医源性胆管损伤修复要点和修复后再狭窄治疗

胆管损伤（BDI）的发生率随着腹腔镜胆囊切除术例数的增多而上升,已成为肝胆外科常见的并发症。外科手术仍是治疗BDI的主要方法。对于BDI的外科处理应由经验丰富的高年资肝胆外科医生完成。BDI修复后再狭窄的发生率较高,需要随诊观察及时发现,并应由包括介入、内镜、肝胆外科、胃肠外科的多学科综合治疗协作组进行诊断、治疗。可选择介入、内镜、外科手术合适的治疗方法联合治疗,肝切除和肝移植对部分病人适用,并可获得良好的疗效。     

胆囊功能的再认识

胆囊的主要功能是浓缩和储存胆汁,由于胆囊结石等疾病的高发病率,腹腔镜胆囊切除术已成为治疗有症状的胆囊的金标准,但其无法保留胆囊功能,术后也可能导致慢性腹泻及近端结肠癌、 胰腺癌、 肝细胞癌、 食管腺癌发生率升高等问题。 保胆取石从保留胆囊功能的角度治疗胆囊结石,在理论上具有合理性,但需大量更高级别的临床证据来验证其可行性,须用循证医学的证据来验证其优缺点与适应证,既不赞成遇到胆囊疾病就切除胆囊,也不赞成盲目地强调保胆。     

肝干细胞与肝癌关系的研究进展

肝癌起源于成熟肝细胞去分化或肝干细胞成熟受阻一直存在争议。肝干细胞存在于成年肝脏Hering管或胚肝,肝干细胞的增值与慢性肝炎的严重程度密切相关。肝癌与肝干细胞有许多相似的特征。如无限增值能力、分化能力、表达相同的蛋白和相似的信号通路等。越来越多的实验结果支持肝癌起源于干细胞的观点。     

努力提高肝门部胆管癌的手术治疗效果

肝门部胆管癌(hilar cholangiocarcinoma)是胆道常见的恶性肿瘤。自1965年K latskin首先系统地报道13例后,肝门部胆管癌才开始被临床医生所认识。手术切除是唯一有希望治愈该病的方法。但由于肿瘤解剖部位的特殊性,手术切除率和治愈率低。因此,目前仍被认为是最难治疗的恶性肿瘤之一。在过去的40年中,随着影像学和肝脏外科的发展,肝门部胆管癌的诊断和治疗尤其是在手术切除率、手术死亡率以及长期生存率等方面都取得了较大的进步。然而,国内治疗肝门部胆管癌的效果与国外相比仍有较大的差距,肝门部胆管癌的治疗尚未规范化,目前仍然面临许多…     

可疑胆囊癌的术前处理

胆囊癌是胆道系统最常见的恶性肿瘤,其发病隐匿,临床症状缺乏特异性,早期常被并存的胆囊结石、胆囊息肉、慢性胆囊炎等症状所掩盖,发现时大部分患者已属中晚期,手术切除率低.加上胆囊癌高度恶性的生物学行为,对放、化疗不敏感,预后极差,患者总体5年生存率＜5%;若患者能接受R0根治性切除术,5年生存率可提高至21%～69%[1].因此,对可疑胆囊癌患者完善相关检查,及早诊断和行根治性切除术是目前治愈胆囊癌的惟一方法.     

DNA甲基转移酶在肝癌中的表达及其临床意义

Objective To investigate the expression of DNA methyltransferases (DNMTs) in liver cancer and its clinical significance. Methods The specimens of liver cancer tissues, adjacent tissues, cirrhotic tissues and chronic hepatitis tissues were collected from 50 patients who received radical resection at the First Affiliated Hospital of Sun Yat-Sen University from July 2007 to April 2008. The mRNA and protein expressions of DNMT1,DNMT3a and DNMT3b in liver cancer tissues, adjacent tissues, cirrhotic tissues and chronic hepatitis tissues were detected by real-time quantitative PCR and immunohistochemical staining. The mRNA expression of DNMTs in the liver cancer tissues was compared with those in the adjacent tissues, cirrhotic tissues and chronic hepatitis tissues by using t test and Mann-Whitney U test. The correlation between the protein expression of DNMTs in the liver cancer tissue and the clinicopathological features was analyzed by chi-square test or Fisher exact test, and the tumor-free survival time was analyzed by using Kaplan-Meier method and the difference in tumor-free survival rate between different patients was analyzed by Log-rank test. Results The mRNA expressions of DNMT1, DNMT3a and DNMT3b in the liver cancer tissue were 2.57, 2.29 and 4.86 times higher than those in the adjacent tissues (t = 3.94, 2. 72, 4. 06, P ＜ 0.05 ). The mRNA expressions of DNMT1, DNMT3a and DNMT3b were 2.38,2.14 and 4.66 times higher than those in the cirrhotic tissues, and 6.12, 4.58 and 12.99 times higher than those in the chronic hepatitis tissues. The mRNA expressions of DNMT1, DNMT3a and DNMT3b in the liver cancer tissue were significantly higher than those in the cirrhotic tissues and chronic hepatitis tissues ( U = 587.5,730. 0,562.5; 65.5, 64.5, 71.0, P ＜ 0.05). The protein expression of DNMT1 was correlated with the size, number,TNM stages and vascular invasion of tumors ( x2 = 4.08, 5.95, 4.08, P ＜ 0.05 ). The protein expression of DNMT3a was correlated with the size, number and TNM stages of tumors (x2 = 4.08, 5.95, 4.08, P ＜ 0.05 ).The mean tumor recurrence time of patients with low expressions of DNMT1 and DNMT3a were 9.4 and 8.7 months, which were significantly longer than 5.0 and 3.2 months of those with high expressions of DNMT1 and DNMT3a (x2 =3.89, 9.91, P＜0.05). Conclusions DNMTs play an important role in hepatocarcinogenesis.High expressions of DNMT1 and DNMT3a are correlated with the postoperative recurrence of liver cancer, which are valuable prognostic factors for liver cancer.     

