核素肝胆动态显像对胆囊结石患者胆囊运动功能的研究

为了探求胆囊结石患者胆囊运动功能的状况，用(99m)锝一二乙基乙酸苯氨基亚氨二醋酸（(99m)Tc-EHIDA）为肝胆显像剂，以脂肪餐为胆囊收缩刺激剂，通过单光子计算机断层（SPECT）装置及计算机系统定量地研究了12例正常受试者和12例胆囊结石患者的胆囊运动情况。结果表明；潜伏期和排胆期在两组间无显著性差异（P＞0．05），而胆囊结石患者的排胆分数和排胆率明显低于正常对照组（P＜O．01）。说明胆囊结石患者的胆囊运动功能是降低的。     

A report card on outcomes for surgically treated gastrointestinal cancers: are we improving?

INTRODUCTION: Longitudinal analyses of cancer registries provide an opportunity for population-based explanations of epidemiology and survival-related outcomes. This study used two population-based data sets to report on nine surgery-related cancers over the past three decades. MATERIALS AND METHODS: Using the SEER cancer database (1973-1999), all patients (>18 years old) with adenocarcinoma of esophagus, gastric, biliary system, pancreas, small bowel, colon, rectum; esophageal squamous cell carcinoma (ESC), or hepatocellular (HCC) carcinoma (n = 379,640) were analyzed. Changes in incidence rates, stage at diagnosis, and 5-year cancer and stage-specific survivals were determined. A separate database, the California inpatient database (1990-2000), was concurrently used to evaluate inpatient mortality after surgical resection (n = 34,057). RESULTS: Incidence rates increased for three cancers (esophageal, HCC, small bowel); decreased for three (rectal, gastric, ESC); and stayed constant for three (biliary, pancreatic, colon). More patients presented with local/regional disease in the 1990s versus 1970s for eight tumors (except small bowel, P < 0.05). Five-year overall survival improved for all but small bowel (P < 0.05); and local stage survival was improved for all except small bowel and biliary (P < 0.05). Finally, inpatient mortality rates improved significantly for liver, esophageal, pancreatic, and gastric resections (P < 0.05) over the past decade. CONCLUSIONS: For these nine surgically treated cancers, we are detecting disease at earlier and therefore more treatable stages, and surgical care and outcomes also appear to have improved. Continued reexamination of longitudinal trends of surgically relevant outcomes is important for future improvement of surgical care.     

The Complexities of Hepatic Drug Transport: Current Knowledge and Emerging Concepts

Recently, hepatic transport processes have been recognized as important determinants of drug disposition. Therefore, it is not surprising that characterization of the hepatic transport and biliary excretion properties of potential drug candidates is an important part of the drug development process. Such information also is useful in understanding alterations in the hepatobiliary disposition of compounds due to drug interactions or disease states. Basolateral transport systems are responsible for translocating molecules across the sinusoidal membrane, whereas active canalicular transport systems are responsible for the biliary excretion of drugs and metabolites. Several transport proteins involved in basolateral transport have been identified including the Na(+)-taurocholate co-transporting polypeptide [NTCP (SLC10A1)], organic anion transporting polypeptides [OATPs (SLCO family)], multidrug resistance-associated proteins [MRPs (ABCC family)], and organic anion and cation transporters [OATs, OCTs (SLC22A family)]. Canalicular transport is mediated predominantly via P-glycoprotein (ABCB1), MRP2 (ABCC2), the bile salt export pump [BSEP (ABCB11)], and the breast cancer resistance protein [BCRP (ABCG2)]. This review summarizes current knowledge regarding these hepatic basolateral and apical transport proteins in terms of substrate specificity, regulation by nuclear hormone receptors and intracellular signaling pathways, genetic differences, and role in drug interactions. Transport knockout models and other systems available for hepatobiliary transport studies also are discussed. This overview of hepatobiliary drug transport summarizes knowledge to date in this rapidly growing field and emphasizes the importance of understanding these fundamental processes in hepatic drug disposition.     

