改良胆肠袢式吻合术的疗效分析

Objective To evaluate the long-term efficacy of modified loop choledochojejunostomy (MLC). Methods The clinical data of 259 patients who had underwent choledochojejunostomy in First Affiliated Hospital of Sun Yat-Sen University from January 2000 to December 2006 were retrospectively analyzed. Of all the patients, 130 underwent MLC (MLC group) and 129 underwent Roux-en-Y choledochojejunostemy (RYC, RYC group). The changes in incidence of cholangitis and liver function between the 2 groups were compared. All the data were analyzed by t test, chi-square test or Fisher exact probability. Results The levels of alaninetransa-minase and alkaline phosphomonoesterase were (63±42) U/L and (147±147) U/L in MLC group, and (84±52)U/L and (256±201)U/L in RYC group, with statistical difference between the 2 groups (t=1.634, 1.655, P>0.05). The level of gamma-glutamyl transferase in MLC group was (116±91)U/L, which was signifieandy lower than (169±96)U/L in RYC group (t=2.461, P<0.05). Three patients (2.3%) in MLC group and 9 (7.0%) in RYC group suffered from acute cholangitis after operation, with no statistical difference in the incidence between the 2 groups (P>0.05). Of the 12 patients with acute cholangids, 1 in MLC group and 7 in RYC group were hospitalized, with statistical difference between the 2 groups (P<0.05). Conclusions The incidence of acute cholangitis in patients who underwent MLC is comparable to that of RYC. However, the procedure of MLC is simpler than RYC, and patients have milder symptom and lesser frequency of reflux cholangitis onset after MLC.     

肝内胆管结石Caroli病7次手术1例分析

病人女性，自1970—2002年（18～50岁）32年间共行7次胆道手术。     

L-精氨酸对肝缺血再灌注损伤的保护作用及其机制

目的　探讨L 精氨酸 (L Arg)对肝脏缺血再灌注 (I/R)损伤的保护及其机制。 方法雄性SD大鼠随机分为 :假手术组 (Sham ) :大鼠开腹游离肝十二指肠韧带 ,不阻断 ;对照组 (Con trol) :单纯入肝血流阻断 ;Arg组 :肝缺血前 5min ,从大鼠阴茎背静脉 (PDV )注射L Arg 2 0 0mg/kg体重 ;Arg +L组 :肝缺血前 10和 5min ,依次从大鼠PDV注射L 硝基精氨酸甲酯 (L NAME) 30mg/kg体重和L Arg 2 0 0mg/kg体重 ;fmk组 :肝缺血前 5min ,从大鼠PDV注射N 笨甲基氧化碳酰 缬氨酸 丙氨酸 天冬氨酸 氟化丙酮 (ZVAD fmk) 15mg/kg体重。各组入肝血流阻断时间为 40min ,比较各组的谷丙转氨酶 (ALT)、Caspase 3活性、肝细胞凋亡数和 7d生存率。 结果　肝缺血 40min再灌注 6h ,Arg组的 7d生存率显著高于对照组和Arg +L组 (P <0 .0 5 )。Arg组ALT、Cas pase 3活性和肝细胞凋亡数明显低于对照组和Arg +L组 (P <0 .0 1)。Arg组的Caspase 3活性和肝细胞凋亡数略高于fmk组和假手术组 (P >0 .0 5 )。结论　L Arg对肝脏I/R损伤有良好的保护作用 ,其保护机理可能是通过一氧化氮 (NO)作用于Caspase 3并使其失活 ,从而抑制肝细胞凋亡的发生而实现的。     

