合并华支睾吸虫感染的老年人胆道疾病的外科治疗

目的 探讨老年人在合并华支睾吸虫感染时胆道疾病的外科治疗特点。方法 手术治疗胆道疾病合并华支睾吸虫感染老年患者85例，其中包括胆道结石62例(72．9％)，单纯吸虫引起的梗阻11例(12．9％)，胆道恶性肿瘤12例(14．1％)。合并急性胰腺炎5例(5．9％)，其中3例由胆道结石引起，1例由吸虫梗阻引起，1例由胆管癌引起。手术以胆囊切除加胆总管探查和内镜下十二指肠乳头扩约肌切开术(EST)为主。结果 良性病变均于术后痊愈出院。12例恶性病变中2例在围手术期内死亡，10例生存期2～6个月。结论老年人华支睾吸虫感染后更易引起相关的胆道外科疾病，外科治疗的同时应注意对吸虫本身的处理。     

急性胆源性胰腺炎的内镜治疗

目的 探讨急性胆源性胰腺炎(acute biliary pancreatitis,ABP)的内镜治疗。方法 对我院1998年3月至2003年3月收治的急性胆源性胰腺炎92例首先行内镜下乳头括约肌切开取石(EST),同时置入鼻胆管引流(ENBD);合并胆囊结石者,待胰腺炎恢复后,施行腹腔胆囊切除术(LC)。结果 全组92例中,53例胆管结石行EST取出,所有病人均行ENBD;胰腺炎顺利治愈88例,治愈率95．6％;合并胆囊结石67例,恢复期行LC,均顺利切除胆囊治愈;经非手术治愈23例占25％;行腹腔镜探查手术69例占75％。结论 EST ENBD能有效治疗急性胆源性胰腺炎,伴胆囊结石者联合应用LC,是目前理想的治疗方法。     

Pathobiology of cholesterol gallstone disease: from equilibrium ternary phase diagram to agents preventing cholesterol crystallization and stone formation

The primum movens in cholesterol gallstone formation is hypersecretion of hepatic cholesterol, chronic surpersaturation of bile with cholesterol and rapid precipitation of cholesterol crystals in the gallbladder from cholesterol-enriched vesicles. Associated events include biochemical defects (increased biliary mucin, and increased proportions of hydrophobic bile salts in the intestine and gallbladder), motility defects (gallbladder smooth muscle hypocontractility in vitro and gallbladder stasis in vivo, sluggish intestinal transit), and an abnormal genetic background. The study of physical-chemical factors and pathways leading to cholesterol crystallization in bile has clinical relevance and the task can be carried out in different ways. The lithogenicity of bile is investigated in artificial model biles made by three biliary lipids - cholesterol, bile salts and phospholipids - variably combined in systems plotting within the equilibrium ternary phase diagram; also, crystallization propensity of ex vivo incubated human bile is studied by biochemical analysis of precipitated crystals, polarizing quantitative light microscopy and turbidimetric methods. The present review will focus on the recent advances in the field of pathobiology of cholesterol gallstones, by underscoring the role of early events like water transport, lipid transport, crystallization phenomena - including a genetic background - in gallstone pathogenesis. Agents delaying or preventing precipitation of cholesterol crystals and gallstone formation in bile will also be discussed.     

Limits and perspective of oral therapy with statins and aspirin for the prevention of symptomatic cholesterol gallstone disease

