Combined laparoscopic and endoscopic treatment for bile duct diseases

BACKGROUND: Clinical application of laparoscopy, duo- denoscopy and choledochoscopy has been accepted as a mini-invasive surgical therapy for bile duct diseases; but ei- ther endoscopic or laparoscopic therapy alone is disadvanta- geous in its narrow indications and in failure to give full play to the individual superiority. The present study was to evaluate the procedures and therapeutic results of combined laparoscopic and endoscopic treatment for bile duct disea- ses. METHODS: Clinical data of 1990 patients with bile duct diseases treated by combination of laparoscopy, duodenos- copy and choledochoscopy in two hospitals were reviewed and analyzed. RESULTS: Patients with cholecystolithiasis and choledo- cholithiasis were treated with combined laparoscopy and duodenoscopy (n =1350) in a single operation with a cure rate of 93.6%. Those with choledocholithiasis (n =332) were treated with combined laparoscopy and choledocho- scopy with a cure rate of 100%. Combined laparoscopy, duo- denoscopy and choledochoscopy was used in 258 patients with choledocholithiasis (29 of them complicated with pan- creatitis) and 24 patients with Mirizzi's syndrome, with a cure rate of 100%. Laparoscopic choledochoenterostomy and preoperative endoscopic nasobiliary drainage were done in 26 patients with a cure rate of 100%. There were no serious operative complications. A follow-up study of 1051 patients for 3 months to 12 years (mean 7.8 years) showed that 10 patients had recurrence of stones but no stenosis of the bile duct. CONCLUSION: Combined laparoscopic and endoscopic procedures are mini-invasive and cause less pain and mini- mal operative complications.

Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures

BACKGROUND Endoscopic management is the first-line therapy for post-liver-transplant anas-tomotic strictures.Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months,data on safety and duration for metal stents in this setting is scarce.Due to limited access to endoscopic retrograde cholan-giopancreatography(ERCP)during the coronavirus disease 2019 pandemic in our centre,there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy.This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents.METHODS Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query.Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records.The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months.Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for≤120 d or>120 d.RESULTS During the study period,a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course.In 33 ERCPs,the stent was removed or exchanged on a 3-month interval.No pancreatitis,perfor-ations or deaths occurred.Minor post-ERCP complications were similar between the 3-month(abdominal pain and intraductal migration)and 6-month(abdominal pain,septic shower and embedded stent)groups-6.1%vs 9.1%respectively,P=0.40.All strictures resolved at the end of the stenting course,but the stenting course was variable from 3 to 22 months.The recurrence rate for stenting courses lasting for up to 120 d was 71.4%and 21.4%for stenting courses of 121 d or over(P=0.03).There were 28 patients that were treated with a single ERCP with Kaffes,21 with removal after 120 d and 7 within 120 d.There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course(71.0%vs 10.0%,P=0.01).CONCLUSION Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Success rate and complications of endoscopic extraction of common bile duct stones over 2 cm in diameter

BACKGROUND:Clinically,common bile duct (CBD) stones >2 cm are difficult to remove by endoscopic retrograde cholangiopancreatography (ERCP).To evaluate this observation,the rates of successful clearance of CBD stones and complications were compared between ERCP extraction of CBD stones of >2 cm and <2 cm in diameter.METHODS:All patients who had undergone endoscopic extraction of CBD stones at the Endoscopy Center of Shanghai First People’s Hospital from May 2004 to May 2008 were reviewed.Patients with CBD stones of >2 cm in diameter were enrolled in the >2 cm group.Two matched controls with CBD stones of <2 cm in diameter were selected for each enrolled patient (<2 cm group).Patient characteristics,success rates,and complications during and after ERCP were compared.RESULTS:Seventy-two patients constituted the >2 cm group and 144 patients were in the <2 cm group.No significant differences were found in the patient characteristics,except for stone size and CBD diameter.Both the overall success rate and the success rate in the first ERCP session were lower in the >2 cm group (77.8% and 58.3%,respectively) than in the <2 cm group (91.7% and 83.3%,P<0.01).During ERCP,the incidence of hypoxemia (30.6%) and hemorrhaging papillae (18.1%) in the >2 cm group was higher than in the <2 cm group (13.2% and 6.3%,P<0.05).After ERCP,the rates of delayed papillae hemorrhage (13.9%),hyperamylasemia (23.6%),acute pancreatitis (8.3%) and biliary infection (18.1%) were higher in the >2 cm group than in the <2 cm group (3.5%,11.1%,2.1%,and 2.8%,respectively,P<0.05).CONCLUSION:The success rate of endoscopic extraction of CBD stones of >2 cm in diameter was lower but the complication rate was higher than that of stones of <2 cm in diameter.

