本文回顾性分析了2017年1月至2021年12月湖南省人民医院收治的11例胰管结石患儿的临床资料，其中男性4例，女性7例，中位年龄13岁，年龄范围8~17岁。所有患儿均经CT及MRI+磁共振胆胰管造影确诊，并行手术治疗。全组患儿无死亡病例，术后出现A级胰漏1例，经保守治疗后痊愈。随访时间3~60个月，随访期间无胰腺内外分泌功能不全表现；术后腹痛明显较前缓解。外科手术是治疗儿童胰管结石的重要手段，积极的手术治疗对于提高患儿生存质量具有重要意义。

Objective:To study and analyse the results of postoperative hemorrhage after laparoscopic pancreaticoduodenectomy (LPD).Methods:The clinical data of patients who underwent LPD from May 2011 to December 2019 at Hunan Provincial People's Hospital were retrospectively analyzed. The clinical characteristics of patients, onset time of postoperative hemorrhage, location of postoperative hemorrhage, postoperative biliary fistula, pancreatic fistula, infection and other short-term complications, reoperation and mortality rates were analyzed.Results:Of 356 patients who underwent LPD in this study, there were 200 males and 156 females, aged (58.0±10.5) years. The postoperative complication rate was 33.1% (118/356), the reoperation rate was 6.5% (23/356), and the mortality rate was 2.5% (9/356). The most common complications were postoperative hemorrhage [15.2% (54/356)], pancreatic fistula [14.6%(52/356)] and abdominal infection [13.8%(49/356)]. The onset time of postoperative hemorrhage was usually in the 1st - 14th day, and the highest rate of postoperative hemorrhage was 3.9% (14/356) on the first day after surgery. The postoperative hemorrhage rate then showed a downward trend, but increased again on the 7th day. The extraluminal hemorrhage locations were relatively widely distributed, and the incidence of gastrointestinal anastomotic hemorrhage in patients with intraluminal hemorrhage was the highest [67.9%(19/28)]. Of the 9 patients who died, 7 were related to postoperative bleeding.Conclusions:LPD resulted in a high incidence of complications. Postoperative hemorrhage was a complication that had the greatest impact on short-term recovery of patients. It was also an important cause of reoperation and death. In addition to postoperative bleeding caused by pancreatic fistula, gastrointestinal anastomotic bleeding was also clinically important.

Objective:To compare between laparoscopic and open pancreaticoduodenectomy in the treatment of distal cholangiocarcinoma.Methods:The clinical data of laparoscopic pancreaticoduodenectomy (LPD group, n=101) and open pancreaticoduodenectomy (OPD group, n=99) in patients with distal cholangiocarcinoma who underwent pancreaticoduodenectomy at Hunan people's Hospital from Jan 2015 to Dec 2019 were analyzed retrospectively. The operation time, intraoperative blood loss, number of lymph node dissection, R 0 resection rate, postoperative hospital stay, postoperative complications and overall survival rate were compared between the two groups. Results:The operation time was (475.0±90.7) min and (444.8±63.3) min, the intraoperative blood loss was (350.9±397.9) ml and (546.7±642.9) ml, the postoperative hospital stay was (11.5±4.7) d and (13.3±5.1) d, the differences were statistically significant ( P<0.05).The number of lymph node dissection was 14.8±3.0 and 15.4±2.4, the R 0 resection rate was 93.1% and 96.0%, respectively, and there was no significant difference ( P>0.05). There was no significant difference in the incidence of residual complications ( P>0.05). During the follow-up of 5-64 months, the OS of 1, 3 and 5 years in the two groups were 90.4%, 41.3%, 20.6% and 94.3%, 50.8% and 24.7%, respectively. ( P>0.05). Conclusions:LPD is safe and feasible in the treatment of distal cholangiocarcinoma, and its short-term curative effect, curative effect and long-term overall survival rate are similar to those of OPD.

患儿男性,5岁,8个月早产儿.因尿色深黄1周,皮肤巩膜重度黄疸1天于2019年4月外院就诊.腹部体检:腹部稍膨隆,上腹部可见腹壁静脉显露,余项无明显异常.白细胞计数10.23×109/L,谷丙转氨酶142?U/L,谷草转氨酶317?U/L,总胆红素151.4?μmol/L,糖基抗原19-9?162.97?U/mL.MRI示:胰头区占位性病变并肝内外胆管扩张.于2019年4月转入湖南师范大学附属第一医院后,复查血常规:白细胞计数13.46×109/L,总胆红素 142.1 ?μmol/L,谷草转氨酶372.16?U/L,谷丙转氨酶100?U/L.

