Microstructural and ultrastructural changes in the healing process of bile duct trauma

OBJECTIVE: To explore the mechanism of benign biliary stricture caused by bile duct trauma. METHODS: A model of trauma of the common bile duct was established in 28 dogs and then repaired. The anastomotic tissues were taken on 3 days, 1 week, 3 weeks, 3 months, and 6 months respectively after operation and examined by using light microscopy and electromicroscopy. Macrophage. transforming growth factor beta I (TGF-β1) and α-smooth muscle actin (α-SMA) were studied immunohistochemically. RESULTS: The mucosal epithelium of the common bile duct restored poorly, chronic inflammation lasted for a long time, fibroblasts proliferated actively, extracellular matrix overdeposited, and myofibroblasts functioned actively during the whole healing process. Immunohistochemical test showed a high expression of macrophage, TGF-β1 and α-SMA during the healing process lasting a long duration. Macrophages were found in the lamina propria under mucosa, TGF-β1 in the granular tissue, fibroblasts and endothelial cells of blood vessels, while α-SMA in the myofibroblasts and smooth muscle tissue. CONCLUSIONS: The healing of the bile duct is in the mode of overhealing. Myofibroblast is the main cause for contracture of scar and stricture of the bile duct. The high expression of macrophage, TGF-β1 and α-SMA is closely related to active proliferation of fibroblasts, extracellular matrix overdeposition and scar contracture of the bile duct.

A study on the expressions and the correlation of TGF-β1 and α-SMA in healing process of bile duct trauma

Objective: To explore the formation mechanism of benign biliary stricture. Methods: A model of trauma of common bile duct was established in 28 dogs and then repaired. The anasomosis tissues were taken on the 1st week, 3rd week and the 3rd month, 6th month respectively after operation and examined by using light microscopy and elec-tromicroscopy. Macrophage, TGF-p, and a-SMA were studied immunohistochemically. Results: The mucosal epithelium of common bile duct restored poorly, chronic inflammation lasted for a long time, fibroblasts proliferated actively, extracellular matrix overdeposited; and myofibroblasts functioned actively and existed during the whole healing process. Immunohistochemical test showed a high expression of macrophage, TGF-β1 and a-SMA during healing process lasting a long duration. Macrophages were found in the lamina propria under mucosa, TGF-β1 in the granulation tissue, fibroblasts and endothelial cells of blood vesssels, while a-SMA in the myofiroblasts and smooth muscle tissue. Conclusion: The healing of bile duct is in the mode of overhealing. Myofibroblast is the main cause for contracture of scar and stricture of bile duct. The high expression of macrophage, TGF-β1 and a-SMA is closely related to active proliferation of fibroblasts, extracelluar matrix overdeposition and scar contracture of bile duct.

Severe liver trauma with complex portal and common bile duct avulsion:A case report and review of the literature

BACKGROUND Given its size and location,the liver is the third most injured organ by abdominal trauma.Thanks to recent advances,it is unanimously accepted that the nonoperative management is the current mainstay of treatment for hemodynamically stable patients.However,those patients with hemodynamic instability that generally present with severe liver trauma associated with major vascular lesions will require surgical management.Moreover,an associated injury of the main bile ducts makes surgery compulsory even in the case of hemodynamic stability,thereby imposing therapeutic challenges in the tertiary referral hepato-biliopancreatic centers’setting.CASE SUMMARY We present the case of a 38-year-old male patient with The American Association for the Surgery of Trauma grade V liver injury and an associated right branch of portal vein and common bile duct avulsion,due to a crush polytrauma.The patient was referred to the nearest emergency hospital and because of the hemorrhagic shock,damage control surgery was performed by means of ligation of the right portal vein branch and right hepatic artery,and hemostatic packing.Afterwards,the patient was referred immediately to our tertiary hepato-bilio-pancreatic center.We performed depacking,a right hepatectomy and Roux-en-Y hepaticojejunostomy.On the 9th postoperative day,the patient developed a high output anastomotic bile leak that required a redo of the cholangiojejunostomy.The postoperative period was marked by a surgical incision site of incomplete evisceration that was managed non-operatively by negative wound pressure.The follow-up was optimal,with no complications at 55 mo.CONCLUSION In conclusion,the current case clearly supports that a favorable outcome in severe liver trauma with associated vascular and biliary injuries is achieved thru proper therapeutic management,conducted in a tertiary referral hepato-bilio-pancreatic center,where a stepwise and complex surgical approach is mandatory.

