回输外引流胆汁和胰液对胰十二指肠切除术疗效的影响

目的 探讨回输外引流的胆汁和胰液对胰十二指肠切除术疗效的影响.方法 回顾性分析2005年6月至2009年3月滨州医学院附属医院收治的51例行胰十二指肠切除术患者的临床资料.根据是否回输外引流的胆汁和胰液分为回输组(32例)和非回输组(19例).观察两组患者术后胆汁和胰液日均引流量,手术情况,肠内营养耐受性,肝脏功能及营养状态等指标.应用x2检验、Fisher确切概率法、两独立样本t检验、Mann-Whitney U检验、单因素方差分析等对数据进行统计分析.结果 术后回输组患者肺部感染率为3％ (1/32),低于非回输组患者的26％( 5/19),两组比较,差异有统计学意义(P＜0.05).回输组患者自术后4～10 d胰液日引流量显著低于非回输组(t=7.143,9.244,8.808,7.915,6.461,14.097,15.038,P＜0.05),而两组患者胆汁日均引流量比较,差异无统计学意义.营养支持治疗后,回输组患者腹泻发生率为9％(3/32),低于非回输组的37％(7/19),两组比较,差异有统计学意义(P＜0.05).回输组达到全量肠内营养支持的平均时间为3d,短于非回输组的4 d(U=145.000,P＜0.05).回输组和非回输组患者术前TBil、DBil、IBil分别为(261±108)、(132±55)、(129±55) μmol/L和(239±92)、(124±46)、(116 +46) μmol/L;营养支持治疗12 d后,两组患者的上述指标分别为(39±19)、(20±10)、(19±9) μmol/L和(55±22)、(29±12)、(26±11) μmoL/L,回输组患者上述指标下降程度高于非回输组(t=7.324,8.437,5.827,P＜0.05).回输组和非回输组患者术前血清前白蛋白、视黄醇结合蛋白、转铁蛋白分别为(0.261±0.021)g/L、(34.3±2.8) mg/L、(3.08±0.26) g/L和(0.263 ±0.021 )g/L、(33.8±3.5) mg/L、(3.10±0.27)g/L;术后两组患者的上述指标迅速下降,营养支持治疗3d后各项指标逐步回升,12 d后,两组患者的上述指标分别为(0.238±0.025)g/L、(30.7±2.0)mg/L、(2.78±0.19)g/L和(0.222±0.025) g/L、(29.3±2.1)mg/L、(2.63±0.21)g/L,并且回输组患者的上述指标明显高于非回输组(t=4.615,6.097,4.913,P＜0.05).结论 胰十二指肠切除术后回输外引流的胆汁和胰液可提高患者对肠内营养耐受性,降低肺部感染发生率,促进血清胆红素水平降低,改善患者营养状态,具有较高实用价值.     

The cytotoxic effects of bile acids in crude bile on human pancreatic cancer cell lines

Pancreatic cancer frequently causes extrahepatic cholestasis. To identify the direct effects of bile acids in jaundiced serum on pancreatic cancer, the proliferation of PANC-1 and MIA PaCa-2 cells as well as the ultrastructural alteration of PANC-1 cells cultured in crude bile modified media were studied. The growth of these cells in the RPMI-1640 media with or without 1%, 2%, and 4% of the refined crude bile was assessed after 48 and 96 h of incubation. The ultrastructure of PANC-1 cells was investigated by scanning and transmission electron microscopy after 24 and 48 h of incubation. The proliferation of both cell lines in the bile-treated media was greatly inhibited. The inhibitory rates of bile on PANC-1 ranged from 24.1% ± 3.3% to 66.9% ± 6.6% (P < 0.01) and those on MIA PaCa-2 ranged from 16.7% ± 3.8% to 50.7% ± 5.5%. (P < 0.01). When the bile-added media were replaced, the cells were able to restore their proliferating ability. The PANC-1 cells incubated in the bile-supplied media indicated that the mirovilli, mitochondria, and other organelles had thus been injured. These results suggest that bile acids appear to inhibit the proliferation of PANC-1 and MIA PaCa-2 cells, and the probable inhibitory mechanism is mainly considered to be due to the cytotoxicity of such bile acids. Received: November 2, 1999 / Accepted: May 30, 2000     

