丹参对梗阻性左半结肠癌一期术后机体自由基水平的影响

目的了解丹参对左半结肠癌患者一期术后外周血自由基水平的影响。方法选择MDA和SOD为指标。将梗阻性左半结肠癌患者分为对照组及应用丹参组,分别测定其手术前后外周血自由基水平。结果术后丹参组MDA水平显著低于对照组(P<0.05),而SOD水平显著高于对照组(P<0.05)。结论梗阻性左半结肠癌患者一期术后早期应用丹参能显著降低患者机体自由基水平。     

急性梗阻性化脓性胆管炎182例的内镜治疗

目的探讨内镜在急性梗阻性化脓性胆管炎治疗中应用的价值。方法回顾性分析182例急性梗阻性化脓性胆管炎患者治疗的临床资料。结果182例患者均经内镜治疗成功,在应用乳头括约肌切开术（EST）后,采用胆道内支架引流（ERBD）治疗25例,鼻胆管引流（ENBD）治疗140例,胆道金属支架引流（EMBD）治疗17例。治疗后所有病例临床症状均明显改善。结论急性梗阻性化脓性胆管炎的内镜治疗是一种快速、安全、有效和经济的治疗手段。     

治疗性ERCP在老年胆胰疾病患者中的应用

目的 探讨治疗性ERCP在老年胆胰疾病患者中的疗效及并发症.方法 回顾性分析123例老年胆胰患者的ERCP治疗效果及并发症,其中胆道结石经内镜乳头括约肌切开术(EST)取石49例,胆道及十二指肠乳头癌37例,急性胆源性胰腺炎21例,急性化脓性胆管炎15例,胆总管术后梗阻性重症黄疸1例.结果 胆总管结石49例,其中27例一次性取石成功,12例放置鼻胆管间隔7d后行第二次取石,6例一次取石加鼻胆管冲洗,4例因多发性充满型结石并慢性化脓性胆管炎鼻胆管引流后放置胆道塑料支架.急性胆源性胰腺炎21例,72h内行乳头切开+鼻胆管引流;急性化脓性胆管炎15例,除1例感染性休克纠正后择期行ERCP治疗外,其余均于48h内急诊行ERCP治疗;胆道外科手术后并发肝总管狭窄、胆窦形成1例,置入胆道塑料支架胆汁内引流.以上治疗成功率100%.胆道及十二指肠乳头癌37例,置入胆道支架胆汁内引流,6例失败,后改行经皮经肝胆管引流(PTCD)术,ERCP治疗成功率83.78%.123例患者ERCP术总成功率95.12%,并发症发生率低,仅发生出血4例(3.25%)、急性化脓性胆管炎3例(2.44%),经积极处理均得以控制.结论 治疗性ERCP对老年胆道结石、急性胆源性胰腺炎、急性化脓性胆管炎具有微创、不需麻醉、并发症少、效果确切等优点,可以替代外科手术;对胆道肿瘤解除梗阻成功率高,失败者多为胆道高位占位严重狭窄,可用PTCD术替补治疗.     

N-乙酰半胱氨酸对急性梗阻性化脓性胆管炎时内毒素性急性肝损伤的保护作用

目的研究N-乙酰半胱氨酸(NAC)对大鼠急性梗阻性化脓性胆管炎(AOSC)时内毒素介导的急性肝损伤的保护作用及其机制。方法健康Wistar大鼠96只,随机均分为3组(n=32):急性胆管炎组(AOC组),结扎大鼠胆总管,于胆总管内注入大肠埃希菌O111:B4(菌落浓度5×1012cfu/L),建立急性AOSC动物模型;NAC预处理组(AOC+NAC组),建模前2h给予300mg/kg NAC预处理;胆总管结扎组(BDL组),仅结扎胆总管。3组动物分别于术后0、4、8、16h活杀取材(每组每时间点8只),检测肝组织中脂多糖(LPS)受体CD14及NF-κB蛋白水平,测定血浆LPS、TNF-α、丙氨酸转氨酶(ALT)和总胆红素(TB)水平,光镜观察肝组织病理学变化。结果随病程延长,AOC组血浆LPS、TNF-α、ALT、TB水平逐渐增高,肝细胞变性、坏死等病理改变逐渐加重,而肝组织中CD14和NF-κB蛋白表达显著增加。AOC+NAC组各时间点肝组织中CD14和NF-κB蛋白表达,血浆LPS、TNF-α、ALT、TB水平及肝组织病理学改变均低于AOC组(P<0.01)。结论 AOSC时内毒素介导的急性肝损伤与肝组织CD14、NF-κB表达上调有关。NAC预处理可通过抑制CD14表达及NF-κB活化而减轻AOSC时内毒素介导的急性肝损伤。     