The prevalence of gallstones disease in Western countries is 10 – 15%. Gallstones can be one of two types – cholesterol or pigment – with cholesterol gallstones representing nearly the 80% of the total. Cholesterol and pigment gallstones have different predisposing factors: cholesterol gallstones are related to supersaturated bile in cholesterol, whereas black pigment gallstones are related to hyperbilirubinbilia factors (hemolysis, etc.); these are necessary, but not sufficient, factors to produce gallstones in vivo. Gall bladder mucosa factors (gall bladder secretion of mucin, local bile stasis and production of endogenous biliary β-glucuronidase) may coexist with the aforementioned factors and facilitate gallstone nucleation and growth. The gold-standard treatment for symptomatic gallstones is laparoscopic cholecystectomy. Several studies have reported a significant reduction in the onset of symptomatic gallstones disease in patients undergoing chronic therapy with statins, which can reduce bile cholesterol saturation. Aspirin, which has been shown to reduce the local production of gall bladder mucins (mucosal or parietal factors of gallstone formation) in animal experimental models, does not appear to reduce the risk of symptomatic gallstones disease when tested alone. The new horizon of oral therapy for the prevention of symptomatic gallstone disease needs to evaluate the long-term effect of statins and chronic aspirin administration in patients with dyslipidemia and/or atherosclerosis.     

腹腔镜联合水刀与十二指肠镜治疗胆囊结石合并肝外胆管结石

目的探讨腹腔镜、水刀和十二指肠镜联合治疗胆囊结石合并肝外胆管结石的临床价值。方法联合应用腹腔镜、水刀和十二指肠镜对68例胆囊结石合并肝外胆管结石患者实施逆行胆管造影,乳头切开取石、鼻胆管引流及腹腔镜胆囊切除术。结果全组病例均先后成功实施了逆行胆管造影＋乳头切开取石＋鼻胆管引流和腹腔镜胆囊切除术,平均住院时间10d,并发症发生率8．8％（6／68）,主要并发症为胆道出血、胰腺炎、胆道感染。结论该治疗方案具有创伤性小,恢复快,并发症少等有点,是一种较好的治疗胆囊结石合并肝外胆管结石的方法。     

Limits and perspective of oral therapy with statins and aspirin for the prevention of symptomatic cholesterol gallstone disease

The prevalence of gallstones disease in Western countries is 10 - 15%. Gallstones can be one of two types - cholesterol or pigment - with cholesterol gallstones representing nearly the 80% of the total. Cholesterol and pigment gallstones have different predisposing factors: cholesterol gallstones are related to supersaturated bile in cholesterol, whereas black pigment gallstones are related to hyperbilirubinbilia factors (hemolysis, etc.); these are necessary, but not sufficient, factors to produce gallstones in vivo. Gall bladder mucosa factors (gall bladder secretion of mucin, local bile stasis and production of endogenous biliary β-glucuronidase) may coexist with the aforementioned factors and facilitate gallstone nucleation and growth. The gold-standard treatment for symptomatic gallstones is laparoscopic cholecystectomy. Several studies have reported a significant reduction in the onset of symptomatic gallstones disease in patients undergoing chronic therapy with statins, which can reduce bile cholesterol saturation. Aspirin, which has been shown to reduce the local production of gall bladder mucins (mucosal or parietal factors of gallstone formation) in animal experimental models, does not appear to reduce the risk of symptomatic gallstones disease when tested alone. The new horizon of oral therapy for the prevention of symptomatic gallstone disease needs to evaluate the long-term effect of statins and chronic aspirin administration in patients with dyslipidemia and/or atherosclerosis.     

Review article: the treatment of acute biliary pancreatitis

World-wide, gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition. Scoring systems based on radiologic findings and serologic markers help predict which patients may have retained bile duct stones. Endoscopic decompression of the biliary tree (by sphincterotomy and stone extraction during ERCP) is safer than surgery, which carries high morbidity and mortality in AP. Four prospective, randomized clinical trials confirm the utility of this approach, however careful patient selection is necessary. Medical therapy for AP is supportive; no agent or medical intervention has been shown consistently to abort or ameliorate the course of AP. Drugs that inhibit inflammatory cytokine production, however, are showing promise.     

内镜十二指肠括约肌切开联合腹腔镜胆囊切除术治疗胆囊结石并胆总管结石疗效观察

目的 探讨腹腔镜联合十二指肠镜、胆道镜胆囊切除术治疗胆囊结石并胆总管结石的方法和临床疗效.方法 选取我院2006年8月-2009年7月收治的60例胆囊结石并胆总管结石患者的临床资料,为治疗组,所有患者均行腹腔镜联合十二指肠镜、胆道镜胆囊和胆总管切除术;选取2004年9月-2006年7月收治的60例胆囊结石患者的临床资料...     

