1概述1.1梗阻性黄疸的原因根据大量临床资料统计，引发梗阻性黄疸最常见的原因是胆总管结石、胰头癌、肝门恶性淋巴结长大； 其次是壶腹部癌、胰腺炎、肝继发性病变； 少见的原因有良性狭窄（医源性、创伤）、复发性胆管炎、Mirizzi’s综合征、硬化性胆管炎、胆管癌、胆道闭锁和胆总管囊肿。
目的 探讨体外转流胆汁在治疗恶性梗阻性黄疸中的作用。方法 随机选择28例恶性梗阻性黄疸患者行胆汁外转流术，并与同期25例行胆汁内引流术的恶性梗阻性黄疸患者进行比较。结果 外转流组术后恢复时间、黄疸消退时间及肝功能恢复时间均较内引流组短； 术后生存时间较内引流组长； 术后并发症较内引流组少； 经统计学处理差异有显著性意义(Ｐ＜0.05)。结论 体外转流胆汁术，具有胆汁内引流及外引流术的优点，同时具备手术操作简单，术后恢复快，住院时间短，并发症少，术后可经T管注药化疗等优点，是一种简单而有效的减黄方法。
【Abstract】ObjectiveTo study the effect of bile reinfusion on immunologic function of erythrocyte in patients with obstructive jaundice after external drainage of biliary tract.MethodsPatients with obstructive jaundice who had received biliary tract external drainage were randomly divided into bile reinfusion group (n=24) and simple external drainage group (n=27). Patients without jaundice,who received cholecystectomy in the same period with the above ones,were selected randomly as control group(n=25). In external drainage groups patients’ bile was collected daily, and was filtered through gauze, and then, pumped back into the patients’ duodenum or jejunum after being heated to 38 ℃-40 ℃. The bile reinfusion could be started after the intestinal function recovered postoperatively. The changes of C3bRRT, ICRT, RFER and RFIR were observed before and after operation. The data were analysed through SPSS8.0.ResultsPreoperative C3bRRT and RFER levels in patients with obstructive jaundice were lower than those without jaundice significantly, and Preoperative ICRT and RFIR levels in patients with obstructive jaundice were higher than those without jaundice significantly. C3bRRT levels in bile reifusion group was higher obviously than those in simple drainage group (P＜0.05) on the 14th postoperative day. ConclusionImmunologic function of erythrocyte in patients with obstructive jaundice is inhibited, and bile reinfusion after biliary tract external drainage can be helpful to the recovery of immunologic function of erythrocyte.
This experimental study was aimed at observing the influence of bile salt and lactulose on intestinal mucosa of obstructive jaundiced rat. Twenty adult Wistar rate were divided into four groups (five rats for each group): sham operation, common bile duct ligation (CBDL), CBDL plus sodium deoxycholate feeding and CBDL plus lactulose feeding. The results showed that the intestinal mucosa of rats with obstructive jaundice took on marked edema, markedly decreased activities of adenosine triphosphatase, alkaline phosphatase and succinic dehydrogenase and intensified acid phosphatase activity. However, the intestinal mucosa of the rats, treated with bile salt or lactulose as compared with that of the obstructive jaundiced rats showed both pathological and histochemical improvement.