肝囊腺癌的细针吸取细胞学诊断及文献复习

目的 探讨肝内胆管囊腺癌的穿刺方法 ,结合文献复习并总结其术前细胞学诊断特点.方法 2例肝脏囊实性占位患者在B超引导下行细针吸取细胞学(fine needle aspiration cytology,FNAC)检查,抽取囊液离心涂片,实质区吸取组织颗粒涂片,常规HE染色,部分吸取组织制作细胞蜡块,切片行HE染色及黏液AB染色,光镜观察,并与术后组织切片对照.结果 2例患者均未出现出血、感染等并发症,两者均抽出多量淡咖啡色及淡黄色黏稠液体,囊液未找到肿瘤细胞;实质区穿刺涂片细胞丰富,上皮细胞形成团状或乳头状,核大深染、重叠拥挤.可见细胞异型.细胞蜡块切片可见腺管状、乳头状、团状的腺上皮,细胞排列杂乱无极性,AB染色显示背景及胞质内淡蓝色黏液的存在.结合影像学及临床资料.2例FNAC诊断考虑为胆管黏液性囊腺癌(例1结合细胞蜡块切片考虑黏液性乳头状囊腺癌).穿刺诊断与术后组织切片基本一致.结论 结合影像学及临床资料,B超引导下的肝脏FNAC是术前诊断肝囊腺癌的一种安全有效的检查方法 ,制作细胞蜡块有利于诊断的进一步完善.有关肝囊腺癌与囊腺瘤的FNAC的鉴别有待进一步积累资料.     

Preliminary study of the anatomy of the venous drainage of the intrahepatic and extrahepatic bile ducts and its relevance to the practice of hepatobiliary surgery

Background : Although there have been many studies of the arterial supply of the biliary system, attempts to study the corresponding venous drainage have been few and all have been incomplete. The purpose of the present investigation is to describe the anatomy of the venous drainage of both the intrahepatic and extrahepatic bile ducts and to determine its relevance to hepatobiliary surgery. Methods : The intrahepatic and extrahepatic venous drainage of the bile ducts was investigated in seven specimens by injecting a solution of 10% gelatin coloured with Alcian blue into the portal vein or the superior mesenteric vein to outline the venous drainage. The specimens were dissected under loop magnification and representative drawings were obtained. Results : The surface of the intrahepatic and extrahepatic bile ducts was covered by a fine venous plexus. On the surface of the supraduodenal common hepatic duct and common bile duct the venous plexus drained laterally into marginal veins, usually two in number and known as the 3 o’clock and 9 o’clock marginal veins. Inferiorly the marginal veins and the venous plexus communicated with the pancreaticoduodenal venous plexus, which in its turn drained into the posterosuperior pancreaticoduodenal vein, a branch of the superior mesenteric vein. Superiorly the marginal veins divided into a number of branches. Some branches followed the left and right hepatic ducts into the liver, communicating with the venous plexus and the adjacent branches of the portal vein. Other branches of variable size entered either segment IV or the caudate lobe or process via the hilar venous plexus. A most important finding was that even after dividing the bile duct and all communicating veins at the upper border of the duodenum, the venous plexus and the marginal veins filled normally to the level of transection. This occurred almost certainly by retrograde filling from above. Conclusion : The satisfactory results of end‐to‐end anastomosis in whole liver transplantation depends partly on the presence of adequate venous drainage. This has been amply demonstrated by the injection studies. This would indicate that the poor results of end‐to‐end repair of the bile duct after surgical trauma results from other factors such as poor technique, devascularization of the cut ends due to trauma, and carrying out the anastomosis under tension. After resection of the hilum for cholangiocarcinoma the venous drainage of the left and right hepatic ducts and their branches depends mainly on the communications between the venous plexus on the ducts and the adjacent branches of the portal vein, even at a lobular or sinusoidal level. The satisfactory results obtained after anastomosis of the left and right hepatic ducts or their branches to a Roux loop of jejunum attest to this. This applies also to the transplantation of segments II and III in paediatric patients from related adult donors and in patients receiving split liver transplants. Finally, the venous drainage at the bifurcation of the common hepatic duct has been shown to enter the caudate lobe and segment IV directly. This suggests that a hilar cholangiocarcinoma may metastasize to these segments, and perhaps partly explain the significantly better long‐term results when the caudate lobe and segment IV are resected en bloc with the cholangiocarcinoma as part of modern radical surgery for this condition.     

