目的 探讨金属银夹标记胆道通道，利用胆道镜技术治疗胆肠吻合术后肝胆管结石复发的可行性、安全性和有效性。方法 回顾性分析大连市友谊医院47例胆管结石行胆肠Roux-en-Y吻合术患者的资料，在空肠盲袢或输出袢处使用银夹作标志，术后通过胆道镜行胆管残留结石或复发结石或狭窄的治疗。结果 11例术后胆管残留结石和5例残留结石合并胆管狭窄者经T管窦道行胆道镜探查、取石及肝胆管狭窄的治疗而治愈。2例结石复发的患者根据空肠的金属银夹标记物，在数字减影血管造影（DSA）下进行穿刺置管建立胆道镜通道，通过胆道镜成功取出了结石，避免了再手术。结论 发挥胆道镜技术治疗肝胆管结石的优势，经以银夹标志的胆道通道，可望成为治疗胆肠吻合术后复发结石手段的有益补充。
【Abstract】 Objective To study the effects of ischemic preconditioning (IP) on the activity of nuclear factor-κB （NF-κB） and the expressions of TNF-α and intercellular adhesion molecule-1 (ICAM-1) during early reperfusion following liver transplantation in rats. Methods The models of rat orthotopic liver transplantation were established. The donor livers were stored for 2 hours in Ringers solution at 4 ℃ before transplantation. All rats were randomly divided into sham operation group （SO group）， control group and IP group. IP group was achieved by clamping the portal vein and hepatic artery of donor liver for 10 minutes followed by reperfusion for 10 minutes before harvesting. The activity of NF-κB and expressions of TNF-α and ICAM-1 at 1 h, 2 h, 4 h and 6 h after reperfusion were measured. Serum ALT, LDH were also determined. Results The liver function of recipients with IP were significantly improved. Compared with SO group， the graft NF-κB activity increased after transplantation in control group and IP group (P＜0.05), while compared with control group that was significantly attenuated at 1 h and 2 h in IP group. Similarly, hepatic levels of TNF-α and ICAM-1 were significantly elevated in control group and were reduced in IP group. Conclusion IP might down-regulated TNF-α and ICAM-1 expression in the grafts after orthotopic liver transplantation through depressed NF-κB activation， and attenuate neutrophil infiltration in the grafts after reperfusion.
ObjectiveTo discuss the reason and treatment strategy of gallbladder muddy stones after cholecysto-lithotomy. MethodsThe clinical data of 62 patients with gallbladder muddy stones after cholecystolithotomy who were treated in our hospital from December 2008 to December 2014 was analyzed retrospectively. ResultsThere were 43 patients without any symptom and 19 patients with acute cholecystitis in 62 patients. Four patients were diagnosed with septation gallbladder, 6 patients with long and tortuous cystic duct, 3 patients with calculus of cystic duct, 4 patients with common bile duct stones, 39 patients with periampullary diverticula, 18 patients with pancreaticobiliary maljunction, 6 patients with duodenal papilla stenosis, 29 patients with duodenal papillitis, and 3 patients with duodenal papilla adenocarcinoma. Two patients were treated with laparoscopic cholecystectomy (LC), 1 patient with endoscopic sphincterotomy (EST) /endoscopic balloon dilation (EPBD) and LC, 1 patient with percutaneous transhepafic gallbladder drainage (PTGD) and open cholec-ystectomy, 14 patients with PTGD and EST/EPBD, 1 patient with PTGD and hepatocholangioplasty with the use of gallbladder (HG), 34 patients with EST/EPBD, 3 patients with EST/EPBD and endoscopic biliay metal stent drainage (EBMSD), 5 patients with HG, and 1 patient with EST/EPBD and HG. The gallbladder muddy stones disappeared after operations in 55 patients with gallbladder reserved, and gallbladder ejection fraction increased from (42±12) % to (59±16) %. Of the 62 patients, 53 patients were followed up for 6 months to 6 years (the median time was 3.6-year). During the follow-up period, 3 patients were diagnosed with gallbladder stones, 2 patients with common bile duct stones, and 2 patients with intrahepatic and extrahepatic bile duct stones. ConclusionBile efferent tract obstruction is the important reason for the formation of gallbladder stones. HG, EST, and balloon expansion are the efficient methods to resolve the bile efferent tract obstruction.