肝切除术治疗肝内胆管结石术后发生并发症的危险因素分析

目的 探讨肝切除治疗肝内胆管结石术后并发症的危险因素.方法 对中山大学附属第一医院近4年来择期行肝切除术的肝内胆管结石363例病人的临床资料进行回顾性分析.根据术后是否发生并发症分成两组,A组为并发症组(n=110);B组为无并发症组(n=253).对可能引起并发症的因素进行单因素和多因素统计分析.结果 本组因并发症病死2例,手术病死率为0.6%.110例病人术后出现并发症,发生率为30.3%.术后并发症包括:伤口感染/液化42例(11.6%)、胸腔积液41例(11.3%)、膈下积液36例(9.9%)、胆漏21例(5.8%)、腹腔积液/感染13例(3.6%)、消化道出血3例(0.8%)、胆道出血2例(0.6%)、肝功能衰竭1例(0.3%).多因素分析结果 显示,既往胆道手术史(P=0.042,OR=0.617,95%CI:0.388～0.982)和手术时间(P=0.0001,OR=0.994,95%CI:0.991～0.997)是术后发生并发症的独立危险因素.结论 既往胆道手术史与手术时间的长短是影响肝内胆管结石肝切除术后并发症发生的独立危险因素.对既往有胆道手术史的病人充分的术前准备,提高手术技巧,仔细分离,尽量缩短手术时间是防止肝切除术后出现并发症的关键因素.     

前入路右半肝切除术与传统右半肝切除术治疗大肝癌的对比观察

Objective To compare the outcomes between anterior versus conventional approach right hepatectomy for large hepatocellutar carcinoma(HCC).Methods A total of 188 consecutive patients with large HCC(≥5 cm)undergoing right hepatectomy were reviewed retrospectively.Among them,92patients received anterior approach right hepatectomy(anterior group)while the other conventional right hepatectomy(conventional group).Their clinicopathologic data and survivals were compared.Results There were five surgical deaths(2.7%),two in the anterior group and three in the conventional group.The biochemical and tumor pathological data(except for tumor size) of these two groups were comparable.The mean intranperative blood loss,the number of patients with massive hemorrhage(＞3000ml)and the volume of blood transfusion of the anterior group were markedly less than those of conventional group.The 1-,3-year disease-free survival rates of the anterior group were significantly better than those of the conventional group anterior group were also markedly higher than those of conventional group.The Cox regression model indicated that tumor size[P=0.014,odd ratio(OD):1.074] and surgical procedure(P:0.009,OD=0.468) were independent risk factors correlated with disease-free survival.And the surgical procedure(P=0.003,OD=0.369) was the only independent risk factor for postoperative cumulative survival.Conclusion Anterior approach right hepatectomy can significantly decrease intraoperative blood loss.The postoperative survivals of large HCC patients are significantly improved by anterior approach right hepatectomy.     

复杂性肝切除的术前评估与决策

复杂性肝切除需要严格掌握手术的适应证和禁忌证。术前应对病人的全身情况、手术的危险性、肝脏的代偿能力作出准确的估计。除了常规的肝功能检查以外,目前估计肝脏功能的常用方法包括（CTP）评分、终末期肝病模式评分系统（MELD）、吲哚青绿15min残留率（ICG R 15）、糖耐量曲线（OGTT）等,在亚洲地区以ICG R15较为准确实用。此外,近年影像学3D图像及体积测量软件的发展使得术前计算残留肝体积（FRLV）成为可能。如果肝硬化病人的ICG R15<10,FRLV>50％应该是安全的。在减少肝切除出血的技术中,尽管有不少新的器械,但钳夹法断肝仍然是值得应用的方法。最近出现的射频消融器Habib 4×可能使断肝过程中出血进一步减少。     

医源性胆管损伤的现状和展望

医源性胆管损伤是腹部手术尤其是胆囊切除术后的严重并发症,目前发生率有上升的趋势。但是,对胆管损伤的病因、诊断还有不少容易忽视的情况,造成认识和诊断的困难,对胆管损伤的分类目前尚未统一。医源性胆管损伤重在预防,其中最重要的预防是临床医生重视和熟悉解剖,一旦发生损伤,如由有经验的胆道外科专科医生处理,有可能获得较好的治疗效果。合并血管损伤特别是右肝动脉的损伤应引起临床的重视。