胆管引流术联合熊去氧胆酸治疗恶性梗阻性黄疸

目的分析胆管引流术联合熊去氧胆酸(UDCA)治疗恶性梗阻性黄疸的临床疗效。资料与方法76例恶性梗阻性黄疸患者,其中肝胆管癌32例,肝门淋巴结转移瘤23例,胰腺癌和壶腹癌21例。随机分为两组:观察组40例,对照组36例。全部患者给予保肝、支持、抗炎治疗,并行经皮经肝穿刺胆管内支架置入术或胆管引流术。观察组同时联合应用UDCA10～15mg.kg-1.d-1,疗程1个月。结果76例中46例行胆管内支架置入术,18例行胆管内外引流术,12例行胆管外引流术。观察组在术后7天、14天及30天血清胆红素均明显下降,术后14天与术后30天血清胆红素水平与对照组比较差异有统计学意义(P<0.05)。胆管梗阻解除后,随着血清胆红素的下降,谷丙转氨酶(ALT)、碱性磷酸酶(ALP)也随之下降,术后14天、30天两组间比较差异有统计学意义(P<0.05)。观察组22例合并胆系感染者,胆管炎控制时间(9±2.1)天,对照组19例胆管炎控制时间(12±1.6)天,两组间差异有统计学意义(P<0.001)。结论胆管引流术是姑息性治疗恶性梗阻性黄疸的有效手段。联合应用UDCA,可加强胆汁排泌,加快降黄速度,保护肝细胞,从而增强保肝降黄的作用。     

两种麻醉药对急性颅脑外伤患者术后血清NSE、S100B蛋白、炎性因子及认知功能的影响

 目的 观察丙泊酚和异氟烷两种麻醉药对急性颅脑外伤患者术后血清NSE、S100B蛋白、炎性因子及认知功能的影响。方法 选择2014-01至2015-12 符合标准的急性颅脑外伤患者98例,采取随机数字表法分成对照组和观察组,每组49例。两组患者均采用芬太尼、维库溴铵、依托咪酯行麻醉诱导,其中观察组静脉注射丙泊酚维持麻醉,对照组吸入异氟烷维持麻醉,比较两组术前、术中2 h、术毕、术后48 h血清S100B蛋白、神经元特异性烯醇化酶(NSE)含量,术前、术后48 h血清肿瘤坏死因子(TNF)-α、白介素(IL)-6水平,并于术后3个月、6个月采取简易精神状态检查量表(MMSE)对两组患者术后认知功能恢复情况进行对比。结果 两组患者术前血清S100B蛋白、NSE水平无统计学差异,对照组患者术中2 h、术毕、术后48 h血清S100B蛋白、NSE水平高于观察组(P<0.05)。两组患者术前血清TNF-α、IL-6水平无统计学差异,观察组患者术后48 h血清TNF-α、IL-6水平低于对照组(P<0.05)。两组患者术后3个月MMSE评分无统计学差异;观察组术后6个月MMSE评分明显高于对照组(P<0.01)。结论 与异氟烷吸入麻醉相比,丙泊酚静脉麻醉可有效降低急性颅脑外伤患者术后血清炎性因子水平,减轻颅脑损伤程度,改善患者认知功能。
     

