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Clinical observation of primary suture following laparoscopic common bile duct exploration in patients aged over 70 years old with common bile duct stones

Objective To explore clinical effect of primary suture following laparoscopic common bile duct exploration (LCBDE) in treatment of patients aged over 70 years old with common bile duct (CBD) stones. Methods The clinical data of 62 patients aged over 70 years old with CBD stones underwent the LCBDE from January 2013 to December 2016 were retrospectively analyzed. Among them, 30 patients underwent the T tube drainage (T tube drainage group) and 32 patients underwent the primary suture (primary suture group) following the LCBDE. The intraoperative and postoperative statuses of these two groups were compared. Results There were no significant differences in the gender, age, body mass index, preoperative comorbidities and ASA classification, number and maximum diameter of CBD stone, and diameter of CBD between the two groups (P>0.05). There were no significant differences in the operative time, hospitalization cost, rates of total postoperative complications and readmission between the two groups (P>0.05). Compared with the T tube drainage group, the amount of intraoperative bleeding was less (P<0.05) and the postoperative hospital stay was shorter (P<0.05) in the primary suture group. Conclusion Primary suture is safe and feasible following LCBDE for patients aged over 70 years old with CBD stones in case of strict indications and proficiency intraoperation and it is more beneficial to recovery of patient.

以反复黄疸为临床表现的胆总管下段癌1 例报道并文献复习

目的 总结 1 例以反复黄疸为临床特点的胆总管下段癌的不典型临床表现、诊断方法及治疗方式。方法对 2020 年 8 月四川大学华西医院收治的 1 例胆总管下段癌患者的临床资料及诊疗经过进行回顾性分析，并进行相关文献复习，总结该病的诊断方法及治疗方式。结果 该例患者以反复黄疸为临床表现，术前常规检查诊断困难，最后经穿刺活检明确为恶性肿瘤，行胰十二指肠切除术，术后组织病理学检查诊断为胆总管下段癌。手术时间 297 min，术中出血量约 200 mL，手术过程顺利。术后无并发症发生，于术后第 11 天出院。术后已随访 6 个月，无不适症状，继续随访。文献复习显示，Vater 壶腹周围肿瘤的具体分型常常根据临床表现及影像学检查进行初步区分，胆总管下段癌以反复黄疸为临床表现者较为罕见，最后确诊需依靠手术切除标本的组织病理学检查。结论 胆总管下段癌的恶性程度高，预后差。临床表现不典型的胆总管下段癌，难以早期明确诊断，导致治疗方式选择困难，由此可能会导致患者手术时机延误，内镜或超声引导下的穿刺活检是早期诊断的有效方法之一。

腹膜巨大间皮囊肿 1 例报道

Effects of Müller cells on expression of occludin in retinal vascular endothelial cells

Obiective lt;brgt;To investigate the change of the activity of proliferation in cultivated Muuml;ller cells treated by advanced glycation endoproducts (AGEs), and the effect of these changes on expression of occludin in bovine retinal vascular endothelial cells (BREC). lt;brgt;Methods lt;brgt;The cultivated Muuml;ller cells were devided into normal growth group and cultured with AGEs group. The cultured BREC were devided into 4 groups:group 1, without any medium; group 2, with normal growth Muuml;ller cell medium (MCM); group 3,MCM treated by AGEs; group 4, without cell as the control. Enzyme-linked immuno sorbent assay was used to detect the content of occludin in the medium in the 4 groups. lt;brgt;Results lt;brgt;The content of expression of occludin was the most in group 2, less in group 1, and the least in group 3. lt;brgt;Conclusion lt;brgt;AGEs may promote the abnormal proliferation of Muuml;ller cells and inhibit the expression of occludin in BREC. lt;brgt;(Chin J Ocul Fundus Dis, 2006, 22: 28-30)

