2018—2021年临床常见胆道感染病原菌分布及耐药性变迁

目的：分析2018—2021年我院胆道感染患者病原菌构成及耐药性变迁。方法：收集2018—2021年天津市南开医院胆道感染病原菌,采用VITEK2 Compact对其进行鉴定及药敏检测,药敏结果按照CLSI 2020年版标准判定,数据采用WHONET 5.6软件进行统计分析。结果：胆汁培养共分离出病原菌4 906株,其中革兰阴性菌3 306株,占67.39%;革兰阳性菌1 494株,占30.45%;真菌106株,占2.16%。耐碳青霉烯的大肠埃希菌、肺炎克雷伯菌检出率分别为2.31%、12.99%。非发酵菌中碳青霉烯类耐药的铜绿假单胞菌（CRPA）和鲍曼不动杆菌（CRAB）检出率分别为62.88%、70.59%。耐甲氧西林的金黄色葡萄球菌(MRSA)和耐甲氧西林的凝固酶阴性葡萄球菌(MRCNS)检出率分别为45.71%、64.40%,未发现对万古霉素、喹努普汀/达福普汀、利奈唑胺、替加环素耐药的葡萄球菌属。肠球菌对万古霉素、利奈唑胺和替加环素的耐药性均较低,万古霉素耐药的屎肠球菌（VRE）检出率0.67%。结论：胆道感染患者病原菌以肠源性细菌为主,主要为革兰阴性菌,多重耐药菌增加,应密...     

胆道感染240例胆汁细菌培养结果及药敏分析

目的了解引起胆道感染的主要病原菌及其对药物的耐药性。方法对我院自2007年1月至2008年12月收治的240例胆道感染病人术中取胆汁进行细菌培养及药敏分析。结果240份胆汁标本中130份培养阳性,培养阳性率为54.2%。共分离出细菌150株,其中革兰阴性杆菌95株,革兰阳性球菌55株。引起胆道感染的主要病原菌依次为铜绿假单胞菌(26.7%)、大肠埃希菌(18.7%)、肠球菌(14.6%)和克雷伯菌(10.0%)。药敏结果显示,革兰阴性杆菌对亚胺培南、美罗培南、头孢吡肟及阿米卡星(丁胺卡那霉素)耐药率较低;革兰阳性球菌对万古霉素、替考拉宁、阿米卡星及头孢哌酮耐药率较低。结论胆道感染仍以革兰阴性杆菌为主,其中铜绿假单胞菌位居首位;阿米卡星可作为治疗胆道感染的首选用药之一。     

2019～2021年某三级综合医院泌尿道感染病原菌分布及耐药性分析

目的探讨某三级综合医院的泌尿道感染病原菌分布及耐药性, 为临床合理使用抗菌药物及院内感染监控提供指导。方法从本院检验系统中筛选2019年1月1日至2021年12月31日泌尿道感染患者的4 748例尿标本培养结果, 回顾性分析其病原菌分布及耐药性。结果 4 748例尿培养标本共分离出1 026株病原菌, 其中革兰阴性菌812株(79.14%), 革兰阳性菌210株(20.47%), 真菌4株(0.39%)。病原菌占比前5位分别是大肠埃希菌610株(59.45%)、屎肠球菌81株(7.89%)、粪肠球菌76株(7.41%)、肺炎克雷伯菌60株(5.85%)、彭氏变形菌51株(4.97%);大肠埃希菌对碳青霉烯类的耐药率<2%, 对阿米卡星、哌拉西林/他唑巴坦的耐药率<10%;粪肠球菌对氨苄西林、呋喃妥因的耐药率<10%, 屎肠道球菌对青霉素类、喹诺酮类、红霉素等的耐药率>90%, 粪肠球菌对青霉素类、呋喃妥因的耐药率<10%, 未检出对万古霉素、利奈唑胺、替加环素耐药的菌株。结论泌尿道感染病原菌以大肠埃希菌为主, 其次为屎肠球菌、粪肠球菌。菌群分布及耐药性监测...     

