Migration of gall stones.

The factors influencing the migration of gall stones are ill understood. Altogether 331 patients undergoing cholecystectomy were studied prospectively. The diameters of the cystic and common bile ducts and of stones in the gall bladder and bile ducts were measured. Increasing pressure was applied to the freshly excised gall bladder in an attempt to evacuate stones through the cystic duct. Stones passed in 33 (60.0%) of patients with choledocholithiasis, 45 (67.2%) of patients with pancreatitis, and 7 (3.2%) of patients without either pancreatitis or choledocholithiasis. Stones migrated in 6 (3.0%) who had a normal cystic duct diameter (less than or equal to 4 mm) and in 46 (32.5%) with a duct over 4 mm diameter. Common bile duct stones were often larger than the diameter of the cystic duct and when reintroduced into the gall bladder would not migrate. The passage of debris (less than or equal to 1 mm) through the cystic duct bore no relation to the presence or absence of choledocholithiasis or a dilated cystic duct. Small stones (1-4 mm diameter) must migrate to initiate and facilitate further migration; some must increase in size in the common bile duct. Increased biliary pressure consequently dilates the duct system retrogradely, allowing larger stones to follow. Patients at risk of stone migration and thereby pancreatitis and jaundice have large ducts that can be detected by ultrasound assessment.     

Intermittent Secretion of Abnormal Bile in Patients with Cholesterol Gall Stones

Gall bladder and hepatic bile was sampled from 66 patients undergoing elective operations on the biliary tract. Fifty-one patients had cholesterol gall stones but only 59% of these were found to have bile which was supersaturated with cholesterol. Repeated sampling of hepatic bile from patients with T-tubes showed that the secretion of supersaturated bile was intermittent.These results indicate that it is impossible to separate patients with cholesterol stones from controls simply by examination of the lipid composition of their bile, since an appreciable number of bile samples from patients with cholesterol stones were unsaturated.The fact that cholesterol gall stones form when the bile is supersaturated with cholesterol only intermittently suggests that the gall bladder may also have a part in their formation.     

胆道系统探查中术中超声的应用及临床价值

目的:探讨胆管系统探查中术中超声(intraoperative ultrasound,IOUS)的应用及临床价值。方法:2007年3月至2014年8月应用术中超声对胆道系统进行探查的病例资料58例,对其术前影像学表现、手术过程、术中超声所见以及术中和术后诊断进行分析,研究术中超声对胆道探查的应用价值。结果:(1)58例应用术中超声病人中,肝内外胆管结石35例、肝门部胆管癌及胆总管癌11例,急性胆囊炎8例,胃癌1例,先天性胆总管囊肿1例,胆总管炎性狭窄1例,胰腺癌1例。术中超声确认取净结石或胆总管未见明显异常34例,定位肝内胆管残余结石6例,发现胆总管内尚有结石2例,术中超声确诊胆管癌2例;另发现胆总管先天性解剖异常2例;(2)在发现胆管结石方面,与术前MRCP无显著性差异(P=0.643);与术前CT、B超比较有显著差异(P0.05),诊断率分别为B超74.3%,MRCP 91.4%,CT 77.1%,IOUS 94.3%。结论:术中超声胆道系统的探查可以在广泛的疾病中得到应用,可以对术前影像学检查起到验证和补充的作用,且在术中引导各种介入操作中起到独特作用。     

胆道手术患者胆汁的菌群分析

本文对59例胆道手术患者的胆汁标本进行了菌群分析。共检出各类细菌156株,其中厌氧菌70株,以类杆菌最为常见(44株);兼性需氧菌86株,以大肠杆菌最为常见(37株)。胆汁细菌培养阳性率为86.4％(51/59);64.4％(38/59)的标本为厌氧菌与兼性厌氧菌混合污染。22.0％(13/59)的标本中仅分离到兼性需氧菌。提示,胆汁中污染的类杆菌及大肠杆菌是胆道手术后感染的主要原因菌。     

