继发性胆总管结石两种开腹胆道探查手术方式的临床研究

目的 比较治疗继发性胆总管结石的两种开腹胆道探查手术方式(术中胆道镜经胆囊颈管胆总管探查术与传统胆道切开探查T管引流术)的临床效果.方法 符合入组标准病例113例,传统术式58例,经胆囊颈管胆道探查55例.对手术成功率、手术时间、术后并发症、住院时间、住院费用等指标行对照研究.结果 两组均成功完成手术且无严重术后并发症,手术时间经胆囊管胆道探查术组与传统手术组无显著差异,平均住院时间及住院费用经胆囊管胆道探查组显著低于传统手术组.结论 对于继发性胆总管结石,经胆囊颈管途径胆道探查较传统方式有较明显优势,应作为胆道探查的首选途径.     

Therapeutic plasma exchange for exogenous insulin antibody syndrome in combined variable immunodeficiency: a case report

A 32-year-old male with type I diabetes presented with profound hypoglycemia due to exogenous insulin antibody syndrome in the setting of newly-diagnosed common variable immunodeficiency. Immunomodulatory therapy was not initially effective, but after the initiation of plasma exchange hypoglycemia resolved, and glucose lability improved.     

British Society for Immunology/United Kingdom Primary Immunodeficiency Network consensus statement on managing non-infectious complications of common variable immunodeficiency disorders

Common variable immunodeficiency (CVID) represents a heterogeneous group of rare disorders. There is considerable morbidity and mortality as a result of non-infectious complications, and this presents clinicians with management challenges. Clinical guidelines to support the management of CVID are urgently required. The UK Primary Immunodeficiency Network and the British Society for Immunology funded a joint project to address this. A modified Delphi Survey was conducted for the assessment, diagnosis and treatment of the non-infectious blood, respiratory, gut and liver complications of CVID. A steering group of 10 consultant immunologists and one nurse specialist developed and reviewed the survey statements and agreed the final recommendations. In total, 22 recommendations and three areas for research were developed.     

Gastrointestinal and non-gastrointestinal complication rates associated with diagnostic esophagogastroduodenoscopy under sedation

Esophagogastroduodenoscopy (EGD) under sedation may result in gastrointestinal (GI) and non-GI complications. However, no previous studies have reported 30-day GI and non-GI complications after diagnostic EGD under sedation.We conducted a retrospective, observational study of 30-day GI and non-GI complication rates after outpatient diagnostic EGD under sedation in subjects ≥18 years between January 2012 and December 2017 based on a common data model database. Thirty-day complication rates were compared with EGD under sedation or not, type of sedation drugs (midazolam only vs midazolam/propofol) and age groups (18-64 year vs ≥65 year) for GI (bleeding and perforation) and non-GI complications (pneumonia, acute myocardial infarction, congestive heart failure and cerebral stroke).In total, 39,910 were performed with sedation (midazolam only, n = 16,033 and midazolam/propofol, n = 23,864) and 22,894 were performed without sedation. Elderly patients significantly favored EGD without sedation (P < .01). GI and non-GI complication rates were similar between EGD under sedation and without sedation (all P > .1) except for acute myocardial infarction rate, which was significantly higher in EGD without sedation than EGD under sedation (1.7/10,000 vs 0.3/10,000 persons, P = .043). All GI and non-GI complications were also similar between the midazolam/propofol and midazolam only groups as well as between young and old patients (all P > .1).Outpatient diagnostic EGD under sedation has an excellent safety profile. In addition, it can be safely performed with midazolam only or midazolam/propofol and in young and old patients.     