Objective:To compare the safety and efficacy of laparoscopic versus open pancreaticoduodenectomy.Methods:The clinical data of 989 patients who underwent pancreaticoduodenectomy at Hunan People's Hospital from January 2015 to December 2019 were analyzed retrospectively. There were 349 patients in the laparoscopic pancreaticoduodenectomy (LPD) group and 640 patients in the open pancreaticoduodenectomy (OPD) group. Propensity score matching (PSM) was used to match the baseline data of the two groups at a 1: 1 ratio. Data including operation time, intraoperative bleeding, postoperative hospital stay, bile leakage, pancreatic fistula and wound infection were compared between the two groups.Results:After PSM, there were 345 patients in each of the 2 groups. When the LPD group was compared with the OPD group, there were no significant differences in postoperative mortality, reoperation, intraoperative blood transfusion, pancreatic fistula, bile leakage, abdominal hemorrhage, abdominal abscess, severe complications, and pulmonary complication rates. The number of lymph node dissected, R 0 resection and overall survival rates between the two groups were also not significantly different ( P>0.05). However, the operation time of the LPD group (478.2±91.3) min was significantly longer than that of the OPD group (410.8±62.0) min ( P<0.05). On the other hand, the postoperative hospitalization time (10.8±4.3) d, intraoperative bleeding (322.0±362.6) ml, wound infection rate 1.2% (4/345) in the LPD group were significantly better than those in the OPD group [postoperative hospitalization time (12.5±7.9) d, intraoperative bleeding (478.8±570.2) ml, and wound infection rate 5.8% (20/345)] ( P<0.05) . Conclusion:LPD was safe and feasible, and it achieved similar curative effect as OPD.

回顾性分析2011年6月至2019年8月湖南省人民医院收治的5例胆石性肠梗阻患者的临床资料和随访情况。1例行一期胆囊切除＋胆囊十二指肠瘘修补＋小肠切开取石术，1例行腹腔镜辅助小肠切开取石术，2例行单纯小肠切开取石术，1例行小肠切开取石术＋二期胆囊切除＋胆囊十二指肠瘘修补术。1例十二指肠瘘，1例伤口感染，余患者术后无并发症发生。我们认为胆石性肠梗阻临床上相对罕见，常常合并多种合并症，治疗复杂，手术风险较大，临床上应结合患者病情严重程度选择个体化治疗。

临床资料 患者女,51岁,湖南汨罗人.因“反复上腹部疼痛伴发热6d”于2018年8月20日,入住本院.患者于2013年因“胆囊结石”在当地医院行“胆囊切除术”.2015年6月12日因“肝脓肿”在某医院行“穿刺引流术”,出院后2d后突发大量呕血,便血.急诊于某医院就诊.造影示左肝动脉一分支主干中远段可见一假性动脉瘤形成及对比剂外渗(图1①②),遂术中使用弹簧圈和生物胶栓塞(图1③).此次患者6d前出现上腹部疼痛伴发热.上腹部CT平扫+增强:左肝内胆管多发结石并扩张,胆总管下端条状高密度影并发射装伪影,胆囊缺如(图2).

Objective:To study the safety and efficacy of laparoscopic surgery in treatment of adult type IV congenital biliary dilatation (CBD).Methods:The clinical data of 63 adult patients with type IV CBD who underwent complete cystectomy and Roux-en-Y choledochojejunostomy at Hunan Provincial People’s Hospital from January 2010 to January 2019 were retrospectively studied. There were 23 patients in the laparoscopy group and 40 patients in the laparotomy group. T-test was used statistically to compare the differences in operation time, intraoperative blood loss, postoperative time to fist flatus, and hospital stay between groups. Chi-square test was used to statistically compare postoperative complications between groups.Results:In the laparoscopy group, there were 4 males and 19 females, aged (29.9±14.0) years, while in the laparotomy group, there were 7 males and 33 females, aged (30.9±15.7) years old. The operation times of the laparoscopy and laparotomy groups were (207.1±21.7) min versus (158.8±23.3) min, respectively. The intraoperative bleeding volume was (189.6±150.5) ml versus (266.0±119.5) ml, respectively. The postoperative time to first flatus was (72.8±16.0) h versus (87.0±17.0) h respectively. The postoperative hospital stay was (9.8 ±3.2) d versus (11.9±3.7) d, respectively. There were significant differences between the two groups ( all P<0.05). There was no significant difference in postoperative complications, including anastomotic stricture, bile leakage and incision infection between groups (all P>0.05) . Conclusions:Laparoscopic surgery to treat adult type IV CBD was safe and feasible. It had the advantages of minimal invasiveness, less bleeding, rapid recovery of gastrointestinal function, and a short hospital stay.