Diagnosis and treatment of trauma of hepatic portal bile duct

Objective To investigate the diagnosis and treatment of trauma of hepatic portal bile duct. Methods Eight cases of trauma of the hepatic portal bile duct were reviewed. All short-term splits were treated with repair plus drainage with supporting tube. In 7 cases, there were combined injuries of 2 or more than 2 organs. The combined injuries were respectively treated. Long-term complication of bile duct stenosis was managed with internal drainage. Results Five cases were found during operation. Of these 5 patients, 3 were with the traumatic split less than 50% diameter and 2 with that more than 50% diameter. After repair,1 of the former 3 died and 2 remained in good condition. However, 1 of the latter 2 died and 1 was reoperated on due to bile duct stricture after the repair. Other 3 cases were found due to postoperative bile leakage. They were treated with internal drainage and good results achieved. Conclusion It is difficult to make a definite diagnosis of traumatic injury of hepatic protal bile

Rare isolated extra-hepatic bile duct injury: A case report

BACKGROUND Extra-hepatic bile duct injury(EHBDI)is very rare among all blunt abdominal injuries.According to literature statistics,it only accounts for 3%-5%of abdominal injuries,most of which are combined injuries.Isolated EHBDI is more rare,with a special injury mechanism,clinical presentation and treatment strategy,so missed diagnosis easily occurs.CASE SUMMARY We report a case of unexplained abdominal effusion and jaundice following blunt abdominal trauma in our department.Of which,surgical exploration of the case was performed and a large amount of bile leakage in the abdominal cavity was found.No obvious abdominal organ damage or bile duct rupture was found.Surgery was terminated after the common bile duct indwelled with a T tube.After 2 wk,a T-tube angiography revealed the lesion in the common bile duct pancreatic segment,confirming isolated EHBDI.And 2 mo later,the T tube was pulled out with re-examined magnetic resonance cholangiopancreatography,indicating narrowing of the common bile duct injury,with no special treatment due to no clinical symptoms and no abnormality in the current follow-up.CONCLUSION This case was featured by intraoperative bile leakage and no EHBDI.This type of rare isolated EHBDI is prone to missed and delayed diagnosis due to its atypical clinical manifestations and imaging features.Surgery is still the main treatment,and the indications and principles of bile duct injury repair must be followed.

基于损伤控制理论的救治管理对肝脏与胆管外伤患者救治效果的影响

目的 探究基于损伤控制理论的救治管理在肝脏与胆管外伤患者救治中的应用效果。方法 回顾性分析2022年8月—2023年3月收治的肝脏与胆管外伤102例的临床资料,根据临床处理方案分为观察组52例和对照组50例,对照组实施常规急诊救治,观察组实施基于损伤控制理论的救治管理。观察2组救治相关指标、并发症及干预前后损伤严重程度、氧化应激指标[髓过氧化物酶(MPO)、丙二醛(MDA)、超氧化物歧化酶(SOD)]变化情况。结果 观察组手术时间、术后肛门首次排气时间及住院时间均短于对照组,术中出血量少于对照组(P<0.01);干预后,观察组损伤严重程度轻于对照组(P<0.05);干预后,观察组血清MPO、MDA水平低于对照组,血清SOD水平高于对照组(P<0.05);观察组多器官功能障碍综合征、失血性休克发生率分别为3.85%(3/52)、1.92%(1/52),低于对照组的18.00%(9/50)、16.00%(8/50),差异有统计学意义(P<0.05)。结论 基于损伤控制理论的救治管理可降低肝脏与胆管外伤患者应激及损伤程度,加速康复进程,改善临床结局。

Sclerosing cholangitis following severe trauma: Description of a remarkable disease entity with emphasis on possible pathophysiologic mechanisms

