目的 比较双镜联合保胆取石术与腹腔镜胆囊切除术(LC)治疗胆囊结石的疗效.方法 回顾性分析2018年1月至2019年12月北京市顺义区医院收治的150例胆囊结石患者的临床资料,根据手术方式不同分为联合组(n=71)与LC组(n=79),联合组采用胆道镜、腹腔镜双镜联合保胆取石术,LC组采用腹腔镜胆囊切除术.比较两组患者手术相关指标、炎性反应程度、并发症及复发率情况.结果 联合组手术时间为(54.27±6.38)min,长于LC组,差异有统计学意义(P<0.05).术后3天两组白细胞介素(IL-6)、C反应蛋白(CRP)水平均高于术前,差异有统计学意义(P<0.05).联合组术后3天IL-6、CRP水平分别为(1.45±0.33)ng/L和(4.32±0.86)mg/L,均低于LC组,差异有统计学意义(P<0.05).联合组并发症发生率为2.82％,低于LC组的12.66％,差异有统计学意义(P<0.05).随访12个月,联合组复发率为2.81％,LC组为2.53％,两组差异无统计学意义(P>0.05).结论 与LC手术比较,双镜联合保胆取石术除手术时间略长外,具有术后炎性反应和并发症发生率低的优点,可作为首选术式.

目的:探讨腹腔镜脾部分切除术(LPS)在脾脏良性病变治疗中的应用价值.方法:选取2019年1月至2021年12月收治的脾脏良性病变患者64例,按随机数字表法分为两组,各32例.对照组予以腹腔镜全脾切除术(LTS)治疗,观察组接受LPS治疗.比较两组手术情况,手术前后免疫功能、生活质量及并发症发生情况.结果:观察组手术时间长于对照组,术中出血量多于对照组,术后排气时间、排便时间及住院时间短于对照组,差异有统计学意义(P<0.05);观察组术后CD3+、CD4+、CD4+/CD8+水平高于对照组,CD8+水平低于对照组,差异有统计学意义(P<0.05);观察组术后生理、心理、社会及环境领域评分高于对照组,差异有统计学意义(P<0.05);观察组并发症发生率低于对照组,差异有统计学意义(P<0.05).结论:采用LPS治疗脾脏良性病变能缩短患者术后排气、排便及住院时间,减轻患者免疫功能损害,减少并发症发生,加快患者生活质量恢复.

目的 研究外伤性肝破裂患者腹腔镜修补术后并发症的危险因素.方法 收集2017年4月至2020年10月本院102例外伤性肝破裂患者作为研究对象,患者均接受腹腔镜下修补术,记录并发症发生情况.采用Logistic多因素分析法探讨其术后并发症的危险因素,并建立指数方程,分析其判断并发症的应用价值.结果 102例患者中,共发生并发症38例,发生率为37.25％,其中术后感染14例,术后胆漏12例,出血8例,肝脓肿4例.Logistic多因素分析结果显示,受伤至入院时间、失血量、低血压持续时间及Alb水平是影响术后并发症的独立影响因素(P<0.05).根据Logistic多因素分析结果建立指数方程Y=0.603 X1+0.654 X2+0.471 X3+0.798 X4+0.899 X5(X1=受伤至入院时间,X2=失血量,X3=肝破裂分级,X4=低血压持续时间,X5=Alb).ROC分析结果显示指数方程判断术后并发症的AUC为0.796(SE=0.066,95％C I=0.666～0.926,P<0.001).结论 外伤性肝破裂患者腹腔镜下修补术后并发症发生率较高,其并发症与受伤至入院时间、失血量、肝破裂分级、低血压持续时间及A lb水平相关.

2019年12月至2021年7月我院共完成腹腔镜下单独肝尾状叶肿瘤切除术3例,男2例,女1例.29～71岁,术前诊断肝细胞癌1例,肝血管瘤2例,病灶直径3.4～6.5 cm,均位于Spiegel叶,2例为体检发现,1例有腹胀不适,肝功能均为Child A级.完善术前准备,包括影像学评估,了解肿瘤位置、边界及周边相关的重要管道结构,评估肝功能、残肝体积及麻醉风险.

