目的 探讨经皮经肝穿刺胆道引流术（PTCD）联合胆道支架置入术治疗恶性梗阻性黄疸的操作技巧及其临床应用价值。方法 2009年8月至2011年5月期间中国医科大学附属第四医院介入科对39例恶性梗阻性黄疸患者施行了PTCD联合胆道支架置入术，对其临床资料和效果进行回顾性分析。结果 39例患者全部穿刺成功，穿刺成功率为100％。穿刺左叶胆管11例，穿刺右叶胆管19例，左右胆管均行穿刺9例；单纯外引流22例，内外引流17例；引流管保留7～14d后均成功行胆道支架置入术。 33例患者自觉症状有缓解。患者术后14d时，其白蛋白、碱性磷酸酶、丙氨酸转氨酶、总胆红素、直接胆红素和间接胆红素水平均较术前降低（P＜0.05）。术后发生胆道感染3例（7.69％），发生急性胰腺炎4例（10.26％），发生支架脱落移位1例（2.56％），无胆汁性腹膜炎等并发症发生。本组32例患者获访，随访时间为8d～16.5个月，平均9.4个月。随访期间，27例患者死于肿瘤进展及多脏器功能衰竭；5例患者存活，无黄疸加重症状。结论 PTCD联合胆道支架置入术是一种姑息治疗恶性梗阻性黄疸的有效方法，具有简便、有效、安全、可重复性等优点，但需注意其适应证的选择和并发症的预防。
ObjectiveTo study the effectiveness of liver function, hepatic energy metabolism, regeneration, and apoptosis on the obstructive jaundice rat after partial hepatectomy (PH) combined with internal biliary drainage under the condition of conspicuous bilirubinemia. MethodsOne hundred and twenty male SD rats were used in research, six of whom were divided into sham operation (SO) group. Twenty rats underwent bridge operation between common bile duct and duodenum after 70% PH (70%PH group), and 6 rats out of the 94 rats who underwent common bile duct ligation (CBDL) for 5 d were randomly selected as CBDL group, and the residual rats were done the second operations after 5 d and were divided into three groups: bile duct obstruction combined with reperfusion of bile flow group （BDO-RBF group， n=20), 42% PH with BDO-RBF group (n=20), and 70%PH with BDO-RBF group (n=25). Levels of TB, ALT, ALB, and ALP in serum; HGF, bcl-2 mRNA and protein； ATP, ADP, and AMP; hepatocyte proliferation/apoptosis index in hepatic tissues were dynamically observed after operation (24 h, 72 h, and 7 d), respectively. The liver function and hepatocyte energy metabolism were only detected in the SO group. ResultsRats without obstructive jaundice would have an excellent liver regeneration after 70% PH, while the liver function and hepatocyte energy metabolism could recover rapidly. The liver function, hepatocyte energy metabolism, HGF and bcl-2 mRNA and protein of liver tissue and the hepatocyte proliferation/apoptosis index in partial (42% or 70%) hepatectomy combined with internal biliary drainage in obstructive jaundice group were significantly influenced while recovered rapidly (Plt;0.05). ConclusionsUnder the condition of conspicuous bilirubinemia, the influences of hepatectomy combined with internal biliary drainage on hepatocyte energy metabolism, liver function, hepatocyte regeneration and apoptosis are severer than that of normal rats who underwent 70% hepatectomy, while also make the rats recover rapidly in hyperbilirubinemia groups. The database suggest that it is not necessary to do preoperative external biliary drainage before performing liver resection.
