87例肝门部胆管癌手术切除的诊疗分析

目的分析手术切除治疗肝门部胆管癌的疗效及技术要点。方法回顾性分析87例肝门部胆管癌患者行肝管高位切除及联合肝切除、肝肠吻合术及姑息性手术的临床资料。总结患者的手术方式,并发症发生情况,观察患者术后5年生存率。结果手术切除率为72.4%(63/87),姑息性引流率为27.6%(24/87)。术后病理结果均回报为胆管细胞癌,63例患者行手术切除,其中根治性切除(R0)占69.8%(44/63),姑息性切除(R1、R2)占30.2%(19/63),姑息性引流24例。围手术期死亡患者3例(2.3%),术后发生胆漏的患者13例(14.9%),术后发生应激性上消化道出血4例(4.6%),其他并发症如发生腹腔出血3例(3.4%),腹腔感染5例(5.7%),肝性脑病8例(9.2%),胸腔积液7例(8.0%),切口感染或裂开者6例(6.9%)。随访患者5年,根治性切除术组的患者5年生存率(28.4%)明显高于姑息性切除组(14.1%)及姑息性引流组(0)。结论肝门部胆管癌手术复杂,连同尾状叶的左、右半肝切除治疗肝门部胆管癌有助于提高根治性手术切除率,并能明显提高患者5年生存率。     

经内镜鼻胆管引流术与经皮经肝胆管造影引流术用于肝门部胆管癌术前减黄的疗效对比

目的对比经内镜鼻胆管引流术(ENBD)与经皮经肝胆管造影引流术(PTCD)用于肝门部胆管癌术前减黄的疗效。方法回顾性分析2016年1月至2017年12月在内蒙古自治区人民医院接受肝门部胆管癌根治术的120例患者资料,按术前减黄方案分为ENBD组(57例)和PTCD组(63例),对比两组围术期肝功能指标、术中情况及围术期并发症发生情况。结果引流前,两组患者总胆红素(TBil)、直接胆红素(DBil)、丙氨酸氨基转移酶(ALT)、门冬氨酸氨基转移酶(AST)、白蛋白(Alb)对比,差异无统计学意义(P0.05);根治术前,ENBD组TBil、DBil、ALT、AST均明显高于PTCD组,差异有统计学意义(P0.05),两组Alb对比差异无统计学意义(P0.05);根治术后,两组TBil、DBil、ALT、AST、Alb对比,差异无统计学意义(P0.05)。ENBD组围术期胆系感染发生率明显低于PTCD组,差异有统计学意义(P0.05)。结论对肝门部胆管癌患者,根治术前行ENBD或PTCD均能够有效减黄,而后者减黄效果更可靠,能够更好地促进肝功能恢复;接受ENBD后胆系感染风险较低。     

老年肝门部胆管癌的诊治特点

目的探讨老年肝门部胆管癌的诊治特点。方法回顾性分析111例60岁以上肝门部胆管癌的临床资料及随访情况。结果43例行肿瘤根治性切除，10例行肿瘤姑息性切除，20例行手术胆道引流，38例行内镜置管或PTCD引流。行根治性或姑息性肿瘤切除的患者，减黄效果、生活质量改善及术后生存时间均明显优于其他方法。结论对老年肝门部胆管癌的手术治疗应持积极态度。     

27例肝门部胆管癌的手术治疗体会

目的探讨肝门部胆管癌的手术治疗方式。方法回顾性分析27例手术治疗的肝门部胆管癌患者的临床资料。结果27例中根治性切除者10例平均生存时间为23．7个月,8例肝肠内引流术者平均生存时间为7．5个月,剖腹探查取活检术者16例,平均生存时间为75d,无手术死亡。结论肝门部胆管癌的手术疗效与术式密切相关,做好术前评估、选择合适手术方式,可提高切除率及疗效。     

老年肝门部胆管癌24例外科诊治分析

目的总结老年肝门部胆管癌的外科诊治经验。方法回顾性分析我院1999~2004年收治的24例老年肝门部胆管癌的临床资料和随访。结果24例中手术切除15例,切除率为62.5%(15/24),其中根治性切除6例、姑息性切除9例。体内引流3例、体外引流4例、探查手术2例。术后并发症7例、1例死于肝肾功能衰竭。根治性切除1、2、3年生存率分别为83.3%、50.0%、16.6%;姑息性切除1、2年生存率分别为37.5%、12.5%;非切除引流者1年生存率为16.6%;探查性手术者生存期均<3个月。结论根治性切除优于姑息性切除,非根治性切除优于引流和探查。术前正确评价病情、术中选择适宜术式、术后并发症的合理治疗是提高疗效的关键。     

