.Conclusion No collateral branches were found between the two lobes and the model was successfully established. The barium casting liver specimen scanned by micro-CT provided a useful method for the morphological observation of rat liver Glissons system.     

硬膜外注射倍他米松-利多卡因混合液对兔神经根炎症及硬膜外粘连的影响

Objective To investigate the effects of epidural administration of a mixture of betamethasone and lidocaine on nerve root inflammation and epidural space adhesion in rabbits. Methods Twenty-four adult male New Zealand white rabbits weighing 2.0-2.1 kg, were randomly divided into 2 groups ( n = 12 each): control group and treatment group. A catheter was inserted into epidural space at L2,3 interspace. Twenty-four hour after epidural catheter placement, talcum powder 0.5 mg/kg was injected into epidural space to make the model of nerve root inflammation and epidural space adhesion. Three days later a mixture of lidocaine 2.5 mg/kg and betamethasone 0.25 mg/kg was injected via the epidural catheter in treatment group, while the equal volume of normal saline was given in control group. At 21 days after administration of lidocaine and betamethasone, the spinal cord was removed, and dura mater and nerve root were checked with naked eye, light microscope and electron microscope.The neutrophil count in the dura mater was determined. Results There was nerve root inflammation and epidural space adhesion in control group. The nerve root inflammation and epidural space adhesion was not observed in treatment group. The neutrophil count was reduced in treatment group (21 ± 12) compared with control group (250 ±43) ( P < 0.01) . Conclusion Epidural administration of a mixture of betamethasone and lidocaine can alleviate nerve root inflammation and epidural space adhesion.     

硬膜外注射倍他米松-利多卡因混合液对兔神经根炎症及硬膜外粘连的影响

Objective To investigate the effects of epidural administration of a mixture of betamethasone and lidocaine on nerve root inflammation and epidural space adhesion in rabbits. Methods Twenty-four adult male New Zealand white rabbits weighing 2.0-2.1 kg, were randomly divided into 2 groups ( n = 12 each): control group and treatment group. A catheter was inserted into epidural space at L2,3 interspace. Twenty-four hour after epidural catheter placement, talcum powder 0.5 mg/kg was injected into epidural space to make the model of nerve root inflammation and epidural space adhesion. Three days later a mixture of lidocaine 2.5 mg/kg and betamethasone 0.25 mg/kg was injected via the epidural catheter in treatment group, while the equal volume of normal saline was given in control group. At 21 days after administration of lidocaine and betamethasone, the spinal cord was removed, and dura mater and nerve root were checked with naked eye, light microscope and electron microscope.The neutrophil count in the dura mater was determined. Results There was nerve root inflammation and epidural space adhesion in control group. The nerve root inflammation and epidural space adhesion was not observed in treatment group. The neutrophil count was reduced in treatment group (21 ± 12) compared with control group (250 ±43) ( P < 0.01) . Conclusion Epidural administration of a mixture of betamethasone and lidocaine can alleviate nerve root inflammation and epidural space adhesion.     

医源性总胆管远段损伤的术中诊治与预防

目的 探讨医源性总胆管远段损伤的术中诊治及预防.方法 回顾性复习1990年2月至2005年2月湖南省人民医院收治的22例医源性总胆管远段损伤的病例.结果 取石钳入腹膜腔(95.5%),注水试验阳性(100%).长臂T管支撑总胆管是有效的手段.全组18例获得随访,平均20.8个月,效果满意.结论 术中胆扩裸露征、注水试验是总胆管远段损伤的有效诊断手段.遵循浅、通、撑、抑四字外科原则,可获满意效果.满意的术野显露是有效的预防措施.

Abstract：

Objective To review the diagnosis and causes of iatrogenic injury to the distal choledochus at operation. Method The case notes of the patients with bile duct injuries that were treated in my Department from 1990.2-2005.2 were reviewed. Results To detect distal bile duct injuries, a sound in the bile duct had an accuracy rate of 95 % while injection of water into the bile duct to detect leakage had an accuracy rate of 100%. Using a long arm T tube in the common bile duct was an effective method to treat the injury. In 18 patients with an average follow-up time of 20. 8 months, the results were satisfactory. Conclusions Injecting water into the bile duct to diagnose distal common bile duct injury at operation was an effective way to detect distal bile duct injury. Adequate exposure of the opeative field is the best method to prevent bile duct injury.     

