内镜下乳头括约肌切开术联合不同时长气囊扩张术治疗胆总管结石的疗效观察

摘要 目的：探讨内镜下乳头括约肌小切开术( endoscopic sphincterotomy,EST)联合不同时长持续时间十二指肠乳头气囊扩张术（Endoscopic papillary balloon dilatation,,EPBD）对胆总管结石患者治疗效果差异。方法：选择2018年1月至2018年12月于我院接受EST联合EPBD治疗的92例胆总管结石患者为研究对象, 按照其术中气囊扩张时间的不同将其分为A组（46例,扩张时间20 s）、B组（46例,扩张时间40 s）,对比两组患者一次净石率、机械碎石率、操作时间及X线暴露时间,对比两组患者术前及术后肝功能指标,术后12 h血淀粉酶,对比两组患者术后胰腺炎、消化道出血、胆道感染、穿孔等并发症的发生率。结果：（1）对比显示两组患者一次净石率、机械碎石率、操作时间、X线暴露时间及12 h血淀粉酶对比差异不具有统计学意义（P>0.05）;（2）术前两组患者总胆红素(Total bilirubin,TBIL)、谷氨酸转氨酶(Glutamate aminotransferase,ALT)、碱性磷酸酶(alkaline phosphatase,ALP)对比差异不具有统计学意义（P>0.05）,术后两组患者上述指标均较治疗前出现明显的下降,但组间比较无差异（P>0.05）;（3）A组患者术后各类并发症发生率为4.35 %（2/46）,B组患者术后各类并发症发生率为17.39 %（8/46）,两组对比差异具有统计学意义（P<0.05）。结论：EST联合EPBD对胆总管结石具有较好的治疗效果,术中不同气囊扩张时间不会对手术成功率、手术时间等指标造成影响,但长时间扩张存在增加术后出血的风险,建议在能够正常实施手术的情况下尽量控制术中气囊扩张时间。     

Dietary zinc intake,supplemental zinc intake and serum zinc levels and the prevalence of kidney stones in adults

ObjectiveThe association between zinc intake and the risk of kidney stones remains controversial. We examined the associations between dietary zinc intake, supplemental zinc intake and serum zinc levels and the prevalence of kidney stones in adults.MethodsAdult participants from the 2007–2016 NHANES were included. Restricted cubic splines were adopted to assess the dose-response relationships.ResultsDietary zinc intake was linearly associated with the prevalence of kidney stones (P_{for non-linearity} = 0.50), and the odds ratios (95% confidence intervals) of kidney stones were 0.75 (0.51–1.04) for 10 mg/day, 0.65 (0.39-0.97) for 20 mg/day, 0.53 (0.30-0.94) for 30 mg/day and 0.45 (0.22-0.95) for 40 mg/day. The linear relationship was also observed among women and overweight/obese individuals. No association was found between supplemental zinc intake and the prevalence of kidney stones. A non-linear relationship was found between serum zinc levels and the prevalence of kidney stones (P_{for non-linearity} = 0.02), and the odds ratios (95% confidence intervals) of kidney stones were 0.52 (0.33-0.82) for 70 ug/dL, 0.43 (0.24-0.77) for 90 ug/dL, 0.56 (0.32-0.98) for 110 ug/dL and 0.77 (0.37–1.62) for 130 ug/dL. The non-linear relationship was also observed among men and overweight/obese individuals.ConclusionsDietary zinc intake and serum zinc levels were inversely associated with the prevalence of kidney stones in adults, and there may be effect modification by participant sex and body mass index. The present analysis is limited in its ability to establish causality.     