目的 观察经皮经肝胆囊穿刺置管引流术(percutaneous transhepatic gallbladder drain-age,PTGD)拔管后早期、晚期行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)对急性重症胆囊炎病人炎性反应和肝功能的影响.方法 前瞻性选择北京市顺义区医院2019年1月至2020年12月116例急性胆囊炎病人作为研究对象,采用隐匿数字随机法分为两组,PTGD拔管后早期(引流管拔除后72 h)行LC的58例病人设为LC早期组,PTGD拔管后晚期(引流管拔除后14～30 d)行LC的58例病人设为LC晚期组,比较两组LC术前、术后24 h炎性反应程度和肝功能.结果 两组PT GD引流时间、术中出血量、术后肛门排气时间差异均无统计学意义(P>0.05).LC晚期组LC手术时间、术后住院时间明显长于LC早期组,差异均有统计学意义(P<0.05).LC术后24 h总胆红素(TBIL)、天冬氨酸转氨酶(AST)、碱性磷酸酶(ALP)、丙氨酸转氨酶(ALT)、γ-谷氨酰转移酶(GGT)水平均较LC术前明显降低,差异均有统计学意义(P<0.05).LC早期组LC术后24 h的TBIL、AST、ALP、ALT、GGT水平均低于LC晚期组,差异均有统计学意义(P<0.05).LC术后24 h肿瘤坏死因子α(TNF-α)、白细胞介素(IL)-1、IL-6、IL-10水平均高于LC术前,超敏C反应蛋白(hs-CRP)、降钙素原(PCT)水平均低于LC术前,差异均有统计学意义(P<0.05).LC早期组LC术后24 h的hs-CRP、PCT、TNF-α、IL-1、IL-6水平均低于LC晚期组,差异均有统计学意义(P<0.05).两组LC术后24 h IL-10水平差异无统计学意义(P>0.05).LC早期组胆漏、胆道损伤等并发症发生率为5.17％(3/58),明显低于LC晚期组的17.24％(10/58),差异均有统计学意义(P<0.05).LC早期组中转开腹率为5.17％(3/58),LC晚期组为3.45％(2/58),差异无统计学意义(P>0.05).结论 PTGD拔管后早期行LC可减轻炎性反应程度,有效保护肝功能,缩短病人手术和住院时间,降低术后并发症的发生率.

目的 探究半乳糖凝集素9(Galectin-9)、NADPH氧化酶1(NOX-l)mRNA在胆囊癌中表达变化及与癌细胞生物学行为指标的关系.方法 选取本院胆囊癌患者84例,检测对比癌组织与与距离癌组织边缘5 cm左右的癌旁正常组织中Galectin-9、NOX-1 mRNA相对表达量,分析癌组织中Galectin-9 mRNA与NOX-1 mRNA关联性及两者与临床病理特征、癌细胞生物学行为指标的关系.结果 癌组织中Galectin-9 mRNA相对表达量低于癌旁正常组织,NOX-1 mRNA相对表达量高于癌旁正常组织,差异有统计学意义(P＜0.05);癌组织中Galectin-9 mRNA与NOX-1 mRNA呈负相关(r-=-0.688,P＜0.001);Galectin-9 mRNA与临床分期、淋巴结转移、分化程度显著相关(P＜0.05);NOX-1 mRNA与临床分期、淋巴结转移、分化程度、肿瘤浸润深度显著相关(P＜0.05);Galectin-9 mRNA与p-STAT3、Bcl-2、MMP-7 mRNA呈负相关,NOX-1 mRNA 与p-STAT3、Bcl-2、MMP-7 mRNA呈正相关(P＜0.05).结论 Galectin-9 mRNA下调、NOX-1mRNA上调可能是胆囊癌发生的重要机制,且两者表达水平与临床病理特征、生物学行为指标密切相关,能为临床诊治提供有效信息.

Objective:To compare the efficacy and safety of laparoscopic combined with duodenoscope (IO-ERCP/EST+ LC) and laparoscopic combined with intraoperative choledochoscope (LC/LCBDE+ IOC) in the treatment of gallstones and choledocholithiasis in the elderly.Methods:From October 2017 to October 2020, clinical data of 80 elderly patients with gallstones and choledocholithiasis were analyzed retrospectively. According to different surgical plans, 40 cases were divided into the group A (IO-ERCP/EST+ LC), and 40 cases were divided into group B (LC/LCBDE+ IOC). Statistical software SPSS21.0 were used for data analysis. Measurement data such as intraoperative and postoperative indicators, liver function indicators and other measurement data were expressed as (±s), and were examined by independent t test. Chi-square test were performed for the analysis of postoperative complications, stones Counting data such as clearance rate and stone residual rate. A P value of <0.05 was considered statistically significant difference.Results:The operation time in group A were significantly shorter than that of group B (P<0.05). There were no statistically significant difference between groups in terms of postoperative complications such as stone removal rate, residual stone rate, postoperative bleeding, perforation, bile leakage, pancreatitis and cholangitis (P>0.05). There were no statistically significant difference between groups in terms of liver function levels of bilirubin, ALT, AST, and ALPbefore and after the operation (P>0.05); The postoperative exhaust time of group A was shorter than that of group B, and the hospitalization time and cost of group A were higher than that of group B, with statistically significant differences (P<0.05).Conclusions:The IO-ERCP/EST+ LC treatment has a shorter operation time and quicker postoperative recovery, however the hospitalization cost is relatively high. Clinically, the most reasonable and optimal program choice should be made according to the specific conditions of the patient.

