胆—肠Ｒoux—en—Ｙ吻合术治肝胆管结石疗效分析

目的：总结胆－肠Ｒoux-en-Ｙ吻合术治疗肝胆管结石的疗效。方法：对８例肝胆管结石患者行胆－肠Ｒoux-en-Ｙ吻合术。结果：无死亡，暂时性胆漏１例，经负压引流１周治愈。随访８例，７例情况良好，１例有症状，术后１年出现右上腹疼痛但无发热及黄疸，Ｂ超示可能为肝内胆管小结石。结论：胆－肠Ｒoux-en-Ｙ吻合术吻合术对肝胆总管结石有良好效果。

胆囊或胆总管肠吻合术治疗胰腺癌体会(附87例临床报告)

目的:探讨对不能切除的胰腺癌患者行胆汁内引流术是通过胆囊还是胆总管最为理想。方法:胆囊—肠吻合术(CCEA)40例。胆总管—肠吻合术(CDEA)47例。术中根据情况同时行预防性胃空肠吻合术17例。结果:术后BIL、ALP、GGT3种血生化指标降至正常时间CDEA组较CCEA组天数少。远期并发症为26%,其中以CCEA组术后胆管炎和黄疸多见。而近期并发症两组均以感染多见。术后30天内死亡率两组无明显差异。结论:对于不能切除的阻塞性胰腺癌患者应尽量选择胆总管—肠吻合术,并根据病情及肿瘤累及程度同时行预防性胃空肠吻合术。

胆肠Roux-Y吻合术对胃酸分泌功能影响的临床研究

本研究对两种胆肠Roux—Y吻合术(端侧吻合和侧侧吻合)后34例病人做平均4年7个月的随防观察,并对14例胆肠Roux—Y吻合术前术后的胃酸分泌情况进行了比较。结果表明:端侧吻合术后胃酸明显增高,但其数值仍属正常;而侧侧吻合术后胃酸无明显增高;无一例消化性溃疡。本研究认为:此术式术后消化性溃疡临床并不常见。

胆源性肝硬化继发肝脓肿伴皮下脓肿形成1例

1临床资料患者女性,58岁,因反复上腹痛23年,乏力、纳差4年,复发伴发热2天入院。患者于1989年诊断为＂肝内胆管结石＂,2008年患者出现纳差、乏力,腹胀,皮肤、巩膜黄染伴皮肤瘙痒,诊断为＂胆汁淤积性肝硬化＂,至2009年先后5次行＂肝内胆管结石取石术、肝叶部分切除术、胆总管取石、胆-肠吻合术＂,术后安置胆道引流管。

Direct cholangioscopy combined with doubleballoon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth Ⅱ gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.

Diagnosis and Treatment of Liver Cystadenocarcinoma:Report of 18 Cases

Objective： To discuss the diagnosis and treatment of liver cystadenocarcinoma. Methods： The clinical, imaging, and pathological data of 18 patients with liver cystadenocarcinoma between January 2000 and December 2004 in our hospital were retrospectively analyzed. Results： The liver cystadeno- carcinoma was seen in males and females （m/f： 9/9）; mean age was 51 years. Ultrasonography revealed cystic parenchymatous mass echoes of fluid predominance with uneven margins. Nonenhanced CT revealed intrahepatic low-density space occupying shadows with nodular protrusions on the margins in all cases. Enhancement CT revealed that part of the nodular protrusions and tissues around the lesions were enhanced and the delayed phase disappeared. 66.67% （12/18） of the lesions were more than 10 cm in diameter. The diagnosis of liver cystadenocarcinoma was confirmed by postoperative pathology in all cases. Of these patients, 12 lesions were in the left lobe, 3 in the right lobe, 1 in the mid lobe, 1 in the right and left lobe, and 1 in the caudate lobe. Of tile 18 patients, 6 had completely resect the cystadenocarcinoma, 2 were surgically explored, one received TAE＋fine needle aspiration cytology＋injection of chemotherapy drugs, and 9 underwent radical hepatectomy＋choledochostomy or T-tube drainage, in which, one patient underwent choledochostomy＋left hepatectomy＋radical gastrectomy for cancer＋lymphadenectomy; one patient underwent resection of the cystadenocarcinoma, who had relapse 20 months after the initial procedure. The patient received repeat reseet for the recurrent cystadenoeareinoma＋eholangio-jejunostomy. Six months later she had another relapse and received repeat reseet （only PMCT） for the recurrent cystadenoearcinoma. The patient died from eholangiopleural fistula after third time operation （PMCT） was attempted perioperatively. Seven patients died of metastatic disease after operation. The remaining 10 patients were alive without cancer recurrence or metastasis （mean follow-up 20 months）. Conclusion： Liver eystadenocarcinoma is rarely seen and grows slowly. It shows some typical clinical and imaging features. The crux for diagnosing and treating liver cystadenoeareinoma is how familiar the surgeon is with the pathology and clinical features of the condition. Prolonged survival can be achieved by radical resection of the tumor.