Current status of peroral cholangioscopy in biliary tract diseases

Peroral cholangioscopy(POC) is an important tool for the management of a selected group of biliary diseases. Because of its direct visualization, POC allows targeted diagnostic and therapeutic procedures. POC can be performed using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope or via the insertion of a small-diameter endoscope directly into the bile duct. POC was first described in the 1970 s, but the use of earlier generation devices was substantially limited by the cumbersome equipment setup and high repair costs. For nearly ten years, several technical improvements, including the single-operator system, high-quality images, the development of dedicated accessories and the increased size of the working channel, have led to increased diagnostic accuracy, thus assisting in the differentiation of benign and malignant intraductal lesions, targeting biopsies and the precise delineation of intraductal tumor spread before surgery. Furthermore, lithotripsy of difficult bile duct stones, ablative therapies for biliary malignancies and direct biliary drainage can be performed under POC control. Recent developments of new types of conventional POCs allow feasible, safe and effective procedures at reasonable costs. In the current review, we provide an updated overview of POC, focusing our attention on the main current clinical applications and on areas for future research.

Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones

AIMTo evaluate the rate of recurrence of symptomatic choledocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for bile duct stone disease. METHODSAll patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period (until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct (CBD) stone recurrence were retrospectively retrieved from patients&rsquo; files. RESULTSA total of 495 patients were included. Sixty seven (67) out of 495 patients (13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 &plusmn; 16.9 mo while twenty two (22) of these patients (32.8%) experienced a second recurrence after 35.19 &plusmn; 23.2 mo. Factors associated with recurrence were size (diameter) of the largest CBD stone found at first presentation (10.2 &plusmn; 6.9 mm vs 7.2 &plusmn; 4.1 mm, P = 0.024), diameter of the CBD at the first examination (15.5 &plusmn; 6.3 mm vs 12.0 &plusmn; 4.6 mm, P = 0.005), use of mechanical lithotripsy (ML) (P = 0.04) and presence of difficult lithiasis (P = 0.04). Periampullary diverticula showed a trend towards significance (P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence. CONCLUSIONBile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters (CBD diameter) and stone characteristics (stone size, use of ML, difficult lithiasis) at first presentation.

Association of extraintestinal manifestations of inflammatory bowel disease in a province of western Hungary with disease phenotype:Results of a 25-year follow-up study

AIM:IBD is a systemic disease associated with a large number of extraintestinal manifestations (EIMs).Our aim was to determine the prevalence of EIMs in a large IBD cohort in Veszprem Province in a 25-year follow-up study. METHODS:Eight hundred and seventy-three IBD patients were enrolled (ulcerative colitis/UC/:619,m/f:317/302, mean age at presentation:38.3 years,average disease duration:11.2 years;Crohn's disease/CD/:254,m/f:125/129, mean age at presentation:32.5 years,average disease duration:9.2 years).Intestinal,extraintestinal signs and laboratory tests were monitored regularly.Any alteration suggesting an EIMs was investigated by a specialist. RESULTS:A total of 21.3% of patients with IBD had EIM (UC:15.0%,CD:36.6%).Age at presentation did not affect the likelihood of EIM.Prevalence of EIMs was higher in women and in CD,ocular complications and primary sclerosing cholangitis (PSC) were more frequent in UC.In UC there was an increased tendency of EIM in patients with a more extensive disease.Joint complications were more frequent in CD (22.4% vsUC 10.2%,P<0.01).In UC positive family history increased the risk of joint complications (OR:3.63).In CD the frequency of type-1 peripheral arthritis was increased in patients with penetrating disease (P=0.028).PSC was present in 1.6% in UC and 0.8% in CD.Dermatological complications were present in 3.8% in UC and 10.2% in CD,the rate of ocular complications was around 3% in both diseases.Rare complications were glomerulonephritis,autoimmune hemolytic anaemia and celiac disease. CONCLUSION:Prevalence of EIM in Hungarian IBD patients is in concordance with data from Western countries.The high number of EIM supports a role for complex follow-up in these patients.

