Several unusual manifestations such as white bile draining in common bile duct (14 cases) and casual massive bleeding (2 cases ) during and following hepatobiliary and pancreatic operations is reported. These manifestations were in fact signs of hepatic insufficiency. The manners of manifestations of hepatic insufficiency and their treatment are discussed, with a stress that liver-protective treatment and nutritional support are the fundamental modalities.
Objective To investigate the effects and mechanisms of bile on small intestine mucosal barrier.Methods Fifty Wistar rats were assinged into 3 groups randomly: obstructive jaundice (OJ) group （n=20）, biliary external drainage group （n=20） and control group （n=10）. Ten days after operation, the plasma endotoxin level was determinated, the terminal ileum mucosas was obtained to be morphologically measured by light microscope, and immunohistochemistry and Western blot were uesd to examine the expressions of tight junction proteins zona occludens-1 (ZO-1) and occludin in the mucosas. Results Atrophy significantly appeared in the distal ileum mucosas in OJ group. Compared with control group, the intestinal villus height, mucosa thickness and crypt depth in OJ group were obviously decreased 27.8%, 21.7%, and 25.4% (P=0.001, 0.001, 0.040). There were no differences between external drainage group and control group (P=0.050, 0.070, 0.080); While the values of external drainage group were significantly higher than those in OJ group (all P=0.001). The level of plasma endotoxin was up to (1.49±0.27) EU/ml in OJ group compared with control group 〔（0.27±0.09） EU/ml〕, P=0.001. In external drainage group, the value was （0.91±0.25） EU/ml, which was obviously higher than that in control group and lower than that in OJ group （all P=0.001）. Immunohistochemical study showed b positive expression of ZO-1 dropped from 7/10 in the control group to 6/20 in OJ group （P=0.040）, occludin expression was 8/10 in control group and 7/20 in OJ Group （P=0.020）; expressions of them in external drainage group 〔8/20 （P=0.100,0.210） and 9/20 （P=0.060, 0.200）〕 displayed no significant differences compared with the other twogroups. Quantitative testing of Western blot showed the expressions of ZO-1 and occludin in OJ group were significantly lower than those in control group (P=0.001, 0.010), the values in external drainage group were higher than those in OJ group （P=0.005, 0.014）. The expression of ZO-1 was lower in external drainage group than that in control group (P=0.001), and there was no significant difference of occludin between the two groups (P=0.062）. Conclusion Lack of intestinal bile will undermine the intestinal tight junction protein composition, and make intestinal mucosal barrier impaired. The intestinal barrier more severely injured when biliary tract obstructs because of multiple factors. Bile plays an important role in the maintenance of intestinal mucosal barrier.
Objective To study the diagnosis and treatment of portal hypertension in secondary biliary cirrhosis(PHSBC). MethodsTwenty-five cases of PHSBC within recent 16 years in our hospital were analyzed. Their clinical, pathological and follow-up data were reviewed retrospectively. They were divided into 4 groups according to their primary diseases:13 patients with hepatolithiasis, 6 with postoperative stricture of biliary duct, 4 with malignancy of biliary duct and 2 with others.Results All patients were diagnosed clinically, and 4 were further pathologically confirmed. Eight cases were treated conservatively, while the remaining 17 underwent operations according to their primary diseases, and one combined with splenectomy and esophagogastric devascularization. The rate of discharge with improvement by surgical and non-surgical treatment was 64.7% and 37.5%, and hospital mortality was 17.6% and 12.5% respectively. Conclusion The diagnosis of PHSBC mainly depends on its characteristic clinical manifestations. The early surgical resolution of bile duct obstruction is the key to good prognosis. If complicated with rupture and hemorrhage of oesophagofundal varices, the surgical procedure should be considered carefully.