保留十二指肠和胆管的胰头全切除术

保留十二指肠和胆管的胰头全切除术(Takada法),手术难度大,在国内开展较少.2013年9月至2014年5月福建省漳州正兴医院和漳州市医院对5例患者(1例胰头部肿块型胰腺炎,2例胰管黏液性囊腺瘤伴灶性癌变,2例慢性胰腺炎、胰管多发结石)施行该手术.5例患者采用Takada法切除病变,联合一期行胰管原位重建,其中胆总管探查引流1例.手术时间为210 ～ 330 min,术中出血量为100 ～500mL,平均术中出血量为300 mL.2例患者为鹿角形结石,3例患者为肿瘤,均无手术死亡.术后发生胰液漏及胆汁漏各1例,均经非手术治疗痊愈.患者术后随访3～11个月无糖代谢异常、胆总管狭窄、慢性消化不良发生及肿瘤复发.对于胰头部肿块型慢性胰腺炎、胰头部良性病变、胰头部低度恶性肿瘤,Takada法安全、有效,患者术后恢复快.     

胰液细胞学检查与PCR-SSP诊断胰腺癌之比较

目的评价胰液细胞学检测与聚合酶链反应一顺序特异性引物（ＰＣＲ－ＳＳＰ）检测Ｋ－ｒａｓ基因点突变诊断胰腺癌的价值。方法１．胰液离心沉淀物涂片,ＨＥ染色细胞学检查;２．采用针对胰腺癌Ｋ－ｒａｓ基因第１２位密码子点突变方式（ＯＧＴ、ＧＴＴ、ＧＡＴ）设计的顺序特异性引物（ＳＳＰ）,对胰液标本进行聚合酶链反应（ＰＣＲ）,产物借助常规电泳和染色检测有无Ｋ－ｒａｓ基因突变及突变方式。结果胰液细胞学检查对胰腺癌的确诊率为２３．６％（４／１７）,ＰＣＲ－ＳＳＰ对胰腺癌的确诊率为９４．１％（１６／１７）。结论ＰＣＲ－ＳＳＰ检测胰液Ｋ－ｒａｓ基因突变诊断胰腺癌特异、敏感,其价值优于胰液细胞学检查。     

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目的 介绍经镜下胆总管内置支架治疗胰腺癌胆管梗阻的手术方法。方法 1999～2002年采用腹腔镜胆总管探查术(LCDE)结合斑马导丝、胆管扩张导管、塑料胆管支架和自膨式金属胆管支架施行腹腔镜胆总管支架术(LCBDS)12例。结果 12例转移病灶取标本中9例病理报告胰腺癌，3例未证实。12例中9例手术获成功，1例因狭窄上端波及肝总管而中转开腹放置塑料支架同时T管引流，1例少量胆漏腹腔引流4d后自愈，1例放置塑料支架同时T管引流术后15d死于胆管感染诱发肝肾功能衰竭。结论 选择合适病例，采用腹腔镜胆总管支架术处理胰腺癌胆管梗阻是一种有效、安全、简便、可行的术式。     

Outcome of paraaortic node-positive pancreatic head and bile duct adenocarcinoma

BACKGROUND: This retrospective study aimed to identify the clinicopathologic features and surgical results of paraaortic node-positive periampullary adenocarcinoma. METHODS: Between 1995 and 1999, 101 patients underwent pancreatectomy with regional and paraaortic lymphadenectomy. Fifteen (15%) patients had histologically proven paraaortic lymph node disease. RESULTS: The 15 patients included 9 (26%) of 34 patients with pancreatic head carcinoma and 6 (17%) of 36 patients with bile duct adenocarcinoma. All 15 patients had locally advanced tumor invading adjacent structures. The 1-, 2-, and 3-year survival rates were 33%, 27%, and 0%, with median survival of 12 months (range 3 to 33). In patients with pancreatic head carcinoma or bile duct adenocarcinoma, survival curve for those without paraaortic lymph node metastasis was significantly better than that for those with involved paraaortic lymph nodes (P = 0.0033 or P = 0.0149). CONCLUSIONS: When the paraaortic lymph nodes obtained from sampling biopsy are histologically positive, radical pancreatectomy with extended lymphatic and soft tissue clearance should be abandoned owing to poor outcome.     