急性胆源性胰腺炎的微创处理

目的探讨急性胆源性胰腺炎的微创处理。方法总结我院自2003年7月至2008年2月收治的48例急性胆源性胰腺炎,ERCP联合EST胆管引流16例,胆囊切除联合胆总管切开取石。"T"管引流及胰周引流术4例。急诊腹腔镜胆囊切除12例,其中中转开腹4例行胆囊切除和胰腺包膜切开减压、胰腺坏死组织清除引流术。急性胰腺炎控制后1～3个月行腹腔镜胆囊切除16例。结果内镜胆管取石及引流成功治疗16例,成功率为80%。腹腔镜胆囊切除28例,多脏器功能衰竭死亡2例。结论EST+胆胰管引流技术是治疗急性胆源性胰腺炎的一种重要手段,严格掌握腹腔镜胆囊切除和胰周引流的时机是提高胆源性胰腺炎治愈率,减少并发症和病死率的重要措施。     

急性胆源性胰腺炎68例外科治疗分析

目的：探讨急性胆源性胰腺炎的外科治疗方法。方法：随机选取来本院进行诊治的急性胆源性胰腺炎患者68例,并对其临床资料进行回顾性分析。结果：经临床分析得知,68例急性胆源性胰腺炎患者中,轻症胰腺炎患者63例,对6例急诊患者行胆囊切除、胆总管切开取石等治疗,病情均好转,保守治疗57例,待病情缓解后实施剖腹或腹腔镜胆囊切除术或胆总管切开取石T管引流术,均痊愈;重症患者5例,均对其进行急诊治疗,2例死亡。结论：临床对急性胆源性胰腺炎患者进行治疗时,应对患者的病情作出正确判断,同时根据患者病情的严重程度,制定相应的治疗方案,合理实施手术,以保证患者的生命安全。     

Effects of fluvastatin on biliary lipids in subjects with an elevated cholesterol saturation index

OBJECTIVE: 3-Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors have been suggested as agents to reduce the biliary cholesterol saturation index (CSI) in duodenal bile and therefore might be supportive in primary or secondary prevention of gallstones. However, the efficiency of the therapy seems to depend on both the HMG-CoA reductase inhibitor used and the study population selected. METHODS: We therefore investigated the effect of a high-dose application of fluvastatin on biliary lipid composition in 21 subjects exhibiting mild hypercholesterolaemia and a history of current gallstones or cholecystectomy due to gallstone disease. Subjects were treated either with 40 mg fluvastatin twice per day over a 3-month period (n = 14) or with placebo (n = 7). Bile samples were aspirated during endoscopy after intravenous ceruletid stimulation before and after therapy. RESULTS: Both groups were comparable in CSI (mean +/- SD) at baseline (1.78 +/- 0.2 placebo vs. 1.97 +/- 0.4 verum). CSI significantly decreased in the verum group to 1.45 +/- 0.4 (P = 0.003) mainly due to increased phospholipid levels, whereas no difference was observed in the placebo group (1.85 +/- 0.7, n.s.). In addition, the verum group exhibited a significant reduction of hydrophobic deoxycholic acid, which has been reported to induce cholesterol crystal precipitation, and an increase of hydrophilic cholic acid. CONCLUSION: Fluvastatin might decrease the risk of cholesterol gallstone formation in patients with elevated biliary CSI during long-term treatment by reduction of biliary cholesterol saturation and percentage change in deoxycholic acid content.     

