胆肠内引流治疗肝内胆管结石的探讨

外科治疗１８１例肝内胆管结石，结果表明，胆肠Ｒｏｕｘ－ｅｎ－Ｙ内引流有排石不净、引流局限、返流及吻合口狭窄等问题，再手术率相对较高，临床不宜滥用，应严格掌握手术适应证，而无肝门胆管狭窄的高位切开取石加单纯外加流治疗，不仅手术创伤小，维护了胆汁的正常生理排泄通道，而且术后并发症少，再手术率低，要后辅以胆道反复多次取石及胆道冲洗，结石取尽率可达９８％。     

Enhanced vasoconstrictor response of the isolated perfused cirrhotic rat liver to humoral vasoconstrictor substances found in portal venous blood

Humoral vasoconstrictor factors in portal venous blood have an important influence on hepatic vascular tone. The aim of this study was to determine whether there is altered reactivity of the intrahepatic portal vascular bed of cirrhotic livers to such factors. Isolated perfused rat liver preparations (IPRLP) obtained from rats with carbon tetrachloride-induced cirrhosis and from normal controls were treated with small aliquots of fresh, heparinized venous blood (4% vol/vol) added to a synthetic perfusate composed of 2.5% bovine serum albumin in Krebs-Henseleit buffer. Compared with blood from the inferior vena cava, portal venous blood produced a greater increase in perfusion resistance of normal IPRLP (2.8 +/- 0.7 vs 15 +/- 3%, P less than 0.05). There was no significant difference in the response of normal IPRLP to portal venous blood obtained from cirrhotic animals compared with portal blood from normal controls (10 +/- 4 vs 15 +/- 3%). However, cirrhotic IPRLP were significantly (P less than 0.05) more responsive to portal venous blood than were control livers, regardless of whether the blood was obtained from control (28 +/- 6%) or cirrhotic (24 +/- 6%) rats. The response of both control and cirrhotic IPRLP to portal blood could be partially inhibited by the alpha-adrenoceptor antagonist phentolamine (5 x 10(-6) mol/L) and cirrhotic IPRLP were more responsive than controls to exogenous noradrenaline (518 +/- 27 vs 363 +/- 21%, P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

肝内胆管结石治疗模式的探讨

目的 探讨多路微创技术治疗肝内胆管结石的疗效。方法 回顾性分析单纯手术（A组）与多路微创技术（B组）两种治疗模式治疗肝内胆管结石的疗效。结果 B组病人在术后恢复，残余结石方面均优于A组。结论 多路微创技术治疗肝内胆管结石具有手术创伤小，取石率高，残余结石率低的优点。值得推广。     

胆道消石汤治疗肝内胆管结石15例疗效观察

作者自拟胆道消石汤治疗15例肝内胆管结石有效10例,无效5例。与对照组14例使用天津胆道排石汤对比,两组有效率有显著差异。提示自拟胆道消石汤在临床上有进一步应用和研究的价值。本文还就肝内结石的中医病名提出讨论。     

Intrahepatic peribiliary glands of humans. I. Anatomy, development and presumed functions

Abstract The intrahepatic biliary tree is regarded as an excretory duct of two secretory units: hepatocytes and intrahepatic peribiliary glands. This review describes the anatomy, development and presumed functions of the latter. These glands are preferentially located around the intrahepatic large bile ducts, and are histologically divided into intramural and extramural structures. The former consist of simple tubular glands with much mucin, and are sparsely and irregularly distributed within the ductal wall. The latter are characterized by the presence of excretory units that consist of seromucinous acini and a conducting system in the periductal tissue. Pancreatic exocrine acini are occasionally admixed with extramural glands. These peribiliary glands appear in the late fetal period and complete their development about 15 years after birth. Extramural and intramural glands secrete neutral and acid mucin into the ductal lumen. Extramural glands contain several enzymes for digestion of protein and lipids. Neural and vascular supply of these glands may be related to the regulation of their secretion. Specific and non-specific immune responses within this glandular system may also be essential in the sterility of bile.     

Benign Strictures of the Intrahepatic Bile Ducts Managed with Percutaneous Transhepatic Cholangioscopy: A Case Report

Benign strictures of the intrahepatic bile ducts were detected, by percutaneous transhepatic cholangioscopy combined with forceps biopsies, in a patient who presented symptoms suggesting cholangitis. The patient was successfully treated by non-operative stricture dilation techniques, with the aid of cholangioscopy. In this paper, the usefulness of percutaneous transhepatic cholangioscopy for the management of benign biliary strictures is discussed.     

