腹腔镜胆囊切除术对机体就激反应的影响

目的 研究腹腔镜胆囊切除术对机体应激反应的影响。方法 将70例胆囊炎、胆囊结石患者随机分成腹腔镜胆囊切除组（LC）和开腹胆囊切除组（OC）。术前和术后第1,3,5,7d采集外周静脉血,测定白细胞介素1β（IL-1β）,肿瘤坏死因子α（TNF-α）,白细胞介素6（IL－6）和C－反应蛋白（CRP）。结果 两组手术前后IL－1β和TNF-α均无明显差异（P＞0．05）,两组间手术前后比较也无明显差异（P＞0．05）;两组手术后IL－6第1d升至最高,与术前及术后第3,5,7d比较有高度显著差异（P＜0．01）而术前与术后第3,5,7d比较无显著差异（P＞0．05）,两组之间比较亦无显著差异（P＞0．05）;两组手术后CRP第1,3,5d均较术前有明显升高（P＜0．05）,以术后第1和第3d升高最明显,而两组之间比较无显著差异（P＞0．05）。结论 LC对机体应激反应与OC相比没有明显差异。     

无症状胆囊结石处理的临床研究

目的　探讨无症状胆囊结石的临床处理原则。方法　将健康体检中发现的无临床症状胆囊结石 13 6例 ,前瞻性非随机分为 2组 :(1)预防胆囊切除组 66例 ;(2 )治疗性胆囊切除组 70例。比较两组间术后病理、并发症发生情况及手术难易程度有无差别。结果　两组间术后病理、并发症及手术难易程度均差异有显著 (P <0 .0 5～ 0 .0 2 5 )。结论　对无症状胆囊结石患者 ,应强调有选择地进行预防性胆囊切除 ,而不应一味地等到发生胆石症的一种或数种合并症后才进行手术治疗。     

甘草甜素预防胆囊切除后大肠癌的实验研究

目的　探讨甘草甜素预防胆囊切除后大肠癌的疗效及机制。方法　建立假手术组 (S组 )、胆囊切除后大肠癌模型组 (C组 )和甘草甜素预防组 (GL组 ) ,比较各组大肠癌发病率、大肠组织NF kB活性、p5 3mRNA ,p2 1mRNA及bcl 2mRNA表达水平。结果　C组大肠癌发病率明显高于GL组( P <0 .0 5 )。C组p5 3mRNA ,p2 1mRNA及bcl 2mRNA表达水平明显高于GL组和S组。C组小鼠NF kB活性明显强于GL组和S组。结论　甘草甜素预防胆囊切除后大肠癌的发生可能是通过抑制NF κB的活化 ,从而下调原癌基因bcl 2和p5 3及p2 1等的表达实现的。     

Bariatric and Associated Operations in Private and Academic Practices

Background: The types of bariatric and the associated operations performed by academic and private surgeons were surveyed. Methods: A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery. Results: 46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background. Conclusion: No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.     

Elective Cholecystectomy During Laparoscopic Roux-En-Y Gastric Bypass: Is it Worth the Wait?

Background: Combined gastric bypass and cholecystectomy have been advocated for open bariatric procedures. Our goal was to evaluate the safety of this technique in laparoscopic bariatric surgery patients with gallstones diagnosed preoperatively. Methods: 94 out of 556 consecutive morbidly obese patients (16.9%) underwent laparoscopic gastric bypass with simultaneous cholecystectomy (LGBP/LC) for cholelithiasis. Results: 328 patients (59%) had a concomitant secondary procedure, most commonly cholecystectomy (28.7%). Preoperative BMI was 48.6±6.9 kg/m² for LGBP/LC patients and 48.8±7.3 kg/m² (P=0.85) for LGBP alone. 5 patients had preoperative biliary colic; the others were asymptomatic for cholelithiasis. Postoperatively, at a mean follow-up of 7.6±6.7 months, the percent excess weight loss (%EWL) was 46.1±0.25 for the combined procedure vs 50.2±63.0 (P=0.55) for LGBP alone. There were no conversions to open procedures for the LC. Port placement for the LGBP was not altered for LC. None required intraoperative cholangiography. Operative time for the combined procedure was 293.4±79.8 minutes vs 244.8±77.2 minutes for LGBP alone (P<0.0001). Length of stay for the combined procedure was 4.35±10.8 days vs 2.69±1.8 days for LGBP alone (P=0.0069).There were no postoperative bile leaks or bile duct injuries. Conclusion: Concomitant LGBP/LC is safe and feasible without altering port placement. Combining these procedures significantly increases operative time and nearly doubles the hospital stay.     

