胆囊切除术医源性胆管损伤的临床分析

目的 探讨医源性胆管损伤如何避免及处理措施.方法 回顾分析15年来我院胆囊切除术致胆管损伤8例.分析损伤的部位、类型、发现时间、手术方法和治疗效果.结果 术中发现胆管损伤并及时采用胆道端端吻合、胆肠吻合并引流6例,术后3天内发现胆道损伤再次手术2例.结论 对于医源性胆管损伤,预防是关键,术中及时发现,采取有效的手术方法至关重要.     

医源性胆管损伤21例的临床诊治体会

目的探讨探讨医源性胆管损伤的诊断、治疗和结果。方法医源性胆管损伤21例,行胆管修补加T管引流术、胆管端端吻合术、Roux—Y胆总管空肠吻合术、胆管十二指肠吻合术。随访2～6年。结果本组均得到治愈,无死亡病例,除2例Roux—Y胆总管空肠吻合术吻合口狭窄,再次行吻合口整形外,其余疗效满意。结论医源性胆管损伤应早诊断,术中、术后可采用各种手术治疗,重在预防。     

医源性胆管损伤的原因及诊断（附13例报告）

目的探讨医源性胆管损伤的原因、诊断和预防措施。方法回顾性分析1995-2007年收治的13例医源性胆管损伤患者的临床资料。结果对损伤的胆管进行修复,均治愈后出院。随访发现一例出现胆管狭窄。结论医源性胆管损伤重在预防,早期处理。     

40例医源性胆道损伤的临床外科分析

胆道疾病是肝胆外科常见的疾病,常常需要外科手术治疗,然而手术者及手术过程中存在的一些因素,常常导致医源性胆道损伤。本文对40例医源性胆道损伤的情况及处理方法进行回顾性分析,探讨医源性胆道损伤的原因、预防及治疗。现报告如下。1资料与方法1.1临床资料本组患者共40例,其     

医源性胆管损伤28例报告

目的：探讨医源性胆管损伤的原因及处理对策。方法：对1991.01-2000.12间收治的28例医源性胆管损伤患者的临床资料进行回顾性分析。结果：单纯胆囊切除引起21例（75％），胆囊切除、胆总管探查引起6例（21.4%)，其它腹部手术引起1例（3.6%)。其中急诊手术损伤15例（53.6%)，LC损伤4例（14.3%)。胆管损伤类型：肝（胆）总管横断5例（17.8%)，胆总管结扎4例（LC钛夹夹闭2例，占14.3%)，肝（胆）管侧壁损伤15例（53.6%)，损伤情况不明4例（14.3%)。28例患者共施行52次手术，术中发现胆管损伤并行胆道修复5例，术后早期发现胆管损伤行胆道修复或引流11例。末次手术施行胆肠吻合术22例，肝总管空肠Roux-Y吻合11例，肝门胆管成形空肠Roux-Y吻合5例，左、右肝管整形空肠Roux-Y吻合2例，肝总管十二指肠吻合2例，胆总管十二指肠吻合2例。优良率87％。结论：①危险的病理、危险的解剖和危险的手术是导致医源性胆管损伤的常见原因。②根据胆管损伤类型，合理把握初次手术时机。成形后的肝管空肠端侧Roux-en-Y吻合术是胆道重建术的最佳选择。     

肝外胆管损伤的诊治及预防

肝外胆管损伤是胆道手术最严重的并发症,据文献报道发生率平均在0.3％。90％以上发生在胆囊手术后,我们在最近15年中,治疗12例医源性肝外胆管损伤,本组病人均发生在胆囊切除术后。12例中10例系慢性胆囊炎伴结石。入院后择期手术,2例系急性胆囊炎行急诊手术、全组病人经治疗后均痊愈出院。     

乳房手术中医源性损伤27例分析

因乳房疾病取手术治疗的病人临床常见,因手术中医源性损伤来院求治者也非罕见。自1984年至1993年,接治有明显症状与体征的27例。本文从解剖学观点分析医源性损伤的原因,旨在提高乳房疾病的治疗效果。 临床资料:本组27例均为女性。年龄21～58岁。以乳房脓肿手术后乳房胀痛、乳管瘘就医者13例。乳癌根治术后患侧上臂疼痛5例,影响前臂内旋及外展6例,导致翼状肩胛3例。     