2015—2017年临床常见血培养病原菌的分布特征及耐药性变迁

目的：分析天津市南开医院临床常见的血培养病原菌的分布特征及耐药性变迁，为血流感染的临床治疗用药及院内感染监控提供依据。方法：收集天津市南开医院2015—2017年的血培养资料，采用BecT/Alert3D全自动血培养仪对血培养瓶进行连续监测，Vitek 2 Compact全自动微生物分析系统对血标本中分离的病原菌进行鉴定及药敏，用whonet5.6软件和SPSS 20.0软件对结果进行回顾性分析。结果：血培养共分离病原菌1834株，其中革兰阳性菌732株，占39.91%；革兰阴性菌968株，占52.78%；真菌84株，占4.58%；厌氧菌50株，占2.73%。革兰阳性菌中凝固酶阴性葡萄球菌最多，其次为屎肠球菌、金黄色葡萄球菌和粪肠球菌；革兰阴性菌检出主要为大肠埃希菌、肺炎克雷伯菌和铜绿假单胞菌。主要分布在肝胆胰外科、重症医学科和微创外科。2015—2017年人葡萄球菌人亚种和表皮葡萄球菌对喹诺酮类药物的耐药率均有显著上升（P<0.05），金黄色葡萄球菌对四环素的耐药率逐年下降（P<0.01）。大肠埃希菌对哌拉西林、头孢他啶、第一、二、四代头孢菌素、氨苄西林/舒巴坦和氨曲南的耐药率均呈下降趋势（P<0.05）。肺炎克雷伯菌肺炎亚种对哌拉西林和妥布霉素的耐药率有所下降（P<0.05），对左氧氟沙星、哌拉西林/他唑巴坦、头孢替坦和阿米卡星的耐药率有所上升（P<0.05），2016年出现对亚胺培南和美罗培南耐药的菌株。铜绿假单胞菌对亚胺培南、氨曲南和喹诺酮类药物的耐药率有显著下降（P<0.05）。结论：我院血培养病原菌以革兰阴性杆菌为主，大肠埃希对多种抗菌药物耐药性较强，肺炎克雷伯菌对部分抗生素耐药率有显著上升，且两者均出现耐碳青霉烯类抗菌药物的菌株，今后应合理使用抗菌药物，加强血流感染病原菌的监测。     

普通外科ICU严重腹腔感染的病原菌分析与治疗体会

【摘要】〓目的〓探讨外科ICU严重腹腔感染患者的病原菌分布及耐药性,为临床经验用药提供参考依据。方法〓回顾性分析2012年1月~2013年12月58例严重腹腔感染患者的资料,对患者的病原学发布及耐药性进行分析。结果〓共分离出病原菌178株,其中革兰阴性杆菌126株,占70.79%,以大肠埃希菌为主;革兰阳性球菌39株,占20.79%,以屎肠球菌为主;真菌13株,占8.42%。大肠埃希菌和肺炎克雷伯菌产ESBLs菌株检出率分别为67.50%和57.25%,对碳青霉烯类抗菌药物耐药率低。初始病原菌分布以革兰阴性杆菌为主,第2、3周之后革兰阳性球菌分离率上升,真菌则多在第3周后出现。58例中混合病原菌感染占89.66%,细菌和真菌混合感染又占30.50%。未检出耐万古霉素肠球菌属。结论〓严重腹腔感染的病原菌以革兰阴性杆菌为主,混合感染的发生率及细菌的耐药率比较高,及早、合理的经验性抗感染治疗有利于控制细菌耐药的产生和播散。     

天津市南开医院 2018—2021年血流感染病原菌分布及耐药性变迁

目的:分析天津市南开医院 2018—2021年血流感染患者病原菌构成及耐药变迁情况。方法:收集南开医院 2018年 1月 1日—2021年 12月 31日住院和门诊患者临床血培养标本中分离的非重复病原菌。采用 VITEK2 Compact对其进行鉴定及药敏检测,药敏结果按照 CLSI 2020年版标准判定,数据采用 WHONET 5.6软件进行统计分析。结果:血培养共分离出病原菌 2 383株,其中革兰阴性菌 1 147株,占 48.13%;革兰阳性菌 1 141株,占 47.88%;真菌 95株,占 3.99%。检出率前五位的主要病原菌分别为大肠埃希菌(21.78%)、人葡萄球菌(15.00%)、肺炎克雷伯菌(12.59%)、表皮葡萄球菌(9.74%)和屎肠球菌( 4.97%)。耐碳青霉烯类大肠埃希菌、肺炎克雷伯菌检出率分别为 0.58%和 12.67%。非发酵菌种碳青霉烯类耐药的铜绿假单胞菌( CR-PA)和鲍曼不动杆菌( CR-AB)检出率分别为 52.94%和 60.00%。金黄色葡萄球菌和凝固酶阴性葡萄球菌中甲氧西林耐药株( MRSA和 MRCNS)检出率分别为 26.67%和 72.77%,未发现对万古霉素、替加环素耐药的葡萄球菌属。肠球菌对万古霉素、利奈唑胺和替加环素的耐药率均较低。结论:血流感染以革兰阴性菌为主,但革兰阳性菌有增长趋势,主要分离菌对临床常用抗菌药物耐药率逐年增加,应密切关注血流感染常见菌群的分布及耐药性变迁。     

