内镜微创保胆术后结石复发的胆囊因素分析

目的 研究内镜微创保胆术后复发的胆囊病变因素。方法 将行内镜微创保胆手术的患者根据胆囊的病变的情况分为9组：①胆囊壁光滑,厚度小于5 mm,②胆囊壁光滑,厚度大于5 mm,③胆囊内分隔,④胆囊壁间结石,⑤胆囊颈部结石嵌顿,⑥胆囊壁胆固醇沉积,⑦胆囊壁厚度大于5 mm伴有胆囊壁间结石,⑧胆囊分隔,胆囊壁厚度大于5 mm,⑨胆囊分隔伴有胆囊壁间结石。每年B超复查,在第5年后统计结石复发率。结果 胆囊壁光滑,厚度小于5 mm,其5年复发率为3.0%;胆囊壁光滑,厚度大于5 mm,其5年复发率为2.4%;胆囊分隔术后5年复发率为4.7%;胆囊颈部结石嵌顿术后5年复发率为2.3%;胆囊壁胆固醇沉积术后5年复发率为2.3%~4.5%;胆囊分隔,胆囊壁厚度大于5 cm术后5年复发率为6.4%;胆囊壁间结石术后5年复发率为0.0%~7.5%;胆囊壁间结石伴有胆囊分隔术后复发率为7.4%~16.9%;胆囊壁厚度大于5 mm伴壁间结石其术后5年复发率为12.5%。结论 胆囊结石行保胆手术时,胆囊壁厚度、胆固醇沉积、胆囊分隔及胆囊壁间结石其复发率不高,可行保胆手术,当胆囊壁间结石合并有胆囊分隔,其术后5年复发率明显升高,应考虑胆囊切除。

影响腹腔镜胆囊手术转开腹手术危险因素分析

目的分析腹腔镜胆囊切除转开腹手术的相关危险因子。方法对1998年1月至2007年12月在上海新华医院普外科进行腹腔镜胆囊手术的2550例患者的临床病例资料进行回顾性分析。结果2550例患者中，255例转为开腹术（10．00％）。其中，高龄、男性、体重超重、有急性胆囊炎史、有上腹部手术史、糖化血红蛋白高，以及低年资医师主刀等是中转开腹的危险因素。慢性肝病不是危险因素。结论丰富的手术经验是避免中转开腹的重要因素。此外，术前仔细分析患者病史及检查结果并以此规划手术细节，有助于降低中转开腹的几率。

Effects of psychological stress on small intestinal motility and expression of cholecystokinin and vasoactive intestinal polypeptide in plasma and small intestine in mice

AIM: To investigate the effects of psychological stress on small intestinal motility and expression of cholecystokinin (CCK) and vasoactive intestinal polypeptide (VIP) in plasma and small intestine, and to explore the relationship between small intestinal motor disorders and gastrointestinal hormones under psychological stress. METHODS: Thirty-six mice were randomly divided into psychological stress group and control group. A mouse model with psychological stress was established by housing the mice with a hungry cat in separate layers of a two-layer cage. A semi-solid colored marker (carbon-ink) was used for monitoring small intestinal transit. CCK and VIP levels in plasma and small intestine in mice were measured by radioimmunoassay (RIA). RESULTS: Small intestinal transit was inhibited (52.18±19.15% vs70.19±17.79%, P<0.01) in mice after psychological stress, compared to the controls. Small intestinal CCK levels in psychological stress mice were significantly lower than those in the control group (0.75±0.53 μg/g vs1.98±1.17 μg/g, P<0.01), whereas plasma CCK concentrations were not different between the groups. VIP levels in small intestine were significantly higher in psychological stress mice than those in the control group (8.45±1.09 μg/g vs7.03±2.36 μg/g, P<0.01), while there was no significant difference in plasma VIP levels between the two groups. CONCLUSION: Psychological stress inhibits the small intestinal transit, probably by down-regulating CCK and up-regulating VIP expression in small intestine.

Pre-operative factors that can predict neoplastic polypoid lesions of the gallbladder

AIM:To investigate the preoperative factors that can predict neoplastic polypoid lesions of the gallbladder(PLGs) as well as malignant PLGs.METHODS:A retrospective analysis was conducted on the 210 consecutively enrolled patients who underwent cholecystectomy due to a PLG larger than 10 mm,as was determined by preoperative trans-abdominal ultrasonography or endoscopic ultrasonography.We ana-lyzed the medical,laboratory,radiologic data and the pathologic results.RESULTS:In 210 cases,146 had non-neoplastic polyps(69.5%) and 64 cases were neoplastic polyps(30.5%).An older age(≥ 65 years),the presence of diabetes mellitus(DM) and the size of polyp(≥ 15 mm) were revealed to be independent predictive variables for neoplastic polyps with odd ratios(OR) of 2.27(P = 0.044),2.64(P = 0.021) and 4.94(P < 0.01),respectively.Among the neoplastic PLGs,an older age(≥ 65 years),the presence of DM and polyp size(≥ 15 mm) were associated with malignancy with ORs of 4.97(P = 0.005),6.13(P = 0.001) and 20.55(P < 0.001),respectively.CONCLUSION:Among patients with PLGs larger than 10 mm in size,higher risk groups such as elderly patients more than 65 years old,those with DM or a large polyp size(≥ 15 mm) should be managed by cholecystectomy.

