Bile Acid Overload Induced by Bile Duct and Portal Vein Ligation Improves Survival after Staged Hepatectomy in Rats

Objective Compared to portal vein ligation(PVL),simultaneous bile duct and portal vein ligation(BPL)can significantly enhance hypertrophy of the intact liver.This study aimed to investigate whether BPL could improve survival after extended hepatectomy independently of an increased remnant liver.Methods We adopted rat models of 90%BPL or 90%PVL.To investigate the role of bile acids(BAs)the BA pools in the PVL and BPL groups were altered by the diet.Staged resection preserving 10%of the estimated liver weight was performed 3 days after BPL;PVL;or sham operation.Histology,canalicular network(CN)continuity;and hepatocyte polarity were evaluated.Results At 3 days after BPL;PVL;or sham operation when the volumetric difference of the intended liver remained insignificant,the survival rates after extended hepatectomy were 86.7%,47%,and 23.3%,respectively(P<0.01).BPL induced faster restoration of canalicular integrity along with an intensive but transient BA overload.Staged hepatectomy after BPL shortened the duration of the bile CN disturbance and limited BA retention.Decreasing the BA pools in the rats that underwent BPL could compromise these effects,whereas increasing the BA pools of rats that underwent PVL could induce similar effects.The changes in CN restoration were associated with activation of LKB1.Conclusion In addition to increasing the future remnant liver,BPL shortened the duration of the spatial disturbance of the CN and could significantly improve the tolerance of the hypertrophied liver to staged resection.BPL may be a safe and efficient future option for patients with an insufficient remnant liver.

Sequential embolization of the branches of the bile duct and portal vein to the targeted hepatic lobe in rats

BACKGROUND: The high recurrence rate of hepatolithiasis and the high operative risk of right posterior, caudate or multiple lobe hepatectomy are the unsettled problems in hepatobiliary surgery. The present study was to investigate the efficacy of chemical hepatectomy performed via applying sequential embolization of the branches of the bile duct and portal vein to the targeted hepatic lobe. METHODS: The bile duct and portal vein branches of the median hepatic lobe of rats were treated with: 1) bile duct embolization followed by portal vein ligation(BDE+PVL) and 2) portal vein ligation followed by bile duct embolization(PVL+BDE). The efficacy of chemical hepatectomy in BDE+PVL and PVL+BDE groups was compared with that of sole BDE by histology and Western blotting analysis of collagen I expression. RESULTS: After six weeks of the chemical hepatectomy, rats in the BDE group showed hepatocyte damages, fibrosis and 'selfcut' only in the periphery of the embolized lobe. In contrast, rats in the PVL+BDE and BDE+PVL groups exhibited complete necrosis of hepatocytes and replacement with proliferative ductules and collagen fibers, leading to complete fibrosis and 'self-cut' phenomenon in the whole targeted lobe. Collagen I expression in the PVL+BDE group was slightly higher than that in the BDE+PVL group; however, no statistically significant difference was noted. CONCLUSION: The sequential embolization of the bile duct and portal vein branches to the targeted hepatic lobe may bea feasible and effective approach to acheive the ideal effect of chemical hepatectomy in a short period of time.

True left-sided gallbladder with variations of bile duct and cholecystic vein

A left-sided gallbladder without a right-sided round ligament,which is called a true left-sided gallbladder,is extremely rare.A 71-year-old woman was referred to our hospital due to a gallbladder polyp.Computed tomography(CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion.CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein.CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct.Laparoscopic cholecystectomy was performed for a gallbladder polyp,and the intraoperative finding showed that the cholecystic veins joined the round ligament.A true left-sided gallbladder is closely associated with several anomalies; therefore,surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