胆石性十二指肠梗阻 1 例报道

医护一体化无痛管理在胆道结石患者围手术期的应用及效果

目的 探讨医护一体化无痛管理在胆道结石患者围手术期疼痛控制中的实施及其效果。 方法 选取 2016 年 3 月 1 日— 8 月 31 日四川大学华西医院胆道外科收治的 479 例胆道结石患者，按其入院时间的不同，将 2016 年 3 月 1 日—5 月 31 日入院的 241 例胆道结石患者围手术期疼痛采用传统的疼痛管理（对照组），2016 年 6 月 1 日—8 月 31 日入院的 238 例胆道结石患者围手术期疼痛采用医护一体化无痛管理（观察组）。比较两组患者的疼痛评分、疼痛控制满意度、术后康复指标（下床活动时间、肛门排气时间、术后住院时间）、采用疼痛解救情况的差异。 结果 观察组患者术后当日睡前～术后 3 d、出院前疼痛评分均较对照组低，疼痛控制满意率（99.16%）明显高于对照组（60.17%），术后下床活动时间[（36.27±9.20）h]、肛门排气时间[（50.28±10.50）h]、术后住院时间[（4.68±1.26）d]均短于对照组[（56.57±12.03）h、（74.88±10.22）h、（6.55±1.76）d]，采用疼痛解救者[21 例（8.82%）]亦低于对照组[241例（ 100.00%）]，差异均有统计学意义（P<0.05）。 结论 医护一体化无痛管理在胆道结石患者围手术期的应用能有效减轻患者术后的疼痛程度，使其能早期下床活动，不仅促进了患者胃肠功能的恢复，缩短了住院时间，提高了患者对疼痛控制的满意度，也促进了患者康复；另外，医护一体化疼痛管理也明显减少了对疼痛爆发的解救次数，从而降低了医护人员的应急工作量。

快速康复法在胆道结石患者术后早期进食中的运用及效果

目的　探讨快速康复对胆道结石（除单纯胆囊结石外） 患者术后早期进食的安全性和可行性。 方法　将2010年12月－2011年3月86例行胆道结石摘除术患者纳入对照组，术后按照常规专科护理待患者肛门排气后指导进食；将2011年4月－6月77例行胆道结石摘除术患者纳入观察组，指导患者术后早期进食。观察两组患者术后肠鸣音恢复正常的时间，肛门排气时间的差异；比较两组患者发生恶心、呕吐、腹胀等并发症的差异；观察两组术后住院天数及术后输液总量的差异。 结果　与对照组相比，观察组患者肠鸣音恢复正常时间、肛门排气时间均提前，术后总输入液量减少、住院天数缩短，两组比较差异有统计学意义（P＜0.05）；两组术后发生恶心、呕吐等并发症的差异无统计学意义（P＞0.05）。 结论　胆道结石患者术后早期进食安全可行、效果好，有利于患者的早期康复。