ObjectiveTo discuss the relation between bile duct anastomotic stricture and bile duct injury by endo-scopic observation following liver transplantation and it, s efficacy of endoscopic treatment. Method The clinical data of 24 cases of bile duct anastomotic stricture following liver transplantation diagnosed by cholangiography were analyzed retro-spectively. Results①Twenty-four cases of bile duct anastomotic strictures were included in 3 cases of typeⅠa, 2 cases of typeⅠb, 4 cases of typeⅡ, 1 case of typeⅢa, 5 cases of typeⅢb, and 9 cases of typeⅢc.②The redness of intrahepatic bile duct mucosa, banding erosion, ulcer and fusion of anastomotic stricture mucosa could be seen in typeⅠa andⅢa. The redness of intrahepatic bile duct and anastomotic stricture mucosa could be seen in typeⅡwithout ulcer and fusion. The extensive erosion and ulcer of intrahepatic bile duct and redness of anastomotic stricture mucosa could be seen in typeⅢb. The extensive erosion, ulcer and partial necrosis of intrahepatic bile duct and anastomotic stricture mucosa could be seen in typeⅠb andⅢc.③Seventeen cases were cured by choledochoscopy through T tube, the biliary casts were moved out and the anastomotic strictures were relieved by balloon dilatation and placement of plastic stenting for 2 to 6 months, no recurrence happened. One case of typeⅠb treated by percutaneous transhepatic cholangial drainage(PTCD) and percuta-neous transhepatic cholangioscopy(PTCS) was developed into the stricture of typeⅡduring following-up for 19 months. Two cases of typeⅠa were treated by ERCP, the biliary casts were moved, one of which was cured, another 1 case was developed into the stricture of typeⅡduring following-up for 5 months. Two cases of typeⅡwere treated by ERCP, the biliary casts were moved, balloon dilatation and placement of plastic stent were performed, one of which was cured, another 1 case was recurrent during following-up for 1 months. The strictures were not relieved by multiple plastic stents for 4 to 6 months in 3 patients with recurrence and progress, but which was relieved by full-covered self-expanding removable metal stents for 4 to 7 months, there was no recurrence during following-up. One case of typeⅢb and one case of typeⅢc received the secondary open operation or choledochoscopy and placement of plastic stent for biliary infection and jaundice after the treatment of ERCP were cured. ConclusionsBiliary stricture following liver transplantation accompanies different degree biliary injury. The slightest is typeⅡand typeⅠa, typeⅢa is the second, typeⅢb is more serious, and typeⅠb and typeⅢc are the worst. Choledochoscopy is a better choose for anastomotic strictures. ERCP is not a better choose for anastomotic strictures of typeⅠb, Ⅲb, andⅢc.
ObjectiveTo establish an individualized nomogram model and evaluate its efficacy to provide a possible evaluation basis for the prognosis of lower third and abdominal part of oesophageal adenocarcinoma (EAC). MethodsLower third and abdominal part of EAC patients were chosen from the SEER Research Plus Database (17 Regs, 2022nov sub). The patients were randomly allocated to the training cohort and the internal validation cohort with a ratio of 7∶3 using bootstrap resampling. The Cox proportional hazards regression analysis was used to determine significant contributors to overall survival (OS) in EAC patients, which would be elected to construct the nomogram prediction model. C-index, calibration curve and receiver operating characteristic (ROC) curve were performed to evaluate its efficacy. Finally, the efficacy to evaluate the OS of EAC patients was compared between the nomogram prediction model and TNM staging system. ResultsIn total, 3945 patients with lower third and abdominal part of EAC were enrolled, including 3475 males and 470 females with a median age of 65 (57-72) years. 2761 patients were allocated to the training cohort and the remaining 1184 patients to the internal validation cohort. In the training and the internal validation cohorts, the C-index of the nomogram model was 0.705 and 0.713, respectively. Meanwhile, the calibration curve also suggested that the nomogram model had a strong capability of predicting 1-, 3-, and 5-year OS rates of EAC patients. The nomogram also had a higher efficacy than the TNM staging system in predicting 1-, 3-, and 5-year OS rates of EAC patients. ConclusionThis nomogram prediction model has a high efficiency for predicting OS in the patients with lower third and abdominal part of EAC, which is higher than that of the current TNM staging system.