梗阻性黄疸大鼠小肠肠系膜微循环变化及意义

目的以肠系膜为微循环观测窗，探讨梗阻性黄疸（简称梗黄）对肠系膜微循环的影响。方法将60只SD大鼠均分为对照组和梗黄组，每组分1、3、7d三个观测时相。将大鼠腹腔内一段回肠袢肠系膜平铺于恒温灌流盒作为微循环观察窗，用微循环显微镜及视频图像分析系统观测肠系膜微循环的动态变化并记录结果。结果梗黄组大鼠肠系膜微循环从微血管形态、微血管流态及微血管周围状态三个方面均发生明显变化，主要表现为毛细血管与微静脉扩张，血流减慢，红细胞聚集，微栓形成、毛细血管通透性增加及出血等，与对照组各相同时相比较差异均有统计学意义（P〈0．05）。结论梗阻性黄疸可引起大鼠肠系膜微循环障碍。     

梗阻性黄疸患者免疫功能的变化

梗阻性黄疸患者由于机体免疫功能障碍而有较高的并发症、病死率。笔者结合近年文献资料初步综述了梗阻性黄疸患者机体免疫功能各个方面的变化及其相关的临床意义。     

Host immune responses and intestinal permeability in patients with jaundice

BACKGROUND: Systemic endotoxaemia is implicated in the development of complications associated with obstructive jaundice. The aims of these studies were to assess the systemic immune response to intervention in patients with jaundice and to compare the effects of surgical and non-surgical biliary drainage on host immune function and gut barrier function. METHODS: In the first study, 18 jaundiced and 12 control patients were studied to assess systemic immune responses before and after intervention. In the second study, immune responses and gut barrier function were assessed following surgical and non-operative biliary decompression in 45 patients with jaundice. RESULTS: Endotoxin antibody concentrations fell significantly in patients with jaundice immediately after surgical intervention, but not after non-operative biliary drainage. This decrease was associated with a significant increase in serum P(55) soluble tumour necrosis factor (sTNF) receptor concentration (5.3 versus 10.5 ng/ml; P < 0.001), urinary excretion of P(55) TNF receptors (21.4 versus 78.8 ng/ml; P = 0.002) and intestinal permeability (lactulose : mannitol ratio 0.032 versus 0.082; P = 0.048). Intestinal permeability was significantly increased in patients with jaundice compared with controls (0.033 versus 0.015; P = 0.002). CONCLUSION: These data suggest that obstructive jaundice is associated with impaired gut barrier function and activation of host immune function that is exacerbated by intervention. Surgery causes an exaggerated pathophysiological disturbance not seen with non-operative biliary drainage procedures.     

Surgical treatment of patients with obstructive jaundice]

The results of treatment of 481 patient operated on for obstructive jaundice have been analysed. In 388 (80.7%) patients, jaundice was caused by non-tumor lesion of the bile ducts. At the peak of jaundice, operated on were 312 (64.9%) patients, who experienced no benefit from conservative therapy. The tactics for operative intervention was chosen individually with regard for the cause of jaundice, concomitant pathology and age of a patient. The main cause of death was the aggravating hepato-renal failure due to prolonged jaundice and late hospitalization.     

Peripheral oxygen extraction in patients with malignant obstructive jaundice

Malignant obstructive jaundice is associated with poor aerobic capacity. We measured oxygen consumption and oxygen extraction (arterial‐venous oxygen content) in the legs of nine patients during cardiopulmonary exercise testing before pancreaticoduodenectomy. The median (IQR [range]) peak oxygen consumption was 67 (49–77 [32–84])% of predicted. Normal patterns of oxygen extraction were seen with increasing power towards lactate threshold. Near maximal oxygen extraction occurred at peak exercise. Femoral venous oxygen pressure and saturation exceeded baseline values whilst recovering from exercise. These findings suggest that peripheral oxygen extraction is normal during exercise in patients with malignant obstructive jaundice. The primary limitation in oxygen consumption is reduced oxygen delivery.     

Body water compartments in patients with obstructive jaundice.

To elucidate the pathogenesis of renal dysfunction associated with obstructive jaundice, body water compartments were measured using a multi-isotope dilution technique in ten patients with biliary tract obstruction and in ten control subjects matched for age, sex, weight, height and body surface area. Expressed as a fraction of body-weight, total body water was reduced in jaundiced patients (41.8 versus 46.2 per cent, P less than 0.02). Extracellular water volume was also reduced in patients with jaundice (20.3 versus 24.3 per cent, P less than 0.003) owing to a reduction of the interstitial space (16.1 versus 19.5 per cent, P less than 0.004) and, to a lesser degree, of the plasma volume (4.2 versus 4.8 per cent, P = 0.1). There was a close correlation in jaundiced patients between plasma volume and the creatinine clearance rate (r2 = 0.56, P less than 0.02) and between plasma volume and extracellular volume (r2 = 0.77, P less than 0.0001). Extracellular volume in such patients also correlated with the percentage weight loss (r2 = 0.42, P = 0.04). Obstructive jaundice is associated with a contracted extracellular water compartment, although extracellular water, as a percentage of body-weight, increased in proportion to the body-weight lost. Reduction of the interstitial volume and a marginally reduced plasma volume may be determinant factors in the pathogenesis of the renal and haemodynamic disturbances observed in patients with biliary tract obstruction.     