电视腹腔镜胆总管切开探查后胆总管Ⅰ期缝合术

目的 探讨腹腔镜胆总管探查手术后胆总管切口的处理方法,免除患者术后带Ｔ型管的痛苦。方法 选择腹腔镜胆总管切开探查术的２０例患者在取出结石或蛔虫后Ⅰ期缝合胆总管,其中２层缝合１７例,１层缝合３例。结果 ２０例均成功完成手术,手术时间４５～１７０ｍｉｎ,平均１２６ｍｉｎ,术后平均６ｄ（３～１０ｄ）出院,１８例患者取出０．６～２．９ｃｍ结石１～６粒,２例患者分别取出死蛔虫１、２条,１层平均６ｄ（３～１０     

Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis

Background

Suture closure and stapler closure of the pancreatic remnant after distal pancreatectomy are the techniques used most often. The ideal choice remains a matter of debate.

Methods

Five bibliographic databases covering 1970 to July 2009 were searched.

Results

Sixteen articles met the inclusion criteria. Stapler closure was performed in 671 patients, while suture closure was conducted in 1,615 patients. The pancreatic fistula rate ranged from 0% to 40.0% for stapler closure of the pancreatic stump and from 9.3% to 45.7% for the suture closure technique. There were no significant difference between the stapler and suture closure groups with respect to the pancreatic fistula formation rate (22.1% vs 31.2%; odds ratio, .85; 95% confidence interval, .66-1.08), although there was a trend toward favoring stapler closure. In 4 studies including 437 patients, stapler closure was associated with a trend (not statistically significant) toward a reduction in intra-abdominal abscess (odds ratio, .53; 95% confidence interval, .24-1.15).

Conclusions

No significant differences occur between suture and stapler closure with respect to the pancreatic fistula or intra-abdominal abscess after distal pancreatectomy, though there is a trend favoring stapler closure.     

可降解胆管修复材料的研究进展

医源性胆管损伤常用的处理方法,如胆肠吻合,由于放弃了奥狄括约肌功能,近远期有并发逆行性胆道感染、胆管炎,甚至胆管癌的风险。随着临床上对奥狄括约肌功能的重视,有必要寻找能维护胆管功能的修复材料。目前已报道的可降解胆管修复材料具有无免疫原性、暂时性支持作用、降解产物对身体无害等优点,有希望成为可供选择的胆管修复材料。本研究就可降解胆管修复材料的研究进展做一综述。     

Pancreatic juice leakage is a risk factor for deep mycosis after pancreatic surgery