156例医源性早产临床分析

目的:探讨医源性早产病因构成及临床干预措施。方法:回顾性分析156例医源性早产病例临床资料,分析医源性早产病因构成。结果:医源性早产病因构成为子痫前期(33.33%),产前出血(17.95%),合并症(17.31%),妊娠肝内胆汁瘀滞症(14.10%),多胎(9.61%)等。结论:对不可避免的医源性早产,定期产前检查和适当的诊治能取得良好的妊娠结局。     

胆囊结石合并胆管树损伤

目的：了解胆囊结石患者其胆管树损伤情况。方法：收集２２例胆囊结石例，１０例猝死尸检例而无肝胆系统闰患者作为对照组，两者经组织喧观察和定量分析。结果：胆囊结石组门管区平均面积０．０８４ｍｍ＾２，对照组０．１０１ｍｍ＾２。胆囊结石组门管区胆管数量３．１，对照组５．３。两者经统计学分析差异有显著性意义（Ｐ〈０．０１）。胆囊结石病例大多有门管区胆管数量的减少和以变质为主的炎症。结论：胆囊结石患者分泌的异常     

医源性膀胱输尿管损伤12例分析

目的探讨降低妇产科剖腹手术膀胱、输尿管损伤率及处理。方法分析12例医源性膀胱、输尿管损伤的原因、治疗及预防措施。结果12例膀胱、输尿管损伤病例,经过及时、正确处理,均痊愈,并发症少。结论对于医源性膀胱、输尿管损伤,应重在预防,做好充分的术前准备,术中解剖清楚,提高警惕,防患于未然。同时要及时发现,正确处理,提高治疗效果。     

MRCP in the diagnosis of iatrogenic bile duct injury

Postoperative biliary tract lesions are becoming increasingly common. The diagnosis is made by direct cholangiography via endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). The present comparative study evaluates the diagnostic efficacy of magnetic resonance cholangiopancreatography (MRCP) in application to iatrogenic bile duct injury. A prospective blind study was performed, contrasting MRCP and ERCP in 10 patients with suspected postoperative biliary tract lesions. MRCP was performed less than 72 h before ERCP. Final diagnosis was made on the basis of findings at surgery and ERCP. The presence of biliary dilatation, excision injury, stricture, fluid collection and free fluid was analyzed. The mean patient age was 66.5 years. There were three males and seven females. The type of postoperative lesion (Bergman classification) are five patients type C, three type D, one type B and one type A. Diagnostic failure was recorded in two cases with ERCP, while in five patients it was unable to define a therapeutic approach. In contrast, MRCP correctly diagnosed all patients. MRCP is effective in diagnosing postoperative biliary tract lesions, and can help decide the best therapeutic approach.     

Adenosquamous carcinoma of extrahepatic bile duct: clinicopathologic study of 12 cases

Adenosquamous carcinoma is a rare histologic subtype of extrahepatic bile duct (EBD) carcinoma and limited information is available on its clinicopathologic characteristics. Twelve cases of adenosquamous carcinoma were collected from 3 institutions and their clinicopathologic characteristics were examined and compared with those of 176 EBD adenocarcinomas. The adenocarcinoma component was more often seen at the surface of the tumor (7 of 12 cases, 58%), while the squamous carcinoma component was slightly more frequent at the advanced edge (7 of 12 cases, 58%). Immunohistochemistry, available in 10 cases, revealed that S100A2 was positive in the squamous carcinoma component in all 10 cases (100%), while it was present in the adenocarcinoma component in only 2 of 10 cases (20%, chi-square test, p=0.001). S100A4 expression did not show any difference between the two components. Patients with adenosquamous carcinomas had worse survival (median survival, 11 months) than those with adenocarcinoma (median survival, 32 months; log-rank test, p=0.003). Patients with predominant squamous cell carcinoma component at the leading edge had worse survival than those without it. In conclusion, patients with adenosquamous carcinoma demonstrated worse survival than those with pure adenocarcinoma. S100A2 immunohistochemical staining may be helpful in detecting the squamous component.     