腹腔镜解剖性肝Ⅲ段切除治疗左肝区域性肝内胆管结石临床效果

目的 探讨腹腔镜解剖性肝Ⅲ段切除治疗左肝区域性肝内胆管结石的手术要点、适应证及可行性。方法 采用回顾性描述性研究方法,收集2021年8月至2022年10月湘雅常德医院(3例)和湘西土家族苗族自治州人民医院(1例)收治的4例局限于肝Ⅲ段的肝内胆管结石患者临床资料,其中男1例,女3例,中位年龄61.5(45.0~69.0)岁。4例患者中,2例为单纯性肝Ⅲ段肝内胆管结石,1例为肝Ⅲ段肝内胆管结石合并胆囊结石、胆总管结石,1例为肝Ⅲ段肝内胆管结石合并胆囊结石。4例患者均接受腹腔镜解剖性肝Ⅲ段切除术式治疗局限于肝Ⅲ段的肝内胆管结石。结果 4例患者均顺利完成腹腔镜解剖性肝Ⅲ段切除术,其中1例实施联合肝左静脉重建的解剖性肝Ⅲ段切除术。无中转开腹病例及切肝范围的变更。手术时间分别为280 min、440 min、220 min及110 min;第一肝门阻断时间分别为60 min、60 min、75 min和25 min。术中均无输血。4例患者术后住院时间分别为12 d、10 d、9 d和6 d。1例发生肝断面积液,经保守治疗吸收治愈;其余3例均无并发症发生。4例患者均获随访,中位随访时间19.5(10.0~24.0)个月,均无结石复发或胆道相关症状。结论 对于符合特定解剖条件的局限于肝Ⅲ段的肝内胆管结石,腹腔镜解剖性肝Ⅲ段切除术安全可行,疗效满意。

大鼠原位肝移植解剖重建研究进展

大鼠肝移植模型的构建,为解决临床肝移植术后并发症及围手术期治疗等问题提供了理想的动物模型。随着对大鼠肝移植模型建立的深入研究,逐渐形成了经典的“二袖套”法。然而,在移植手术过程中,手术视野差、血管扭转、胆道损伤和无肝期较长等问题仍是传统方法无法避免的。目前国内外大鼠肝移植模型改进方式主要围绕肝上下腔静脉、门静脉、肝下下腔静脉和胆管这4个重要解剖结构的重建展开。为此,本文就肝上下腔静脉、门静脉、肝下下腔静脉和胆管重建领域的最新进展进行整理总结,以便为大鼠肝移植模型的构建提供参考,促进肝移植技术的进一步发展。

The Ortholog of LYVE-1 Is Required for Thoracic Duct Formation in Zebrafish

LYVE-1 (also termed CRSBP-1), a 120-kDa disulfide-linked dimeric type I membrane glycoprotein, is a specific marker for lymphatic endothelial cells (LECs) and exhibits multiple ligand (hyaluronic acid and growth factors/cytokines) binding activity in mammals. Recent studies indicate that LYVE-1/CRSBP-1 ligands (VEGF-A165, PDGF-BB, oligopeptides containing the cell-surface retention sequence (CRS) motifs of VEGF-A165 and PDGF-BB) induce opening of lymphatic intercellular junctions in vitro and in vivo. To determine the function of the ortholog of mammalian LYVE-1 in zebrafish, we cloned it (zLyve-1). The cloned cDNA (zLyve1) encodes a 328-amino-acid type I membrane glycoprotein. The protein and genomic structure evidence supports the notion that the cloned zLyve-1 is the ortholog of LYVE-1 in zebrafish. zLyve-1 expressed in cultured cells by transfection exhibits hyaluronic acid binding activity but lacks the growth factor binding activity seen in mammalian homologs. Knockdown of zLyve-1 levels by embryo microinjection with a specific antisense morpholino oligonucleotide (MO2) in wild-type and Tg(fli1:EGFP)-transgenic zebrafish causes defects in thoracic duct (TD) formation. Such zebrafish injected with MO2 also exhibit impaired TD flow (as determined by intramuscular injection of FITC-dextran). The phenotypes in these zebrafish injected with MO2 are reversed by co-injection with zLyve1cDNA. In situ hybridization reveals that zLyve-1 is expressed in the posterior cardinal vein (PCV). Expression of zLyve-1 at the highest level in the PCV occurs at 3 dpf which coincides with the time for TD formation in zebrafish development. These results suggest that zLyve-1 is required for TD formation. They also suggest that zLyve-1 is distinct from mammalian LYVE-1 in its role in lymphatic function.