ERCP联合LC治疗胆囊结石合并胆总管结石临床分析

目的：探讨ERCP联合LC治疗胆囊结石合并胆总管结石的临床价值。方法 ERCP联合LC治疗胆囊结石合并胆总管结石40例;ERCP/EST术后3~7 d 行LC。结果40例均取石成功,其中32例行EST,患者均顺利行LC手术。结论 ERCP/EST联合LC治疗部分胆囊结石合并胆总管结石具有良好的临床应有价值,而且还具有创伤小、恢复快的优点。     

急性胆源性胰腺炎的手术治疗

目的探讨急性胆源性胰腺炎（ABP）的手术时机和手术治疗方式。方法回顾分析112例ABP的临床资料。结果23例急诊手术,分别进行了内镜下Oddi括约肌切开取石＋腹腔镜胆囊切除术、胆道探查＋胰腺包膜切开引流,发生并发症5例,死亡2例。89例延期手术,分别进行了腹腔镜胆囊切除术、开腹胆囊切除术、胆囊切除术＋胆总管探查、胆囊切除＋胆总管探查＋左肝外叶切除、胆囊切除＋胰腺假性囊肿内引流术,未发生严重并发症。结论ABP首选非手术治疗,延期手术较急症手术有更大的安全性。     

Drugs affecting biliary lipid secretion and gallbladder motility: their potential role in gallstone treatment and prevention

Gallstone disease in the Western world has an estimated prevalence of 10-15% and more than 75% are cholesterol-enriched gallstones. Defective gallbladder motility has been identified as an important pathogenic factor for cholesterol gallstone disease. Various agents may enhance or impair postprandial gallbladder motility, and their effects on interdigestive gallbladder and intestinal motility should also be taken into account. Patients in high-risk situations for gallstone disease, and those chronically treated with drugs inhibiting gallbladder motility (e.g. somatostatin analogues) may benefit from improving gallbladder motility with prokinetic agents. Whether such a strategy can really prevent gallstone formation is still unknown, long-term studies are lacking so far. The efficacy of bile acid therapy with UDCA for gallstone dissolution or for prevention in high risk patients is limited and hampered by high recurrence rates. The efficacy of UDCA in prevention of colics or gallstone related complications in symptomatic patients with gallbladder stones with contraindications for operation or on the waiting list should be explored further, since several retrospective studies showed favourable outcomes with this strategy.     

腹腔镜胆囊切除术在胆源性胰腺炎治疗中的应用

目的 研究腹腔镜胆囊切除术在急性胆源性胰腺炎中的应用及手术时机的选择。方法 对16例急性胆源性胰腺炎病人在综合治疗的支持下，行腹腔镜胆囊切除术并按胰腺炎诊疗规范完成个体化治疗。手术时间为入院后3～15d。结果 所有病例全部治愈，疗效满意，随访3～31个月，无手术并发症和(或)胰腺炎发生。结论 腹腔镜胆囊切除术可用于急性胆源性胰腺炎的早期治疗，不论是否存在胆道梗阻。     

十二指肠乳头旁憩室与胆结石的关系探讨(附167例分析)

目的 探讨十二指肠憩室在胆结石发病中的作用。方法 回顾性分析我院行逆行胰胆管造影(ERCP)检查的167例患者,其中合并乳头憩室31例(憩室组),无合并乳头憩室136例(非憩室组)。分析比较两组患者年龄、胆结石的发病率、结石发生部位及结石成分方面的差异。结果 本组167例患者中,合并乳头憩室31例,占18.56％。憩室组平均年龄62岁,明显高于非憩室组的52岁(P<0.01),且憩室发生率随年龄的增大而增高。本组发现的86例胆结石患者中24例合并十二指肠憩室,胆结石并憩室发生率27.9％;而非结石组81例中仅7例合并十二指肠憩室,占8.6％。结石组并十二指肠憩室的发生率明显高于非结石组(P<0.05)。本组中乳头旁憩室胆结石发生率(100％)明显高于乳头周围型憩室者(46.2％),有显著性差异(P<0.05)。乳头旁憩室患者的原发性胆总管结石发生率明显高于继发性胆总管结石及胆囊结石,且结石成分主要为胆色素结石。结论 十二指肠乳头旁憩室患者胆结石发病率显著增高,且主要与原发性胆总管结石相关。     