Cholecystectomy in Patients with Normal Gallbladder Function Did Not Alter Characteristics in Duodenal Motility Which Was Not Correlated to Size of Bile Acid Pool

Nine gallstone patients with normal gallbladderfunction as assessed by hepatobiliary scintigraphy wereincluded. Fasting and postprandial duodenal motilitywere studied before and one month after an uncomplicated laparoscopic cholecystectomy. An ambulatorycontinuous pressure recording was obtained from 5 PM to8 AM with a sampling frequency of 4 Hz. At 6 PM, thepatients received a 1400-kJ standard meal. The size of the bile acid pool after cholecystectomy wasmeasured according to the dilution principle using[¹⁴C]cholic acid as the marker.Preoperatively the migrating motor complex (MMC) cyclewas 0.48/hr (quartiles 0.42-0.68) compared to 0.68/hr(0.43-0.77) postoperatively. This difference was notsignificant. An increase in the MMC cycle frequency wasobserved postoperatively in three patients, and a decrease was seen in four patients. Themigration velocity was 5.61 cm/min (4.26-8.01)preoperatively and 7.16 cm/min (4.79-9.71)postoperatively, a difference that was not significant.The time period from meal ingestion to appearance of phase IIIwas 297 min (218-431) at the preoperative examinationand 443 min (192-494) at the postoperative examination.This difference was not significant. The size of the bile acid pool after cholecystectomy was3.68 mmol (2.69-8.47) and was not significantlycorrelated to the frequency of the MMC cycle or the timeperiod from food ingestion to phase III activity. It is concluded that in gallstone patients witha normally functioning gallbladder, cholecystectomy doesnot alter duodenal motility, which was not correlated tothe size of the bile acid pool.     

胆囊癌放疗、化疗的进展

目的 总结腹腔镜下处理急性胆囊炎的临床经验。方法 回顾性分析1998年3月～2004年5月58例急性胆囊炎行腹腔镜胆囊切除术(LC)的临床资料：结果58例中经胆囊管造影6例，显示胆总管结石5例，其中2例在LC联合胆道镜下行胆总管切开取石T管引流；其余3例由于胆囊三角关系不清而中转开腹行胆囊切除胆总管切开取石T管引流。单纯胆囊结石52例，50例LC成功，2例因炎症粘连明显而中转开腹。有1例术后发生黄疸，3例术后漏胆汁，均保守治疗后痊愈。结论大多数急性胆囊炎的患者行腹腔镜胆囊切除术是安全的。     

胆囊切除术后复发性胰腺炎的内镜诊治

目的　探讨胆囊切除术后复发性胰腺炎的内镜诊治方法。方法　对 2 1例胆囊切除术后复发性胰腺炎患者行ERCP检查和内镜十二指肠乳头括约肌切开术 (EST )治疗的临床资料进行分析。结果　 2 1例患者经ERCP检查后 19例确诊为Oddi括约肌功能障碍 (SOD) ,2例为胆总管结石 ;2 1例患者经EST治疗后近期疗效均满意 ,无手术并发症发生。结论　ERCP对胆囊切除术后复发性胰腺炎的病因诊断有重要价值 ;EST是治疗胆囊切除术后复发性胰腺炎的安全有效方法。     

胆囊结石合并胆心综合征的外科治疗

目的　 评价胆囊结石合并胆心综合征的外科治疗效果。 方法　 回顾性分析 14 9例胆囊结石术前合并心血管症状和心电图异常者的临床资料。结果　本组胆心综合征发生率为 39.4% ( 14 9/378)。 14 9例均行胆囊切除 ,无严重并发症或手术死亡。术后 3月随访率 82 .6 % ( 12 3/14 9) ,其中10 2例 ( 82 .9% )心电图恢复正常或明显改善 ,自觉症状消失 ;15例 ( 12 .2 % )心电图无明显改变 ,但自觉症状明显减轻。 结论　 胆囊切除术是治疗胆心综合征的根本方法。对无症状胆囊结石合并心血管症状者 ,如患者心功能能耐受手术 ,也应行胆囊切除术     

Suspected Biliary Complications After Laparoscopic and Open Cholecystectomy Leading to Endoscopic Cholangiography A Retrospective Comparison

To study how suspected postoperative biliarycomplications are influenced by surgical technique, wecompared clinical profiles of 63 patients referred forERCP after open (OC) and laparoscopic cholecystectomy (LC) over a four-year period. ERCP was notperformed for postoperative pain alone and only six(9.5%) studies were normal. Referrals after LC wereyounger (mean 39.1 vs 53.6 years, P < 0.001) and ERCP was requested earlier (mean 71.6 vs 2360 days,P < 0.001) in the postoperative course.Choledocholithiasis (CDL) alone, the most commonfinding, was successfully managed with a single ERCP in97.2% of cases. CDL after LC occurred in youngerpatients (35.5 vs 58.9 years, P < 0.01) who presentedearlier (mean 98.6 days vs 5.1 years, P < 0.01),without biliary ductal dilatation (P < 0.01).Although CDL after LC was associated with higher ALT andbilirubin levels than after OC, the difference was notstatistically significant. Cystic duct leaks (LC: sixpatients, OC: four patients) were typically associated with CDL after OC and 90% resolved withendoscopic therapy. Biliary ligation (four cases) wasmanaged successfully with choledochojejunostomy. Weconclude that findings at ERCP for suspected biliaryobstruction or injury after OC or LC are similar andusually can be endoscopically managed. After LC,referrals currently are younger, present much earlier,and retained stones are less likely to be associatedwith ductal dilatation than after OC.