局部胆管内压大小及持续时间对犬胆管壁的影响

目的探讨局部胆管内压大小及持续时间对犬胆管壁的影响。方法设计并自制一内置入式胆管扩张器,体外测试扩张气囊内压力与注水容积及囊径的关系。将20只杂交犬随机分为五组,A组为假手术组仅在胆总管内放置胆管扩张器;B、C组分别向扩张气囊内注水0.1ml、0.2ml（球囊压力分别为0.24Kpa、0.58Kpa）扩张胆总管10min后抽空气囊并留置胆管扩张器作胆汁引流;D、E组分别向扩张气囊内注水0.1ml、0.2ml扩张胆总管后,不抽空气囊并留置作胆汁引流。各组分别术后7天再次剖腹。观察各组扩张前后血清总胆红素（TB）、丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）值及胆管直径（BD）变化、胆管壁及肝组织学改变。结果与A组比较,C组扩张后BD增宽（P〈0.05）。D组扩张后BD显著增宽（P〈0.01）,E组扩张后TB、ALT、AST均增高（P〈0.01）。A、B组胆管壁组织学无明显变化,C组胆管壁粘膜充血水肿,部分粘膜脱落,D组胆管直径增粗及胆管壁增厚,E组胆管壁部分坏死,与网膜或十二指肠粘连。结论局部胆管内压大小及持续时间对犬胆管壁的影响存在双向互变关系,正常胆管壁在一定的时间内可承受一定的局部胆管内压而不致发生胆管壁的病理变化,适宜的局部胆管内压可引起局部胆管及其上游胆管壁扩张,反之,胆管壁可出现破坏性改变。     

损伤性高位胆管狭窄41例报告

目的 总结损伤性高位胆管狭窄外科治疗的经民教训。方法 性调查４１例损伤性高位胆管狭窄患者的治疗方法，并发症及远期疗效。结果 采用胆肠吻主３８例，无手术死亡。其中肝管空肠Ｒｏｕｘ－Ｙ吻合术２６例，随访２～１０年，优良率８３．３％；肝管十二指肠吻合１２例，随访３年以上，优良率７０％。结论 肝管空肠Ｒｏｕｘ－Ｙ吻合术是治疗损伤性高位胆管狭窄的最佳方式，肝管十二指肠吻合术对高危胆管狭窄患者仍然是有效方法之     

医源性晚期胆管狭窄的起因和处理

本组医源性晚期胆管狭窄的７６例病例中６３例,是胆囊切除或胆道探查手术损伤所致,其中曾行一次或多次胆管修复无效者３８例,隐性胆管损作远期发生狭窄１４例,胆道探查“Ｔ”管引流后期胆管狭窄１４例,胆道探查“Ｔ”管引流后期胆管狭窄１１例;因胆肠吻合术的适应证选择不当或吻合口狭窄１３例。胆管损伤的早期修复的关键是根据不同情况选择恰当的修复术式,缝合技术准确精细,吻合口宽大,无张力,避免胆漏和感染,晚期胆管狭     

Zur operativen Behandlung von Gallengangscysten im Kindesalter

Zusammenfassung Es wird über neun Fälle einer cystisch-zylindrischen Gallengangserweiterung berichtet, die in den Jahren 1970 bis 1984 an der Kinderchirurgischen Klinik im Dr. von Haunerschen Kinderspital der Universität München operiert wurden. Das Alter der Patienten betrug im Mittel 4,2 Jahre. Als optimales diagnostisches Vorgehen hat sich die Oberbauchsonographie, ergänzt durch eine hepato-biliäre Funktionsszintigraphie oder Computertomographie, bewährt. Die Operationsmethode der Wahl besteht in einer möglichst totalen Excision der Cyste mit nachfolgender End-zu-End-Anastomose oder einer Hepatico-Jejunostomie nach der Roux-Y-Technik. Postoperative Frühkomplikationen wie Cholangitis wurden nicht gesehen, als Spätkomplikation wurde bei einem Patienten eine Anastomosenstenose nach primärer Hepato-Choledochostomie gesehen.

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Operative treatment of bile duct cysts in childhood

Summary Nine cases of cystic and cylindric bile duct dilatation are discussed. They were treated at the Children's Surgical Hospital of the University of Munich from 1970 to 1984. The patients' mean age was 4.2 years. Upper abdominal sonography in combination with hepatobiliary functional scintigraphy or computer tomography has been proven the best diagnostic procedure. The operating procedure of choice is a total cyst excision followed by an end-to-end anastomosis or a hepatojejunostomy according to the RouxY-technique. There were no immediate postoperative complications such as cholangitis. In one case we found a stenosis of the anastomosis after primary hepatocholedochostomy.