Endocrine cell carcinoma of extrahepatic bile duct

An endocrine cell carcinoma of the extrahepatic bile duct in a 79-year-old man is described. The patient had complaints of jaundice and epigastric pain due to a small tumor located at the confluence of the common hepatic duct with the cystic duct. Microscopically, the tumor showed a well differentiated tubular adenocarcinoma and was confined to the mucosa. Numerous tumor cells showed argyrophil and/or argentaffin reactions. Immunoperoxidase staining revealed that the tumor tissue contained somatostatin-, gastrin-and serotonin-immunoreactive cells. From these findings the tumor was diagnosed as endocrine cell carcinoma. Four years later he remains well without any evidence of recurrence or metastasis. The histogenesis of endocrine cells in the biliary tract is briefly discussed.     

Hepatic progenitor cells in the mouse extrahepatic bile duct after a bile duct ligation

The intrahepatic bile duct has been suggested to be a source of hepatic progenitor cells in the severely damaged liver. In contrast, little attention has been paid to the question of whether hepatic progenitor cells exist in the extrahepatic bile duct (EHBD). In the present study, we examined the phenotypic changes of the mouse EHBD following bile duct ligation. After bile duct ligation, the number of c-Kit-positive epithelial cells increased in the EHBD. The ligated EHBD expressed mRNA for hepatic progenitor cell markers, including c-Kit and Thy-1. Hepatocyte markers such as albumin and cytochrome P450 7a1 were also transiently detected in the EHBD after a bile duct ligation. In a culture of EHBD cells, we detected hepatic progenitor cells that were positive for both staining with anti-albumin antibodies and Dolichos biflorus agglutinin, a biliary epithelial cell-specific lectin. Furthermore, hepatic progenitor cells positive for both c-Kit and albumin were found in the cultured EHBD population. Additionally EHBD-derived hepatocyte-like cells were also observed in the culture. A transplantation study revealed that EHBD cells integrate into the parenchyma and are albumin positive. These data suggest that hepatic progenitor cells emerge in the EHBD following bile duct ligation, that subsequently give rise to hepatocyte-like cells. We also observed that the gall bladder transiently expressed hepatocyte markers after bile duct ligation. Our results suggest a potential of the EHBD and gall bladder as useful transplantable sources for liver injury.     

Clinicopathological significance of olfactomedin-4 in extrahepatic bile duct carcinoma

The clinicopathological and prognostic significance of olfactomedin-4 (OLFM4) expression has not yet been elucidated in extrahepatic bile duct carcinomas (EBDCs). Immunohistochemical analysis of OLFM4 expression in 31 normal biliary epithelia, 33 biliary intraepithelial neoplasias (BilINs), and 180 surgically resected EBDCs (54 perihilar and 126 distal) was performed and was used to analyze clinicopathological variables including patient survival. The expression of OLFM4 showed a progressive increase from normal biliary epithelia (0.2 ± 0.4) to BilINs (2.8 ± 3.2) to EBDCs (4.6 ± 4.2; P < 0.001). OLFM4 was highly expressed in 26.1% (47/180) of the EBDC cases, and high OLFM4 levels were more frequently observed in tumors with nodular growth (P = 0.029), well differentiation (P = 0.011), and lower T-category (P = 0.025) and stage grouping (P = 0.013). Patients with EBDC having high expression of OLFM4 had better survival than those with low expression of OLFM4 (median, 43.3 vs. 29.2 months; P = 0.037). OLFM4 might play an important role in carcinogenesis and in the progression from BilINs to EBDCs. High OLFM4 expression predicted less aggressive clinical behavior in patients with EBDC.     

Prognostic significance of fascin expression in extrahepatic bile duct carcinomas

Extrahepatic bile duct (EBD) carcinoma is an aggressive cancer with a poor prognosis. Fascin is an actin-bundling protein with roles in forming cell protrusions and mesenchymal and neuronal cell motility. Many human neoplasms up-regulate fascin. High fascin expression is thought to be a poor prognostic factor in some cancers; however, few data are available for the role of fascin in EBD carcinoma. We investigated fascin immunoreactivity in EBD carcinoma and tested it for correlations between fascin expression and clinicopathological parameters.Conventional tissue sections of 114 cases of EBD carcinomas were immunohistochemically analyzed for fascin expression.Fascin expression was tested by cytoplasmic staining. Negative, weak positive, and strong positive fascin staining was observed in 49 (43.0%), 32 (28.1%), and 33 cases (28.9%), respectively. Fascin expression in EBD carcinomas was significantly correlated with histological grade (P<0.0001), primary tumor (T) (P=0.002), TNM stage (P=0.036), lymphatic invasion (P=0.048), venous invasion (P=0.024), and adjacent organ invasion (P<0.0001). High fascin expression was a significant poor prognostic factor (P=0.0001) in EBD carcinoma. High fascin expression (P=0.004) and TNM stage (P=0.001) in EBD carcinoma were independent adverse prognostic factors.High fascin expression is significantly correlated with aggressive tumor phenotype in EBD carcinoma and is an independent poor prognostic factor in EBD carcinoma.     