MM： Persistent cholestasis is a rare complication of severe trauma or infections. Little is known about the possible pathomechanisms and the clinical course.METHODS： Secondary sclerosing cholangitis was diagnosed in five patients with persistent jaundice after severe trauma （one burn injury, three accidents, one power current injury）. Medical charts were retrospectively reviewed with regard to possible trigger mechanisms for cholestasis, and the clinical course was recorded.RESULTS： Diagnosis of secondary sclerosing cholangitis was based in all patients on the primary sclerosing cholangitis （PSC）-Iike destruction of the intrahepatic bile ducts at cholangiography after exclusion of PSC. In four patients, arterial hypotension with subsequent ischemia may have caused the bile duct damage, whereas in the case of power current injury direct thermal damage was assumed to be the trigger mechanism. The course of secondary liver fibrosis was rapidly progressive and proceeded to liver cirrhosis in all four patients with a follow-up 〉2 years. Therapeutic possibilities were limited.CONCLUSION： Posttraumatic sderosing cholangitis is a rare but rapidly progressive disease, probably caused by ischemia of the intrahepatic bile ducts via the peribiliary capillary plexus due to arterial hypotension.Gastroenterologists should be aware of this disease in patients with persistent cholestasis after severe trauma.

经内镜逆行胰胆管造影联合取石术与腹腔镜胆囊切除术治疗胆管结石的效果

目的探讨经内镜逆行胰胆管造影联合取石术与腹腔镜胆囊切除治疗胆管结石的效果。方法选择胆管结石患者78例,按不同术式分为对照组与观察组,各39例。对照组予腹腔镜胆囊切除术联合胆总管探查取石术治疗,观察组予经内镜逆行胰胆管造影联合取石术与腹腔镜胆囊切除术治疗。对比2组手术相关指标与术后恢复情况、手术应激反应、手术并发症发生情况及肝功能指标。结果观察组手术用时、术中出血量、结石残留率、胃肠道功能恢复时长、住院时长均少于对照组(P<0.05),且观察组结石残留率(0.00%,0/39)低于对照组(10.26%,4/39)(P<0.05);观察组术后24 h皮质醇(Cor)、去甲肾上腺素(NE)、促肾上腺皮质激素(ACTH)水平均低于对照组(P<0.05);观察组手术并发症发生率低于对照组(P<0.05);观察组术后24 h丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、碱性磷酸酶(ALP)水平均高于对照组(P<0.05)。结论经内镜逆行胰胆管造影联合取石术与腹腔镜胆囊切除术治疗胆管结石创伤小、并发症少,可减轻肝功能损伤。

荧光染色对肝外胆管的保护作用在老年急性胆囊炎手术中的应用

目的:探讨荧光染色对肝外胆管的保护作用在老年急性胆囊炎手术中的应用。方法:选择2022年12月—2023年3月高安市人民医院普外科收治的老年急性胆囊炎手术患者80例为研究对象,随机数字表法分为两组,各40例。对照组术中常规采用白光辅助,观察组采用荧光染色对肝外胆管进行保护,术后7 d评估效果,比较两组显影率(胆囊管、肝总管、胆总管、右肝管)、术后胃肠功能、炎症因子、肝肾功能及术后并发症发生率。结果:观察组胆囊三角解剖后胆囊管、肝总管、胆总管及右肝管显影率均高于对照组;胆囊切除后胆囊管显影率高于对照组,肝总管、胆总管及右肝管显影率均低于对照组,差异均有统计学意义(P<0.05);观察组术后排气、肠鸣音恢复、术后排便时间均早于对照组,手术时间、术中出血量及住院时间均少于对照组,差异均有统计学意义(P<0.05);观察组手术后7 d白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)及C反应蛋白(CRP)水平均低于对照组,差异均有统计学意义(P<0.05);两组术前、手术后7 d白蛋白(ALB)水平差异均无统计学意义(P>0.05);观察组手术后7 d丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素(TB)、尿素氮(BUN)及肌酐(Cr)水平均低于对照组,差异均有统计学意义(P<0.05);观察组术后胆汁瘘、胆管损伤、术后再手术、肠梗阻、严重腹腔感染总发生率低于对照组,差异有统计学意义(P<0.05)。结论:荧光染色对肝外胆管能发挥良好的保护作用,能提高胆囊管、肝总管、胆总管、右肝管显影率,有助于促进患者胃肠功能恢复,降低炎症因子水平,且对患者肝肾功能影响较小,可降低术后并发症发生率。