Ｈｅｍｏｄｙｎａｍｉｃ ｃｈａｎｇｅｓ ｏｆ ｓｙｓｔｅｍｉｃ ａｎｄ ｐｏｒｔａｌ ｖｅｉｎ ｆｌｏｗ ａｎｄ ｒｅｇｕｌａｔｉｏｎ ｏｆ ｉｎｄｏｍｅｔｈａｃｉｎ ｈａｖｅ ｂｅｅｎ ｓｔｕｄｉｅｄ ｉｎ ７３ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｏｂｓｔｒｕｃｔｉｖｅ ｊａｕｎｄｉｃｅ（ｇｒｏｕｐ Ａ）ａｎｄ ３９ ｃａｓｅｓ ｗｉｔｈ ｓｉｍｐｌｅ ｇａｌｌｂｌａｄｄｅｒ ｓｔｏｎｅｓ（ｇｕｏｕｐ Ｂ）．Ｏｂｓｔｒｕｃｔｉｖｅ ｊａｕｎｄｉｃｅ ｗａｓ ｓｕｂｇｒｏｕｐｅｄ ｉｎｔｏ ｇｒｏｕｐ Ａ１（ｎｏｉｎｄｏｍｅｔｈａｃｉｎ ａｄｍｉｎｉｓｔｒａｔｉｏｎ），ｇｒｏｕｐ Ａ２（ｐｒｅｏｐｅｒａｔｉｖｅ ａｄｍｉｎｉｓｔｒａｔｉｏｎ ｏｆ ｉｎｄｏｍｅｔｈａｃｉｎ），ｇｒｏｕｐ Ａ３（ｐｏｓｔｏｐｅｒａｔｉｖｅ ａｄｍｉｎｉｓｔｒａｔｉｏｎ ｏｆ ｉｎｄｏｍｅｔｈａｃｉｎ），ａｎｄ ｇｒｏｕｐ Ａ６（ｓｅｎｉｌｅ ｏｂｓｔｒｕｃｔｉｖｅ ｊａｕｎｄｉｃｅ）．Ｏｆ ｔｈｅｍ ｇｒｏｕｐ Ａ１ ｗａｓ ｓｕｂｇｒｏｕｐｅｄ ｉｎｔｏ ｇｒｏｕｐ Ａ４（ｍａｌｉｇｎａｎｔ ｏｂｓｔｒｕｃｔｉｏｎ）ａｎｄ ｇｒｏｕｐ Ａ５（ｂｅｎｉｇｎ ｏｂｓｔｒｕｃｔｉｏｎ）ａｇａｉｎ．Ｔｈｅ ｒｅｓｕｌｔｓ ｓｈｏｗｅｄ ｔｈａｔ ｔｈｅ ｓｔｒｏｋｅ ｖｏｌｕｍ（ＳＶ），ｃａｒｄｉａｃ ｏｕｔｐｕｔ（ＣＯ）ａｎｄ ｃａｒｄｉａｃ ｉｎｄｅｘ （ＣＩ）ｗｅｒｅ ｈｉｇｈｅｒ ｉｎ ｅａｃｈ ｇｒｏｕｐ ｏｆ ｏｂｓｔｒｕｃｔｉｖｅ ｊａｕｎｄｉｃｅ ｔｈａｎ ｔｈｏｓｅ ｉｎ ｇｒｏｕｐ Ｂ（Ｐ＜０．０１），ａｎｄ ｔｈｅ ｍｅａｎ ａｒｔｅｒｙ ｐｒｅｓｓｕｒｅ （ＭＡＰ），ｓｔｒｏｋｅ ｖｅｓｓｅｌ ｒｅｓｉｓｔａｎｃｅ （ＳＶＲ）ａｎｄ ｐｏｒｔａｌ ｖｅｉｎ ｂｌｏｏｄ ｆｌｏｗ（ＰＶＦ）ｗｅｒｅ ｌｏｗｅｒ ｉｎ ｅａｃｈ ｇｒｏｕｐ ｏｆ ｏｂｓｔｒｕｃｔｉｖｅ ｊａｕｎｄｉｃｅ ｔｈａｎ ｔｈｏｓｅ ｉｎ ｇｒｏｕｐ Ｂ（Ｐ＜０．０１）．Ｔｈｅ ＭＡＰ，ＳＶＲ ａｎｄ ＰＶＦ ｉｎ ｇｒｏｕｐ Ａ２ ａｎｄ ｇｒｏｕｐ Ａ３ ｓｈｏｗｅｄ ｂｅｔｔｅｒ ｉｍｐｒｏｖｅｍｅｎｔ ｔｈａｎ ｔｈｏｓｅ ｉｎ ｏｔｈｅｒ ｓｕｂｇｒｏｕｐｓ，ｂｕｔ ａｓ ｃｏｍｐａｒｅｄ ｗｉｔｈ ｇｒｏｕｐ Ｂ ｔｈｅｒｅ ｗｅｒｅ ｓｉｇｎｉｆｉｃａｎｔ ｄｉｆｆｅｒｅｎｃｅｓ （Ｐ＜０．０１）．Ｔｈｅ ａｕｔｈｏｒｓ ｃｏｎｓｉｄｅｒ ｔｈａｔ ｉｎｄｏｍｅｔｈａｃｉｎ ｃａｎ ｉｍｐｒｏｖｅ ｔｈｅ ｃｉｒｃｕｌａｔｉｏｎ ｆｕｎｃｔｉｏｎ，ＰＶＦ ａｎｄ ｌｉｖｅｒ ｆｕｎｃｔｉｏｎ ｉｎ ｐａｔｉｅｎｔｓ ｗｉｔｈ ｏｂｓｔｒｕｃｔｉｖｅ ｊａｕｎｄｉｃｅ．
The comparison made between two experimental models with obstructive jaundice, which were newly established reversible model and traditional bile duct ligation and internal drainage model, showed that the new model was superior to the traditional one. This study suggests that the new model would be an ideal model, which could replace the traditional one for studying obstructive jaundice.