降脂益生菌对非酒精性脂肪性肝病小鼠胆汁酸代谢及转运的影响和机制初探

目的探讨降脂益生菌(鼠李糖乳杆菌DM9054和植物乳杆菌86066联合制剂)对非酒精性脂肪性肝病(nonalcoholic fatty liver disease, NAFLD)小鼠胆汁酸代谢及转运的影响和可能机制。方法 18只雄性FXR~(-/-)小鼠随机分为3组(n=6):正常饮食组、高脂饮食组和高脂饮食+降脂益生菌组。其中正常饮食组给予普通饮食和生理盐水灌胃,高脂饮食组给予高脂饮食和生理盐水灌胃,高脂饮食+降脂益生菌组给予高脂饮食和降脂益生菌灌胃。所有小鼠干预12周,处死小鼠1周前行胰岛素耐量试验和腹腔注射葡萄糖耐量试验。小鼠处死后自动生化分析仪检测血脂、胆汁酸及肝功能指标;RT-PCR检测肝脏和回肠组织炎症因子相对表达量;HE染色评估肝脏和回肠组织病理情况;Western blot检测法尼醇受体(Farnesoid X receptor, FXR)通路中的成纤维细胞生长因子15(fibroblast growth factor 15,FGF15)、成纤维细胞生长因子受体4(fibroblast growth factor receptor 4,FGFR4)和小分子异源二聚体(short heterodimer partner, SHP)、胆汁酸合成限速酶胆固醇7α-羟化酶(cholesterol 7α-hydroxylase, CYP7A1)及胆汁酸转运相关的胆盐输出泵(bile salt export pump, BSEP)的蛋白表达。结果和高脂饮食组相比,高脂饮食+降脂益生菌组小鼠血清中胆汁酸含量明显下降(P=0.000 1),FGF15、FGFR4和BSEP蛋白表达水平升高(P=0.009 7、0.024 2、0.000 1),CYP7A1的蛋白表达水平降低(P=0.006 9)。此外,通过降脂益生菌干预还明显改善了高脂饮食FXR~(-/-)小鼠的糖脂代谢紊乱(P=0.002 4)、肝脏脂肪变性、肝脏和回肠组织炎症(P=0.013 8、0.000 1、0.000 1)以及肠黏膜屏障功能(P=0.014 2)。结论降脂益生菌具有类似选择性肠道FXR激动剂的作用,能够通过调控肠道FXR-FGF15通路改善胆汁酸的代谢及转运,进而缓解高脂饮食FXR~(-/-)小鼠的NAFLD。     

ERCP/EST-LC治疗胆囊结石合并胆总管结石临床疗效及并发症

目的:考察内镜下逆行胰胆管造影术/十二指肠乳头括约肌切开术加腹腔镜胆囊切除术(endoscopic retrograde pancreatic angiography/endoscopic sphincterotomy-1aparoscopic cholecystectomy,ERCP/EST-LC)对胆囊结石合并胆总管结石的临床疗效和安全性。方法:选80例胆囊结石合并胆总管结石患者,随机数字表法分为两组,每组40例,对照组进行LCBDE-LC手术,研究组进行ERCP/EST-LC手术,以手术成功率、围术期相关指标和术后并发症等指标考察对患者的临床疗效。结果:对照组手术成功率为95.0%,研究组患者手术成功率为97.5%,两组无显著差异(P>0.05),研究组患者的手术时间和术中出血量与对照组相比均无显著差异(P>0.05),研究组胃肠功能恢复时间为39.64±5.34 h,显著长于对照组的37.19±3.17 h(P<0.05),研究组住院时间为14.17±2.06 d,显著长于对照组的11.85±2.71 d(P<0.05)。两组患者的胆道感染、急性胰腺炎、肠穿孔、结石残留以及胆管炎的发生率无显著差异(P>0.05),对照组胆漏发生率为7.50%,显著高于研究组的0.00%(P<0.05),而研究组术后出血发生率为10.00%,显著高于对照组的2.50%(P<0.05),对照组并发症总发生率为12.50%,研究组为15.00%,两组比较无显著差异(P>0.05)。对照组术后一年复发率为15.00%,研究组的复发率为17.50%,经统计分析,两组术后复发率无显著差异(P>0.05),其余患者无腹痛、发热、黄疸等情况。结论:ERCP/EST-LC治疗胆囊结石合并胆总管结石临床疗效确切、并发症少,安全性高。     

Lipid and protein oxidation in hepatic homogenates and cell membranes exposed to bile acids

Cholestasis occurs in a variety of hepatic diseases and causes damage due to accumulation of bile acids in the liver. The aim was to investigate the effect of several bile acids, i.e. chenodeoxycholic, taurochenodeoxycholic, deoxycholic, taurodeoxycholic, ursodeoxycholic, lithocholic and taurolithocholic (TLC), in inducing oxidative damage. Hepatic tissue of male Sprague-Dawley rats was incubated with or without 1 mM of each bile acid, with or without 0.1 mM FeCl₃ and 0.1 mM ascorbic acid for the purpose of generating free radicals. Several bile acids increased lipid and protein oxidation, with TLC being the most pro-oxidative (657% and 175% in homogenates and 350% and 311% in membranes, respectively). TLC also enhanced iron-induced oxidative stress to lipids (21% in homogenates and 29% in membranes) and to proteins (74% in membranes). This enhancement was dose- and time-dependent and was reduced by melatonin. These results suggest that bile acids differentially mediate hepatic oxidative stress and may be involved in the physiopathology of cholestasis.     

