带侧孔T管在胆囊肝总管吻合术中的应用

目的探讨胆囊肝总管吻合术中带侧孔T管的应用价值。方法回顾性分析2009年7月至2012年7月期间笔者所在医院60例胆囊肝总管吻合术患者的临床资料,比较常规T管与带侧孔T管患者术后的胆囊大小、收缩功能及黏膜恢复情况。结果24例胆囊肝总管吻合术中使用常规T管,术后6-8周行经T管胆道造影,见胆囊均不显影,17例胆囊黏膜色泽正常,无明显水肿;6例胆囊黏膜充血水肿;1例胆囊正常黏膜结构消失。36例使用带侧孔T管,术后6-8周造影见胆囊均显影,胆囊黏膜无水肿、糜烂,胆囊收缩功能均正常。结论胆囊肝总管成形术中使用带侧孔T管,术后胆囊内絮状物、血凝块及炎症物质可通过T管排泄入肠道或引流出体外,胆汁可经T管进入胆囊内进行浓缩。使用带侧孔T管术后即可恢复胆汁的生理流向,从而能促进胆囊功能的早期恢复。     

Omental wrapping of esophageal rupture in combination with T-tube drainage

Esophageal rupture is a potentially fatal condition. Rapid and correct diagnosis and urgent surgical treatment are mandatory. Various surgical treatment methods have been reported. We introduced a new surgical procedure for treatment of spontaneous esophageal rupture. Upon thoracotomy continuing to laparotomy, a T-tube was inserted into the esophageal lumen through the ruptured site. The ruptured esophageal wall was sutured interruptedly, and the insertion site was covered with the pedicle omental flap. The T-tube was replaced by a thinner catheter tube from postoperative day (POD) 45 and finally withdrawn on POD 66. The patient was discharged in good condition on POD 98. The procedure described here is safe and effective. It is applicable for patients restricted to minimally invasive surgery, those with poor general condition and severely infectious contamination but without a widely necrotic esophageal wall around the ruptured site.     

Electrosonic ejector microarray for drug and gene delivery

We report on development and experimental characterization of a novel cell manipulation device—the electrosonic ejector microarray—which establishes a pathway for drug and/or gene delivery with control of biophysical action on the length scale of an individual cell. The device comprises a piezoelectric transducer for ultrasound wave generation, a reservoir for storing the sample mixture and a set of acoustic horn structures that form a nozzle array for focused application of mechanical energy. The nozzles are micromachined in silicon or plastic using simple and economical batch fabrication processes. When the device is driven at a particular resonant frequency of the acoustic horn structures, the sample mixture of cells and desired transfection agents/molecules suspended in culture medium is ejected from orifices located at the nozzle tips. During sample ejection, focused mechanical forces (pressure and shear) are generated on a microsecond time scale (dictated by nozzle size/geometry and ejection velocity) resulting in identical “active” microenvironments for each ejected cell. This process enables a number of cellular bioeffects, from uptake of small molecules and gene delivery/transfection to cell lysis. Specifically, we demonstrate successful calcein uptake and transfection of DNA plasmid encoding green fluorescent protein (GFP) into human malignant glioma cells (cell line LN443) using electrosonic microarrays with 36, 45 and 50 μm diameter nozzle orifices and operating at ultrasound frequencies between 0.91 and 0.98 MHz. Our results suggest that efficacy and the extent of bioeffects are mainly controlled by nozzle orifice size and the localized intensity of the applied acoustic field.     

The postoperative choledochoscopy in the management of the residual hepatolithiasis involving the caudate lobe: A retrospective study

To reveal the role of the postoperative choledochoscopy in treating the residual calculi in the caudate lobe (CL) of the liver.We recruited 66 patients with T-tube/percutaneous transhepatic cholangioscopy tract who still had residual gallstones in the CL at least 6 weeks after the operation. Imaging examinations determined the gallstones’ locations in the patients, and all of them underwent the postoperative choledochoscopic examination through the T-tube/percutaneous transhepatic cholangioscopy tract for therapeutic intervention.Among the 66 patients, the residual gallstones were mostly located in the Spiegel lobe (48/66, 72.7%), and the residual gallstones that located in the origin of the CL bile branches were successfully determined in the 57 patients (57/66, 86.4%), the remaining 9 patients were unclear because the proximal ducts were severely narrow or even atresia. The mean frequency of the postoperative choledochoscopy was 3.6 (range, 1–10) times. There were 9 patients with complications, and no mortality occurred. In the origin-proved 57 patients, 6 patients failed to remove the gallstones altogether, and the final residual gallstone clearance rate was 77.3% (51/66). There was no significant difference between the Spiegel lobe and the other parts of the CL in determining the bile duct''s origins, gallstone clearance rate, and complications. However, the frequency of choledochoscopy in the other parts of the CL was more than in the Spiegel lobe.The postoperative choledochoscopy, an essential method for treating the residual gallstones in the CL, commands high efficiency for calculi extraction and fewer complications. The main reasons for failing to remove the residual gallstones are that the bile duct''s origins could not be determined, and the distal bile ducts are atretic in the CL.     