胆囊管变异汇入右肝管后支的胆囊切除一例

肝脏肺吸虫病1例报道

　　患者，女，35岁，因反复右上腹痛伴发热15 d急诊入院。15 d 前患者无明显诱因感右上腹持续性胀痛，放射至背心，同时出现发热，最高体温（T）39 ℃，伴恶心、呕吐、腹胀等，抗生素治疗后症状有好转，其后上述症状反复发作，抗生素治疗有效，为进一步诊治来我院。入院时查体： T 38.3 ℃，R 87次/min， P 20次/min，BP 109/68 mm Hg(1 mm Hg=0.133 kPa)； 急性病容，神志清楚，皮肤、巩膜无黄染； 心、肺(-)； 腹软，右上腹压痛、叩痛，肌张力不高; 肝脏于肋下4 cm，质软，轻触痛，移浊(-)。急诊血常规： Hb 99.8 g/L, WBC 6.5×109/L； B超： 左、右肝低密度占位。入院诊断： 肝脓肿，肝肿瘤待排。入院后按肝脓肿治疗,用三联抗生素，T 36.7～39.5 ℃，右肝区叩痛。经上述抗感染治疗5 d后，T仍达39.2 ℃，复查血常规： Hb 100.2 g/L,WBC 6.3×109/L,N 0.496,淋巴细胞比例0.096，淋巴细胞数0.58×109/L； 嗜酸性细胞比例0.341，嗜酸性细胞数2.05×109 /L。TB 12 μmol/L，DB 4.2 μmol/L，AST 17 U/L，ALT 19 U/L，Alb 37.7 g/L,GLB 32.0 g/L； 血清CEA、CA15-3、AFP、CA19-9 均正常； 血培养24 h阴性。 心电图、胸片未见异常。CT检查： 左肝内叶、右肝前叶低密度占位但无明显液性暗区形成(图1)； 复查B超： 肝右前叶及左外叶稍弱回声区7.2 cm×3.0 cm、4.3 cm×4.2 cm及 2.5 cm×2.0 cm大，边界不清，内见蜂窝状无回声。经全科讨论认为，肝低密度占位明确，以细菌性肝脓肿可能性大，经抗感染治疗后T仍高达39.2 ℃，有手术引流指征。于入院后第6天急诊行肝脓肿引流+活检。术中见左、右肝增大，色泽红； 左肝SⅡ、SⅢ各扪及包块约1.5 cm×2.0 cm×2.0 cm大，切开后有粉红色脓液； 右肝SⅤ～SⅥ各有包块6 cm×6 cm×6 cm大，质较硬，切开后有黄白色脓液20 ml及淡黄色颗粒样物，脓肿壁厚约0.5 cm，似干酪样。取含脓肿壁的肝组织送病检。术后诊断： 细菌性肝脓肿或肝结核继发细菌性肝脓肿。术后1 d症状缓解，T 37.4 ℃，肝区叩痛减轻，脓腔引流约10 ml/d。术后3 d，肠功能恢复，开始进流食，下床活动，T逐步降至正常，脓腔引流＜5 ml/d。术后第5天拔出引流管后出院。血培养报告： 1周无细菌、真菌生长； 脓液涂片： 革兰染色无细菌，未见抗酸杆菌。术后病理报告： 肝组织内窦道样嗜酸性脓肿形成，可见夏科-雷登结晶，未见虫体及虫卵， 多为肺吸虫病。　　讨论　肝脏肺吸虫病罕见，文献中仅有数例报道。本例为中青年女性，起病急，以发热、右上腹痛为主症，T高达39.5 ℃，无畏寒、寒战。抗生素治疗有效，但反复发作。WBC总数和中性粒细胞比例正常，淋巴细胞比例（0.096）明显降低，嗜酸性细胞绝对数及比例（0.341）明显增高。影像学检查示左、右肝多发性低密度区，但无明显液性暗区形成。术中探查： 肝明显增大，显暗红色，符合炎性表现，脓液有粉红色及黄白色，含淡黄色颗粒物，脓壁明显增厚（约0.5 cm），有干酪样物，引流后无明显脓液流出，临床症状缓解，T降至正常。本例临床表现与常见细菌性肝脓肿很相似，但本例感染症状明显,而WBC不高，中性粒细胞正常，淋巴细胞明显减少，嗜酸性细胞明显增高，这符合寄生虫感染表现。此病术前明确诊断困难，易诊断为细菌性肝脓肿，但若注意其特殊的血常规结果，结合影像学检查中的无典型表现，均可提示非细菌性肝脓肿的可能性。

Treatment and Prognostic Factor of TypeⅢHilar Cholangiocarcinoma in 170 Cases

ObjectiveTo explore the treatment and prognostic factors of typeⅢhilar cholangiocarcinoma. MethodsThe data of 170 cases of typeⅢhilar cholangiocarcinoma treated in our hospital from Jan. 2002 to Dec. 2011 were retrospectively analyzed. ResultsAmong these 170 patients of typeⅢhilar cholangiocarcinoma, 109 patients underwent surgical exploration in which 60 patients underwent resection and the remaining 49 patients were found unresectable and underwent U-tube or metallic stent drainage. Sixty one patients were preoperatively assessed as unresectable in which 14 patients underwent percutaneous transhepatic cholangial drainage and the remaining 47 patients refused any surgical intervention. Results of Cox proportional hazard model showed that residual tumor status (HR=4.621, 95% CI:1.907-11.199, P=0.001), lymph node metastasis (HR=2.792, 95% CI:1.393-5.598, P=0.004), and hepatectomy (HR=3.003, 95% CI:1.373-6.569, P=0.006) were independent prognostic factors which associated with patients in resection group. Besides, treatmentR0 resection (HR=0.177, 95% CI:0.081-0.035, P < 0.001), no treatment (HR=5.568, 95% CI:2.733-11.342, P < 0.001)] and vascular invasion (HR=1.667, 95% CI:1.152-2.412, P=0.007) were prognostic factors associated with all patients. ConclusionsTreatment and vascular invasion are the most important predictors of prolonging survival associated with typeⅢhilar cholangiocarcinoma. Besides, R0 resection including hepatectomy without lymph nodes metastasis is feasible in the majority of patients with resectable hilar cholangiocarcinoma.