POSTOPERATIVE BILE PERITONITIS

Bile peritonitis may occur after open operations on the biliary tract or following needle biopsy of the liver.Usually it is secondary to rupture of the common duct caused by overlooked common duct stone.Sterile intraperitoneal bile collections may be tolerated fairly well for long periods.Placing drains in the abdomen after biliary tract operations helps prevent dangerous accumulations of bile.Patients with extensive bile peritonitis should be operated upon as soon as possible. Ideally, the operation should include drainage of the abdomen and repair of any underlying pathological cause, but the condition of the patient may be so poor that only drainage can be carried out at the moment.     

Proteins of guinea-pig bile: selective resorption in the gall bladder

We have examined and compared the proteins present in guinea-pig bile as collected either from the common hepatic duct or from the gall bladder. Guinea-pig bile, collected from the common bile duct, has a rather low concentration of protein. Detailed examination shows that the concentrations of actively transported proteins such as immunoglobulin A and haptoglobin.haemoglobin complexes are markedly lower than in rats although the concentrations of proteins which, like albumin, leak non-specifically into bile are similar in the two species. We also find that the protein composition of guinea-pig bile is extensively and selectively modified by resorp-tion of protein in the gall bladder.     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的:探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法:在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果:158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论:在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的：探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法：在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果：158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论：在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

SPECIALTY CONFERENCE: The Treatment of Retained Gallstones

Various techniques are available to evaluate patients suspected of having common duct stones before an operation on the biliary tract. In patients without jaundice, intravenous cholangiography with tomography may provide satisfactory visualization of the biliary system and its contents. Sonography and computerized axial tomography are useful noninvasive methods. Endoscopic retrograde and transhepatic cholangiography are invasive techniques; but, when successful, they provide the most precise preoperative information obtainable about the presence or absence of stones in the biliary system. The most appropriate diagnostic procedures must be carefully selected for each patient. Each year in 3,000 to 4,000 cases, stones are found remaining in the bile ducts after common duct exploration for the removal of stones. Retained stones can be treated by nonoperative extraction, by irrigation techniques and by surgical removal. Extraction methods probably deserve first consideration, if experienced personnel are available. The technique of irrigation of the common bile duct with cholic acid or other solutions, although limited in success, may also be tried; if these procedures fail, then reoperation is indicated.     

Profiling circulating and urinary bile acids in patients with biliary obstruction before and after biliary stenting

Bile acids are considered as extremely toxic at the high concentrations reached during bile duct obstruction, but each acid displays variable cytotoxic properties. This study investigates how biliary obstruction and restoration of bile flow interferes with urinary and circulating levels of 17 common bile acids. Bile acids (conjugated and unconjugated) were quantified by liquid chromatography coupled with tandem mass spectrometry in serum and urine samples from 17 patients (8 men and 9 women) with biliary obstruction, before and after biliary stenting. Results were compared with serum concentrations measured in 40 age- and sex-paired control donors (20 men and 20 women). The total circulating bile acid concentration increases from 2.7 μM in control donors to 156.9 μM in untreated patients with biliary stenosis. Serum taurocholic and glycocholic acids exhibit 304- and 241-fold accumulations in patients with biliary obstruction compared to controls. The enrichment in chenodeoxycholic acid species reached a maximum of only 39-fold, while all secondary and 6α-hydroxylated species--except taurolithocholic acids--were either unchanged or significantly reduced. Stenting was efficient in restoring an almost normal circulating profile and in reducing urinary bile acids. Conclusion: These results demonstrate that biliary obstruction affects differentially the circulating and/or urinary levels of the various bile acids. The observation that the most drastically affected acids correspond to the less toxic species supports the activation of self-protecting mechanisms aimed at limiting the inherent toxicity of bile acids in face of biliary obstruction.     