Alkaline Phosphatase: Diagnostic Value of Isoenzyme Determination

Abstract. The isoenzyme pattern of the alkaline phosphatases was determined in the sera of 51 normal subjects, 28 patients with hepatobiliary diseases and 17 patients with bone diseases. Two quick and technically simple methods of differentiation were used for a semiquantitative determination: stereospecific sensitivity to L-phenylalanine, especially of the small intestine phosphatase, and the separation of the bone and liver/biliary tract phosphatases by a combination of heat inactivation and stereo-specific inhibition. The basic principles of these methods are described. The results, statistically evaluated, are discussed. The alkaline phosphatase activity in the serum of healthy adults stems from isoenzymes of the small intestine (about 20%), of bone and of hepatobiliary origin. In hepatobiliary diseases the proportion of bone to liver/biliary tract phosphatases changes significantly in favour of the latter. In diseases of the skeleton, however, which are accompanied by increased activity of serum alkaline phosphatase, there is a significant increase in the absolute fraction of bone phosphatase in the total activity. In addition to the demonstration of these qualitative and quantitative changes in the isoenzyme distribution patterns, limiting values were determined for a normal group; values outside these can be considered as pathognomonic for diseases of the liver and biliary tract and the skeleton respectively. Of particular importance for early diagnosis is the fact that changes in the isoenzyme distribution pattern are demonstrable not only when the total activity is increased, but at a time when the serum activity lies still within normal limits. The methods used are suitable for a rapid and reproducible semiquantitative determination of the isoenzymes of alkaline phosphatase, and for early differential diagnosis of diseases of the skeleton (especially metastatic tumours), the liver and biliary tract.     

急性胰腺炎行全肠外营养所致肝胆并发症的临床观察（附17例分析）

目的：了解急性胰腺炎全肠外营养支持包致肝胆并发症的发生情况。方法：对我院1995年1月－2000年12月收治的符合纳入标准的17例急性胰腺炎，进行血清酶（GGT、ALP、ALT、AST），胆红素（TB、DB）、白蛋白（Alb)的动态定量分析，B型超声的动态定性分析，以及并发症（黄疸、感染等）和预后的观察。结果：17例患者中血清酶分别在发病初期和疾病后期出现两次高峰期，血清胆红素水平有随病情进展而降低的趋势，血清白蛋白则先降低后随病情好转而恢复正常，17例患者中发生胆汁淤积7例，感染4例，无肉眼黄疸及死亡发生。结论：急性胰腺炎本身可以在早期引起肝功能损害，随病情好转而恢复；但当急性胰腺炎病期延长，全肠外营养支持所致肝胆并发症的发生则不容忽视，急需早期预防和诊治，提倡尽可能早期行肠内营养支持。     

肝胆外科进修医师带教体会

肝胆外科进修医师的教学属于继续教育的范畴。在教学工作中,采用"以人为本"的进修教学计划,进行医院优良传统教育,构建自主和谐的进修学习氛围,采用PBL教学方法,运用丰富生动的多媒体课件,适度增加手术和操作实践,达到了满意的教学效果。     

输注白蛋白在肝胆疾病术后的临床价值分析

目的:分析肝胆疾病术后患者输注白蛋白的临床价值。方法:使用前瞻性随机对照方法,将102例肝胆疾病术后早期的低白蛋白血症的患者随机分配到白蛋白组52例和生理盐水组50例,观察患者术后低白蛋白血症的发展、营养状态、术后液体平衡情况、术后并发症及住院天数。结果:不管有无输注白蛋白,肝胆疾病术后患者白蛋白水平均显著下降,两组的血浆白蛋白浓度下降幅度、营养指标、预后等均无显著性差异(P<0.05)。结论:对肝胆疾病术后早期低白蛋白血症,输注白蛋白并无临床价值。