目的总结肝包膜下胆汁瘤（HSB）的病因、临床诊断及治疗方法。 方法回顾性分析笔者所在医院收治的1例HSB患者的临床资料，并进行文献复习。 结果12例患者中，术前诊断为胆总管结石/胆囊结石慢性胆囊炎4例，胆总管结石1例，胆囊结石2例，急性化脓性胆囊炎2例，不详3例；行腹腔镜胆囊切除术（LC）7例，行内窥镜逆行胰胆管造影1例，行LC+腹腔镜胆管取石术1例，行开腹胆囊切除术3例；发病至手术时间7～40 d，平均14.3 d；右肝9例，胆囊窝及右肝前叶膈顶部、胆囊窝及右肝后叶和左肝各1例；11例单发，1例左肝多发；HSB直径7.6～29.1 cm，平均15.7 cm；肝脏包膜下积液量800～3 000 mL，平均1 400 mL；液体吸收时间7～120 d，平均37 d。主要治疗方案为置管引流7例（包括手术开腹置管外引流2例），B超引导下反复穿刺抽吸4例，1例不详；2例反复穿刺引流效果较差，行手术治疗。 结论HSB的发病原因目前尚无统一意见，诊断首选影像学检查，治疗以保守治疗+B超引导下经皮反复穿刺抽吸为主。
目的:分析原发性胆汁性肝硬化(PBC)患者的临床表现,试验室检查及治疗情况。方法:回顾性分析48例PBC患者临床资料。结果:93.8%是中年女性患者,平均年龄53.2±8.73。主要的临床表现包括肝功能异常(ALT、GGT、AKP升高)95.8%,乏力纳差83.3%,黄疸79.2%,瘙痒66.6%,肝肿大62.5%,脾大58.3%等。常合并干燥综合征(25%),类风湿关节炎(16.7%)等自身免疫性疾病及结缔组织疾病。所以患者AMA及AMAM-2均为阳性。全部病例使用熊去氧胆酸治疗,但仅31.3%患者病情有不同程度好转。结论:加强对PBC的认识,重视对AMA 或AMA-M2的检测,尤其对长期不明原因肝功能异常的女性患者。
ObjectiveTo investigate the clinical effect of biliary stent implantation through T-tube lumen and nasobiliary drainage through intrahepatic bile duct in the treatment of biliary leakage after biliary tract exploration.MethodsRetrospective analysis was performed on the clinical data of one case of bile leakage after common bile duct exploration admitted to the Department of Hepatobiliary Surgery of Nanchong Central Hospital in December 2016.ResultsIn this case, the biliary stent was placed in the T-tube lumen and the nasal bile duct was placed in the intrahepatic bile duct for biliary drainage. The guidewire was inserted into the hilum of liver through the tunnel in the T-tube cavity, and nasobiliary drainage was placed to the hilum of liver. In addition, a guide wire was inserted through the T-tube into the duodenum, and a 8.5F plastic stent was placed into the duodenum. One end of the stent was placed in the common bile duct, and the other end was placed in the intestinal cavity for biliary drainage. After drainage, the patient’s bile leakage stopped and the abdominal infection was controlled. Ten days after the biliary stent implantation, the patient was discharged successfully, the T-tube and nasobiliary duct were clamped 20 days after the surgery, and T-tube angiography and abdominal B-ultrasound were performed 2 months later, and it found that the scaffold of the lower common bile duct had fallen off, so removed the T-tube. The patient recovered completely after 2 years of follow-up.ConclusionThe means of T-tube tunnel biliary stent and the nasobiliary duct drainage through the intrahepatic bile duct are effective methods to treat biliary leakage, the operations are simple and easy to operate.
