成人肠旋转不良、胰腺体尾缺如合并下段胆管癌手术治疗一例

患者女 ,5 8岁。因黄疸 1个月入院。患者 2 0 0 0年 12月底尿色偏黄 ,伴厌油、腹胀、低热 ,近 1周黄疸逐渐加重 ,伴陶土样便。MRI提示肝内外胆管扩张、胆总管下段梗阻、胰腺反位可能。查体 :皮肤、巩膜黄染 ,脾脏位于左中腹 ,质中。辅助检查 :TB 14 1 7umol /L ,DB 110 6umol /L ,血糖 4 6mmol/L ,CA19 931 7U/ml。胸片示右侧第 5前肋分叉畸形。B超示肝内外胆管扩张 ,胰腺显示不清 ,脾脏位于左中腹。ERC :十二指肠球腔明显增大 ,乳头角度不佳 ,未见副乳头 ,胰管无法显影 ,胆管造影见肝内外胆管扩张 ,胆总管下段1cm狭窄段。全身麻醉…     

超半肝切除扩大根治术治疗肝门胆管癌一例

患者男性，54岁，因“乏力、纳差伴腹痛5周”于2007年4月13日入院。既往有乙型肝炎病史8年。入院查体：皮肤、巩膜略黄染，腹部阴性，总胆红素26．7μmol／L，直接胆红素13．2μmol／L，丙氨酸转氨酶276．9U／L，碱性磷酸酶446U／L，CA19-9380．6U／ml，癌胚抗原（-）、甲胎蛋白（-），乙肝五项中HBsAg（＋）、HBeAb（＋）、HBcAb（＋）。     

电凝法治疗下肢静脉曲张240例报告

大隐静脉高位结扎加剥脱术一直是治疗单纯大隐静脉曲张的经典手术。手术创伤大 ,出血多 ,术后病人留下许多切口疤痕 ,影响外观。探讨既能取得相同疗效又能减少痛苦的手术一直是病人和医务工作者的共同愿望。近些年来 ,虽然有多种术式改进 ,但未能完全脱离原来的治疗框架。致使很多病人因惧怕手术而拖延治疗。我院普外科自 1998-10～ 2 0 0 1-12 ,采用电凝法治疗下肢静脉曲张 2 40例 ,治疗效果满意 ,现报告如下。1　资料和方法1·1　一般资料　下肢静脉曲张病人 2 40例 ,其中男性 160例 ,女性 80例。年龄最小 2 6岁 ,最大 75岁。平均 45岁。…     

成人先天性胆总管囊肿17例误诊分析

先天性胆总管囊肿在成人中发病比较少见,有近60%的病人在10岁前被诊断出来,只有不到20%在20岁以后才来就诊[1].在西方国家发病率为1/50 000～1/200 000,但在亚洲其发病率就明显升高,女性发病比例较高,约为男性的4倍[2].     

CCK及CCKAR基因多态性与胆道癌及胆石症遗传易感性的关系

目的:研究胆囊收缩素(cholecystokinin,CCK)rs747455位点及胆囊收缩素A受体(cholecystokinin A receptor,CCKAR )rs1800856位点的基因多态性与上海市区人群胆道癌及胆石症易感性的关系。方法:采用全人群病例-对照研究的方法,运用实时荧光定量PCR系统对253例胆囊癌、133例肝外胆管癌、53例壶腹癌和440例胆石症患者以及445名正常对照进行CCK rs747455及CCKAR rs1800856位点基因型分析。结果:无胆石个体中携带CCK rs747455位点CT基因型者较携带CC基因型者罹患壶腹癌的风险降低,其比值比(odds ratio,OR)=0.31,95%可信区间(confidence interval,CI)为0.10～0.96,经过Bonferroni校正后此差异仍有统计学意义(P=0.042);饮酒个体中携带rs747455位点TT基因型或CT基因型者较携带CC基因型者罹患胆石症的概率增加(OR=2.81, 95%CI:1.08～7.29;OR=2.93, 95%CI:1.03～8.33),但经过Bonferroni校正后差异无统计学意义(P=0.061)。在CCKAR rs1800856位点的分层分析中未发现该位点与胆道癌及胆石症有显著相关性。结论:CCK基因rs747455位点可能与中国上海人群胆道癌及胆石症的发生相关。     