改良胆肠袢式吻合术的疗效分析

Objective To evaluate the long-term efficacy of modified loop choledochojejunostomy (MLC). Methods The clinical data of 259 patients who had underwent choledochojejunostomy in First Affiliated Hospital of Sun Yat-Sen University from January 2000 to December 2006 were retrospectively analyzed. Of all the patients, 130 underwent MLC (MLC group) and 129 underwent Roux-en-Y choledochojejunostemy (RYC, RYC group). The changes in incidence of cholangitis and liver function between the 2 groups were compared. All the data were analyzed by t test, chi-square test or Fisher exact probability. Results The levels of alaninetransa-minase and alkaline phosphomonoesterase were (63±42) U/L and (147±147) U/L in MLC group, and (84±52)U/L and (256±201)U/L in RYC group, with statistical difference between the 2 groups (t=1.634, 1.655, P>0.05). The level of gamma-glutamyl transferase in MLC group was (116±91)U/L, which was signifieandy lower than (169±96)U/L in RYC group (t=2.461, P<0.05). Three patients (2.3%) in MLC group and 9 (7.0%) in RYC group suffered from acute cholangitis after operation, with no statistical difference in the incidence between the 2 groups (P>0.05). Of the 12 patients with acute cholangids, 1 in MLC group and 7 in RYC group were hospitalized, with statistical difference between the 2 groups (P<0.05). Conclusions The incidence of acute cholangitis in patients who underwent MLC is comparable to that of RYC. However, the procedure of MLC is simpler than RYC, and patients have milder symptom and lesser frequency of reflux cholangitis onset after MLC.     

常用抗生素在动物及人胆汁中的浓度分布和药效学研究

目的研究常用抗生素在胆汁中的浓度和对致病菌的抗菌活性。方法分别静脉注射常用6种抗生素后于不同时间收集家兔胆汁标本，采用高效液相色谱法测定各抗生素的浓度，计算出药动学参数；测定胆道手术患者胆汁常用5种抗生素浓度，对临床分离的157株胆道细菌进行抗菌活性分析。结果家兔胆汁平均药峰浓度较高的为：哌拉西林7950．16μg／ml，头孢哌酮5274．52μg／ml，头孢曲松1107．01μg/ml。在患者胆总管和胆囊胆汁中的平均浓度较高的为：头孢哌酮／舒巴坦563．75／14．76和169．90／8．83μg／ml，哌拉西林／他唑巴坦350．38／16．69和139．81／15．92μg／ml，头孢曲松249．78和82．06μg／ml。美罗培南和莫西沙星的体外抗菌活性最强，增加β-内酰胺酶抑制剂后的哌拉西林和头孢哌酮复合制剂较单一制剂的抗菌活性显著增强。头孢哌酮／舒巴坦、哌拉西林／他唑巴坦、莫西沙星对胆道致病菌的杀菌指数最大。结论家兔胆汁中6种测定的抗生素均超过有效杀菌浓度，哌拉西林、头孢哌酮、头孢曲松胆汁药物浓度很高。头孢哌酮／舒巴坦和哌拉西林／他唑巴坦、莫西沙星在人胆汁中杀菌效力最强，可作为肝胆系统感染经验治疗的首选用药。     

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目的：探讨肝胆管结石手术时机的选择对术后并发症及其治疗效果的影响。方法：回顾性分析1992～2002年因肝胆管结石行手术治疗457例的胆管炎发作史，再手术史，手术方式，术后并发症及结石残留等情况。结果：457例中急症期内行手术治疗213例，出现术后并发症47例(22．1％)，死亡3例，术后结石残留率37．3％；择期行手术治疗244例，出现术后并发症31例(12．7％)，死亡2例，术后结石残留率21．7％。结论：严格掌握肝胆管结石手术时机，避免急症期内被动手术和减少再次手术率，可减少术后并发症和残留结石发生，提高治疗效果。     