Objective To assess the efficacy and safety of S-adenosyl-l-methionine (SAMe) for outcome improvement of intrahepatic cholestasis of pregnancy. Methods Randomized controlled trials (RCT) and quasi-randomized controlled trials were identified from MEDLINE (1983 to 2003), The Cochrane Library (Issue 4,2003), EMBASE (1980 to 2003), China Hospital Digital Library (CHDL) and Wanfang data (1994 to 2003). We also handsearched the relative references. Two researchers evaluated the quality of the trials and extracted the data independently. RevMan software 4.2 was used for meta-analysis. Results Eight studies involving 424 pregnant women were included. The following data were the results of meta-analysis of SAMe for improvements: ① Reducing cesarean-section ratio: no significant difference was seen between SAMe and placebo groups with OR 1.00, 95%CI 0.23 to 4.33 and P= 1.00; significant differences were seen SAMe versus dexamethasone and SAMe versus Dianglining with OR 0.44, 95%CI 0.23 to 0.85 and P=0.01; OR 0.28 95%CI 0.10 to 0.75 and P=0.01 respectively。② Prolonging the period of pregnancy: SAMe had no significant difference compared with placebo groups with WMD=0.70, 95%CI －0.69 to 2.10, P=0.32. SAMe was more effective than dexamethasone, Ganyinling and Qianglining on prolonging the period of pregnancy with WMD=1.10，95%CI 0.46 to 1.74, P=0.000 07; WMD=2.50，95%CI 1.86 to 3.14, P≤0.000 01; WMD=2.20，95%CI 1.61 to 2.79, P≤0.000 01 respectively；③ Increasing the weight of the newborn: meta-analysis showed that SAMe group had not significant difference compared with placebo group on increasing the weight of the newborn with WMD=-26.27，95%CI -338.35 to 285.82, P=0.87. Significant differences were seen between SAMe and dexamethasone, SAMe and Ganyiling, SAMe and Qiangling with WMD=386.86，95%CI 134.41 to 603.31, P=0.002; WMD=410.00,95%CI 321.10 to 498.90, P≤0.000 01 respectively. ④ Fetal distress: There was no significant difference compared with dexamethasone and Kuhuang groups on decreasing the fetal distress with OR=0.47, 95%CI 0.14 to 1.16, P=0.23; OR=0.44, 95%CI 0.10 to 1.97, P=0.29 respectively; ⑤ Decreasing pollution of amniotic fluid: no significant differences were seen in SAMe versus dexamethasone, SAMe versus ursoddeoxycholic and SAMe versus Kuhuang with OR=0.46, 95%CI 0.21 to 1.02, P=0.06; OR=0.68, 95%CI 0.20 to 2.31, P=0.53; OR=0.82 95%CI 0.24 to 2.81,P=0.75 recpectively. ⑥ Newborn stifile: SAMe group had no significant difference compared with dexamethasone and Kuhuang groups on decreasing the Newborn stifile with OR=0.19, 95%CI 0.01 to 4.06, P=0.29; OR=0.31, 95%CI 0.08 to 1.13, P=0.08 respectively. Compared with Qianglining group, SAMe group had better effect on reducing ratio of newborn stifile with OR=0.09, 95%CI 0.02 to 0.42, P=0.002. ⑦ Improving Apgar scores: no significant differences were seen between SAMe and placebo, dexamethasone and ursoddeoxycholic with OR=0.25, 95%CI 0.02 to 3.04, P=0.28; OR=2.09, 95%CI 0.70 to 6.27, P=0.19; OR=1.22, 95%CI 0.35 to 4.19, P=0.75 respectively. Six RCTs mentioned the side effects of S-adenosy-l-methionine, only one RCT reported mild gastrointestinal irritation. Conclusions SAMe is partly effective on improving the pregnancy outcomes of intrahepatic choletasis of pregnancy, such as reducting cesarean-section ratio, prolonging the period of pregnancy and increasing the weight of the newborn. The specified efficacy and safety of SAMe require rigorously designed, randomized, double-blind and placebo-controlled trials to offer evidence.
To study of plasma lipoprotein cholesterol and effects of these changes on bile acids and cholesterol in bile during gallstone formation in rabbit model. This gallstone model was induced by high cholesterol diet (HCD). The rabbits were divided into five groups and there were ten animals in each group. The plasma highdensity lipoprotein cholesterol (HDL-C) and its subgroups (HDL2-C, HDL3-C), low-density lipoprotein cholesterol (LDL-C), very low-density lipoprotein cholesterol (VLDL-C), total cholesterol, triglyceride, phospholipid, bile acids and cholesterol of bile were investigated in different time. The results were as follow: ①As the time of feeding HCD passed by, the plasma total cholesterol, LDL-C and VLDL-C increased markedly (3-week group and 4-week group vs control group, Ｐ＜0.05). Though the plasma HDL-C and its subfractions HDL2-C and HDL3-C did not change significantly, the function of HDL in transporting plasma cholesterol decreased markedly (from 80.00% to merely 3.68%); ②Cholesterol in bile increased gradually and there were significant differences when 3-week group and 4-week group comparing with control group. The concentration of GDCA and GCA in bile changed slightly (Ｐ＞0.05). These results suggest that the changes of plasma lipoprotein cholesterol may affect the metabolism of cholesterol and bile acids and it may take an important role in the formation of gallstone.