肝脏单独与肝肾整块快速获取方法的比较★

目的：目前器官移植尸体供体来源仍占相当的比例，多器官来源于同一供体的需求增多，快速整块获取的技术发展迅速。比较肝脏单独与肝肾整块快速获取的技术特点与脏器损伤情况的差异。 方法：①回顾分析2004-03/2006-07解放军第二军医大学东方肝胆外科医院单个手术组获取并应用于移植的74例供肝资料。②使用快速肝脏获取方法，不进行热解剖，开腹先进行腹主动脉联合门静脉原位冷灌注。肝脏单独切取方法：肾静脉上缘离断腔静脉，胰颈下方离断肠系膜上血管；腹主动脉前解剖法剥离肠系膜上动脉至根部，与肾动脉之间离断腹主动脉，游离胰腺体尾、腹主动脉后方，取下肝脏。肝肾整块获取方法：肝周韧带游离后，游离结肠、输尿管、肾及脾脏，离断肠系膜上血管，横断腹主动脉、腔静脉，游离血管、肝胰脾肾后方，整块切取肝肾。离体腹主动脉后解剖法显露分离肝肾动脉，离断下腔静脉，完全分离肝肾。③记录两种方法的肝脏热缺血、肝脏获取、冷缺血时间，统计肝肾主要部位的获取损伤率并进行比较。 结果：①完成肝脏单独获取28例，肝肾整块获取46例，两组中分别有1例同时获取心脏。未发生因器官获取原因导致的器官损失，获取肝脏全部用于移植，无原发性器官无功能发生，无肝动脉血栓形成。②单独获取患者肝脏获取时间短于肝肾整块获取患者（P < 0.01）。③肝肾整块获取患者的腹腔动脉和肠系膜上动脉的Carrel袖片损伤率低于肝脏单独获取患者（P < 0.05）。 结论：快速肝脏单独和快速肝肾整块获取方法的主要技术差别在于分离肝肾血管的先后顺序及解剖显露肝肾动脉的方法；快速肝脏单独获取在手术耗时上少于快速肝肾整块获取，但更容易出现腹腔动脉和肠系膜上动脉Carrel袖片的损伤。     

肝部分切除与肝十二指肠韧带骨髂化治疗肝门部胆管癌

Objective To summarize the surgical experience of partial hepatectomy with skeletonization of the hepatoduodenal ligament in the treatment of hilar cholangiocarcinoma.Methods Between Jan.1999 and Dec,2001,67 consecutive patients with hilar cholangiocarcinoma underwent surgical exploration at the Second Military Medical University,Eastern Hepatobiliary Surgery Hospital.The clinical data of these patients were reviewed.Results Of the 67 patients,65(97%) underwent surgical resection.Fourty-nine patients(73%) received curative resection:22 skeletonization resection(SR) and 27 SR combined with partial hepatectomy.In 16 patients(9%) with curative resection the tumor margin was histologically postive and the resection was therefore considered palliative.The tumors were classified according to Bismuth with SR was type Ⅱ(17cases),various types of partial hepatectomy with SR was type Ⅲ and type IV.Right lobectomy with right caudate lobectomy was indicated in type Ⅲ(6cases),left lobectomy with complete caudate lobectomy in type Ⅲb(15cases),right loobectomy with complete caudate lobectomy(3 cases),left lobectomy with complete caudate lobectomy(9 cases) and quadrate lobectomy(2 cases)in type IV.SR and left lobectomy with complete caudate lobectomy was successfully performed in 2 patients(3%) who had undergone palliative biliary resection and cholangiojejunostomy before.Eight patients(12%) had local resecton of the tumor with Roux-en-Y hepaticojejunostomy reconstruction using intrahepatic stents.Two patients(3%) had palliative biliary drainage.Combined portal vein resection was performed in 13 patients(20%) and hepatic artery resection in 27 patients(40%) .Twenty-four atients(36%) had no postoperative complication,23 patients(34%) had minor complications only ,and the remaining 20 patients(30%) had major complications.Of the 20 patients with major complications,14 recovered,the remaining 6 patients died from hepatorenal failure with other organ failures,from myocardial infarction or from intraabdominal or gastrointestianl bleeding 7,12,14,42,57 or 89 days after surgery.The 30-day operative mortality was 4.5%.The mean survival of the patient with curative resecton was 16 months(range 1-32 months);for those undergong palliative resection mean survival was 7 months(range 1-14months).Conlusion Partial hepatectomy with SR for hilar cholangiocarcinoma can be performed with acceptable morbidity and mortality.For curative treatmet of hilar cholangiocarcinoma,caudate lobectomy is always recommended in Bismuth Ⅲ/IV.