ERCP治疗急性胆源性胰腺炎

急性胆源性胰腺炎(ABP)是消化内科常见急腹症之一,是急性胰腺炎中最常见的类型,占急性胰腺炎每年发病人数的40%-60%,病死率较高,常规药物治疗不能从根本上解除病因,易导致复发,手术治疗风险较大,创伤较大,费用较高,住院时间较长,易引起其术后并发症,不利于患者恢复。而经内镜逆行胰胆管造影(ERCP)作为一种内镜与放射技术相结合的诊断治疗方法,对胆管内结石并发急性胰腺炎的诊断率是最高的,诊断结石的敏感性大于95%。在20世纪70年代被认为是急性胆源性胰腺炎的禁忌症,近年来随着ERCP技术的不断发展和广泛应用,ERCP已成为治疗胆胰疾病的一种安全有效的技术。ERCP可清除胆管结石,从而达到通畅胆道,减少胆汁向胰管反流,迅速改善患者病情,阻断病情进展的目的,并有效缩短住院时间,减轻患者痛苦,减少复发和改善总体预后,为广大ABP患者带来了福音,此外,还能减少患者住院费用,节省医疗资源,对于个人及社会均具有积极意义,值得推广。     

Fibrinolysis in Cholestatic Jaundice

The fibrinolytic system was studied in primary biliary cirrhosis (16 patients) and large bile duct obstruction (10 patients, nine of whom had carcinoma). Plasma fibrinolysis (plasminogen activator activity) was decreased and fibrinogen increased in both groups of patients, particularly in those with large duct obstruction. These changes were related to the degree of cholestasis. Plasminogen activator activity was inversely related to serum triglyceride levels in patients with primary biliary cirrhosis. Urokinase inhibitors were decreased in both groups and antiplasmins increased in patients with large duct obstruction; fibrin/fibrinogen degradation products were normal in primary biliary cirrhosis and moderately increased in large duct obstruction. None of these fibrinolytic indices was related to the degree of cholestasis. Fibrinolytic activity and fibrinogen returned almost to normal levels after palliative surgery in the three patients with large duct obstruction who were studied. The decreased plasma fibrinolysis and increased fibrinogen may be due to altered lipid metabolism in cholestatic jaundice. In patients undergoing surgery for large duct obstruction there may be an increased risk of thrombosis.     

Usefulness of bile cytology in the diagnostic management of patients with biliary tract obstruction

Eighteen patients with evidence of biliary tract obstruction had a total of 29 satisfactory bile samples submitted for diagnostic cytology during a two-year period. These 29 specimens were reviewed in order to determine if bile cytology is useful in the diagnostic management of patients with obstructive biliary tract disease. Twenty-one of the bile specimens were from patients with malignant biliary stricture, and eight were from patients with benign biliary obstruction. Bile cytology was positive for carcinoma in eight samples from patients with malignant stricture and was inconclusive for malignancy in two. There were no false positives. The diagnostic specificity of bile cytology was 100%, the diagnostic sensitivity was 48%, and the diagnostic accuracy was 62%. When carefully collected and promptly processed, bile proved an excellent specimen for cytologic evaluation and was a valuable adjunct to other diagnostic procedures for the detection of carcinoma causing biliary tract obstruction.     

塑料胆道支架引流术治疗复杂性胆总管结石的临床研究

目的:探讨内镜下逆行胰胆管造影术(ERCP)下塑料胆道支架引流术治疗复杂性胆总管结石的临床疗效和安全性。方法:回顾性分析2011年9月至2013年9月在我院经ERCP下胆道支架引流术治疗的32例复杂性胆总管结石患者的临床病例资料。结果:32例患者塑料胆道支架引流术全部成功,平均手术时间15-30分钟。术后,2例发生高淀粉酶血症,经禁食72小时后恢复正常,无穿孔、消化道大出血等ERCP严重并发症发生。术后1周,患者腹痛、发热消失,转氨酶及胆红素水平明显下降,平均住院时间6-15天。3个月复查B超,发现结石缩小19例,结石碎裂1例,支架脱落1例。术后7天、术后3个月的肝功能指标与术前比较均显著改善,差异均有统计学意义(P0.05)。结论:ERCP下塑料胆道支架引流术是一种复杂性胆总管结石安全有效的治疗方法,具有创伤小、风险较低、操作时间短、患者易耐受及手术成功率高等优点。     