选择性门静脉栓塞术联合肝动脉化疗栓塞术治疗肝转移癌的对照研究

目的探讨选择性门静脉栓塞术(PVE)联合肝动脉化疗栓塞术(TACE)治疗肝转移癌的疗效和安全性。方法将49例无法或拒绝接受手术切除肝转移癌的患者分为对照组和治疗组。对照组(26例)单纯行TACE,治疗组(23例)在此基础上联合选择性门静脉栓塞术,观察比较2种疗法对患者术后肝功能、肝脏体积、不良反应、并发症及近期疗效和累积生存率的影响。结果①术后6个月治疗组有效率65.2%(15/23)高于对照组30.8%(8/26)(P=0.04);治疗组肿瘤最长径总和由术前(9.92±2.63)cm下降为术后(7.32±2.61)cm,对照组由术前(10.34±3.12)cm下降为术后(9.13±3.42)cm,治疗组优于对照组;治疗组和对照组中位生存时间分别为21个月及13个月,累积生存率比较P<0.05。②肝脏体积变化比较:对照组术后肝脏体积无明显变化;治疗组术前非栓塞叶体积为(481±251)cm3,术后2,4,8周分别为(523±250)cm3,(548±249)cm3,(552±249)cm3,分别比术前增加(10.1±7.6)%,(16.1±10.9)%,(17.2±11.5)%。③术后肝功能:两组患者术后血浆白蛋白水平变化均不明显,治疗组术后第1,3天,ALT、AST、TB等指标较术前明显升高,至术后第7天下降(P>0.05)。两组相比,术后第1天、第3天ALT、AST、TB治疗组高于对照组,第7、14天差异无统计学意义。结论选择性PVE联合TACE能够有效的控制和缩小肝转移癌,改善患者累积生存率,是治疗无法手术切除肝转移癌安全有效的选择,值得进一步研究应用。     

部分脾动脉栓塞联合胸腺五肽对乙型肝炎肝硬化脾功能亢进患者细胞免疫和肝纤维化的作用北大核心CSCD

目的探讨部分脾动脉栓塞术(PSE)联合胸腺五肽对乙型肝炎(乙肝)肝硬化脾功能亢进患者细胞免疫、肝纤维化标记物和肝脏硬度值(LSM)的改善作用。方法选取84例乙肝肝硬化脾功能亢进患者,采用随机数字法分为对照组(n=42)和观察组(n=42)。均行PSE术,术后对照组予以护肝、抗感染、抗病毒及对症支持治疗,观察组在此基础上另予以胸腺五肽肌内注射,疗程24周。6个月后比较两组外周血淋巴细胞亚群(CD^(3+)、CD^(4+)、CD^(8+)、CD^(4+)/CD^(8+))、血清肝纤维化标记物[层粘连蛋白(LN)、Ⅳ型胶原(C-Ⅳ)、透明质酸(HA)、Ⅲ型前胶原(PCⅢ)]水平及LSM(肝脏超声瞬时弹性成像测定)变化。结果6个月后,两组CD^(3+)、CD^(4+)计数百分率和CD^(4+)/CD^(8+)比率较治疗前显著升高(P<0.05),CD^(8+)计数百分率较治疗前显著降低(P<0.05),而观察组CD^(3+)、CD^(4+)计数百分率和CD^(4+)/CD^(8+)比率显著高于对照组(P<0.05),CD8+计数百分率显著低于对照组(P<0.05);两组LN、C-Ⅳ、HA、PCⅢ水平均较治疗前显著降低(P<0.05),而观察组均显著低于对照组(P<0.05);对照组LSM较治疗前无显著降低(P>0.05),观察组LSM显著低于治疗前(P<0.05),且低于对照组(P<0.05)。结论乙肝肝硬化脾功能亢进患者PSE术后使用胸腺五肽可改善细胞免疫功能,降低肝纤维化标记物水平,降低肝脏硬度,综合疗效优于单独PSE,具有较好的临床推广价值。     

急性梗阻性化脓性胆管炎患者内镜治疗的护理体会

急性梗阻性化脓性胆管炎（AOSC）是一种危重急症，大多年龄较大，并发症较多或多次行胆道手术。一旦遇此类病人，大都采用传统的经典式手术，术中、术后并发症较多，甚至危及生命，医生治疗，护士护理均感到棘手。随着内镜技术不断推广，临床水平不断提高，急诊内镜胆道引流术（ERBD），乳头肌切开（EST）及取石术的应用，给这些患者带来了福音。     

内镜下鼻胆管引流术联合中药治疗急性梗阻性化脓性胆管炎的临床应用

目的观察内镜下鼻胆管引流术(ENBD)联合中药治疗急性梗阻性化脓性胆管炎(AOSC)的临床疗效。方法对65例AOSC患者行胰胆管造影(ERCP)明确梗阻部位后,行ENBD留置鼻胆管至梗阻上方,术后给予清热解毒、消炎利胆中药治疗。结果 65例ENBD成功率100%,治疗后黄疸、发热、腹痛等临床症状、体征均迅速减轻或消失。结论 ENBD合并清热解毒、消炎利胆中药治疗AOSC安全、有效、可靠。     