Pancreaticoduodenectomy with combined superior mesenteric vein resection without reconstruction is possible:A case report and review of the literature

We report the case of a 56-year-old woman with pancreatic adenocarcinoma(PA) discovered during an episode of febrile jaundice. A computed tomography(CT) scan showed a mass in the head of the pancreas with circumferential infiltration of the superior mesenteric vein(SMV) and dilatation of the biliary and pancreatic ducts without metastases. The patient benefited from neoadjuvant chemotherapy(FOLFIRINOX) followed by radio-chemotherapy(45 Gy) and chemotherapy(LV5 FU2). The revaluation CT revealed SMV thrombosis without portal vein(PV) thrombosis. There was no contact of the tumor with the PV. Pancreatoduodenectomy with combined resection of the SMV was performed with no reconstruction of this venous axis after confirmation of adequate PV, splenic, and left gastric venous flow and the absence of bowel ischemia. The pathological diagnosis was p T4 N1 R0 PA. There were no bowel angina issues during the follow-up period. At 15 mo after surgery, the patient died of metastatic recurrence.

胸导管与静脉吻合术在复发性重症乳糜胸治疗中的临床应用

目的探讨胸导管与静脉吻合术治疗复发性重症乳糜胸治疗中的应用价值。方法根据引流量以及有无胸导管损伤,将我院2014年1月至2021年12月收治的乳糜胸病人63例分为A、B两组。其中,A组37例,每日胸腔引流量<1000 ml且无胸导管损伤;B组26例,每日引流量>1000 ml且淋巴管造影证实有胸导管损伤。分别采用保守治疗、胸导管结扎或胸导管与静脉吻合等不同方式进行干预,观察病人的症状、胸腔闭式引流液的性状及量、术后恢复时间和预后等。结果根据多因素分析,年龄>60岁(P<0.01)、长期吸烟(P=0.04)、长期饮酒(P=0.03)、曾有恶性肿瘤病史(P=0.02)的病人发生B组乳糜胸的几率更大。A组乳糜胸多数经保守治疗可治愈,而B组中21例保守治疗无效。这些病人采用胸导管结扎手术治疗,其中3例结扎后仍反复乳糜胸病人采用胸导管与静脉吻合术治愈。结论每日引流量>1000 ml伴胸导管损伤类型的乳糜胸应积极手术治疗,胸导管结扎术对常规类型的乳糜胸有良好的治疗效果,但对于持续反复的重症乳糜胸,胸导管与无名静脉或奇静脉吻合术更为有效。

大豆黄酮对二花脸青年去势公猪生长的影响

4头装有慢性颈静脉血管导管的100日龄二花脸去势公猪,采用自身对照试验,试验期1周。在日粮中添加 500mg/kg的大豆黄酮,由血管导管采集对照期和试验期血样,每次间隔15min,连续采集6h。结果表明,血清中生长激素（GH）总体水平上升37.52％,基线水平增加11.64％,峰频率增加 52.63％;试验期猪血清中IGF-1与对照期相比增加 32.16％,差异显著;T3、T4分别下降41.51％、44.87％。代谢产物尿素氮、胆固醇浓度下降,谷丙转氨酶活性、葡萄糖浓度增加,总的趋势是促进去势公猪的生长。

原位中心静脉导管置换在ICU的应用

目的探讨原位中心导管置换的临床意义。方法对33例次已进行中心静脉穿刺置管的病例实施原位导管置换。结果30次换管成功,3例换管失败,换管后导管功能正常。结论原位中心静脉导管置换操作简单,对病人安全、痛苦小、无创伤。

心包腔置管引流并注射沙培林治疗恶性心包积液

目的:观察经B超引导下用中心静脉导管经皮穿刺行心包引流,并腔内注射沙培林治疗恶性心包积液的疗效。方法:19例恶性心包积液患者,采用Seldinger穿刺法,B超引导下经皮穿刺置入Arrow中心静脉导管,留置导管行心包引流后腔内注射沙培林5KE。结果:中心静脉导管穿刺心包积液引流并发症低、引流彻底,同时腔内注射沙培林疗效好、副作用小。结论:用中心静脉导管穿刺引流并腔内注射沙培林治疗恶性心包积液方法简单易行、疗效好。