目的 探讨成人先天性胆总管囊肿的诊治方法和手术技巧。方法 对2001年5月至2011年5月期间我院手术治疗的成人先天性胆总管囊肿38例的临床资料进行回顾性分析。结果 全部病例均行B超和磁共振（MRCP）检查确诊，均行手术治疗。其中7例行急诊囊肿外引流术。行择期手术者中24例行囊肿切除、胆肠吻合术，其中3例合并肝叶切除术； 行内引流术4例； 仅行胆囊切除术3例。囊肿剥除采用点状钳夹、电凝及推剥囊肿黏膜外纤维血管束的办法，不出血，无副损伤。无手术死亡病例，术后恢复顺利。38例患者中术后获随访28例（73.68％），失访10例； 随访时间 3～120个月，平均74个月。24例行囊肿切除者症状消失20例，偶感上腹痛、抗炎治疗后症状可缓解1例，3例失访；11例行内或外引流术者术后近期均有不同程度的胆管炎症状，其中6例于术后2～10 年再手术，另5例失放，6例再手术者中2例术中发现癌变，分别于再手术后2个月和10个月死亡，余4例临床症状消失；3例仅行胆囊切除术者，2例失访，1例仍有反复发作的畏寒、发热及右上腹痛。结论 B超和MRCP检查有助于明确诊断； 囊肿全切除、肝管空肠Roux-en-Y 吻合术应作为胆总管囊肿的首选术式，囊肿外引流术仅在合并严重感染、全身情况差的患者采用； 手术技巧的改进可为手术提供安全保障。
Objective To investigate the clinical applications of plasma shock wave lithotripsy （PSWL） in the treatment of calculi via choledochoscope. Methods Between 2004 and 2009, 56 huge residual calculi (54 cases) were underwent PSWL via choledochoscope treatment in our hospital. Calculi size: diameter ≤10 mm in 9 calculi, 10 mm lt;diameter ≤15 mm in 24 calculi, 15 mm lt;diameter ≤20 mm in 17 calculi, and diameter gt; 20 mm in 6 calculi. Twenty four cases of these 54 patients had bile duct stricture. Procedure: Firstly found the calculus, and then the lithotriptor wire was introduced to the place 0.5-1.0 mm far away from the calculus surface through choledochoscope channel, and powered on, fired, destructed. Results Forty-eight cases of 54 patients were cured by PSWL with 1 times, 2 cases with 2 times, 2 cases with 3 times, and 2 cases with 4 times. Shock 4-300 times were exported per PSWL, with an average of 65 times. Crushing each stone needed shock for 4-680 times, with an average of 77 times. The calculi were ruptured in different degrees by PSWL, of which 20 cases were completely ruptured. All calculi were completely extracted. Except one case with bile duct stricture was found a small amount of bile duct bleeding during operation, all other patients had no operation complications. Conclusion PSWL technique plays an important role in lithotripsy. It is easy to deal with intrahepatic impacted calculi by PSWL, especially the pigment stones with rough surface.
Objective To investigate the diagnostic value of a double action MR contrast agent——gadobenate dimeglumine （Gd-BOPTA） for focal liver lesion and biliary system disease. Methods Articles about Gd-BOPTA in CNKI and PubMed for the past few years were searched and the value of Gd-BOPTA in the diagnosis of focal liver lesion and biliary system disease was summarized. Results For focal liver lesion, Gd-BOPTA not only can reveal blood supply of the lesion, but also reveal the hepatocellular functional status in the lesion. For biliary system, biliary excretion of Gd-BOPTA can be used to evaluate the anatomic structure of bile duct， function of gallbladder and biliary system disease. Conclusions Gd-BOPTA has an important value in the diagnosis of focal liver lesion and biliary system disease. Gd-BOPTA may have wider applications in the future.
目的 探讨经胆道镜联合钬激光碎石治疗肝内外胆管难取性结石的价值。方法 纤维胆道镜窥视下用钬激光碎石治疗肝内外胆管难取性结石29例，观察临床效果。结果 经1～3次胆道镜下钬激光碎石治疗，28例患者结石全部取尽，1例未完全取净，成功率为96.55%（28/29）； 近期无胆道出血、漏胆、黄疸等并发症发生。26例获得随访，随访时间6～20个月，平均13个月，未发现结石复发及胆管狭窄。结论 经胆道镜钬激光碎石是一种治疗肝内外胆管难取性结石简便、安全及有效的方法。
目的 探讨胰管结石慢性胰腺炎的诊断和治疗。方法 收集我院1993年3月至2003年9月经手术治疗的胰管结石慢性胰腺炎患者34例的临床资料并进行回顾性分析。结果 全组病例均经B超和CT检查确诊，均经手术治疗。手术方式： 胰十二指肠切除术5例； 胰管切开取石、胰空肠Roux-Y吻合术27例，其中同时行胆囊切除术6例，Oddi扩约肌切开、T管引流术4例，胆肠Roux-Y吻合术2例； 胃空肠、胆肠吻合加活检术2例。治愈31例，缓解2例，死亡1例。结论 影像学检查是诊断本病的重要手段，准确率高。根据合并症和胰管扩张程度选择合适的手术方式，可取得良好治疗效果。
目的 探讨胆道再次手术的原因和对策。 方法 对1997年12月至2003年12月206例胆道再次手术的原因和术式进行回顾性分析。结果 172例（83.5%）因结石复发和（或）残留主要行胆总管切开取石术、肝叶切除术、胆总管空肠Roux-Y吻合术及胆道镜取石术； 9例（4.4%）胆道恶性肿瘤主要行根治性切除术、内外引流术； 5例（2.4%)胆管损伤及3例（1.5%）十二指肠损伤主要行胆总管断端吻合术、T管引流术、胆肠吻合术、十二指肠修补及造瘘术； 17例（8.3%）因其他原因再手术者主要行胆总管囊肿切除+胆肠吻合术、腹腔引流术、腹腔探查、止血术等。结论 ①胆道再手术主要原因是残留结石和（或）复发； ②为降低胆道再手术率，应强调术前诊断明确、选择正确术式和审慎操作。