Purpose  Deep mycosis (DM) is an opportunistic infection that can be fatal in immunocompromised hosts. Pancreatic surgery is associated with a high degree of stress and patients who undergo pancreatic surgery are considered to be immunocompromised. This study retrospectively evaluated whether DM affects the clinical course after pancreatic surgery. Methods  Between January 2005 and April 2007, 67 patients underwent pancreatic surgery. There were 42 males (62.7%) and 25 females (37.3%) with a mean age of 66.7 years. Their diagnoses consisted of cancer of the papilla of Vater (n = 9), pancreatic head cancer (n = 20), pancreatic tail cancer (n = 3), bile duct cancer (n = 17), duodenal cancer (n = 3), and others (n = 15). Surgical procedures included pancreatoduodenectomies (PD; n = 52), hepato-pancreatoduodenectomies (HPD; n = 4), distal pancreatectomies (DP; n = 7), total pancreatectomies (TP; n = 2), and the modified Puestow procedure (m-Pp; n = 2). Patients who were positive for any of CAND-TEC (C-T), β-d-glucan (β-d), or culture for mycosis were classified into group 1 (G1; n = 12) and those who were negative for all these examinations were classified into group 2 (G2; n = 55). The preoperative, perioperative, and postoperative data were compared between G1 and G2. An antifungal drug (Micafungin; 75 mg per day) was given to G1 patients. Results  The preoperative data included the neutrophil and lymphocyte counts, total protein, blood urea nitrogen, and amylase, and there were no significant differences in these parameters between the two groups. However, the incidences of diabetes mellitus and total bilirubin at maximum in G1 and G2 were 41.7% and 7.3% (P = 0.04), 4.6 ± 1.5 and 1.4 ± 0.9 (P = 0.007), respectively. The mean operation time in G1 and G2 was 548.5 ± 138.1 and 510.0 ± 133.7 min (P = 0.39) and intraoperative blood loss was 762.2 ± 369.5 and 782.5 ± 599.1 ml (P = 0.88), respectively. The postoperative complications included pneumonia (G1: G2 = 7: 20; P = 0.14), pleural effusion (7: 24; P = 0.27) and ascites (10: 33; P = 0.11), with no significant intergroup differences. However, the respective durations of pancreatic juice leakage in G1 and G2 were 12 and 12, respectively, with a statistically significant difference (P < 0.01). All the G1 patients were treated with the antifungal drug for 7.8 days. Postoperative hospital stays in G1 and G2 were 47.3 days and 38.7 days, respectively (P = 0.15) and the survival rates at 19 months after surgery were 46.7% and 79.4%, respectively (P = 0.04). Conclusions  Deep mycosis was observed in patients with pancreatic juice leakage, thus contributing to a poor outcome. Therefore, an early diagnosis of DM and the initiation of antifungal treatment are necessary for the improving prognosis.     

小血管张力测量与小血管减张缝合技术研究

目的 制备小因管张力计测量小血管断端张力,并探讨减张缝合法在小血管损伤中的作用。方法 采用手术于套橡胶条小血管张力计并应用于观察离体猪桡动脉吻合口张力大小与通畅情况的关系。测量小血管断是张力大小,并根据情况应用两断端间血管壁上缝减张线的减张缝合法治疗１０６例小血管损伤。结果 小血管吻合口张力大小与吻合成功明显有关,张力小于１０＾６时直接套入可获成功,张力大于１５０时即使减张缝合也很难保证吻合口通畅     

卡锁环肌腱缝合法在伸指肌腱修复中的作用

目的：以改良Kessler法作为参照，研究卡锁环缝合法在修复伸指肌健中的抗拉力作用效果。方法：术中随机对50根断裂伸指肌腱平均分为两组，分别采用卡锁环（Locking loop）法和改良Kessler法进行修复，然后进行屈指活动抗拉力测试观察。结果：两组肌腱出现拉松和缝线拉脱的例数分别为：卡锁环法组2，0，改良Kessler组7，5。结论：卡销环法抗拉力作用显，适合于伸指肌腱的修复。     

磁共振胰胆管成像与经内镜逆行胰胆管造影对胆胰疾病诊断价值的比较研究

目的 评价磁共振胰胆管成像(MRCP)与经内镜逆行胰胆管造影(ERCP)对胆胰疾病的诊断价值.方法 对134例怀疑为胆胰管疾病病人行MRCP,并与58例ERCP比较,所有病例均经手术病理证实.结果 134例MRCP均获成功,在行ERCP中54例成功,4例失败者改行PTC检查成功.MRCP和ERCP总的诊断准确率分别为90.3%和88.9%.结论 MRCP对胆胰系统疾病中恶性梗阻所致的梗阻性黄疸诊断准确性较高,对胆总管、肝内胆管较小结石的诊断不如ERCP敏感及准确,而且不能治疗,提示MRCP和ERCP各有优越点,二者合理应用可提高胆胰系统疾病的诊断符合率.     