胆管损伤愈合过程中显微结构和超微结构的变化

目的 探讨良性胆管狭窄形成机制 .方法 建立犬胆总管损伤修复动物模型后 ,于术后 3d,1 ,3wk,3,6mo取材分别行光镜、电镜观察及免疫组化观察巨噬细胞、转化生长因子 (TGF-β1 )、平滑肌肌动蛋白 (α- SMA)在胆管愈合过程不同时期组织中的表达强度、阳性细胞数和组织分布 .结果 光、电镜显示 :炎性渗出期较长 ,胆道粘膜上皮愈合较慢 ,瘢痕组织细胞持续增生活跃 ,细胞外基质过度沉积 ,胶原纤维排列致密杂乱 .肌成纤维细胞 (MFB)功能活跃 ,持续存在于整个愈合过程中 .免疫组化 :巨噬细胞、转化生长因子 (TGF-β1 )、平滑肌肌动蛋白 (α- SMA)在胆管愈合过程中表达较强 ,且持续较长时间 .MΦ阳性主要表达于胆道粘膜下固有层 ;TGF-β1 主要表达于肉芽组织、成纤维细胞、MΦ及血管内皮细胞胞质和细胞膜 ;α- SMA表达于 MFB质、平滑肌组织 .结论 胆管愈合方式属于过度愈合 ;MFB功能活跃 ,持续存在 ,是导致胆管瘢痕性挛缩的重要原因 ;MΦ、TGF- β1 及 α- SMA高表达是造成胆管愈合过程中成纤维细胞增殖旺盛、细胞外基质过度沉积。

带血管蒂肝圆韧带瓣转位修复胆管缺损的应用解剖

观察30例成人肝圆韧带标本,肝圆韧带呈纤维条索样,内含少许不规则残腔。肝圆韧带的血液供养主要来自肝右动脉的分支及伴行的附脐静脉。由于肝圆韧带近端紧邻胆管,远端易于游离,提出了带血管蒂的肝圆韧带瓣作为自体生物材料来修复肝外胆管的缺损,并讨论了该术式有关的应用解剖要点。

带蒂脐静脉瓣修复胆管缺损28例

目的：总结了２８例带蒂脐静脉瓣修复缺损的临床经验，恢复正常的胆道生理状态，保留Ｏｄｄｉ括约肌功能，预防上行性胆道感染。方法：①胆道后壁对端吻合，上下端胆管前壁纵行切开，带蒂脐静脉瓣胆管前壁缺损修复术１５例；②部分的胆管壁缺损修复术４例；③炎性胆管狭窄、胆管缺损修复术９例。结果：术后３年以上２０例，其中优良者１７例，３例再手术。本组无１例死亡。结论：带蒂脐静脉瓣是修复胆管缺损的一种理想的自体移植物。

带蒂脐静脉瓣胆道修复术与远期疗效

目的 总结带蒂脐静脉瓣胆道重建的临床经验和远期随访结果。方法 第一种术式 ,胆管上下端后壁对端吻合 ,前壁纵行切开 ,其缺损以带蒂脐静脉瓣修复 2 2例 ;第二种术式 ,胆管狭窄切开、整形 ,胆管缺损以带蒂脐静脉瓣修复 19例。结果 本组无死亡病例 ,术后达 7年以上 2 5例 ,其中再手术 3例 ,术后 7- 12年ERCP 10例 ,MRCP和双剂量静脉胆道造影各 1例 ,胆道显影均正常 ;轻度胆管炎 2例 ;另 8例无任何胆道感染症状 ,B超胆道未见异常。结论 带蒂脐静脉瓣胆道重建是一种理想的胆道修复手术。

医源性胆总管远端损伤个体化诊治(附9例报道)

目的探讨医源性胆总管远端损伤的不同防治方法。方法回顾性分析9例医源性胆总管远端损伤的临床资料。结果 9例病人均通过Oddi括约肌切开、长臂T管支撑引流术、单纯修补或积极外引流而得到治愈。结论医源性胆总管远端损伤的预防、术中发现及处理十分重要。根据致伤机制不同、发现时间早晚不同作出相应的个体化处理,是患者得以迅速康复的关键。

创伤性肝胆管损伤的外科处理

目的探讨创伤性肝胆管损伤的处理方法。方法回顾性分析近10年我院收治的220例肝创伤中12例肝胆管损伤患者的临床资料。结果除外院转入1例因来院过晚,失去手术时机衰竭死亡外,另11例均获痊愈。其中7例再手术治疗:1例持续胆漏予以近端漏口缝扎,胆总管引流;3例因反复发作化脓性胆管炎、梗阻性黄疸,行胆管空肠Roux-Y吻合术;另3例伴有肝萎缩、创伤性胆道出血分别行肝段、叶切除术。尚有4例胆漏维持通畅引流,亦获满意结果,于2周内停止胆漏。结论肝创伤合并肝胆管损伤,经初期和后期认真处理,均可获得良好预后。