目的:探讨腹腔镜技术在治疗复杂急性阑尾炎诊治中的应用.方法:回顾性分析2012.5-2016.10收治的复杂阑尾炎158例,行腹腔镜手术治疗的临床效果.其中坏疽性穿孔性阑尾炎80例,肝下阑尾12例,腹膜后位阑尾26例,重度肥胖患者16例,阑尾周围脓肿24例,均行腹腔镜下手术.结果:除1例坏疽性阑尾炎转开放手术,其余均行腹腔镜下阑尾切除术,阑尾周围脓肿行腹腔镜下引流管置入引流.术后出现Trocar口感染5例,腹腔内脓肿形成10例,术后出血2例,肠瘘1例,Trocar疝2例.结论:复杂类型阑尾炎患者采取腹腔镜手术治疗,手术创伤小、恢复快、并发症低,具有良好的临床效果.

目的:探讨腹腔镜胆囊切除中转开腹手术的原因及预防措施.方法:回顾性分析我院2008.9-2016.10行腔镜胆囊切除术1216例中转开放手术29例患者,观察腹腔镜胆囊切除术中转开腹的原因及术后并发症发生情况.结果:本组29例患者中转开腹手术,中转率2.4%(29/1216),胆囊周围粘连致密8例,Calot三角分离不清12例,出血3例,Mirizzi综合征2例,胆囊十二指肠瘘1例,术中胆囊癌2例,术中胆漏1例.患者转开腹后均一次手术成功,术后出现胆漏1例,伤口感染2例,无胆管损伤.结论:胆囊三角不清及胆囊周围粘连、出血、术中胆漏等是中转开腹的常见原因,术中及时中转开腹可有效避免严重并发症发生,术前充分评估、合理处理胆囊三角及胆囊床可有效预防腹腔镜胆囊切除中转开腹.

[目的]探讨经皮经肝胆道支架植入术(PTIBS)治疗恶性梗阻性黄疸的临床观察和护理方法。[方法]对45例恶性梗阻性黄疸病人行 PTIBS,在术前、术中、术后加强一般护理、皮肤护理、引流管护理,术后加强并发症观察及护理。[结果]45例支架植入成功42例,其中4例放置双支架。术后1周~4周血清胆红素下降明显,胆道梗阻解除,肝功能改善,病人生活质量提高。术后胆道感染8例,胰腺炎3例,胆漏2例,胆道出血2例,腹腔内出血死亡1例。术后随访平均生存时间11.8个月。[结论]PTIBS 是一种安全有效治疗恶性梗阻性黄疸的方法,加强临床护理能有效减轻病人痛苦,减少并发症,提高病人生存质量和生存时间。

Objective To study and evaluate clinical efficacy of percutaneous transhepatic insertion of baliary stent in treating malignant baliary obstructive jaundice.Methods 45 maligant obstructive jaundice patients were performed PTIBS,which included cholangiocarcinoma 32 cases and carcinoma of head of pancreas 13 cases.The total bilirubin(TBIL) were detected to observe the efficacy of lessening jaundice.Results 42 patients were planted stent successed.The successful rate was 93.3%,4 of them were inserted 2 stents.The stents opened well while the bile drainaged smoothly,TBIL decreased obviously after operation 1 to 4 weeks,the jaundice were relieved obviously.One case died because of abdominal cavity bleeding,hemobilia 2 cases,biliary leak 2 cases,pancreatitis 3 cases,the infection of baliary duct 8 cases.According to the follow-up,the mean survival time was 11.8 months and the longest was 24 months.Conclusion PTBIS was a safe and effective treatment for maligant biliary obstructive patients and it prolonged the survival time and lessened the bitness and improved quality of life.

Objective To summarize the clinical experience and methods by analyzing treatment of SAP(severe acute pancreatitis).Methods Retrospective analysis of 168 cases with severe acute pancreatitis treatment in our hospital in past 5 years(from Oct.2006 to Oct.2011).Results In all 168 cases,142 cases were cured by medical treatment while 9 patients died,14 cases were cured by surgery(including ERCP + EST,cholecystectomy and common bile duct exploration,or laparoscopic cholecystectomy after ERCP or pancreatic necrosis debridement treatment) while 3 patients died.Of all patients,12 cases with gastrointestinal bleeding,20 cases with acute renal failure,ARDS 12 cases,liver function abnormal 98 cases,MODS 18 cases,3 cases with pancreatic pseudocyst huge cyst,3 cases with pancreatic leakage.Conclusion Treatment of severe acute pancreatitis was mainly with non-surgical treatment,if necessary,take traditional surgery,endoscopic surgery and laparoscopic surgery treatment.