经皮经肝穿刺胆管引流治疗内镜难治性恶性胆道梗阻

目的探讨经皮经肝穿刺胆管引流术(PTBD)对梗阻性黄疸的介入治疗的意义。方法23例梗阻性黄疸患者,男14例,女9例,年龄61～88岁,平均(72.6±10.9)岁,其中胆管癌10例(术后5例),胰头癌3例,胃癌术后7例,十二指肠乳头癌2例,肝癌1例,不宜行十二脂肠镜逆行胰胆管造影(ERCP)或ERCP失败,经皮肝穿刺放置引流管或内支架。结果全部PTBD成功,其中外引流6例,内外引流13例(3例左右胆管双引流),金属内支架4例。引流术前血清总胆红素(321.6±132.1)μmol/L,引流术后1周血清总胆红素(88.6±10.1)μmol/L,较前明显下降(P<0.05),直接胆红素从(252.3±36.3)μmol/L降至(53.3±9.4)μmol/L(P<0.05)。结论PTBD对梗阻性黄疸是一种安全、有效的治疗方法。     

肝门部胆管癌外科治疗及临床疗效分析41例

目的:探讨外科手术在肝门部胆管癌(hilar cholangiocarcinoma,HC)治疗中的疗效.方法:回顾性分析2007-10/2010-03遵义医学院附属医院肝胆胰外科收治的41例肝门部胆管癌患者的临床资料.结果:41例患者术后并发症发生率为36.59%(15/41).包括术后切口感染2例,肺部感染3例,胆漏3例,并发胸腹水7例.根治性切除组术后1、3、5年生存率分别为:78.6%、42.9%、21.4%,姑息性手术切除组术后仅为41.7%、16.7%和0.0%,减黄治疗组术后生存率分别为:25.0%、8.3%、0.0%.结论:根治性手术切除可明显提高肝门部胆管癌患者生存率.     

肝内胆管—空肠间置管内引流治疗晚期肝门部胆管癌

对无法行根治性切除的32例肝门部胆管癌行肝内胆管—空肠间置管内引流治疗。结果为手术后的血总胆红素、谷丙转氨酶、碱性磷酸酶明显下降(P<0.01),且无并发症发生。认为肝内胆管—空肠间置管内引流是一种操作简便、减黄效果明显、安全可靠的姑息性手术。     

进展期胆囊癌侵犯肝门胆管致梗阻性黄疸15例

目的:探讨进展期胆囊癌侵犯肝门胆管致梗阻性黄疸时的外科治疗价值.方法:回顾性分析15例进展期胆囊癌侵犯肝门胆管致梗阻性黄疸病例的外科治疗情况,并与同期行胆道引流或支架治疗以及保守治疗的15例患者的生存情况进行比较.结果:Kaplan-Meier生存分析显示扩大根治术组中位生存时间为16.0mo±6.1mo,癌灶切除胆肠吻合组中位生存时间为6.0mo±1.1mo胆道引流组中位生存时间为6.00mo±0.77mo保守治疗组中位生存时间为2.00mo±0.45moGehan比分检验对各组生存时间比较,发现扩大根治术组显著长于其余各组(P<0.01),癌灶切除胆肠吻合组与介入胆道引流组无统计学差异(μ=0.015,P=0.09).术后黄疸下降及营养改善,癌灶切除胆肠吻合组显著优于胆道引流组,但肝脏酶学的恢复两组间无差异.结论:扩大根治术能显著提高进展期胆囊癌侵犯肝门胆管致梗阻性黄疸患者的生存时间胆囊及肝方叶癌灶切除胆肠吻合的姑息性手术对于严格选择的病例亦能达到提高生活质量和改善预后的目的.     