经胆囊管胆道引流在肝移植胆道重建中的临床应用价值Meta分析

[摘要] 目的 评价经胆囊管胆道引流（transcytic bile drainage,TBD）对肝移植术后胆道并发症的预防作用。方法 计算机检索PubMed、EMbase、sinoMed、Web of Science、the Cochrane Central Register of Controlled Trials（CENTRAL）、万方数据库、中国知网以及维普数据库等。查找并筛选出所有比较经胆囊管胆道引流（transcytic bile drainage,TBD）与T管引流（T-tube,T-T）或non-TBD对肝移植术后胆道并发症影响的随机对照试验（randomized controlled trial,RCT）,同时手动检测纳入文献的参考文献,检索时间均为建库至2017年2月28日。主要结局指标：胆道并发症总的发生率、胆道狭窄、胆漏以及拔管相关性胆漏。按纳入、排除标准由2位评价者独立进行RCT的筛选、资料提取和质量评价后,采用RevMan（5.30版） 软件进行Meta分析,并采用GRADE pro3.6软件进行证据质量评价。结果 共纳入文献6篇,其中TBD与T管引流（T-T）对照研究3篇,TBD与胆管直接吻合（primary closure）对照研究文献1篇,TBD、T-T与直接吻合三者对照研究2篇。纳入病例542例,其中TBD组347例,T-T组102例,non-TBD组133例。Meta分析结果显示：与T-T组相比,TBD虽然不能降低胆道并发症总的发生率和总的胆漏发生率（7.3% vs 10.8%,RR=1.27,95% CI =0.50～1.16, P =0.21;23.9% vs 30.4%,RR=1.03,95% CI =0.30～1.45, P =0.30）,但是能显著降低肝移植术后胆道狭窄和拔管后胆漏的发生率（14.3% vs 30.2%,RR=3.37,95% CI =0.33～0.75, P =0.0008;1.7% vs 18.8%,RR=2.48,95% CI =0.05～0.70, P =0.01）。与胆管直接吻合相比,TBD能降低肝移植术后胆道并发症总的发生率以及胆道狭窄的发生率,但差异没有统计学意义（25.8% vs 39.2%,RR=0.29,95% CI =0.58～1.50, P =0.77;14.0% vs 19.2%,RR=0.61,95%CI=0.54～3.24, P =0.54）,并且不会明显增加胆漏的发生率（17.4% vs 15.8%,RR=0.47,95% CI =0.47～1.59, P =0.64）。结论 在肝移植术后胆道并发症的预防上,TBD与胆管直接吻合相当,优于T管引流。因此,TBD在肝移植胆管重建中是可行的,并且具有一定的临床价值。     

胆道镜经胆囊管胆道取石术的临床应用研究

目的观察经胆囊管胆道取石术治疗胆总管结石的效果。方法通过回顾性分析方法对郫县人民医院2005年至2010年行胆囊管胆道取石术与同期行开腹T管引流术的患者120例,通过比较手术时间、术中出血、术后止痛次数、肠蠕动恢复时间、一次性结石清除率以及发症发生例数,评价治疗效果。结果与开腹T管引流术相比,胆囊管胆道取石术所用时间、术中出血、术后镇痛次数、胃肠道恢复时间以及住院时间均低于前者(P<0.05),同时胆囊管胆道取石术发生胆管结石术后并发症也较OCHTD组少(P<0.05)。而两种手术对胆总管结石的一次性清除率无明显差异(P>0.05)。结论胆囊管胆道取石术术式微创,临床效果好,能取代大部分开腹胆总管探查术,值得进一步推广。     

经T管造影螺旋CT胆道成像的临床价值

目的探讨经T管造影螺旋CT胆道成像(spiral CT cholangiography,SCTC)的技术应用及临床价值。方法40例胆道手术患者术后2周经T管注入25%泛影葡胺50 ml行常规胆道造影检查摄片;隔日螺旋CT进行平扫,然后注入5%泛影葡胺50 ml,进行螺旋CT胆道造影,三维重建方法用最大信号强度投影和表面阴影显示法。结果SCTC在显示Ⅲ,Ⅳ级肝管,肝管汇合情况,发现肝内外胆管残石方面均优于T管常规造影(P<0.05)和B超(P<0.05),在发现胆道残石方面与胆道镜检查结果相当,两者差异无统计学意义(P>0.05)。结论经T管造影螺旋CT胆道成像结合常规CT断层像可同时观察胆道内外病变,弥补单纯胆道造影不足。螺旋CT胆道三维成像显示肝内和肝门部胆管立体构像及细节,为外科临床工作提供了实时放射解剖学资料。     

经T管窦道输尿管镜气压弹道碎石治疗胆管残余结石67例分析

目的探讨经T管窦道输尿管镜气压弹道碎石治疗胆管残余结石的可行性和临床实用价值。方法回顾分析应用输尿管镜气压弹道碎石术经T管窦道治疗胆管残余结石67例患者的临床资料。结果 67例中3例因T管窦道条件不适合输尿管镜气压弹道碎石术治疗失败;另外64例中61例完全取净结石,结石取净率95.3%,3例结石残留,均无胆管炎、胆漏、胆道大出血、胆管及十二指肠损伤等并发症发生。结论输尿管镜气压弹道碎石术经T管窦道治疗胆管残余结石是一种操作简单、快捷、安全、临床效果良好的方法,具有实用性及可推广性。