经皮经肝门静脉栓塞术在肝门部胆管癌手术中的应用

目的探讨对肝门部胆管癌行扩大右半肝切除术前使用经皮经肝门静脉栓塞术(portalveinembolization,PVE)的疗效。方法2005年10月对1例伴有肝硬化的肝门部胆管癌施行经皮经肝门静脉栓塞术(percutaneousportalveinembolization,PTPE),记录肝脏在血流动力学、体积、功能、病理方面的改变。结果PTPE术后第5天体温升至39.2℃,然后逐渐下降,同时伴有轻度右上腹痛,无恶心呕吐,未见腹腔出血及胆漏。PTPE术后左叶体积从417.0ml增加到522.4ml(肥大率125.2%);右叶体积从1041·3ml减少到1017·4ml(萎缩率97.7%);左叶占全肝的体积比从28.6%升至33·9%。左矢状部血流速度术前为12·8ml/s,术后当日、第6天分别为23·2、17·1ml/s。较原流量增加100%和39%(术后当日,第6天)。PTPE术后17d左肝胆汁的引流量超过右肝。PTPE术后34d患者接受扩大右半肝切除术,术中见肝左叶可见明显的肥大,肝脏5、6、7段(S5,6,7)与其余肝段间有明显的界限,术后3个月病情平稳。术后病理:栓塞叶门静脉狭窄及闭塞而肝细胞变性,坏死及凋亡。结论PVE能有效诱导未栓塞肝叶的肥大,从而提高对伴有肝损害的患者行扩大肝脏切除的安全性。

肝尾状叶脉管构筑的应用解剖

应用55例成人肝剥离标本及45例胎儿、新生儿肝管道铸型,研究了肝尾状叶的鞘系及静脉回流。尾状叶有两个恒定的蒂、接受左、右侧鞘系的双重供应,以左侧为主;而尾状突主要由右后叶鞘系分布。15例肝铸型标本的尾状叶左、右侧动脉形成吻合弓。尾状叶动脉供应形式可分为三种,静脉可分为三型并直接汇入下腔静脉。由于血管吻合的存在,在病理状态下,尾状叶也应是沟通门一腔静脉的桥梁。

部分门静脉动脉化对大鼠肝门部胆管的影响

目的探讨部分门静脉动脉化重建胆管血流后对大鼠肝门部胆管、肝功能及胆管上皮细胞凋亡的影响。方法 45只大鼠随机分为对照组(A组)、肝动脉结扎组(B组)和部分门静脉动脉化组(C组),每组15只,分别于术后3d、7d和1月应用HE染色观察胆管病理学改变,检测血清ALP、GGT变化、肝门部胆管上皮细胞的凋亡情况。结果 A组各时间点肝门部胆管未见明显改变,B组术后3d,可见部分胆管上皮细胞胞质空泡化,7d胆管壁增厚,伴腺体增生,仍可见少量上皮细胞胞质空泡化,1个月胆管壁恢复正常;C组仅3d时出现胆管上皮细胞轻度水肿,无胞质空泡化及腺体增生。血清ALP、GGT均值B组最高,但无统计学意义。各组肝门部胆管上皮细胞均未检测到阳性凋亡。结论部分门静脉动脉化明显减轻肝总动脉结扎后对大鼠肝门部胆管的损害。

部分门静脉动脉化后肝门部胆管细胞增生的实验研究

目的了解部分门静脉动脉化后大鼠肝门部胆管上皮细胞的增生改变情况。方法 30只SD大鼠随机分为对照组(A组)、肝总动脉结扎+胆管再通组(B组)及部分门静脉动脉化+胆管再通组(C组),每组10只。A组仅游离肝动脉、门静脉及胆管,不做其他处理,B、C组进行相应的处理。于造模后1个月,取大鼠静脉血检测肝功能的改变,随后处死大鼠取肝门部胆管,行免疫组化染色,检测各组胆管上皮细胞核增生情况和肝门部胆管的病理改变。结果各组大鼠术后均存活。与A组比较,B、C两组胆管细胞表现出较明显的增生,以B组增生最为明显(P<0.01)。三组间碱性磷酸酶水平比较无显著性差异(P>0.05);与A、C组(0.520±0.155,0.590±0.251U/L)比较,B组的γ-谷氨酰胺转移酶水平(0.740±0.135U/L)更高,差异有统计学意义(P<0.05)。与A、C组比较,B组肝门部胆管表现出明显的慢性增生性炎症改变。结论部分门静脉动脉化可以明显减轻肝动脉结扎后所致的肝门部胆管损伤,满足肝门部胆管的动脉血供需求。