Sphincter of oddi function studied by radioimmunoassay of biliary trypsin in patients with bile duct stones and in controls

The trypsin level in bile was studied by radioimmunoassay in a prospective series of 63 patients with gallstone disease but without signs or symptoms of cholecystitis or pancreatitis in order to find indirect evidence of a retrograde flow of pancreatic juice. Mobile duct stones were present in 18 patients and impacted stones in 12. The remaining 33 patients had stones only in the gallbladder and served as controls.The average intraoperative trypsin level of the ductal bile was normal, both in the control group and in the group with stones occluding a potential retrograde reflux of pancreatic juice. After removal of the impacted stones, the bile showed a significantly higher trypsin level. The average intraoperative trypsin level for the group with mobile stones was significantly higher than that of the control group, and was further increased 10 days postoperatively.The trypsin level of ductal bile from 23 of the 30 patients (77%) with bile duct stones exceeded that of the 33 patients with stone-free bile ducts, indicating an inflow of pancreatic juice to the bile ducts of patients with bile duct stones. The present results correspond well to those in a previous report on retrograde phasic contractions of the sphincter of Oddi in the majority of patients with bile duct stones. This dysfunction of the sphincter, which persisted for 10 days after surgical stone removal, may be the primary disorder, probably consisting of a retrograde propulsive activity of the sphincter of Oddi.     

人胰液蛋白质组的双向电泳方法初步研究

目的 在已有实验基础上进一步建立优化的用于人胰液差异蛋白质组研究的双向凝胶电泳(two-dimensional electrophoresis,2-DE)方法;探讨利用混合胰液进行胰腺疾病的胰液差异蛋白质组学的可行性.方法 通过ERCP术中放置鼻胰管引流收集5例胰腺癌(其中2例手术病理分别为胰腺中分化导管腺癌及导管内乳头状瘤癌变,另外3例经影像学检查结合临床诊断)和6例慢性胰腺炎胰液标本,取其中一例慢性胰腺炎胰液标本,通过改进胰液标本的处理方法、泡胀液的组成和一向等电聚焦条件后进行双向凝胶电泳,并和先前实验条件下的胰液2-DE图谱进行比较分析;同时利用优化后的双向凝胶电泳方法比较单份胰液和同病种混合胰液标本的2-DE图谱.结果 应用优化的2-DE方法,在胰液蛋白质加样量为200 μg时,可见凝胶上约有280个蛋白质点,有较好分辨率,较原条件下电泳图谱有较大改进.单份胰液和同病种混合胰液标本的2-DE图谱有较高程度的相似性(>75%).结论 优化后的胰液2-DE方法切实可行,通过各不同胰腺疾病混合胰液的2-DE图谱差异比较可为胰腺疾病的胰液差异蛋白质组学研究建立良好的基础.     

腹腔镜胆管探查并胆总管Ⅰ期缝合术33例临床分析

目的：评价腹腔镜胆管探查并胆总管Ⅰ期缝合术的临床疗效。方法：回顾分析近9个月为33例患者施行腹腔镜胆管探查并胆总管Ⅰ期缝合术的临床资料。结果：手术时间60~150 min,术后1例发生胆漏,3 d后停止。术后住院10~14 d。结论：只要严格掌握手术适应证,具备娴熟的操作技术和丰富的临床经验,腹腔镜胆管探查并胆总管Ⅰ期缝合术将成为此类患者最佳的治疗方法之一。     

胰十二指肠切除术治疗远端胆管癌和胰头癌的临床效果分析

目的比较胰十二指肠切除术治疗远端胆管癌和胰头癌的临床效果。方法回顾性分析2016年1月至2020年12月于南京医科大学第一附属医院胰腺中心行胰十二指肠切除术且术后病理学检查结果为远端胆管癌或胰头癌的1 005例患者的临床和病理学资料。其中远端胆管癌组112例, 男性71例, 女性 41例, 年龄为[M(IQR)]65(15)岁(范围:40～87岁);胰头癌组893例, 男性534例, 女性359例, 年龄为64(13)岁(范围:16～91岁)。通过χ2检验、Fisher确切概率法、秩和检验或Log-rank检验分析两组患者临床病理学特征和术后生存时间之间的差异。采用倾向性评分匹配的方法, 按1∶1匹配后, 通过Kaplan-Meier法比较两组患者术后总体生存时间的差异。结果与胰头癌组相比, 远端胆管癌组手术时间短[240.0(134.0)min比261.0(97.0)min;Z=2.712, P=0.007], 联合静脉切除比例低[4.5%(5/112)比19.4%(173/893);χ2=15.177, P<0.01], 肿瘤最大径小[2.0(1.0)cm比3.0(1.5)c...