Dynamic CT of acute cholangitis: early inhomogeneous enhancement of the liver

OBJECTIVE: Our objective was to describe the dynamic CT findings of acute cholangitis, especially early inhomogeneous enhancement of hepatic parenchyma. MATERIALS AND METHODS: Inhomogeneous enhancement of hepatic parenchyma was retrospectively evaluated on dynamic CT in 406 consecutive patients without irregular fatty liver or multiple hepatic tumors. Dynamic CT scans were obtained 30 sec (early phase) and 90 sec (late phase) after starting the contrast material injection. Thirteen patients were diagnosed as having acute cholangitis (cholangitis group), and the remaining 393 patients were classified as the control group. The frequency of inhomogeneous enhancement was compared between these two groups. In nine of the 13 patients in the cholangitis group, we also evaluated changes in inhomogeneous enhancement on follow-up dynamic CT scans obtained after the patients had undergone treatment for acute cholangitis. RESULTS: In the cholangitis group, 11 (85%) of 13 patients showed nodular, patchy, wedge-shaped, or geographic inhomogeneous enhancement throughout the liver in the early phase on dynamic CT. In the control group, 19 (5%) of 393 patients also showed inhomogeneous enhancement in the early phase on dynamic CT. The frequency of inhomogeneous enhancement was significantly higher in the cholangitis group than in the control group (p < 0.001). Follow-up dynamic CT performed after treatment for acute cholangitis showed decreased inhomogeneous enhancement or no inhomogeneous enhancement in seven (78%) of nine patients in the cholangitis group. CONCLUSION: Inhomogeneous enhancement in the early phase on dynamic CT is frequently seen in patients with acute cholangitis; this finding usually disappears after treatment.     

Discrimination of suppurative cholangitis from nonsuppurative cholangitis with computed tomography (CT)

PURPOSE: Suppurative cholangitis is characterized by obstruction, inflammation, and pyogenic infection of the biliary tract. This disease represents a true emergency. The purpose of this study was to compare the computed tomography (CT) findings between acute calculous suppurative and nonsuppurative cholangitis and to determine if there are findings that assist in the differential diagnosis. MATERIALS AND METHODS: Fifteen patients with acute suppurative cholangitis were enrolled in this study. Findings at endoscopic retrograde cholangiopancreaticography (ERCP) were the standard of reference for suppurative cholangitis. To compare the findings of suppurative cholangitis with those of nonsuppurative cholangitis, 35 patients with nonsuppurative cholangitis were randomly selected. The following findings were evaluated: the presence of papillitis, the presence of stones in the ampulla, the presence of intrahepatic stones, the presence of early inhomogeneous enhancement of the liver, the degree of bile duct dilatation, the degree of bile duct wall thickening and presence of cholecystitis. Sensitivity and specificity for each of the individual findings were calculated. Statistical analyses were performed the Pearson chi(2) test, Fisher's exact test and the Mann-Whitney U test. RESULTS: Papillitis showed the highest specificity 86% with 60% sensitivity. Marked inhomogeneous enhancement of the liver during the arterial phase showed 80% specificity with 60% sensitivity. In multivariate logistic analysis, papillitis and marked early inhomogeneous enhancement of the liver were the most significant predictors of acute suppurative cholangitis. The combination of these two CT findings improved specificity (97% specificity) for the diagnosis of suppurative cholangitis. CONCLUSION: Papillitis and marked early inhomogeneous enhancement of the liver were found to be the most discriminative CT findings for the diagnosis of acute suppurative cholangitis and the differentiation between suppurative and nonsuppurative cholangitis.     

MR characteristics of acute cholangitis

Purpose: To describe the MR appearance of acute cholangitis and discuss the role of MR imaging as a diagnostic method in this disease.Material and Methods: Of 60 patients with clinical acute cholangitis, 12 were examined with MR before endoscopic retrograde pancreatography (ERCP). A retrospective review was performed of MR and ERCP findings. The MR findings registered were presence of biliary duct dilatation, intraluminal filling defects due to stones or sludge, bands of mucosal oedema of the biliary ducts, intra- and retroperitoneal oedema/fluid, and definition of the cause of obstruction, e.g. stones, stenosis or tumour was made.Results: Acute cholangitis was related to obstruction from choledocholithiasis (n=8), pancreatic cancer (n=1), benign biliary duct stricture (n=1), papillary stenosis (n=1) and without evidence of an obstructing cause (n=1). One patient had an acute obstructive suppurative (toxic) cholangitis.Conclusion: MR imaging has a role in the non-invasive radiographic arsenal of techniques to confirm or exclude the diagnosis of acute cholangitis, especially in older patients where the clinical symptoms may be vague.     