经皮肝穿刺胆道引流术联合125I粒子条治疗肝内胆管细胞癌合并恶性梗阻性黄疸的临床疗效观察

目的 探讨经皮肝穿刺胆道引流术(PTCD)联合¹²⁵I粒子条治疗肝内胆管细胞癌(ICC)合并恶性梗阻性黄疸(MOJ)的临床疗效和生存期。方法 回顾性分析上海中医药大学附属普陀医院肿瘤介入科60例恶性梗阻性黄疸患者的临床及影像资料,PTCD胆道引流为对照组(30例),PTCD胆道引流联合¹²⁵I粒子条为治疗组(30例),观察两组PTCD管留置时间、肿瘤标志物、肝功能、总生存期及并发症。结果 治疗组留置PTCD管时间为(89.77±33.77)天,对照组留置PTCD管时间为(108.40±36.00)天,治疗组留置PTCD管时间明显小于对照组(P<0.05);治疗组有23例因胆道通畅行PTCD管拔除,PTCD管拔除率76.67%,对照组有12例因胆道通畅行PTCD管拔除,PTCD管拔除率40.00%,治疗组PTCD管拔除率明显高于对照组;两组的肿瘤标志物CA199、CA724、CA242都有所下降,与对照组比较,治疗组下降更明显(P<0.05);治疗组和对照组总胆红素、直接胆红素、丙氨酸氨基转移酶、r-GT都明显下降,差异有统计学意义...     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

N-acetyl-L-cysteine combined with mesalamine in the treatment of ulcerative colitis： Randomized,placebo-controlled pilot study

AIM： To evaluate the effectiveness and safety of oral N-acetyl-L-cysteine （NAC） co-administration with mesalamine in ulcerative colitis （UC） patients.
METHODS： Thirty seven patients with mild to moderate UC were randomized to receive a four-wk course of oral mesalamine （2.4 g/d） plus N-acetyl-L-cysteine （0.8 g/d） （group A） or mesalamine plus placebo （group B）. Patients were monitored using the Modified Truelove-Witts Severity Index （MTWSI）. The primary endpoint was clinical remission （MTWSI ≤ 2） at 4 wk. Secondary endpoints were clinical response （defined as a reduction from baseline in the MTWSI of ≥ 2 points） and drug safety. The serum TNF-α, interleukin-6, interleukin-8 and MCP-1 were evaluated at baseline and at 4 wk of treatment. RESULTS： Analysis per-protocol criteria showed clinical remission rates of 63% and 50% after 4 wk treatment with mesalamine plus N-acetyl-L-cysteine （group A） and mesalamine plus placebo （group B） respectively （OR = 1.71; 95% CI： 0.46 to 6.36; P = 0.19; NNT = 7.7）. Analysis of variance （ANOVA） of data indicated a significant reduction of MTWSI in group A （P = 0.046） with respect to basal condition without significant changes in the group B （P = 0.735） during treatment. Clinical responses were 66% （group A） vs 44% （group B） after 4 wk of treatment （OR = 2.5; 95% CI： 0.64 to 9.65; P = 0.11; NNT = 4.5）. Clinical improvement in group A correlated with a decrease of IL-8 and MCP-1. Rates of adverse events did not differ significantly between both groups.
CONCLUSION： In group A （oral NAC combined with mesalamine） contrarily to group B （mesalamine alone）, the clinical improvement correlates with a decrease of chemokines such as MCP-1 and IL-8. NAC addition not produced any side effects.     

Delorme's transrectal excision for internal rectal prolapse

Surgical therapy of functional outlet obstruction in patients with internal rectal intussusception may include abdominal, perineal, or transrectal procedures. Because abdominal procedures often result in significant physiologic impact but unrelieved constipation, the authors have elected Delorme's transrectal excision for management of these patients. Since a short-term placebo effect attends many therapies, this report describes results of transrectal excision only after a threeyear postoperative period. Delorme's transrectal excision of internal intussusception accomplished sustained symptomatic relief in over 70 percent of otherwise refractory constipated patients. The association of internal intussusception with other abnormalities underscores the importance of defining both anatomic and functional components when selecting patients whose constipation may require surgical therapy. Critical technical elements, surgical pitfalls, and potential complications of the procedure are discussed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

The oral glucose tolerance test: A comparison of the time points on the basis of limit values,normal dispersion,and reproducibility

Summary Time points in the glucose tolerance test (GTT) are compared on the basis of limit values, dispersion within a reference population, and reproducibility. We suggest using the distance between a limit value and the median reference value as a measure of the magnitude of abnormality. The distance between 140 mg/100 ml and the median fasting plasma glucose value is chosen as a standard distance and limits for other points in the GTT are calculated to equal this standard distance of abnormality. We suggest that the probability of correctly interpreting an inividual result is directly related to the reproducibility of the test and inversely related to the percentage of the total range of values which is dispersed among the normal population. The ratio of reproducibility to percentage normal dispersion is proposed as an index of the probability of correctly interpreting an individual result. According to this index, the probability of correct interpretation varies in order: fasting plasma glucose concentration>3-h>2-h>0.5-h>1-h plasma glucose concentration.