Successful endoscopic treatment of an intraductal papillary neoplasm of the bile duct

We present a case of a 76-year-old man with right upper quadrant abdominal pain and weight loss,who was found to have an intraductal papillary neoplasm of the bile duct(IPNB)of the pancreaticobiliary subtype,deemed curatively resectable.The patient declined surgery and opted for endoscopic therapy.He underwent two sessions of endoscopic retrograde cholangiopancreatography(ERCP)-guided radiofrequency ablation(RFA).Ten months later,no evidence of recurrence was identified on repeat ERCP.To our knowledge,this is the first reported case of successful use of RFA as a primary treatment modality for resectable IPNB.

Bile duct cyst in adults:Interventional treatment,resection,or transplantation?

Cystic dilatations of the bile ducts may be found along the extrahepatic biliary tree,within the liver,or in both of these locations simultaneously.Presentation in adults is often associated with complications.The therapeutic possibilities have changed considerably over the last few decades.If possible,complete resection of the cyst(s)can cure the symptoms and avoid the risk of malignancy.According to the type of bile duct cyst,surgical procedures include the Roux-en-Y hepaticojejunostomy and variable types of hepatic resection.However,the diffuse forms of Todani type Ⅴ cysts(Caroli disease and Caroli syndrome)in particular remain a therapeutic problem,and liver transplantation has become an important option.The mainstay of interventional treatment for Todani typeⅢbile duct cysts is via endoscopic retrograde cholangiopancreatography.The diagnostic term"bile duct cyst"comprises quite different pathological and clinical entities.Interventional therapy,hepatic resection,and liver transplantation all have their place in the treatment of this heterogeneous disease group.They should not be seen as competitive treatment modalities,but as complementary options.Each patient should receive individualized treatment after all of the clinical findings have been considered by an interdisciplinary team.

Comparison of Endoscopic Retrograde Cholangiopancreatography(ERCP)and Magnetic Resonance Cholangiopancreatography(MRCP)in Bile Duct Imaging

Purpose: The aim of this study was to compare magnetic resonance cholangiopancreatography (MRCP) with endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing bile duct pathologies. Materials and Methods: We documented the data of 171 patients with both ERCP and MRCP between January 2009 and December 2010 at the Konya Education and Research Hospital. Results: Of the 171 patients, 100 (58.5%) were female and 71 (41.5%) were male. The median age was 63 (55 to 89). ERCP was used to diagnose bile duct stones in 102 (59%) patients, bile duct tumour in 14 (8%) patients, hydatic cysts opening up to the bile duct in 4 (2%) patients and bile duct stenosis in 3 (1.8%) patients. For the detection of bile duct stones, MRCP had a sensitivity of 92%, a specificity of 74% and a diagnostic accuracy of 83%. For bile duct tumours, MRCP had a sensitivity of 85%, a specificity of 98% and a diagnostic accuracy rate of 92%. Conclusion: In our centre, the results of MRCP and ERCP were similar for the last two years. However, MRCP was superior with respect to diagnosis as it was cheaper and non-invasive. Thus, ERCP should be preferred for therapeutic processes.

Magnetic resonance cholangiopancreatography image enhancement for automatic disease detection