结核患者下呼吸道感染菌群分布及药敏分析

目的探讨肺结核并发下呼吸道感染者病原菌分布特点及耐药性,分析肺结核并发下呼吸道感染的危险因素。方法2011年1月至2013年12月对住院肺结核患者进行细菌分离及药敏试验,分析影响患者下呼吸道感染的危险因素。结果485例肺结核住院患者中并发下呼吸道感染125例（25．77％）,共分离病原菌425株,其中革兰阳性球菌165株（38．82％）,革兰阴性杆菌228株（53．65％）,真菌32株（7．53％）。革兰阳性菌对利奈唑胺敏感性较高,铜绿假单胞菌对氨曲南、头孢他啶及头孢吡肟敏感,肺炎克雷伯菌对头孢吡肟敏感,大肠埃希菌对亚胺培南、派拉西林及环丙沙星敏感性高,鲍曼不动杆菌对常规抗菌药物均表现为耐药。年龄、病程、病灶、抗菌药物应用种类及住院时间是影响肺结核并发下呼吸道感染的危险因素。结论肺结核并发呼吸道感染者细菌耐药性较高,临床应加强对高龄、病程长、病灶多、住院时间长等高危患者的管理,合理应用抗菌药物,加强对患者耐药性观察,可有效降低肺结核并发下呼吸道感染的发病率。     

急性坏死性胰腺炎合并感染的病原菌及耐药性分析

目的：研究急性坏死性胰腺炎（ANP）合并感染的病原菌分布及耐药性,并探讨其对ANP患者预后的影响。 方法：回顾性分析2010年10月—2014年10月收治的72例有明确病原学依据的ANP合并感染患者的临床资料。 结果： 72例ANP患者中,腹腔及腹膜后感染47例（65.28%）,呼吸道感染37例（51.39%）,血流感染32例（44.44%）,其中血流感染与患者死亡密切相关（P<0.05）。检出病原菌235株,其中革兰阴性细菌159株（67.66%）,革兰阳性细菌60株（25.53%）,真菌16株（6.81%）。获得的病原菌中排名前6位的依次是：鲍曼不动杆菌（24.68%）,铜绿假单胞菌（8.94%）,肺炎克雷伯菌（8.09%）,屎肠球菌/粪肠球菌（8.09%）,大肠埃希菌（7.66%）,金黄色葡萄球菌（4.68%）。耐药性分析显示,鲍曼不动杆菌和铜绿假单胞菌对亚胺培南耐药率分别达95.92%和52.63%,对头孢哌酮/舒巴坦的耐药率分别为59.26%和50.00%。肺炎克雷伯菌和大肠埃希菌产超广谱β-内酰胺酶（ESBLs）检出率分别为64.29%和80.00%,对头孢哌酮/舒巴坦的耐药率分别为31.58%和18.75%,而对亚胺培南的耐药率分别为23.08%和7.14%。19株屎肠球菌/粪肠球菌中仅1株对万古霉素耐药,对利奈唑烷尚未发现耐药菌株。耐甲氧西林金黄色葡萄球菌检出率为72.73%,对万古霉素、利奈唑烷和呋喃妥因尚未发现耐药菌株。16株真菌对常用抗真菌药物均未发现耐药菌株。 结论：血流感染是ANP患者死亡的重要原因。ANP患者的病原菌仍以革兰阴性菌为主,但革兰阳性菌和真菌的比例不容忽视。多重耐药菌已成为ANP合并感染的巨大的挑战。     