梗阻性黄疸时胆道的细菌学特点

本文收集１９８０年至１９９５年所作的肝外胆道患者细菌培养６４１例及其药敏试验结果资料，进行回顾性分析，并就胆道感染途径及常见细菌和其药物敏感性问题讨论。大肠杆菌仍是梗阻性黄疸合并感染时的常见致病菌，但条件致病菌、厌氧菌等感染增加。梗阻性黄疸合并感染时抗生素选用应遵循一定的原则，并应同时给以提高免疫力等综合治疗措施。     

Efficacy of transcutaneous endobiliary procedures in patients with obstructive jaundice

Transcutaneous endobiliary procedures (TEP) were performed in 378 patients with obstructive jaundice (OJ). External decompression of the biliary ducts was carried out as the first stage of treatment in all the patients with OJ of various etiology. This procedure led to reduction of cholangitis symptoms and hepatic failure, improvement of general condition of the patients before radical surgery. Endoprosthesis of the bile ducts made in 121 patients allowed physiological passage of bile into the intestine and improved quality of life especially in inoperable patients with hepatic and pancreatoduodenal tumors. During external drainage in 27 (7.1%) patients dislocation of drainage of the common bile duct occurred. Postoperative lethality was 8.5%. After open surgeries 2 (1.2%) patients died.     

顺式阿曲库铵用于梗阻性黄疸手术患者的药效学研究

目的 观察梗阻性黄疸患者与肝功能正常患者行上腹部手术时顺式阿曲库铵肌松药效的变化.方法 选择无神经肌肉疾患,肾功能正常,在全麻下行择期手术的患者40例,分为两组:观察组(L组),20例,ASAⅢ级,有梗阻性黄疸;对照组(Ⅱ组),20例,ASAⅠ或Ⅱ级,肝功能正常.均采用静吸复合麻醉,顺式阿曲库铵首剂量为3×ED<,95>(0.15 mg/kg).术中用单刺激颤搐值/对照值(T/Tc)监测肌松,当其值达10%时追加肌松药顺式阿曲库铵1.5×ED<,95>(0.075 mg/kg).结果 与Ⅱ组相比,Ⅰ组患者顺式阿曲库铵的90%起效时间、临床时效、追加肌松药后90%恢复时间有延长趋势,但差异无统计学意义.结论 顺式阿曲库铵可以安全地用于梗阻性黄疽的患者,但应加强术中的肌松监测.     

Effects of biliary drainage in obstructive jaundice on microcirculation,phagocytic activity,and ultrastructure of the liver in rats

Background/Purpose: Biliary drainage before surgery for obstructive jaundice has been thought to be indispensable, because these patients tend to develop various complications after the surgery. We developed jaundiced rat models, and studied the effects of biliary drainage on the hepatic blood flow rate, portal pressure, and phagocytic activity. Methods: We generated rats with obstructive jaundice by surgical ligation followed by cutting of the common bile duct; some jaundiced rats then underwent biliary drainage. Lipopolysaccharide (LPS) was intraperitoneally administered to some rats. Control rats underwent open abdominal surgery alone. Ultrastructural changes of the liver sinusoidal endothelial cells were examined by scanning electron microscopy. Results: The hepatic blood flow rate and phagocytic activity in the jaundiced rats and the LPS-treated jaundiced rats were lower than those in the control rats. Biliary drainage improved the hepatic blood flow rate in both the jaundiced rats and the LPS-treated jaundiced rats to the control levels. Scanning electron microscopic observation of the liver sinusoids showed that, in the jaundiced rats, the endothelial cells were hypertrophic and there was a reduced number of fenestrae. In jaundiced rats that underwent biliary drainage, the hypertrophy was reduced, and the number of fenestrae was increased in comparison with those in the jaundiced rats without the drainage. Conclusions: These findings indicate that biliary drainage was effective in jaundiced and LPS-treated jaundiced rats. Received: November 16, 2001 / Accepted: February 11, 2002     

恶性梗阻性黄疸患者血清内毒素和肿瘤坏死因子的检测

目的 探讨恶性梗阻性黄疸病人不同引流术式对血清内毒素（ET）及肿瘤坏死因子（TNF）水平的影响。方法 测量36例恶性梗阻性黄疸病人内外引流术的手术前术后血清ET和NTF水平。结果 胆肠吻合内引流术10d后ET和TNF较术前明显降低（P＜0．01），而外引流组则术前术后无显著变化（P＞0．05）。术前两组差异无显著性（P＞0．05），手术10d后内引流组显著低于外引流组（P＜0．01）。结论 尽管内外引流均可使黄疸减退，但内引流术能更有效地降低因清ET和TNF水平，因此，在肿瘤无法切除时应尽量采取内引流术。     

Single stranded DNA binding antibodies in patients with obstructive jaundice

An elevation of single stranded (ss) DNA binding antibodies was present in patients with biliary tract stones and/or tumor of the biliary tract or of the pancreas. The incidence of the appearance of ssDNA binding antibodies was 22 percent in cases of non-obstructive jaundice and 50 percent in those with obstructive jaundice. The incidence was particularly high (70 percent) in patients with obstructive jaundice of over 50 days duration. No significant correlation was seen between the levels of ssDNA binding antibodies and the serum total bilirubin. However, a significant correlation was observed between the levels of ssDNA binding antibodies and the serum IgM.     

Single stranded DNA binding antibodies in patients with obstructive jaundice

An elevation of single stranded (ss) DNA binding antibodies was present in patients with biliary tract stones and/or tumor of the biliary tract or of the pancreas. The incidence of the appearance of ssDNA binding antibodies was 22 percent in cases of non-obstructive jaundice and 50 percent in those with obstructive jaundice. The incidence was particularly high (70 percent) in patients with obstructive jaundice of over 50 days duration. No significant correlation was seen between the levels of ssDNA binding antibodies and the serum total bilirubin. However, a significant correlation was observed between the levels of ssDNA binding antibodies and the serum IgM.