手术切除治疗原发性肝癌的疗效评价

目的评价原发性肝癌手术切除治疗后的疗效。方法分析１９６０年１月至１９９６年９月原发性肝癌３９３２例行手术切除治疗后手术死亡率和生存率。结果比较１９６０～１９７７年（ｎ＝１８１）、１９７８～１９８９年（ｎ＝９２１）、１９９０～１９９６年（ｎ＝２８３０）三阶段，术后死亡率分别为８．８４％、０．４３％、０．３５％，而５年生存率分别为１６．０％、３０．６％、４８．６％。比较局部肝切除术（ｎ＝９０２）与规则性肝切除术（ｎ＝１１４９）表明，局部切除术手术死亡率低（０．１０％对４．７％，Ｐ＜０．０５），而５年生存率两者无明显差异（３６．１％对４０．３％，Ｐ＞０．０５）。比较大肝癌（＞５ｃｍ，ｎ＝３２２３）与≤５ｃｍ肝癌（ｎ＝７０９）和≤３ｃｍ肝癌（ｎ＝２４１）资料，１、３、５年生存率分别为６２．５％、４２．６％、２７．５％；８９．９％、８５．０％、７９．８和９５．５％、９１．７％、８５．３％。肝癌切除加门静脉（ｎ＝６５）或胆管内（ｎ＝２３）癌栓清除术治疗肝癌伴有癌栓者，术后２年生存率分别为２５．３％和３６．５％。肝癌切除加脾切除和／或门奇断流术治疗肝癌合并门静脉高压者（ｎ＝４８），术后１、２年生存率为８３．４％和７５．２?

胆管狭窄替代性组织修复的再认识

目的 :提高胆管狭窄的治疗水平。方法 :报告 2例胆管狭窄病人治疗后再手术的经过。结果 :1例损伤性胆管狭窄、1例Mirizzi综合征病人均用脐静脉修复 ,分别于术后半年及 2年出现狭窄复发 ,再行胆管 空肠Roux Y吻合治愈。结论 :用非胆道组织修补胆管取决于胆管缺损大小与奥迪氏括约肌功能正常与否。

中药涂敷预防PICC致机械性静脉炎的临床观察

[目的]探讨中药外敷在预防PICC致机械性静脉炎方面的临床效果。[方法]将158例PICC肿瘤患者随机分为观察组(78例)与对照组(80例),观察组行PICC置管后24h,在穿刺点上方3～4cm处延穿刺静脉走行预防性涂敷中药10×5cm,连续5d,对照组行PICC后不应用中药外敷,观察两组患者机械性静脉炎的发生率。[结果]观察组机械性静脉炎发生率为6.41%,对照组为17.5%,观察组机械性静脉炎发生率明显低于对照组(P<0.05)。[结论]PICC置管后预防性中药涂敷可有效降低机械性静脉炎的发生率。

脐静脉修复胆管狭窄的复发

目的 提高胆管狭窄的治疗水平。方法 报告 2例胆管狭窄病人用脐静脉修复后再狭窄的经过。结果 1例损伤性胆管狭窄 ,1例Mirizzi综合征病人均用脐静脉修复 ,分别于术后半年及 2年出现狭窄复发 ,再行胆管—空肠Roux Y吻合治愈。结论 用非胆道组织修补胆管取决于胆管缺损大小与奥迪括约肌功能正常与否。

导管持续引流并注射博来霉素治疗恶性心包积液

目的：观察导管持续引流并博来霉素心包腔内注射对恶性心包积液的疗效。方法：31例恶性心包积液患者行中心静脉导管持续引流后,心包腔内注射博来霉素。结果：中心静脉导管穿刺心包积液引流并发症低、引流彻底,同时腔内注射博来霉素疗效好、副作用小。结论：用中心静脉导管穿刺引流并腔内注射博莱霉素治疗恶性心包积液方法简单易行，疗效显著。