小切开EST联合EPBD与单纯EST对85岁以上老年胆总管结石患者疗效的比较

目的:对比内镜下十二指肠乳头括约肌(expressed sequence tags,EST)小切开术联合内镜下十二指肠乳头括约肌扩张术(endoscopic papillary balloon dilation,EPBD)与单纯EST对85岁以上老年胆总管结石患者的疗效。方法:选择我院于2014年1月～2020年2月收治的85岁以上老年胆总管结石患者150例,根据入院顺序随机分成两组,每组各75例,给予对照组单纯小切开EST术治疗,给予研究组小切开EST+EPBD术治疗。对比两组的一次取石成功率、机械碎石、结石复发率等指标;术中操作时间、术中出血量、住院天数、术后排便天数等临床指标;术后胆道感染、急性胰腺炎、高淀粉酶血症、术后腹痛等并发症的总发生率。结果:研究组一次取石成功率显著高于对照组,机械碎石、结石复发率均显著低于对照组(P0.05);研究组的术中操作时间、术中出血量、住院天数、术后排便天数均显著低于对照组(P0.05);研究组术后胆道感染、急性胰腺炎、高淀粉酶血症、术后腹痛、术后迟发性出血等并发症的总发生率为9.33%(7/75),显著低于对照组37.33%(28/75),差异具有统计学意义(P0.05)。结论:小切开EST联合EPBD对85岁以上老年胆总管结石患者的疗效显著,该方法可有改善患者临床指标,降低术后并发症发生率,值得推荐至临床广泛应用。     

Distribution of opioidergic,sympathetic and neuropeptide Y-positive nerves in the sphincter of Oddi and biliary tree of the monkey,Macaca fascicularis

Summary The opioidergic, sympathetic and neuropeptide Y-positive innervation of the sphincter of Oddi (common bile duct sphincter and pancreatic duct sphincter), as well as other segments of the extrahepatic biliary tree was studied in the monkey by use of immunohistochemistry. Methionine-enkephalin-positive nerves were seen to innervate the smooth muscle of all portions of the sphincter of Oddi and also local ganglion cells. No methionine-enkephalin-positive nerves could be detected in the common bile duct, pancreatic duct or gallbladder. Tyrosine hydroxylase-positive nerves occurred between smooth muscle bundles and also ran to local ganglion cells as well as along the common bile duct. Neuropeptide Y-positive nerves were observed within smooth muscle of the sphincter of Oddi (all portions), common bile duct, pancreatic duct and gallbladder. No evidence of any differential innervation of the pancreatic duct and common bile duct sphincters could be detected with these markers.     