AIM:To sufficiently improve magnetic resonance cholangiopancreatography(MRCP) quality to enable reliable computer-aided diagnosis(CAD).METHODS:A set of image enhancement strategies that included filters(i.e.Gaussian,median,Wiener and Perona-Malik),wavelets(i.e.contourlet,ridgelet and a non-orthogonal noise compensation implementation),graph-cut approaches using lazy-snapping and Phase Unwrapping MAxflow,and binary thresholding using a fixed threshold and dynamic thresholding via histogram analysis were implemented to overcome the adverse characteristics of MRCP images such as acquisition noise,artifacts,partial volume effect and large inter-and intra-patient image intensity variations,all of which pose problems in application development.Subjective evaluation of several popular pre-processing techniques was undertaken to improve the quality of the 2D MRCP images and enhance the detection of the significant biliary structures within them,with the purpose of biliary disease detection.RESULTS:The results varied as expected since each algorithm capitalized on different characteristics of the images.For denoising,the Perona-Malik and contourlet approaches were found to be the most suitable.In terms of extraction of the significant biliary structures and removal of background,the thresholding approaches performed well.The interactive scheme performed the best,especially by using the strengths of the graphcut algorithm enhanced by user-friendly lazy-snapping for foreground and background marker selection.CONCLUSION:Tests show promising results for some techniques,but not others,as viable image enhancement modules for automatic CAD systems for biliary and liver diseases.

Duplication of the common bile duct manifesting as recurrent pyogenic cholangitis:A case report

BACKGROUND Duplication of the extrahepatic bile duct(DCBD)is an extremely rare congenital anomaly of the biliary system.There are five types of DCBD according to the latest classification.Among them,Type V is characterized by single drainage of the extrahepatic bile ducts.Reports on DCBD Type V are scarce.CASE SUMMARY A 77-year-old woman presented with recurrent epigastric pain but without fever or chills.Computed tomography revealed a dilated common bile duct(CBD)that harboured multiple choledocholithiasis.Endoscopic retrograde cholangiopancreatography(ERCP)was performed,and the stones were extracted using a Dormia basket.She was discharged without any complications;however,she visited the emergency department a day after she was discharged due to epigastric pain and fever.Laboratory findings were suggestive of cholestasis.After urgent ERCP for stone removal,magnetic resonance cholangiopancreatography was performed to evaluate remnant choledocholithiasis.Magnetic resonance cholangiopancreatography revealed a DCBD Type Va and remnant choledocholithiasis in the right CBD.Both CBDs were accessed,and the stones were cleared successfully during a subsequent ERCP.CONCLUSION In this article,we report an extremely rare case of DCBD manifesting as recurrent pyogenic cholangitis.This case highlights the importance of recognizing DCBD because stones in the unrecognized bile duct could make the patient’s prognosis critical.

Impact of previous cyst-enterostomy on patients' outcome following resection of bile duct cysts

AIM:To analyze the impact of previous cyst-enterostomy of patients underwent congenital bile duct cysts(BDC)resection.METHODS:A multicenter European retrospective study between 1974 and 2011 were conducted by the French Surgical Association.Only Todani subtypes I and IVb were included.Diagnostic imaging studies and operative and pathology reports underwent central revision.Patients with and without a previous history of cystenterostomy(CE)were compared.RESULTS:Among 243 patients with Todani types I and IVb BDC,16 had undergone previous CE(6.5%).Patients with a prior history of CE experienced a greater incidence of preoperative cholangitis(75%vs 22.9%,P<0.0001),had more complicated presentations(75%vs 40.5%,P=0.007),and were more likely to have synchronous biliary cancer(31.3%vs 6.2%,P=0.004)than patients without a prior CE.Overall morbidity(75%vs 33.5%;P<0.0008),severe complications(43.8%vs 11.9%;P=0.0026)and reoperation rates(37.5%vs 8.8%;P=0.0032)were also significantly greater in patients with previous CE,and their Mayo Risk Score,during a median follow-up of 37.5 mo(range:4-372 mo)indicated significantly more patients with fair and poor results(46.1%vs 15.6%;P=0.0136).CONCLUSION:This is the large series to show that previous CE is associated with poorer short-and longterm results after Todani types I and IVb BDC resection.