Inter‐subject alignment of MEG datasets in a common representational space

Pooling neural imaging data across subjects requires aligning recordings from different subjects. In magnetoencephalography (MEG) recordings, sensors across subjects are poorly correlated both because of differences in the exact location of the sensors, and structural and functional differences in the brains. It is possible to achieve alignment by assuming that the same regions of different brains correspond across subjects. However, this relies on both the assumption that brain anatomy and function are well correlated, and the strong assumptions that go into solving the under‐determined inverse problem given the high‐dimensional source space. In this article, we investigated an alternative method that bypasses source‐localization. Instead, it analyzes the sensor recordings themselves and aligns their temporal signatures across subjects. We used a multivariate approach, multiset canonical correlation analysis (M‐CCA), to transform individual subject data to a low‐dimensional common representational space. We evaluated the robustness of this approach over a synthetic dataset, by examining the effect of different factors that add to the noise and individual differences in the data. On an MEG dataset, we demonstrated that M‐CCA performs better than a method that assumes perfect sensor correspondence and a method that applies source localization. Last, we described how the standard M‐CCA algorithm could be further improved with a regularization term that incorporates spatial sensor information. Hum Brain Mapp 38:4287–4301, 2017. © 2017 Wiley Periodicals, Inc.     

Clinical comparison of extracorporeal piezoelectric lithotripsy (EPL) and intracorporeal electrohydraulic lithotripsy (EHL) in difficult bile duct stones

Today, nearly 90% of common bile duct stones are extracted endoscopically. Problems are encountered if there are large stones or a duct stenosis. Extracorporeal piezoelectric lithotripsy (EPL) as well as intracorporeal electrohydraulic lithotripsy (EHL) serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. A total of 35 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected on the condition that stone visualization through ultrasound was possible and that the papilla was within easy reach of the endoscope. Patients fulfilling the inclusion criteria were randomly treated either by EPL or EHL. The average age of our patients was 73 years. The main reasons for failure of conventional endoscopy were due to the large size of the stones (13 patients), impacted stones (16), or the presence of a biliary stricture (6). In the EPL group, visualization of the stones by ultrasound and ensuing treatment were possible in 16 of 18 patients (89%); stones could be fragmented in 15 patients. In 13 patients, the biliary tree could then be completely freed of calculi; the success rate was 72% for all the patients (13 of 18). On average, the patients had 2.3 treatments on the lithotripter, and 3870 shock waves were applied per treatment. In the EHL group stones were successfully fragmented in 13 of 17 patients (76.5%). The average number of treatments was 1.4. Comparing both therapies, there was no difference in stone-free rates. In both groups, additional endoscopic interventions were necessary to clear the bile duct. The mean number of lithotripsy sessions was less in the EHL group (1.4 vs 2.3). There were no major differences in average hospital stay, 30-day mortality was zero in both groups. Combined treatment including EPL, EHL, and intracorporeal laser lithotripsy was finally successful in 32 patients (91.5%). It is concluded that EHL might be the method of choice for smaller, single stones in the more proximal parts of the common bile duct. In these cases, complete duct clearance in one lithotripsy session can be achieved. Multiple and large stones are probably best accessible to EPL. With a combination of the methods described, the bile duct can be cleared of concrements in almost every instance. As a result, surgery for choledocholithiasis has become the absolute exception.This work was presented in part at the 1993 Annual Meeting of the american Gastroenterological Association in Boston and published in abstract form (Gastroenterology 104:A347, 1993).     

Management of common bile-duct stones and associated gallbladder stones: surgical aspects

In most countries, endoscopic sphincterotomy is the first-choice treatment for common bile-duct stones. In patients with residual gallbladder stones, laparoscopic cholecystectomy is the next step. The optimal timing of laparoscopic cholecystectomy after endoscopic sphincterotomy remains to be determined. An alternative approach of combined cholecystocholedocholithiasis consists of laparoscopic cholecystectomy together with laparoscopic stone removal. The advantage of this ‘single-stage’ therapy appears to be limited to patients with stones that can be removed transcystically. This approach is successful in about half of the patients. Laparoscopic common bile-duct exploration is technically more demanding, more time-consuming, and associated with increased postoperative morbidity. If transcystic removal is not possible, a postoperative ERCP with endoscopic sphincterotomy is a good option. Intraoperative ERCP and endoscopic sphincterotomy are also feasible, but require specific organisational efforts.Recurrence of choledocholithiasis after ES is reported in a considerable number of patients (6–21%), resulting from de novo primary stone formation or recurrent secondary migration from the gallbladder. Primary choledocholithiasis is associated with bactobilia and delayed bile-duct clearance, indicated by CBD dilation. Endoscopic reintervention is safe and usually easy to perform. Surgery should be reserved for intractable cases. In selected patients, an underlying lithogenic bile composition (low-phospholipid-associated cholelithiasis) should be identified, and preventive medical treatment with UDCA could be considered.