腹腔镜胆囊切除胆道损伤后再手术时机和选择

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)致胆管损伤(bileduct injury,BDI)的手术时机、手术方式及技巧。方法回顾性分析我院收治的21例接受手术治疗的LC后胆管损伤病例,胆管损伤Ⅰ型2例、Ⅱ型11例、Ⅲ型仅2例、Ⅳ型6例。结果本组1例术中Ⅱ型胆总管损伤,经中转开腹行胆总管修补和T管引流而治愈,术后2例出现胆漏,经充分引流后自愈。术后随访1.5～5年,无胆道狭窄及胆管炎发作。其余20例均接受了毁损的胆管切除、肝总管或左右肝管的胆肠吻合术,并获得治愈。结论LC致BDI手术仍是BDI的首选治疗。把握手术时机,避免盲目手术,及早选择有经验的专科肝胆外科医生恰当处理是提高治愈率的关键。

肝外胆管外伤的诊断与治疗

肝外胆管外伤较少见,常合并其他脏器伤,术前很难诊断,多需在剖腹探查术中才能确诊。治疗方法须根据具体伤情谨慎选择①一次性手术主要选择受伤至手术时间不超过24 h、生理机能破坏程度较轻、未合并其他脏器伤或虽合并其他脏器伤但程度较轻者;②损伤控制性手术主要运用于受伤至手术时间长、合并肝脏、胰、十二指肠等重要脏器伤,出现休克、低体温、严重酸中毒及凝血功能紊乱的伤员;③单纯肝外胆管外伤延迟诊断的治疗早期主要表现为胆汁外溢,易形成胆汁瘤,可采用胆管支架、鼻胆管引流、超声或CT引导下腹腔穿刺置管引流等措施;④肝外胆管外伤的远期手术发生胆管狭窄、胆系感染等,需再次手术切除狭窄段,施行胆肠吻合术。肝外胆管外伤早期死亡常与其他脏器的外伤程度密切关联,晚期死亡则主要取决于胆系感染是否有效控制以及胆汁性肝硬变相关并发症。

早期脐静脉瓣修补治疗胆管损伤

目的探讨早期以脐静脉瓣修补治疗胆管损伤的疗效。方法通过与单纯吻合术对比,比较两种术式的近、远期并发症发生率、再手术率,并作统计学分析。结果早期脐静脉瓣修补术的并发症发生率特别是胆道狭窄的发生率、再手术率较单纯吻合术明显减少(P<0.05)。结论在早期胆道损伤中脐静脉瓣修补是一种理想的胆道修复手术,值得推广。

肝外胆管近端损伤即时处理的若干经验

目的 探讨治疗肝外胆管近端损伤的有效方法。方法 回顾性分析联合应用稀疏缝合、吻合部短期内支撑 ,以及术后持续低负压吸引技术治疗 5例肝外胆管近端损伤的临床资料 ,并对各例进行长期随访。结果 5例术后早期均未发生胆漏及腹腔感染等并发症。经长达 8个月至 10年的随访 ,各例均无与胆道有关的不适症状及黄疸 ;B超复查各例均无肝组织萎缩及硬化征象 ,肝内、外胆管无扩张、无结石 ;肝功能均正常。结论 肝外胆管近端损伤后即时 ,在行修复手术及治程中 ,联合应用缝合、支撑、吸引技术可有效预防肝管—肝管吻合及肝管 -空肠 Roux- Y吻合术的近。

腹腔镜胆总管探查术治疗胆总管结石的临床研究

目的:探索腹腔镜胆总管探查术在胆总管结石患者中的应用价值。方法:选取我院普外科2015年2月—2017年12月收治的胆总管结石患者62例为研究对象,根据治疗方法分组,对照组行开腹胆总管探查术,观察组行腹腔镜胆总管探查术,收集两组的围术期指标。结果:观察组术中出血量低于对照组,P<0.05;手术时间、术后首次排气时间、术后住院时间:观察组均短于对照组,P<0.05;术后随访1年,观察组的结石复发率与对照组差异不明显,P>0.05。结论:腹腔镜胆总管探查术的应用有助于减轻胆总管结石患者的手术创伤,促进术后康复,且手术彻底,复发率低,值得推广。