诊断性腹腔镜检查对患者肝肾功能的影响

目的 探讨诊断性腹腔镜检查对患者肝肾功能的影响。方法 对58例腹部疑难疾病患者腹腔镜检查前后的肝肾功能进行对比分析,其中腹水原因待查35例,腹水+腹部包块23例。结果 58例患者中诊断为结核性腹膜炎31例,恶性腹膜间皮瘤23例,腹膜转移癌(腺癌)2例,盆腔结核及慢性盆腔炎各1例。术前所有患者的肝肾功能均正常。术后24h,58例患者中仅4例ALT轻度升高,为40-60U/L,其余患者的ALT及所有患者的TBil、AST、GGT、BUN、Cr均在正常值范围内。术后48h所的患者的上述指标也均在正常值范围内。检查后24h、48h分别与检查前比较,P均>0.05。结论 腹腔镜检查对患者肝肾功能无明显影响。     

Hepatobiliary toxicity of 5-fluoro-2'-deoxyuridine. Intra-arterial versus portal venous routes of infusion.

Biliary sclerosis remains the dose-limiting toxicity in a subset of patients receiving hepatic arterial (HA) floxuridine (FUDR) for the treatment of hepatic malignancy. To investigate the etiology of FUDR-associated sclerosing cholangitis, portal vein catheters were placed in mixed-breed hounds (N = 4) and connected to an implanted infusion pump system. Floxuridine 0.3 mg/kg/day was infused for 49 to 77 days each, as a continuous infusion. Cholangiograms were performed before and after infusion, and weekly liver function tests were obtained. The results were compared to dogs (N = 6) that received HA FUDR 0.3 mg/kg/d x 30 days, and dogs (N = 5) that received HA saline for 100 days. Elevation in the serum glutamic pyruvic transaminase and alkaline phosphatase, indistinguishable from the HA group, was seen in all four dogs with portal vein infusion. Maximum bilirubin levels ranged from 0.6 to 3.0 (mean 1.7), compared to a range of 6.4 to 28 (mean 13.4) for the HA dogs. Cholangiograms demonstrated hepatic volume loss consistent with hepatocellular injury, but no biliary sclerosis. These data suggest that sclerosing cholangitis resulting from intra-arterial infusion of FUDR is unlikely to be due to metabolites of the drug excreted in the bile, but due to direct toxicity to the biliary tree.     

经内镜胆管引流术治疗胆道梗阻

目的：评价胆道梗阻的内镜治疗效果。方法：应用鼻胆管引流术9ENBD）及胆道内支架置入术（ERBD）进行胆道内、外引流。结果：58例病人内镜下胆管引流88例次，成功84次，成功率95．5％，ENBD 37例次，ERBD 51例次，引流后黄疽均有减退，恶性胆道梗阻者带瘤生存平均9．7月（3－18月），生活质量较高。结论：内镜下胆管引流是胆道梗阻的有效治疗方法，是急性梗阻性胆管炎、胆源性胰腺炎的有效治疗措施，可延长胆道恶性梗阻者带瘤生存时间并提高生活质量。     

血必净注射液对急危重症患者多器官功能障碍的阻断作用研究

目的探讨血必净注射液对急危重症患者全身炎症反应综合征(SIRS)和多脏器功能障碍综合征(MODS)阻断作用的临床意义。方法将120例急危重症患者APACHEⅡ评分>13分,随机分为对照组(60例)和血必净治疗组(简称治疗组,60例),观察入院后第1、3、7、10天血清肿瘤坏死因子-α(TNF-α)、白细胞介素-1β(IL-1β)、IL-6含量,血常规,肝、肾功能及APACHEⅡ分值,ICU住院天数、病死率、发生MODS例数。结果治疗组治疗后第3、7、10天血清TNF-α、IL-1β及IL-6水平较对照组有不同程度下降(P<0.05或P<0.01);第3、7天CRP较对照组明显下降(P<0.01)。第3、7、10天血WBC、BPC、ALB、Tbil、Cr及ALT较对照组明显改善(P<0.05或P<0.01)。治疗组器官衰竭率、病死率、住ICU天数及第7、10天APACHEⅡ分值均低于对照组(P<0.05)。结论血必净注射液可明显抑制血浆内毒素产生,下调促炎介质TNF-α、IL-1β及IL-6水平,改善微循环和组织灌注,保护重要脏器功能,阻断SIRS恶性发展及MODS形成。