肝细胞癌患者树突状细胞免疫功能的研究

 目的：研究肝细胞癌患者树突状细胞(DCs)的免疫功能变化。方法：从人外周血中分离单个核细胞（PBMC），用GM-CSF和IL-4体外诱导、培养和扩增DCs，流式细胞仪测定DCs表面分子的表达，分别用ELISA、ELISPOT、MTT法测定HCC患者和健康人的DCs分泌IL-12；T淋巴细胞分泌IFN-γ和T淋巴细胞的增殖反应。结果：GM-CSF和IL-4能成功地体外诱导、培养和扩增DCs。HCC患者DCs的CD86表达明显低于健康对照者（91.7％ vs83.5%, P<0.05）。HCC患者DCs分泌IL-12与健康者差异不显著［（324.6±171.0）ng/L vs（436.5±142.7）ng/L, P>0.05］，接受内毒素LPS刺激后，差异更明显［（478.6±142.7）ng/L vs（630.0±151.9）ng/L, P<0.05］。DCs刺激T淋巴细胞分泌IFN-γ 的量在HCC患者明显低于健康者［（133.4±51.2）103U/L vs (183.0± 60.2)103U/L, P<0.05］，DCs刺激T淋巴细胞的增殖能力在HCC患者明显低于健康者（2.3±0.7 vs3.5±0.8, P<0.01）。CTL杀伤实验表明，当效靶比为 10∶〖KG-*2〗1 和 20∶〖KG-*2〗1 时，HCC组的CTL对肝癌细胞Hep G2的杀伤活性明显低于健康组。结论： HCC患者DCs功能和T淋巴细胞功能低于健康者，HCC患者DCs诱导的CTL杀伤活性亦明显低于健康者。     

腺病毒介导的T-bet基因转染诱导Th1型淋巴细胞分化

目的：构建含有T细胞转录因子T-bet(T-box expressed in T cells)的重组腺病毒Ad.T-bet，并诱导Th1型淋巴细胞分化。 方法： 采用RT-PCR的方法从健康人外周血淋巴细胞的总RNA中克隆T-bet基因，亚克隆入腺病毒穿梭载体成为pAdtrack-CMV.T-bet，与腺病毒基因组载体pAdeasy-1同源重组为pAd.T-bet，经Pac I酶切后转染293细胞，用 Western blotting 和RT-PCR的方法鉴定Ad.T-bet；联合腺病毒和脂质体以感染倍数(m.o.i) 5000感染活化的淋巴细胞，用ELISA 法检测培养液中IFN-γ含量。 结果： 采用RT-PCR方法从健康人外周血淋巴细胞中扩增出T-bet基因，构建出重组腺病毒Ad.T-bet，Western blotting 和RT-PCR均检测出细胞内T-bet蛋白表达；联合Ad.T-bet和脂质体感染淋巴细胞诱导Th1型细胞因子IFN-γ持续高表达。 结论： 重组腺病毒Ad.T-bet有效诱导Th1型细胞分化，有望成为改变肿瘤患者免疫抑制状态的有效方法。     

一种改进的阻塞性黄疸大鼠模型的建立

目的 利用胆总管置管末端结扎制作改进阻塞性黄疸模型,观察TB达峰时间及其与经典模型的差异.方法 SD大鼠随机分为9组,分别为假手术组3、7、12 d处死,经典阻塞性黄疸(obstructive jaundice,OJ)模型组3、7、12 d处死,改进OJ模型3、7、12 d处死.观察大鼠大鼠状态、死亡率、肝功能指标,以及肝组织切片HE染色病理组织变化.结果 OJ后大鼠死亡3只,主要发生在OJ 10 d时.OJ后TB 7 d时最高,12 d时下降,改OJ模型与经典OJ模型的TB、DB、GGT、ALT、ALB变化规律相似.OJ 7 d后大鼠肝脏病理变化和人相似,呈现局部坏死、汇管区扩大伴大量炎症细胞浸润的表现,12 d开始出现肝纤维化表现.改进模型和经典模型变化相似.结论 大鼠阻塞性黄疸模型以结扎胆总管7天为佳.改进OJ模型和经典OJ模型血清肝功能指标以及肝脏组织病理结构变化相似,提示其可以作为一个较为稳定的阻塞性黄疸模型.