Effect of electroacupuncture at Lower He-Sea points including Yanglingquan(GB 34)on nuclear factor-κB and interleukin-1βin guinea pigs with acute cholecystitis

Objective:To observe the effect of electroacupuncture(EA)at Lower He-Sea points on the expression levels of interleukin-1β(IL-1β)in the serum and gallbladder tissues,and nuclear factor-κB(NF-κB)in gallbladder tissues of the guinea pigs with acute cholecystitis(AC),and to explore whether Yanglingquan(GB 34),the Lower He-Sea point pertaining to Dan Fu(gallbladder),is relatively specific for the Dan Fu(gallbladder)disorders.Methods:Eighty-two healthy guinea pigs were randomly divided into 6 groups according to the random number table method,a blank group,a model group,a Yanglingquan(GB 34)group,a Zusanli(ST 36)group,a Shangjuxu(ST 37)group,and a Xiajuxu(ST 39)group,with 12 guinea pigs in the blank group while 14 in the other groups,respectively,half males and half females in each group.Except for the blank group,guinea pigs in the other groups were injected with E.coli into the gallbladder to establish AC models.Guinea pigs in the blank group were fed routinely without special treatment;those in the model group were daily tied up for 30 min without EA treatment;those in the 4 groups receiving EA treatment were acupunctured at the corresponding Lower He-Sea points after daily binding and stimulated with the SDZ-V EA instrument.After successful modeling and treatment for 5 d,blood was collected from the abdominal aorta of the guinea pigs,and the gallbladder tissues in each group were isolated for hematoxylin-eosin(HE)staining to observe the morphological changes.Enzyme-linked immunosorbent assay(ELISA)was used to detect the serum IL-1βlevel,and immunohistochemistry(IHC)was used to detect the expression levels of NF-κB and IL-1βin gallbladder.Results:On the 3rd day after modeling,the guinea pigs in the five groups with modeling were mentally depressed with decreased appetite,significantly reduced activities,slouch,lassitude,slack and matted fur,and loose stools;two guinea pigs were selected from each group(one male and one female,not included in the final statistics)to isolate the gallbladder after sacrifice;macroscopic observation showed that the gallbladder wall was differently thickened;the bile color was dark green and opaque with particles suspended or accumulated;light microscope observation showed that the submucosal blood vessels of the gallbladder were congested,along with mucosal edema,ulceration,necrosis,shedding,and a large number of inflammatory cells infiltrating in the lamina propria,indicating that the AC model was successfully prepared.Compared with the model group,the gallbladder tissue injuries of the four groups receiving EA treatment were all differently repaired,the serum IL-1βlevels were reduced(P<0.01 or P<0.05),and the IL-1βlevels in the gallbladder tissues were reduced(P<0.01 or P<0.05).Compared with the model group,the NF-κB expression level in the Yanglingquan(GB 34)group was significantly reduced(P<0.01),but was not statistical different in the Zusanli(ST 36)group,Shangjuxu(ST 37)group and Xiajuxu(ST 39)group(all P>0.05).Compared with the Yanglingquan(GB 34)group,the gallbladder tissues of the Zusanli(ST 36)group,Shangjuxu(ST 37)group and Xiajuxu(ST 39)group were more severely damaged,and the expression levels of serum IL-1β,the NF-κB and IL-1βin the gallbladder tissues were increased(P<0.01 or P<0.05).Intervention effect of Yanglingquan(GB 34)on AC guinea pigs was superior to that of Zusanli(ST 36),Shangjuxu(ST 37)and Xiajuxu(ST 39).Conclusion:EA at the Lower He-Sea points of the stomach,large intestine,small intestine and gallbladder can produce curative effects on AC guinea pigs and reduced the inflammatory symptoms.Intervention effect of Yanglingquan(GB 34)on AC guinea pigs is superior to that of Zusanli(ST 36),Shangjuxu(ST 37)and Xiajuxu(ST 39).The mechanism of EA at Yanglingquan(GB 34)in treating AC may be regulating IL-1βand NF-κB to control the inflammatory response and improve the gallbladder tissue damage.

Why are we performing fewer cholecystectomies for mild acute biliary pancreatitis?Trends and predictors of cholecystectomy from the National Readmissions Database(2010–2014)

Background:Current guidelines recommend cholecystectomy for patients with mild acute biliary pancreatitis(MABP)during the index admission because it is associated with better outcomes.In this study,we aimed to assess national trends in cholecystectomy during index admissions for MABP and to identify factors associated with cholecystectomy completion and 30-day readmission.Methods:Using diagnostic codes and the National Readmissions Database,we identified patients admitted with MABP between 2010 and 2014.Differences in cholecystectomy rates were computed on the basis of various characteristics.We conducted a multivariable analysis to identify factors associated with 30-day readmission and cholecystectomy during the same admission.Results:We identified 255,695 unique index MABP cases(41.3%male)and the 30-day readmission rate was 12.6%.Overall,43.8%underwent cholecystectomy and 25%underwent endoscopic retrograde cholangiopancreatography(ERCP)with sphincterotomy.We observed a decreasing trend in both procedures during the study period(P<0.001).In multivariate analysis,odds of 30-day readmission were reduced for patients undergoing ERCP with sphincterotomy(odds ratio,0.78;95%confidence interval,0.74–0.84)or cholecystectomy(odds ratio,0.37;95%confidence interval,0.35–0.39).Conclusions:For patients with MABP,cholecystectomy or ERCP with sphincterotomy during the index admission decreased the risk of 30-day readmission.Despite this benefit and national guidelines recommending cholecystectomy during the index MABP admission,the rate of cholecystectomies performed nationally decreased during the study period.Further research is needed to understand the implications and reasons underlying this deviation from guidelines.