The impact of laparoscopic cholecystectomy on the treatment of symptomatic cholelithiasis

Background: There has been a debate about the cost-effectiveness of laparoscopic cholecystectomy (LC), as well as a concern regarding its possible overutilization and changes in the indication for surgery. Methods: A retrospective analysis of all cholecystectomies performed at UCDMC from 1988 to 1994 was done. The annual rate of cholecystectomy increased by 50% in 1990 when LC was introduced but has since stabilized at a rate 11% higher than the rate before LC. The disease status and severity did not change. Results: The incidence of nonelective surgery remained stable at 31.2% to 37.5%. Elective cholecystectomy had lower mortality (0.16% vs 1.8%, P=0.029), morbidity (2.6% vs 11.2%, P=0.0001), and conversion rate (2.6% vs 16%, P=0.0001) and a shorter length of stay (2.1 days vs 5.4 days), compared with nonelective procedure. Conclusions: The indication for surgery in cholelithiasis has not changed since the introduction of LC. In patients with symptomatic gallstones, early elective surgery is recommended and may be more cost-effective.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, FL, March 12–14, 1995     

胆源性胰腺炎与胆道感染的关系

目的　研究胆石性胰腺炎病人胆道感染情况。方法　观察 4 9例病人临床、生化指标和胆汁细菌学检查。结果　年龄、血糖和ALT 3项指标在胆汁细菌培养阴性组和阳性组中结果明显不同 (P <0 .0 5 )。 2 2例阳性胆汁有 32种细菌 ,包括 1 2种革兰氏阳性细菌、1 8种革兰氏阴性细菌和 2种厌氧菌。最常见的微生物是埃希氏大肠杆菌 (2 5 % ) ,其次是肠球菌 (2 1 .9% )和链球菌 (1 2 .5 % )。结论　急性胆石性胰腺炎与胆汁感染有关 ,应该早期应用抗革兰氏阴性杆菌和革兰氏阳性球菌抗生素     

胆结石对肝脏细胞钙稳态影响与调整的实验研究

用低蛋白饮食方法建立豚鼠胆色素结石模型，共设对照、致石、维生素Ｃ修复、丹参修复和对照修复等５组，规定时间内处死动物，用放射免疫、固相酶联免疫、生物化学等方法检测肝细胞内环—磷酸腺甙（ｃＡＭＰ）、环—磷酸鸟嘌呤（ｃＧＭＰ）、钙调素（ＣａＭ）、钙，三磷酸腺甙酶（Ｃａ２＋－ＡＴＰａｓｅ）、磷酸化酶ａ等水平。致石组豚鼠肝脏细胞内ｃＡＭＰ和磷酸化酶ａ升高，而ｃＧＭＰ，ＣａＭ和Ｃａ２＋－ＡＴＰａｓｅ下降，表明肝细胞钙稳态呈失调状态。维生素Ｃ和丹参可调整肝细胞的上述改变，说明维生素Ｃ和丹参具有维持肝细胞钙稳态的作用。     

男性胆囊结石患者血清性激素和前列腺素改变的探讨

借助RIA,对28例胆囊结石男性(平均57.5岁)及26名健康中、老年男性(平均63.3岁)进行了血清雌二醇(E_2)、孕酮、睾酮和前列腺素类(PGs)检测,以探索胆石形成机理。结果,1)在胆石男病人中.平均E_2和平均孕酮水平均高,他们的平均睾酮则低下,与健康对照男性相应诸值比较,差异非常显著或显著(P<0.001,0.05,0.05);2)至于平均PGs,胆石男性组者与健康对照男性相比,前者也相当高(23.01pg/ml对16.31pg/ml),只是两组间差异尚无统计学意义。作者等初步设想,胆石男性小,如同胆石女性那般,本症也可能是某种垂体性腺激素分泌紊乱性疾病。     

Differences in gallstone structure in primary common bile duct lithiasis and gallbladder lithiasis

Summary Some differences between gallbladder lithiasis and primary common bile duct lithiasis are described. Microbiological cultures and biochemical analyses were carried out on the bile of two groups of patients: 27 suffering from gallbladder and 5 from primary common duct lithiasis. The microstructure and composition of gallstones were also examined by polarized light microscopy and X-ray diffraction. Women predominated in gallbladder lithiasis but not in primary common duct lithiasis group (P<0.05) and body weight was higher in the former group (P<0.02). Primary common duct lithiasis patients had a higher, although not significant, incidence of duodenal diverticulosis (P=0.15), and a higher incidence ofE. coli-positive cultures in bile (P<0.001). No significant difference in the biochemical composition of the bile was found between the groups. Brown pigment stones predominated in primary common duct lithiasis, while cholesterol stones did in gallbladder and secondary common duct lithiasis (P<0.0001). Stones formed in the gallbladder generally show linear, radial growths of cholesterol crystals, while those from the common duct present a polystratified, concentric deposition of microgranules composed mainly of pigmentary salts.These differences should be taken into account as additional criteria in the differential diagnosis between primary and secondary common duct lithiasis, as the classical criteria for diagnosing of the former greatly underestimate its actual incidence. The distinction between primary and secondary common duct lithiasis is of practical significance, since each entity requires different treatment.Abbreviations CBD common bile duct - CBDL common bile duct lithiasis - ERCP endoscopic retrograde cholangiopancreatography - GBL gallbladder lithiasis - HDL high density lipoproteins - PCBDL primary common bile duct lithiasis - SCBDL secondary common bile duct lithiasis - SGOT serum glutamic-oxalacetic transaminase - SGPT serum glutamic-pyruvic transaminase     