To investigate the cause of septicemia in patients with obstructive jaundice,the correlationship between intra-biliary tract pressure(IBTP),portal veinous flow rate(PVFR)and interleukin-2(IL-2),soluble interleukin-2 receptor(sIL-2R),T lymphocyte subpopulation in patient with obstructive jaundice(Group A)has been studied.Group A was subdivided into A1,emergency operation group;A2,elective surgery group;A3,patient’s age over 60 years and A4,age under 60.Ninety patients with simple gallstone(Group B)were also tested as a contrast.The result showed that of all Group A,CD3+,CD4+,CD8+ before operation were much lower than those 10 days after operation(Plt;0.05 or Plt;0.01),while the postoperative sIL-2R was significantly higher than that of 10 days after operation(Plt;0.01),in Group A1,emergency surgery,the preoperative sIL-2R was much more higher than that in others of the jaundice group(Plt;0.01).Corralation analysis showed IBTP was negatively corralated to IL-2,CD3+,CD4+,CD8+,but it had positive correlation with sIL-2R(Plt;0.01).PVFR was positively correlated to IL-2(Plt;0.01).These indicate that obstructive jaundice with infection is closely related to the decreased host immunity.
目的:探讨胆总管结石致急性梗阻性黄疸手术治疗的效果。方法:回顾分析72例手术治疗胆总管结石致急性梗阻性黄疸患者的临床资料。结果:术后死亡3例。随访3~6年,效果优良者62例。3例胆总管T管引流术后3年复发肝胆管结石。结论:对该病的治疗术前应尽量做全面辅助检查,明确结石的部位及大小,胆管的形态及位置。根据病情确定手术时机和方式,对保证患者安全,减少术后并发症,提高治愈率有重要意义。
Objective To discuss the therapeutic effect and safety of laparoscopic cholecystectomy plus laparoscopiccommon bile duct exploration （LC＋LCBDE） and endoscopic retrograde cholangiopancreatography/endoscopic sphincte-rotomy plus LC （ERCP/EST＋LC） for cholecystolithiasis with choledocholithiasis patients with obstructive jaundice. Methods The clinical data of cholecystolithiasis with choledocholithiasis patients with obstructive jaundice from January2011 to June 2012 were analyzed retrospectively. During this period， 48 patients were treated by LC＋LCBDE （LC＋LCBDE group）， and 76 patients by ERCP/EST＋LC （ERCP/EST＋LC group）. Results ①There were no statistical significances in the age， gender， preoperative total bilirubin， alanine aminotransferase， number and maximum diameter of common bile duct stone， and internal diameter of common bile duct in two groups （P＞0.05）. ②No perioperative mortality occurred and no significant differences were observed in terms of stone clearance from the common bile duct， postoperative morbidity， and conversion to open surgery in two groups （P＞0.05）. However， the operative time and post-operative hospital stay in the LC＋LCBDE group were shorter than those in the ERCP/EST＋LC group （P＜0.05）. In addi-tion， the costs of surgical procedure and hospitalization charges in the LC＋LCBDE group were less than those in the ERCP/EST＋LC group （P＜0.05）. Conclusions Both LC＋LCBDE and ERCP/EST＋LC are safe and effective therapies forcholecystolithiasis with choledocholithiasis patients with obstructive jaundice. However， LC＋LCBDE is better for pati-ents’ recovery and cost effective. Especially for patients with common bile duct＞1.0cm in diameter or with multiple common bile duct stones， LC＋LCBDE is the best choice. To sum up， the choice of minimally invasive treatment must be individualized according to the patient’s condition and the availability of local resources.