继发性胆总管结石外科治疗策略研究

摘要：目的　探讨继发性胆总管结石的外科治疗策略,比较并分析腹腔镜下一期缝合手术及内镜治疗方法的优缺点及适应证。方法　收集接受腹腔镜下一期缝合手术及内镜治疗的188例继发性胆总管结石患者的临床资料并随访,所有患者均合并胆囊结石,65例患者（一期缝合组）接受了腹腔镜下胆总管切开取石（LCBDE）一期缝合联合胆囊切除术（LC）,123例患者（内镜取石组）施行了内镜下逆行胰胆管造影检查（ERCP）联合十二指肠乳头肌切开取石术（EST）并二期行LC。对2组患者手术适应证、结石大小、结石分布、胆道感染情况、合并基础疾病及住院时间、术后近远期并发症、费用等进行比较分析。结果　2组患者的胆总管直径、结石数量及大小差异无统计学意义。一期缝合组住院时间、住院费用均低于内镜取石组（P＜0.05）。一期缝合组术后轻微胆瘘2例,内镜取石组术后高淀粉酶血症21例。术后1年随访2组均无胆道狭窄及结石复发。结论　在同时满足适应证的情况下,胆总管一期缝合手术治疗继发性胆总管结石相较内镜取石住院时间更短、费用更低且不破坏正常生理结构。     

Risk factors and pathogenesis of cholesterol gallstones: state of the art

The aim of this article is to present an update of selected aspects of the pathogenesis and risk factors of cholesterol gallstones, a highly prevalent Western disease. The etiology of cholesterol cholelithiasis is considered to be multifactorial, with interaction of genetic and environmental factors. Mechanisms of cholesterol lithogenesis include biliary cholesterol hypersecretion, supersaturation and crystallization, stone formation and growth, and bile stasis within the gallbladder. Each of these various steps could be under genetic control and/or be influenced through intermediate pathogenic steps linked to a variety of environmental factors.     

ERCP在胆囊切除术后胆总管结石诊断与治疗中的价值评价

目的：评价内镜下逆行胰胆管造影术（ERCP）对胆囊切除术后胆总管结石的诊断和治疗价值。方法：选择2005年1月～2007年12月期间在我院经ERCP检查者152例,将ERCP检查结果与B超、CT检查结果进行比较,对发现胆总管结石的患者行内镜下十二指肠乳头括约肌切开术（EST）取石。结果：83例胆囊切除术后胆总管结石患者,ERCP检测正确率显著高于B超、CT检测结果,差异有统计学意义（X2=53.05,X2=26.38,P〈0.05）。内镜取石成功率为93.8（76/81）,结石一次性清除率为81.6（62/76）,并发症发生率为6.2（5/81）;其中急性胆管炎1例,急性胰腺炎3例,消化道活动性出血1例。结论：ERCP是一种诊断和治疗胆囊切除术后胆总管结石的有效方法,其可作为胆囊切除术后胆总管结石的首选方法。     

急性胆源性胰腺炎早期内镜治疗的疗效评价

目的 观察内镜治疗急性胆源性胰腺炎(ABP)的疗效及其并发症.方法 急性胆源性胰腺炎70例,其中37例于24 h内行逆行胰胆管造影术(ERCP)、内镜下乳头括约肌切开(EST)后用网篮取石或碎石网篮碎石后气囊取石术及内镜下鼻胆管引流术(内镜组);另33例行保守或急诊外科手术治疗(对照组).结果 内镜组治疗的成功率为92%,未发生与内镜操作有关的严重并发症;与对照组比较,内镜组术后腹痛缓解时间、住院时间明显缩短(P<0.01),术后第1天血及尿淀粉酶无明显差异(P>0.05),但术后第2天血及尿淀粉酶明显降低(P<0.05),第3天降低更为明显(P<0.01).结论 急性胆源性胰腺炎早期ERCP及内镜治疗安全有效,是治疗急性胆源性胰腺炎的理想方法.