     

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由于腹腔镜胆囊切除术的应用和普及,越来越多的医生能够掌握和应用腹腔镜进行胆囊切除术,但随之而来的胆管损伤的发生率也在随之增高(0.3%～1.4%)。胆道手术是引起胆管损伤的主要原因[1],在医源性胆管损伤中,90%发生于胆囊切除术,故胆管损伤是外科常见的手术并发症。如果处理不     

腹腔镜经胆囊管胆道探查取石术36例报告

目的：探讨腹腔镜经胆囊管治疗胆总管结石的疗效。方法我院2006年6月～2013年10月腹腔镜下经胆囊管治疗胆总管结石36例，分离胆囊管至近胆总管处，Hem-o-lok结扎胆囊管近端，横行剪开胆囊管远端1／2～2／3周径，置入胆道镜。结果手术时间45～110 min，平均77 min；术后住院时间3～5 d，平均4．2 d。均无胆漏，无胆道残余结石发生。36例随访2～24个月，平均15个月，无上腹部疼痛症状，无结石复发。结论腹腔镜经胆囊管胆道探查取石术治疗胆总管结石创伤小、恢复快，具有很好的临床应用价值。     

Teratoma arising from anomalous common bile ducts: a case report

Teratoma arising from extrahepatic common ducts is very rare entity. The authors found 2 teratoma cases originating from common bile duct in the literature. As a third case, the authors report on a 4-month-old girl with benign cystic teratoma arising from distal common hepatic bile duct and with anomalous common bile ducts. Surgical management of the patient also is discussed.     

经验值得注意——再论胆管损伤与损伤性胆管狭窄

自腹腔镜胆囊切除术普遍开展之后,胆囊切除的病例很快增多,而胆管损伤发生率也随之升高,胆管损伤与胆管狭窄又重新成为本世纪的热门话题。医源性胆管损伤重在预防,预防手术中胆管损伤的基本点仍然是强调外科手术的基本要求,认真细致地施行手术,必要时中转开放手术。在专科中心及有经验的外科医生手中,修复手术结果优良者一般可达到90％,初期修复的效果优于再次修复。恢复胆道生理功能是修复手术的最终目的,当前广泛应用的仍然是肝管Roux-en-Y空肠吻合术。     

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目的 了解我国当前对医源性胆管损伤外科治疗概况及胆管损伤治疗效果。方法 通过检索解放军医学图书馆中文生物医学期刊数据库（CMCC）从1995年1月至2000年1月全国各级期刊关于胆管损伤的论文,统计来自165个医疗单位2742例医源性胆管损伤。结果 统计显示胆管损伤的94％来自与胆囊有关的手术,以胆管横断伤为多（47％）,损伤类型时要为胆总管（44％）和肝总管（36％）,有40％为术中及时发现处理,胆管损伤修复手术因狭窄再手术占总数的23％,术中发现和术后发现及胆管修复的方式有明显的差异。结论 胆管损伤后期的修复防止狭窄是较困难的,调查修复方式显示术中发现的作胆管修补＋T管支撑引流,术后发现手术作胆管空肠吻合＋长期支撑的手术方式效果较好。     

EARLY BILE DUCT CARCINOMA

The clinocopathologic features of seven patients with early bile duct carcinoma are reported. Early bile duct carcinoma has been defined as bile duct carcinoma limited to the bile duct wall. The seven patients included six men and one woman ranging in age from 44 to 77 years. Six patients complained of jaundice and the other presented with right hypochondralgia. Ultrasonography showed a dilated proximal bile duct in the seven with a polypoid mass in three. Computerized tomography showed a dilated biliary tree in the seven together with a polypoid mass in two. Direct visualization of the bile duct with endoscopic retrograde cholangiography and/or percutaneous transhepatic cholangiography showed a polypoid tumour of the bile duct and a dilated proximal biliary tree in all seven. Each of the seven polypoid tumours were well differentiated papillary or tubular adenocarcinoma restricted to the bile duct wall with minimal stromal invasion. There was neither any lymph node metastasis nor perineural invasion. Five of the seven patients were doing well at 24–112 months after a complete resection. One patient died from multiple liver metastases 21 months after intervention. The other patient died from other diseases 138 months after operation. These seven cases can be classified as early bile duct carcinoma due to both the limited invasion and favourable prognosis. The clinical features of the seven patients were quite similar to those of usual bile duct carcinoma. However there are still no proper diagnostic clues for early bile duct carcinoma and these patients represent fortunate cases that clinicians happened to discover by chance.