皮下通道型胆囊肝胆管成形术治疗肝胆管结石 和胆管狭窄的临床研究

目的：总结皮下通道型胆囊肝胆管成形术的临床效果。方法：统计了1994年以来我院76例行STHG手术患者的适应症、临床效果及术后早期并发症。并选择同期实施的125 列行传统胆肠吻合（CJ）的患者进行对照。结果：STHG的手术适应症与传统胆肠吻合基本相同;STHG组患者的手术时间、住院时间、术中出血量明显少于CJ组,术后恢复良好,仅2例次并发症。结论;该术式既保存了胆囊及Oddi括约肌功能,又保证了胆汁的生理流向;防止了肠液的反,所以避免了消化功能紊乱,防止了反 流性胆管炎,对患者的影响小,是一种较为理想的治疗肝胆管结石和肝门胆管狭窄的术式。     

皮下通道型胆囊肝总管吻合术治疗区域性肝胆管结石27例报告

目的：为了解决传统胆肠内引流术在治疗区域性肝胆管结石中的诸多不足。方法：设计并应用了 一种新技术式以皮下通道型胆囊肝总管吻合术替代胆肠内引流术。在切除肝脏区域性结石病灶后, 切开肝总管约1．5cm,将胆囊壶腹部切开相应大小的切口与之吻合,并适当游离胆囊,使其底部可被固定于切口皮下,建立皮下胆囊与肝内外胆管间的吻合通道。结果：已完成该术式的27例患者,手术顺利,术后恢复良好,未发现并发症。1例患者于术后1年零9个月,肝内再次发现结石且伴胆道感染症状,急诊局麻下切开皮下胆囊通道行胆道镜取石,效果满意。结论：该术式简单、方便、易行,既能保存胆囊、胆管、Oddi括约肌及胃肠道的正常生理功能, 又为术后结石复发或残留提供了一治疗新途径,且避免了传统肠吻合术的不足,因而不治疗区域性肝胆管结石的较理想的方法。     

胆道外科中肝尾状叶病变的处理

目的：探讨肝门胆管部和尾状叶肝结石术中对尾状叶的处理。方法：对２１例肝尾状叶因以上疾病经外科治疗的患者进行随访总结。结果与结论：肝尾状病变处理棘手;肝门部胆管癌常侵及尾状叶,其根治范围应包括肝尾状叶的切除;尾状叶肝管结石应切开左右肝管,力争术中取尽结石。     

Biliary–enteric fistulas: report of five cases and review of the literature

Internal biliary fistulas (IBF) are seen rarely. Because the symptoms and signs of IBF are not specific and the diagnosis is not suspected, these patients are commonly investigated with plain abdominal films (PAF), ultrasonography (US), upper gastrointestinal series (UGIS), barium enema (BE), and computed tomography (CT), but not always with endoscopic retrograde cholangiopancreatography (ERCP). The purposes of this article are (a) to attract attention of radiologists to presumptive findings of IBF, so as not to misdiagnose this unsuspected and rare disease, and (b) review of the literature while presenting radiologic features of our cases. Five cases of IBFs in which extrahepatic biliary tree communicating with duodenum (four cases) and colon (one case) are reported. Diagnostic work-up of cases were done by PAF, US, UGIS, BE, and CT. Aerobilia, which cannot be explained using other means, ectopic gallstone and small bowel dilatation, nonvisualization of the gallbladder despite no history of cholecystectomy, and thick-walled shrunken gallbladder adherent to neighboring organs were suggestive findings of IBF in our study. Knowledge of imaging findings suggestive of IBF and a high index of suspicion increase the diagnostic rate of IBFs. Received: 4 June 1998; Revision received: 28 July 1998; Accepted: 14 October 1998     

Determinants for gallstone formation – a new data cohort study and a systematic review with meta-analysis*

Objective: Only few determinants of gallstone formation have been identified in cohort studies. The aim was to identify further determinants for gallstones in a Danish cohort and to perform a meta-analysis of results from existing cohorts.

Material and methods: Data from a cohort study was used. Gallstone incidence was assessed through repeated ultrasound examinations. Body mass index (BMI), blood pressure, self-rated health, lifestyle variables, blood lipids, and use of female sex hormones were measured at the baseline examination. Statistical analyses included logistic regression. Based on a prospective protocol, a systematic review of the literature was performed identifying all articles dealing with determinants of incident gallstones. Meta-analyses of comparable determinants were performed through fixed effect models.

Results: Participants with no gallstones at baseline and with at least one re-examination were followed-up completely (mean 11.6 years, N?=?2848). The overall cumulative incidence of gallstones was 0.60% per year. Independent positive determinants for incident gallstones were age, female sex, non-high density lipoprotein (non-HDL) cholesterol, and gallbladder polyps. In addition, BMI was positively associated in men. The systematic review additionally identified associations for comorbidities, parity, and dietary factors. Meta-analysis confirmed the significant associations for incident gallstones and age, female sex, BMI, and non-HDL cholesterol. No significant associations were found for blood pressure, smoking, alcohol consumption, HDL cholesterol, or triglycerides in meta-analyses.

Conclusions: Age, female sex, BMI, non-HDL cholesterol, and polyps are independent determinants for gallstone formation. Incident gallstones and the metabolic syndrome share common risk factors. More studies are needed for further exploration.