SpyGlass临床应用的现状

近年来胆道镜技术发展迅速,单人操作的胆道镜系统SpyGlass借助其细小、操作简单、能够直观且清晰地观察胆胰管等优势逐渐应用于临床。对于一些使用传统方法诊治困难的胆胰管疾病,SpyGlass内镜直视系统相较于传统方法在这些疾病的诊治上具有更大的优势,它能够更加直观地观察胆管及胰管,同时也能够在管腔中做一些治疗性的操作及取样,从而提高胆胰管疾病的诊断准确性。本文总结了SpyGlass在胆胰管疾病方面的临床应用现状。分析表明SpyGlass对胆胰管疾病的诊治有显著价值,参考其在这些方面的应用,可以将其拓展使用至其他疾病的诊治中去。随着技术愈加成熟,SpyGlass必将在未来有更好的发展应用。

2种方法治疗胆囊结石并胆总管结石的临床分析

目的比较腹腔镜胆囊切除术(LC)+腹腔镜胆总管探查一期缝合术(LBEPS)及LC+腹腔镜经胆囊管胆总管探查术(LTCBDE)2种术式的临床治疗效果。方法回顾性分析2018年1月至2023年6月昆明医科大学第二附属医院肝胆胰外科收治的64例采用LC+LBEPS及LC+LTCBDE治疗的胆囊结石并胆总管结石患者的临床资料,其中35例行LC+LBEPS,29例行LC+LTCBDE,比较2组患者的手术时间、术中出血量、腹腔引流时间、手术成功率、总住院时间、总住院费用、手术并发症发生率及结石复发率。结果2组患者基线资料、手术成功率及术后并发症发生率比较差异无统计学意义(P>0.05);LC+LBEPS组手术时间[160.00(150.00,167.50)]min vs[114.00(95.00,126.00)]min、术中出血量[30.00(27.40,40.00)]mL vs[22.00(20.00,25.00)]mL、腹腔引流时间[5.00(5.00,6.00)]d vs[3.00(3.00,4.00)]d、总住院时间(8.31±1.98)d vs(6.14±2.07)d及总住院费用[2.82(2.32,3.44)]万元vs[1.68(1.61,1.86)]万元均高于LC+LTCBDE组,差异有统计学意义(P<0.05)。结论LC+LBEPS及LC+LTCBDE均是治疗胆囊结石并胆总管结石的2种免T管有效治疗方式,但LC+LTCBDE手术时间、术中出血量、腹腔引流时间、总住院时间、总住院费用更低,临床治疗效果更优,在满足手术适应症的前提下可优先选择。

Oddi’s括约肌切开成形术43例疗效分析

目的探讨Oddi’s括约肌切开成形术的疗效。方法回顾分析43例括约肌切开成形术的临床资料。其中胆囊切除术后括约肌狭窄11例,胆管壶腹部结石嵌顿3例,胆总管切开取石伴胆管末端狭窄19例,复发性胆源性胰腺炎6例,内镜下括约肌切开术后4例;第1次手术24例,第2次手术19例。结果腹部切口感染5例,短暂性胆漏2例,括约肌手术处渗血3例,37例(占86%)经5￣15年随访,效果满意。结论正确掌握手术适应证和操作方法,可取得良好效果。

Cx43对胆总管结扎大鼠心肌损伤的负向调控作用及其机制

目的探讨缝隙连接蛋白43(Cx43)在胆总管结扎(CBDL)引起的大鼠心肌损伤中的作用及其分子机制。方法将18只SD大鼠随机分为假手术组、CBDL组及Cx43抑制剂组,每组6只。假手术组大鼠行胆总管游离术,CBDL组大鼠游离、结扎并切断胆总管,Cx43抑制剂组大鼠术前24 h通过尾静脉单次注射25 mg/kg的Gap 26后,游离、结扎并切断胆总管。三组大鼠饲养至术后第14天时采用心脏超声检查评估心脏射血分数(EF)、缩短分数(FS)和心率(HR);随后测定三组大鼠血清总胆红素(TBil)、苯丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、乳酸脱氢酶(LDH)、肌酸激酶-MB(CK-MB)、超氧化物歧化酶(SOD)、谷胱甘肽过氧化物酶(GSH-PX)活性及丙二醛(MDA)水平;取三组大鼠心脏组织行HE染色和Masson染色;采用免疫印迹实验检测心脏组织中Cx43、Wnt 3α、β-catenin蛋白的水平。结果心脏超声检查结果显示,CBDL组、Cx43抑制剂组大鼠心脏EF、FS、HR均显著低于假手术组(F=22.95~43.55,t=5.10~9.32,P<0.05)。血生化及氧化应激指标检测结果显示,与假手术组相比,CBDL组、Cx43抑制剂组大鼠血清中TBil、AST、ALT、LDH、CK-MB、MDA、GSH-PX水平显著升高,SOD的水平显著降低(F=19.29~100.60,t=3.67~13.72,P<0.05)。HE染色及Masson染色结果显示,CBDL组和Cx43抑制剂组大鼠发生心肌损伤及心肌间质纤维化。免疫印迹实验结果显示,与假手术组相比,CBDL组和Cx43抑制剂组大鼠心脏组织中Cx43水平显著下降,Wnt 3α、β-catenin水平显著升高(F=28.50~70.07,t=4.32~11.79,P<0.05);与CBDL组相比,Cx43抑制剂组大鼠心脏组织中Cx43水平显著下降,Wnt 3α、β-catenin水平显著升高(t=4.95~5.20,P<0.05)。结论CBDL大鼠心脏组织中Cx43下调可负向调控激活Wnt 3α/β-catenin通路,导致大鼠心肌组织损伤加剧及心脏功能下降。