Study on variou operations and prognosis extrahepatic bile duct cance

AIMS To evaluate clinically the surgical procedures and their in- fluence on the prognosis of extrahepatic bile duct cancer. METHODS A total of 55 patients with pathologically and clini- cally verified extrahepatic bile duct cancer treated in our depart- ment between January 1984 and December 1993 were retrospec- tively analyzed.Clinical courses with respect to the surgical pro- cedures employed and the survival period of these patients were followed up and compared. RESLUTS Of these patients,24 involved the upper third of ex- trahepatic biliary tract,12 the middle third,and 19 the lower third.Diagnosis of bile duct cancer was confirmed histopatholo- gically in 42 patients,with a clear predominance of adenocarcino- ma(97.6 percent).Eleven(26.2 percent)patients received cu- rative resection;30 received palliative procedures,i.e.,biliary- enteric bypass(n=14)and external drainage(n=16);6 re- ceived permanent PTCD alone and 8 received exploratory laparo- tomy only or conservative treatment.Forty-eight patients(87.3 percent)were followedup.The overall mean survival period was 10.8±9.7months(±s);patients with curative resection had the longest survival period(21.4±16.7 months,±s,P<0. 01)and highest survival rate(P<0.05);a significant survival difference was observed in patients with biliary-enteric anastomo- sis compared with those with external drainage,ect.(P<0. 05);but there was no significant difference in survival period be- tween patients having PTCD(n=23)and not(n=26)prior to surgery(P>0.05). CONCLUSIONS Curactive resection is the treatment of choice for suitable patients with extrahepatic bile duct cancer;biliary-en- teric anastomosis is preferable in those with unresectable tumor in order to improve the prognosis and quality of life.

Pyogenic liver abscess after choledochoduodenostomy for biliary obstruction caused by autoimmune pancreatitis

A 68-year-old man underwent cholecystectomy and choledochoduodenostomy for biliary obstruction and nephrectomy for a renal tumor. Based on clinical and histopathologic findings, autoimmune pancreatitis (AIP) was diagnosed. The renal tumor was diagnosed as a renal cell cancer. Steroid therapy was started and thereafter pancreatic inflammation improved. Five years after surgery, the patient was readmitted because of pyrexia in a preshock state. A Klebsiella pneumoniae liver abscess complicated by sepsis was diagnosed. The patient recovered with percutaneous abscess drainage and administration of intravenous antibiotics. Liver abscess recurred 1 mo later but was successfully treated with antibiotics. There has been little information on long-term outcomes of patients with AIP treated with surgery. To our knowledge, this is the second case of liver abscess after surgical treatment of AIP.

肝门部胆管癌的非切除性辅助治疗方式选择

目的探讨肝门部胆管癌的非切除性辅助治疗方式。方法经皮肝胆管引流术(PTCD)22例(A组),其中12例放置金属内支架。胆肠吻合术29例(B组)。两组对胆管炎、引流管相关问题、黄疸、住院时间、是否用抗生素、止痛药六个参数进行评价,对1个月内生存质量进行评估。结果A组4例PTCD黄疸消退不明显或黄疸复发,B组仅3例黄疸消退不满意。A、B两组生存质量评估显示与引流管相关问题尤为明显(40.8%),其中PTCD5例,出现引流管滑移或阻塞,12例金属内支架一次性置入成功。结论金属内支架置入术是辅助治疗非切除性肝门部胆管癌的有效方法,其生存质量高于PTCD。