A novel marker for assessment of liver matrix remodeling: An enzyme-linked immunosorbent assay (ELISA) detecting a MMP generated type I collagen neo-epitope (C1M)

A competitive enzyme-linked immunosorbent assay (ELISA) for detection of a type I collagen fragment generated by matrix metalloproteinases (MMP) -2, -9 and -13, was developed (CO1-764 or C1M). The biomarker was evaluated in two preclinical rat models of liver fibrosis: bile duct ligation (BDL) and carbon tetra chloride (CCL4)-treated rats. The assay was further evaluated in a clinical study of prostate-, lung- and breast-cancer patients stratified according to skeletal metastases. A technically robust ELISA assay specific for a MMP-2, -9 and -13 neo-epitope was produced and seen to be statistically elevated in BDL rats compared to baseline levels as well as significantly elevated in CCL4 rats stratified according to the amount of total collagen in the livers. CO1-764 levels also correlated significantly with total liver collagen and type I collagen mRNA expression in the livers. Finally, the CO1-764 marker was not correlated with skeletal involvement or number of bone metastases. This ELISA has the potential to assess the degree of liver fibrosis in a non-invasive manner.     

Improvement of bilirubin adsorption capacity of cellulose acetate/polyethyleneimine membrane using sodium deoxycholate

Bilirubin (BR) adsorbents have low removal efficiency because of the tight binding of BR with human albumin (HA) in a complicated blood system. Sodium deoxycholate (SDC) was selected as an adsorption promoter to improve the BR adsorption capacity of a cellulose acetate (CA)/polyethyleneimine (PEI) membrane. Static adsorption experiments show that the maximum BR adsorption capacity of the membrane with SDC in BR–HA mock solution is 100–200% at the molar ratio of SDC to HA ranging from 8 to 12, higher than that without SDC. It is also found that SDC is more efficiently adsorbed by the membrane than BR and HA. Absorption, circular dichroism, and zeta potential studies demonstrate that SDC can be bound with the BR–HA complex to form a ternary BR–HA-SDC_m complex. On the basis, the facilitated adsorption mechanism of BR with SDC was proposed that SDC aggregates or micelles form a quasi-multilayer adsorption on the membrane, increase approachable binding sites, and prolong the distance between the BR–HA complex and the membrane. Thus, SDC as a spacer reduces the influence of the steric hindrance of HA, resulting in an enhanced BR adsorption capacity. Dynamic adsorption results further evidence the facilitated adsorption mechanism.     

Survival of Rats Undergoing Continuous Bile Drainage Depends on Maintenance of Circadian Rhythm of Bile Secretion

It is very difficult to collect bile secretions from animals for extended periods of time. We compared the use of saline or water as drinking fluids to sustain the animals, which were being continuously drained of bile. Complete bile drainage was performed in 16 male Wistar rats by surgical intervention. After surgery, 8 rats were given tap water, and the other 8 were given normal saline for water. The rats that received water rapidly lost weight after bile drainage, and all died within 8 days after the operation. In contrast, all rats that drank saline maintained their body weight and survived 14 days or longer after surgery. Serum biochemistry of the rats with water intake on the third day after bile drainage revealed hyponatremia, hypochloremia, and acute renal failure resulting in hyperkalemia. In contrast, electrolyte balance and renal function were normal in the rats with saline intake, and bile was secreted continuously with a circadian rhythm. These results clearly demonstrate that saline as drinking water is essential to the replacement of lost fluids and loss of electrolytes due to bile drainage. Further, saline proved efficacious for sustaining experimental animals undergoing continuous bile collection.     

Characterization of store-operated Ca channels in pancreatic duct epithelia

Store-operated Ca²⁺ channels (SOCs) are activated by depletion of intracellular Ca²⁺ stores following agonist-mediated Ca²⁺ release. Previously we demonstrated that Ca²⁺ influx through SOCs elicits exocytosis efficiently in pancreatic duct epithelial cells (PDEC). Here we describe the biophysical, pharmacological, and molecular properties of the duct epithelial SOCs using Ca²⁺ imaging, whole-cell patch-clamp, and molecular biology. In PDEC, agonists of purinergic, muscarinic, and adrenergic receptors coupled to phospholipase C activated SOC-mediated Ca²⁺ influx as Ca²⁺ was released from intracellular stores. Direct measurement of [Ca²⁺] in the ER showed that SOCs greatly slowed depletion of the ER. Using IP₃ or thapsigargin in the patch pipette elicited inwardly rectifying SOC currents. The currents increased ∼8-fold after removal of extracellular divalent cations, suggesting competitive permeation between mono- and divalent cations. The current was completely blocked by high doses of La³⁺ and 2-aminoethoxydiphenyl borate (2-APB) but only partially depressed by SKF-96365. In polarized PDEC, SOCs were localized specifically to the basolateral membrane. RT-PCR screening revealed the expression of both STIM and Orai proteins for the formation of SOCs in PDEC. By expression of fluorescent STIM1 and Orai1 proteins in PDEC, we confirmed that colocalization of the two proteins increases after store depletion. In conclusion, basolateral Ca²⁺ entry through SOCs fills internal Ca²⁺ stores depleted by external stimuli and will facilitate cellular processes dependent on cytoplasmic Ca²⁺ such as salt and mucin secretion from the exocrine pancreatic ducts.