Surgical treatment of the biliary ductal stricture complicating localized left hepatolithiasis

AIM To summarize the experience in the clinical treatment of the biliary ductal strictures complicating localized left hepatolithiasis in recent two decades.

IgG4相关消化系统疾病临床误诊分析

目的 分析IgG4相关消化系统疾病的诊断措施及误诊原因、防范措施。方法 回顾性分析2021年1月—2023年6月误诊为胰腺癌或胆管癌等消化道肿瘤的IgG4相关消化系统疾病9例的临床资料。结果 4例因黄疸入院,4例因腹痛入院,1例因腹痛腹泻、发热为主要表现入院。其中8例IgG4升高,1例IgG4正常。3例癌胚抗原及癌抗原125(CA125)升高,2例CA199升高,2例抗核抗体升高,2例类风湿因子升高。2例甲状腺功能异常,3例肝功能异常。2例血糖高,3例淀粉酶及脂肪酶升高。5例误诊胰腺癌,3例误诊为胆管癌,1例误诊为肠道淋巴瘤。误诊时间为2个月~1.5年。本组均行活检,结合CT、MR考虑IgG4相关消化系统疾病。确诊后予糖皮质激素治疗,症状均改善,复查肿瘤标志物及IgG4均正常。2例症状改善后自行停药,再次出现腹痛症状,IgG4再次升高,再次给予糖皮质激素治疗有效。目前所有患者均在随访中,未发现有消化道肿瘤证据。结论 IgG4相关消化系统疾病缺乏特异性临床表现及检查方法,容易误诊为消化道肿瘤,临床医生应该提高对该病的认识,及时完善相关检查,并结合病史、影像学、病理检查等结果综合分析,确诊者应早期使用糖皮质激素治疗。

Donation after cardio-circulatory death liver transplantation

The renewed interest in donation after cardio-circulatory death (DCD) started in the 1990s following the limited success of the transplant community to expand the donation after brain-death (DBD) organ supply and following the request of potential DCD families. Since then, DCD organ procurement and transplantation activities have rapidly expanded, particularly for nonvital organs, like kidneys. In liver transplantation (LT), DCD donors are a valuable organ source that helps to decrease the mortality rate on the waiting lists and to increase the availability of organs for transplantation despite a higher risk of early graft dysfunction, more frequent vascular and ischemia-type biliary lesions, higher rates of re-listing and re-transplantation and lower graft survival, which are obviously due to theinevitable warm ischemia occurring during the declaration of death and organ retrieval process. Experimental strategies intervening in both donors and recipients at different phases of the transplantation process have focused on the attenuation of ischemia-reperfusion injury and already gained encouraging results, and some of them have found their way from pre-clinical success into clinical reality. The future of DCD-LT is promising. Concerted efforts should concentrate on the identification of suitable donors (probably Maastricht category Ⅲ DCD donors), better donor and recipient matching (high risk donors to low risk recipients), use of advanced organ preservation techniques (oxygenated hypothermic machine perfusion, normothermic machine perfusion, venous systemic oxygen persufflation), and pharmacological modulation (probably a multi-factorial biologic modulation strategy) so that DCD liver allografts could be safely utilized and attain equivalent results as DBD-LT.