急性胆管炎患者胆汁培养结果和药敏分析

目的研究急性胆管炎患者胆汁培养的病原学现状,病原体分布特点以及药敏情况为急性胆管炎的治疗提供更为合理的抗生素指导方案。方法回顾性分析2015年1月~2018年1月湛江地区我院收治符合病例研究纳入标准共314例急性胆管炎患者的临床病例资料,对其胆汁培养的病原菌分布及耐药性进行分析。结果 314例急性胆管炎胆汁培养的病原菌阳性率为82.80%,共检出病原菌358株,革兰氏阴性菌230株,革兰氏阳性菌122株,真菌6株。最常见的细菌是大肠埃希菌129株(36.0%)、粪肠球菌59株(16.5%)、铜绿假单胞菌27株(7.5%)、肺炎克雷伯菌肺炎亚种24株(6.7%)以及屎肠球菌17株(4.7%)。胆道培养为革兰氏阴性致病菌总体上对碳氢酶烯类(厄他培南耐药率0%,亚胺培南耐药率8.41%,美罗培南耐药率22.22%)及氨基糖苷类(阿米卡星耐药率1.35%,庆大霉素耐药率20.00%、妥布霉素10.19%)相对敏感度较高。胆道培养为革兰氏阳性致病菌总体上对临床上常用的大部分抗生素耐药率较低,譬如对米诺环素、莫西沙星、氨苄西林、头孢曲松耐药率均低于10%。而对于临床上较少应用的抗菌素如克林霉素、红霉素耐药率则高于40%。结论急性胆管炎患者胆汁培养的病原学现状仍然以革兰阴性菌为主,而药敏以碳氢酶烯类及氨基糖苷类相对敏感度较高,故临床上对其应用抗菌素治疗时要重视加强管理及监控。     

白血病患者并发革兰菌血流感染临床特点及耐药情况的研究

目的探讨白血病患者并发血流革兰菌感染的临床特点及其耐药性情况。方法选取95例白血病并发血流革兰菌感染的患者为研究对象,分析患者的病原菌种类、分布,临床特征及耐药情况。结果 95例血流革兰菌感染者中52例(54.74%)为革兰阴性(G-)杆菌感染,共检测菌株185株;43例(23.24%)为革兰阳性(G+)球菌感染,共检出菌株128株。G-杆菌感染者临床症状表现为高热寒战,而G+球菌感染则表现为中低度发热G-杆菌感染者体温、CRP、PCT水平均高于G+球菌组,差异具有统计学意义(P均0.05)。G-杆菌感染者对哌拉西林他唑巴坦(TZP)以及左氧沙星(LVX)的药敏性较高,而对头孢唑啉(KZ)、胺曲南(ATM)、头孢美唑(CMZ)、头孢他啶(CAZ)的敏感性较低。G+球菌均对替考拉宁(TEG)及万古霉素(VAM)药敏性较高,而对其他抗菌药物表现为较低的药敏性。结论 G-杆菌对TZP和LVX药敏性较高,而G+球菌对TEG和VAM药敏性较高。临床应重视白血病患者病原学调查,并应根据患者的临床体征及药敏试验选取合适的治疗方案,以降低白血病患者血流革兰菌感染发生率及病死率。     

Study of serum calcium and trace elements in chronic cholelithiasis

Background: High biliary calcium and trace elements (copper, zinc and iron) in patients with chronic cholelithiasis can be associated with gallstones. Methods: Estimations of calcium, copper, zinc and iron were done in the serum, gall bladder bile and gallstones of 48 patients with chronic cholelithiasis and in 20 age‐ and sex‐matched controls. Biliary levels of calcium and trace elements and bile/serum ratio of calcium and trace elements were compared in the two groups. Results: Serum calcium was significantly less (P= 0.009) than controls, but biliary calcium was higher in the patients with chronic cholecystitis. All trace elements were found to be significantly higher (P≤ 0.036) in the bile of patients with chronic cholelithiasis. The bile/serum ratio of calcium, copper and zinc was significantly greater (P≤ 0.03) in patients of chronic cholelithiasis. Gall bladder bile in patients with chronic cholelithiasis was slightly more alkaline. Pigment stones contained significantly more calcium, copper and iron than cholesterol stones (P≤ 0.001). Conclusion: Higher biliary calcium and trace elements as well as a defective pH of gall bladder bile in patients with chronic cholelithiasis could be the underlying factor in the pathogenesis of gallstones.     