• in patients with combined cholecystocholedocholithiasis, endoscopic sphincterotomy should be followed by elective laparoscopic cholecystectomy, even in the elderly; however, a ‘wait-and-see’ policy does not lead to higher mortality, and therefore expectant management can be advocated in case of significant contraindications to surgery

• laparoscopic cholecystectomy combined with laparoscopic stone removal offers a one-stage treatment of patients with combined cholecystocholedocholithiasis. Laparoscopic transcystic duct clearance is associated with low morbidity and short hospital stay. In contrast, laparoscopic common bile-duct exploration remains a procedure with increased risk of biliary complications and prolonged hospital stay. In case of stones that cannot be removed transcystically, it may be wise to perform an intraoperative or early postoperative ERCP

• performing an endoscopic sphincterotomy during laparoscopic cholecystectomy using a ‘rendezvous’ procedure may be beneficial in selected patients (especially in case of earlier failed ERCP)

• laparoscopic cholecystectomy after endoscopic sphincterotomy is associated with increased conversion rates to open procedure compared to laparoscopic cholecystectomy for uncomplicated gallstones; laparoscopic cholecystectomy planned early after endoscopic sphincterotomy may reduce this risk

• morphological or functional bile-duct defects, indicated by a dilated CBD, may lead to bactobilia and biliary stasis, thus promoting primary stone formation

• in a subgroup of patients with recurrent bile-duct stones, an MDR3 gene mutation must be considered, resulting in low-phospholipid-associated cholelithiasis. These patients are characterised by early onset of symptoms, recurrence after cholecystectomy, hyperechogenic foci in the liver, and often a history of intrahepatic cholestasis of pregnancy. Ursodeoxycholic acid is beneficial in these patients

• the optimal timing or ERCP in patients scheduled for laparoscopic cholecystectomy (before, during, or after the operation) still needs to be defined.

• further data are needed to determine potentially increased incidence of conversion and postoperative complications for laparoscopic cholecystectomy after endoscopic sphincterotomy compared to laparoscopic cholecystectomy for uncomplicated gallstones

Subjects with allergic rhinitis show signs of more severely impaired paranasal sinus functioning during viral colds than nonallergic subjects

BACKGROUND: Viral cold is thought to be the major contributing factor in the pathogenesis of sinusitis, as it causes ostiomeatal obstruction. The aim was to evaluate whether paranasal sinus functioning during viral colds is similar in subjects with and without allergic rhinitis. METHODS: Forty-eight volunteers were examined during an early (2-4 days) natural cold and again 3 weeks later. The examinations included computed tomography (CT) scans, nasal mucosal biopsies, and viral and bacterial specimens. Subjects with positive skin prick tests and persistent or intermittent rhinitis were considered to have allergic immunoglobulin E (IgE)-mediated rhinitis. In addition, specific IgE antibodies to staphylococcal enterotoxin B (SEB) were measured. RESULTS: Nine subjects (19%) had allergic rhinitis. The allergic subjects were significantly more often IgE sensitized to SEB than the nonallergic subjects (33%vs 3%, P = 0.02). Viral etiology of the cold was identified in 32 (67%) subjects. The subjects with allergic rhinitis had significantly higher CT scores compared with nonallergic subjects during the colds (median (range) scores 16 (6-22) vs 6 (0-17), P = 0.004). In both groups, the median scores declined markedly during convalescence, but the difference remained significant (P = 0.009). Among the allergic subjects, those who were IgE sensitized to SEB tended to have the highest CT scores [median (range) 16 (16-22)]. Total serum IgE and the nasal subepithelial eosinophil counts correlated with the CT scores during the cold (rs = 0.38, P = 0.008 and rs = 0.46, P = 0.001, respectively). CONCLUSIONS: Subjects with allergic IgE-mediated rhinitis had more severe paranasal sinus changes in CT scans than nonallergic subjects during viral colds. These changes indicate impaired sinus functioning and may increase the risk of bacterial sinusitis.