不同术式的经内镜下行乳头括约肌切开术（EST）对肠胆反流的影响

目的：目前认为,十二指肠胆道反流是引起胆道反复感染,进而导致胆道结石再发和胆道狭窄的原因之一。近年来应用以内镜下逆行胆胰管造影术（endoscopicretrogradecholangiopancreatography,ERCP）为基础的微创治疗胆总管结束的技术开展颇为广泛。它主要包括ERCP、Oddi括约肌切开术（endoscopicsphincterotomy,EST）、十二指肠乳头球囊扩张术（endoscopicpapillarybal—Iondilation,EPBD）、胆管结石碎石取石术、胆总管支架植入术和鼻胆管引流术六大技术。本文主要研究了采用不同术式的EST,即EST中切口和EST小切口＋EPBD术,在术后早期对患者十二指肠胆道反流的影响。方法：63例胆总管结石患者,男30例,女33例,予行经内镜下逆行的胆胰管造影（ERCP）后分别采用不同术式EST,术后安放胆总管引流管。术后l周留取胆汁采用口服核素和测定胆汁中的胃蛋白酶I、II的浓度,对十二指肠胆道反流进行定量和定性的测定。结果：EST中切口术组、EST小切口＋球囊扩张（EPBD）组分别与无EST组相比,年龄和性别无统计学意义（P=0．07,P=0．416）。行EST中切开和小切开＋球囊扩张患者胆汁中的锝计数明显高于无EST组,且这两组不同术式的患者锝计数存在显著的统计学差异（P〈0．05）。行EST中切口者、EST小切口＋球囊扩张术者胆汁中的PGII质量浓度明显低于无EST组（P〈0．05）,但是EST中切口者和EST小切口＋球囊扩张术后两组间胆汁中PGII的质量浓度无统计学差异。结论：行EST中切口取胆总管结石的患者在手术早期较易发生十二指肠胆道的反流。因此,建议对于胆总管结石患者尽量选择行EST小切口＋球裳扩张术（EPBD）的手术方式。     

梗阻性黄疸患者经内镜逆行胰胆管造影术后胆道感染的病原菌分布、耐药性及影响因素分析

目的:探讨梗阻性黄疸患者经内镜逆行胰胆管造影(ERCP)术后胆道感染病原菌分布、耐药性以及导致术后胆道感染的影响因素。方法:选择2016年3月至2019年10月我院收治的310例行ERCP治疗的梗阻性黄疸患者,根据ERCP术后是否发生胆道感染将其分为感染组(50例)和未感染组(260例)。检测胆道感染患者病原菌种类及其耐药性,多元Logistic回归分析影响梗阻性黄疸患者ERCP术后胆道感染的影响因素。结果:ERCP术后胆道感染发生率为16.13%,大肠埃希菌、铜绿假单胞菌、粪肠球菌、屎肠球菌是主要致病菌,检出率分别为40.79%、13.16%、9.21%、6.58%。大肠埃希菌、铜绿假单胞菌对头孢类、氨基糖苷类抗生素耐药率高,粪肠球菌、屎肠球菌对利福平、喹诺酮类抗生素耐药率高,大肠埃希菌、铜绿假单胞菌、粪肠球菌、屎肠球菌均对利奈唑胺、亚胺培南敏感。多元Logistic回归分析结果显示,恶性病变、ERCP2次及以上、胆胰管汇流异常、术后胆管引流不畅是梗阻性黄疸患者ERCP术后胆道感染的危险因素(P0.05),术后预防性使用抗生素是保护因素(P0.05)。结论:梗阻性黄疸患者ERCP术后存在一定胆道感染风险,革兰氏阴性菌是主要致病菌,临床应注重对高危因素预防,有必要术后选择敏感抗生素预防性治疗。     

Granular cell tumor of the biliary system: a report of 2 cases with cytologic diagnosis on endoscopic brushing

BACKGROUND: Granular cell tumors (GCTs) of biliary system are rare. GCTs show a striking preponderance for young, black females, who generally present with obstructive jaundice. To our knowledge, these are the first 2 reports of GCT of biliary system identifed on endoscopic brushing cytology. CASES: In case 1, a 24-year-old, black woman presented with a 5-month history of pruritus. Radiographic studies demonstrated a mass in the distal common bile duct. Endoscopic biopsy and bile duct brushing were diagnosed as GCT. A Whipple procedure was confirmatory of GCT. In case 2, a 38-year-old, black female presented with a 7-month history of pruritus and jaundice. Radiographic studies showed a stricture of the common hepatic duct at the hilum. Endoscopic brushing cytology of the stricture yielded only a few sheets of granular cells that were missed on initial screening. Suspicion of cholangiocarcinoma prompted surgery, and final histopathology showed GCT. Both patients were well 1 1/2 and 6 years after presentation. CONCLUSION: GCT of the bile duct can be diagnosed on endoscopic brushing and should be considered in the cytologic differential diagnosis in the appropriate clinical settings.