乙肝病毒感染与胆泥形成的关系及其意义

目的　探讨乙肝病毒感染与胆泥、胆石形成的关系。 方法　 收集３５ 例乙肝病毒感染患者和３３ 例非乙肝病毒感染患者的胆囊内胆汁，用偏振光显微镜进行检测。 结果　５ 例乙肝病毒感染和４ 例非乙肝病毒感染胆石症患者的胆汁均发现有胆泥形成（１００ ％ ） 。３０ 例乙肝病毒感染患者的胆汁发现胆泥形成１０ 例（３３ ％ ） ，其中８ 例慢性肝炎患者的胆汁胆泥形成４ 例（５０ ％ ） ，２９ 例非乙肝病毒感染对照组患者发现胆泥３ 例（１０ ％ ） 。乙肝病毒感染组胆泥形成阳性检出率较对照组有显著差异（ Ｐ＜ ００１） 。 结论　胆泥形成是胆石形成的必经阶段，乙肝病毒感染与胆泥形成、胆石症发病率增高有密切关系。     

经ERCP途径获取胆汁培养病原菌分布及耐药性分析

背景与目的:胆道感染是临床常见急腹症,处理不及时可引发感染性休克,甚至死亡.因此,了解胆道感染患者胆汁中细菌的种类及药敏情况对指导临床治疗至关重要.本研究分析胆道疾病患者经内镜逆行胰胆管造影(ERCP)途径获取胆汁培养病原菌分布及耐药情况,以期为临床胆道感染患者的抗菌药物合理使用提供依据.方法:回顾性分析2016年1月...     

胆总管结石行内镜下逆行胰胆管造影术治疗后结石复发的相关危险因素分析

目的对影响胆总管结石（CBDS）患者行内镜下逆行胰胆管造影（ERCP）术治疗后结石复发的相关危险因素进行研究并分析。 方法选取2014年3月至2017年3月在上海第六人民医院行ERCP术治疗的患者200例,将术后CBDS复发86例患者作为观察组,术后CBDS未复发114例作为对照组,结合两组患者资料进行单因素分析,对筛选出的危险因素进一步行多因素Logistic回归分析。 结果观察组患者年龄、病程、胆总管直径、有胆道手术史、胆道狭窄、有乳头旁憩室、结石大小（≥10 mm）、结石数量（≥2枚）的例数均显著多于对照组,差异有统计学意义（均P<0.05）;多因素分析显示,年龄、有胆道手术史、乳头旁憩室、结石数量≥2枚、胆总管直径、结石大小（直径≥10 mm）为患者术后复发的独立危险因素（P<0.05）。 结论患者年龄、有既往胆道手术史、合并乳头旁憩室、结石数量≥2枚、胆总管直径≥10 mm是CBDS胰胆管造影术后复发独立危险因素。     

Intrahepatic gallstones. A case report

A Coloured woman was admitted to hospital with a 3-day history of acute right upper abdominal pain, nausea and vomiting. Acute cholecystitis was confirmed by biliary imaging using technetium-99m. An acutely inflamed gallbladder and two pigment stones in the common bile duct were removed. There were numerous retained gallstones in biliary radicles of the right hepatic duct; attempts to dislodge these by saline flushing failed. An extended choledochotomy with further exploration of the intrahepatic radicles also failed to remove the incarcerated stones. Biliary enteric drainage was achieved by choledochoduodenostomy and short-term postoperative progress was uneventful.     

Cholelithiasis and cholecystitis

Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.     

腹腔镜胆道探查胆总管一期缝合术治疗胆管结石的疗效分析

目的探讨腹腔镜下胆道探查术、胆总管一期缝合术的临床疗效与可行性。方法2014年2月至2017年2月收集贵州医科大学附属医院106例胆总管结石病人,男性44例、女性62例,年龄18~75岁,平均(46.5±15.7)岁。106例胆总管结石病人,伴或不伴胆囊结石与肝内胆管结石,其中腹腔镜下胆道探查胆总管一期缝合术67例,腹腔镜下胆道探查T管引流术39例,对两组病例手术适应证、手术时间、术后恢复情况、并发症等进行比较。结果胆总管一期缝合组的手术时间、术后住院天数、腹腔引流管放置时间分别为(72.8±21.0)min、(2.8±1.9)d和(5.5±2.3)d,优于T管引流术组的(95.5±26.5)min、(5.7±1.4)d和(8.1±2.6)d(均P0.05),术后肛门排气时间两组分别为(1.9±0.8)d和(2.1±0.5)d、差异无统计学意义;两组均无肝衰竭、腹腔感染、胆管残余结石、胆道出血及穿孔,胆漏发生率T管引流术组(3例)高于胆总管一期缝合组(0例)(P0.05)。结论腹腔镜胆道探查胆总管一期缝合术治疗胆管结石是安全、可行的,病人明显受益,值得临床推广应用。     