Morphological and immunohistochemical assessment of intrahepatic bile duct development in the rat

The hypotheses that intrahepatic bile ducts are derived either by a transformation of periportal liver cells or by dichotomous branching of the extrahepatic bile ducts were investigated in fetal and postnatal rat livers by histological and immunohistochemical methods using an antiserum to prekeratin which, in the liver, binds to biliary epithelial cells (BEC). In conventionally stained sections, bile duct development was observed to begin in the 19 day fetus around the larger branches of the portal vein, with the formation of lumina surrounded by cuboidal or elongated hepatoblast-like cells on the portal aspect and readily distinguished hepatoblasts on the lobular aspect. At 21 days, these structures had developed into canals of Hering lined jointly by recognizable liver cells and BEC. The number of canals of Hering per portal tract peaked at 22 days' gestation and diminished in number at birth and over the ensuing 56 h, with a concomitant increase in fully formed ducts. Bile ducts lined completely by BEC were first found at 20 days. Immunohistochemically, prekeratin antigens were first detected at 20 days in duct-like structures not only in phenotypic BEC but also in adjacent cells with an hepatoblast phenotype. Such intermediate cells were present until birth. These findings support the view that intrahepatic bile ducts develop by a reorganization and modulation of the periportal hepatoblasts to BEC.     

LAPAROSCOPIC EXPLORATION OF INTRA- AND EXTRAHEPATIC BILE DUCTS AND T-TUBE DRAINAGE

Laparoscopic cholecystectomy (LC) has rapidly become the procedure of choice for the management of patients with gall-bladder stones. This contrasts with patients who have common bile duct and intrahepatic duct stones who still usually need an open operation. On the basis of experience of a number of LC by one surgeon and animal experiments, we have completed laparoscopic exploration of both intra- and extrahepatic ducts and T-tube drainage of 57 patients with intra- and extrahepatic bile duct calculi over 13 months during 1992–1993 with satisfactory results. The average operating time was 150min. with a range of 100 to 220 min. Most patients were mobile and on oral fluids within 24 h postoperative. Average hospital stay was 4 days. Retained stones were found via T-tube cholangiography in four patients (7%) and for each patient these were removed by fibre-optic choledochoscope 2 weeks postoperatively. Laparoscopic exploration of intra- and extrahepatic bile ducts is achievable by experienced surgeons and may be particularly helpful for patients who are not a good operative risk.     

Secretory component and immunoglobulins in the intrahepatic biliary tree and peribiliary gland in normal livers and hepatolithiasis

Distribution of secretory component (SC), IgA, IgM and joining chain (J chain) in the intrahepatic biliary epithelium and peribiliary glandular epithelium were studied in normal livers and hepatolithiasis. In normal livers, SC was immunohistochemically demonstrated homogeneously in the cytoplasm of the biliary lining and peribiliary glandular epithelium. Immunoelectron-microscopically, SC was localized in the basolateral plasma membranes, nuclear membranes, rough endoplasmic reticulums, Golgi complexes and intracytoplasmic small vesicles, suggesting that the biliary lining and peribiliary glandular epithelium has an ability to synthesize SC. On the other hand, IgA and IgM were found heterogeneously in the biliary lining epithelium, and immunoelectron-microscopically they were only localized in the basolateral plasma membranes and vesicles. J chain was found in similar portions, suggesting that IgA and IgM in biliary lining and glandular epithelium were polymeric. It seems likely that polymeric IgA and IgM combine with SC on the biliary lining and glandular epithelial membranes, and subsequent endocytic transport and secretion of these complexes into the bile occur. In hepatolithiasis in which biliary living epithelia are hyperplastic and peribiliary glands proliferate markedly, such endocytic transport and secretion seemed to be increased. From these findings, it was suggested that the peribiliary glandular as well as biliary lining epithelium contributes to a local immunity in the biliary tree, especially in hepatolithiasis.     

Changes in the small biliary passages in the hepatic localization of Hodgkin's disease

Summary The authors have investigated the behaviour of the small biliary passages in the liver biopsies of six patients suffering from untreated Hodgkin's disease with hepatic localization. No obstruction of the major bile ducts was demonstrated in any patient. Three of the patients were anicteric, while the three others presented with jaundice. In the first three cases typical Hodgkin's granulation tissue appears to be limited to portal tracts and collagen reaction is virtually absent. The three cases with cholestasis showed granulomatous tissue associated with heavy connective tissue rearrangement invading and dissociating the lobular structure. They also show a conspicuous bile-duct proliferation, which is not observed in the three anicteric patients. In these latter cases, however, the small bile ducts running within or near the granulomatous tissue present various morphologic changes, including basal membrane thickening, dilation or constriction of the lumen and alterations of the biliary epithelial lining. Complete disappearance of the bile duct may occur.The authors are indebted to Professor Valeer J. Desmet, Chief of the Department of Pathology II, Leuven, Belgium, for his appreciation and valuable suggestions