A comparison of spur valve and percutaneous enterostomy in Roux-Y portoenterostomy for biliary atresia

Objective To compare the advantages and disadvantages of two procedures: Roux-Y with enterostomy and Roux-Y with spur valve in the treatment of biliary atresia.Methods Twenty-four patients with biliary atresia underwent hepatic portoenterostomy with percutaneous jejunal enterostomy (Group A) and 24 patients underwent Roux-Y with antireflux spur valve (Group B). Clinical data were reviewed retrospectively.Results Ten patients remained alive in the Group A. Among them, 9 survived without jaundice, the oldest one being 9-years old. One of the 9 patients had portal hypertension. The remaining one who survived with jaundice and portal hypertension was 8-years old at follow up. Ten patients in the Group B remained alive. Of them, 8 survived without jaundice and 2 with jaundice.Conclusions Two surgical procedures had similar effects in preventing reflux cholangitis, while spur valve has the benefit of quitting cutaneous enterostomy.

The presence of primary sclerosing cholangitis in patients with ileal pouch anal-anastomosis is associated with an additional risk for vitamin D deficiency

Objective:Vitamin D deficiency is common in patients with ileal pouch-anal anastomosis(IPAA)for ulcerative colitis(UC).Whether vitamin D levels are further lowered in patients with concomitant IPAA and primary sclerosing cholangitis(PSC)is not known.The aim of this study was to evaluate the presence of PSC as a risk factor for vitamin D deficiency in patients with UC and IPAA.Methods:In this case control study,74 patients with concurrent IPAA and PSC were included in the study group,and 79 patients with IPAA,but without PSC,served as controls.Forty-four variables were analyzed.Univariate analysis and multivariate analysis with stepwise logistic regression were performed.Results:A total 153 eligible patients were included,with 74(48.4%)in the study group and 79(51.6%)in the control group.Vitamin D level in the study group was 18.961.4 ng/dL compared with 30.361.7 ng/d in the control group(P=0.011).Vitamin D deficiency(≤20 ng/dL)was present in 65(42.5%)patients.PSC occurred in 49(75.4%)of the 65 patients with vitamin D deficiency.In the multivariate analysis,only the presence of PSC(odds ratio[OR]:7.56;95% confidence interval[CI]:2.39–24.08;P=0.001)and vitamin D supplementation(OR:2.58;95% CI:1.57–9.19;P=0.018)remained associated with vitamin D deficiency.Conclusion:The presence of PSC was found to be an independent risk factor for vitamin D deficiency in UC patients with IPAA.These patients should be routinely screened and closely monitored for vitamin D deficiency.

Comparative analysis of different hepaticojejunostomy techniques for treating adult type I choledochal cyst

Objective:To compare Roux-en-Y hepatico-jejunostomy with complete resection of the cyst or incomplete resection with 1-cm remnant proximal cyst wall in treating adult type I choledochal cyst(CC).Methods:The medical records of 267 adult patients with type I CC from January 1998 to December 2015 were reviewed retrospectively.Among them,171 underwent Roux-en-Y hepatico-jejunostomy with complete resection(PBD 0-cm group)and 96 underwent Roux-en-Y hepatico-jejunostomy with 1-cm proximal cyst wall left(PBD 1-cm group).The short-and long-termpost-operative complications were compared between the two groups.Results:No significant difference was observed in operative time or anastomotic diameter between the two groups.The incidence of perioperative complications was significantly higher in the PBD 1-cm group than that in the PBD 0-cm group(28.1%vs 14.0%,p¼0.005),especially post-operative cholangitis(7.3%vs 1.2%,p¼0.021).The incidence of long-term post-operative complications was not significantly different,including anastomotic stricture,reflux cholangitis,intra-hepatic bile duct stones and bile leak(all p>0.05).Post-operative intra-pancreatic biliary malignancy occurred in one patient in the PBD 0-cm group at 25 months and one patient in the PBD 1-cm group at 5 month,respectively.Anatomical site malignancy was observed in one patient in the PBD 1-cm group at 10 months.Conclusion:Ease of performing anastomosis does not justify retaining a segment of choledochal cyst in type I CC due to its higher risk of post-operative complication and malignancy.A complete excision of the CC with anastomosis to the healthy proximal bile duct is necessary in treatment of type I CC.