Surgical pathology at early elective operation for suspected acute gallstone pancreatitis: preliminary report of a prospective clinical trial

Fifty-five patients presenting with acute abdominal symptoms and found to be hyperamylasaemic underwent early biliary tract investigation, giving 31 patients in whom the presence of gallstones was suspected. In accordance with the protocol of a randomized controlled trial of early elective biliary tract surgery for patients suspected of having acute gallstone pancreatitis, 19 of these patients underwent laparotomy at a mean of 6.9 days after emergency admission. In this group operation showed that four patients had biliary tract stones and pancreatitis; ten patients had calculous cholecystitis (53 per cent) but no stigmata of pancreatitis; four patients had pancreatitis but no stones; one had a negative laparotomy. None of this group was found to have ampullary obstruction due to an impacted stone. Biliary tract investigations carried out during the first week following admission were unhelpful or misleading in 14 out of the whole group of 55 patients, and in all of those patients (11 per cent) who died or required surgical intervention during the same hospital admission. There appears to be a pathological heterogeneity among patients diagnosed as 'gallstone pancreatitis' on clinical and biochemical grounds alone.     

胆道手术后复发结石腹腔镜再次手术的可行性及术式探讨

目的:探讨胆道手术后复发结石再次行腹腔镜手术的可行性及术式选择。方法:回顾分析2014年9月至2019年9月收治的胆道手术后复发结石患者再次手术治疗的临床资料,将胆道手术后再次行开放与腹腔镜胆总管切开取石(开腹组与腹腔镜组)、左肝外叶切除(开腹肝组与腹腔镜肝组)患者的临床资料与疗效进行两两对比分析,总结手术经验。结果:患者均顺利治愈出院。腹腔镜组术中出血量、住院时间、切口感染率优于开腹组,差异有统计学意义(P<0.05)。腹腔镜肝组住院时间、切口感染与胸水发生率优于开腹肝组,差异有统计学意义(P<0.05);两组手术时间差异无统计学意义(P>0.05)。结论:选择合适病例经腹腔镜胆道再次手术安全、有效,可缩短住院时间,减少胆道手术后切口感染,值得在硬件设备齐全、具有熟练腹腔镜手术技巧与丰富开腹胆道手术经验的临床中心推广应用。     

The role of cystic duct resistance in the pathogenesis of cholesterol gallstones

Several recent clinical and laboratory observations suggest that impaired gallbladder emptying is important in the pathogenesis of cholesterol cholelithiasis. However, the exact mechanism by which gallbladder stasis occurs in the majority of patients who form gallstones has not been clear. We tested the hypothesis that impaired gallbladder emptying antedates cholelithiasis and results from increased resistance to bile flow. Using the prairie dog gallstone model, resistance to flow through the cystic duct (CD) and sphincter of Oddi (SO) was measured in control and cholesterol-fed animals. Prairie dogs were fed either a control (trace cholesterol) or a 0.4% cholesterol-enriched diet known to induce gallstones in 6 weeks. Resistance across the CD and SO was measured at 4 weeks (pregallstone) and 16 weeks (gallstone). Resistance was measured by infusing lactated Ringer's solution through the CD and SO at four separate flow rates while gallbladder and distal common bile duct pressures were recorded. Resistance to flow through the cystic duct increased prior to gallstone formation and continued to increase during the 16 weeks of cholesterol feeding. In comparison, sphincter of Oddi resistance remained normal despite chronic exposure to lithogenic bile and formation of stones within the gallbladder. The increased cystic duct resistance observed prior to gallstone formation provides a mechanism for diminished gallbladder emptying and suggests an etiological role for increased cystic duct resistance in the pathogenesis of cholesterol gallstones.