新生儿肝外胆道的应用解剖学研究

本文对50例新生儿的肝外胆道作了解剖学观察,其中包括肝左、右管的汇合特点及与肝门的关系;肝左、右管的长度、外径;副肝管的出现、走行及长度;胆囊管与肝总管的汇合情况、各部长度及外径等,并结合临床手术应用进行了讨论。     

Small cell carcinoma of the extrahepatic bile duct: case report and immunohistochemical analysis

A small cell carcinoma of the extrahepatic bile duct in a 75-year-old Japanese man is reported. The patient suffered from obstructive jaundice, and percutaneous transhepatic cholangiography-drainage (PTCD) revealed a massive lesion in the lower common bile duct. Because it was diagnosed as a malignant tumor, pancreaticoduodenectomy was performed. A nodular infiltrating tumor measuring 4.5 x 3.0 x 2.0 cm was located in the intrapancreatic portion of the extrahepatic bile duct. Histologically, the tumor was composed of a dense proliferation of small atypical cells with a little region of high-grade dysplasia in the adjacent epithelium of the common bile duct. Tumor cells were immunoreactive to neuroendocrine markers such as chromogranin A, synaptophysin, CD56, and Leu7. Although carcinoma cells invaded into pancreas and duodenum, there were no histological findings that indicated the carcinoma arose from the mucosa of either the pancreatic duct or duodenum. These results indicated that the tumor was a small cell carcinoma derived from the epithelium of the extrahepatic bile duct; a rare neoplasm with only a few cases reported. A few neuroendocrine cells were recognized in the adjacent epithelium of the extrahepatic bile duct, suggesting that the tumor cells might be derived from them. Using immunohistochemical examination, no p53 abnormality was found. Tumor cells showed positive nuclear staining for p16, while negative for cyclin D1, suggesting that functional retinoblastoma protein (pRB) might be lost in the p16/pRB pathway, as in small cell lung cancer.     

Clinical and prognostic significances of nuclear and cytoplasmic KIT expressions in extrahepatic bile duct carcinomas.

After receiving FDA approval as a therapeutic regimen in gastrointestinal stromal tumors, the tyrosine kinase inhibitor imatinib mesylate has been applied to the treatment of other solid malignant neoplasms. To evaluate the usefulness of imatinib mesylate as a possible therapeutic regimen in extrahepatic bile duct carcinomas, an immunohistochemical study for KIT was performed in 289 cases of extrahepatic bile duct carcinomas, and mutational analysis of exon 11 of the c-kit gene was performed in 20 cases that were arbitrarily retrieved from the cases with KIT expression. Cytoplasmic KIT expression was observed in 54 cases (19%) and nuclear KIT in 58 cases (20%) of extrahepatic bile duct carcinoma. Nuclear KIT expression was more frequent in cases with vascular invasion (P<0.001), whereas cytoplasmic KIT expression was more common in tumors of T1-T3 than in those of T4 (P=0.04), and was more frequently observed in cases with a papillary growth pattern (P=0.03). Patients with cytoplasmic KIT-positive tumors had significantly better survival both by univariate (P=0.01) and multivariate analyses (P=0.04). Infrequent cytoplasmic KIT expression without mutation of exon 11 suggests that imatinib mesylate may not be effective for the treatment of extrahepatic bile duct carcinoma. However, immunohistochemical study for KIT may be helpful in routine pathologic examinations for evaluating better prognosis for patients with extrahepatic bile duct carcinoma. In addition, more frequent nuclear expression of KIT in cases with vascular invasion suggests that nuclear KIT expression may contribute to the progression of extrahepatic bile duct carcinoma.