Objective: To investigate the efficacy and safety of primary closure of the common bile duct plus nasobiliary drainage via antegrade transabdominal approach in treatment of common bile duct stones. Methods: One hundred and thirty-eight patients with gallstones and concomitant choledocholithiasis admitted in the Department of Hepatobiliary Surgery of Hunan Provincial People's Hospital from August 2015 to February 2017 were enrolled. Of the patients, 45 cases underwent laparoscopic cholecystectomy, common bile duct exploration and endoscopic nasobiliary drainage with primary choledochal closure (nasobiliary drainage group), and 93 cases underwent laparoscopic cholecystectomy and common bile duct exploration plus T-tube drainage (T-tube drainage group). The main clinical variables between the two groups of patients were compared. Results: Operations were successfully completed in all the 138 patients, and no serious surgical complication occurred. In nasobiliary drainage group compared with T-tube drainage group, the operative time, intraoperative blood loss and volume of bile drainage on the first postoperative day showed no significant difference (all P>0.05), but the time to postoperative bowel function recovery, retention of the bile drainage tube, length of hospital stay and hospitalization cost as well as the amount of postoperative fluid infusion, and the volume of bile drainage on the second and third postoperative day were all significantly reduced (all P<0.05). There was no significant difference in overall incidence of postoperative complications between the two groups (P>0.05), but the incidence of symptoms of electrolyte imbalance such as nausea and vomiting in nasobiliary drainage group was significantly lower than that in the T-tube drainage group (P<0.05). Conclusion: Nasobiliary drainage extends the indications for primary closure of the common bile duct, and can shorten the tube retention time and length of hospital stay, and reduce the fluid and electrolyte disorders, with no increase of complications such as bile leakage and biliary stricture. It has certain superiority to T-tube drainage, but its indications should be followed.

Objective:To investigate the expressions of annexin A2 and the epithelial-mesenchymal transition (EMT) markers E-cadherin and vimentin in hepatolithiasis-associated intrahepatic cholangiocarcinoma and their significance.Methods:The expressions of annexin A2,E-cadherin and vimentin in tumor tissues from 46 patients with hepatolithiasis-associated intrahepatic cholangiocarcinoma (tumor group),bile duct tissues with chronic inflammation from 50 patients with simple hepatolithiasis (inflammation group) and normal bile duct tissues form 35 patients undergoing surgical resection for hepatic hemangioma or liver injury (normal group) were determined by immunohistochemical staining.The expressions of the three proteins among the groups were compared and their relations with clinicopathologic factors and prognosis of the patients with hepatolithiasis-associated intrahepatic cholangiocarcinoma were analyzed.Results:The positive expression rates of both annexin A2 and vimentin were presented in descending order as tumor group＞inflammation group＞normal group (69.6％ vs.36.0％ vs.11.4％;54.3％ vs.28.0％ vs.8.6％,all P＜0.05),while the opposite pattern was seen in that of E-cadherin (21.7％ vs.48.0％ vs.71.4％,all P＜0.05).In cholangiocarcinoma tissues,there was a positive correlation between the annexin A2 and vimentin expression (r=0.627,P＜0.05),and negative correlation between the E-cadherin expression and either the annexin A2 or vimentin expression (r=-0.682;r=-0.575,both P＜0.05).The expressions of annexin A2 and vimentin were significantly associated with the degree of tumor differentiation,lymph node metastasis and TNM stage,and E-cadherin expression was significantly associated with the degree of tumor differentiation and lymph node metastasis (all P＜0.05).Among the patients with hepatolithiasis-associated intrahepatic cholangiocarcinoma,the survival rate in cases with positive annexin A2 or vimentin expression was significantly lower than that in their corresponding negative ones,and the survival rate in cases with negative E-cadherin expression was significantly lower than that in those with its positive expression (all P＜0.05).Conclusion:The annexin A2/EMT pathway may probably play an important role in the development and progression of hepatolithiasis-associated intrahepatic cholangiocarcinoma.The expressions of annexin A2,E-cadherin and vimentin are closely related to the degree of malignancy of the tumor and prognosis of the patients.

Objective:To investigate the alteration of serum microRNAlet-7a (let-7a) level in patients with hepatocellular carcinoma (HCC) and its diagnostic value for HCC.Methods:The let-7a expressions in 60 HCC patients and 46 healthy subjects undergoing health maintenance examination were measured by qRT-PCR.And then the relations of serum let-7a level with clinicopathologic factors of HCC patients were analyzed and the diagnostic efficacy of let-7a for HCC was determined by using a receiver operating characteristic curve (ROC).Results:The relative expression level of serum let-7a in HCC patients was significantly lower than that in healthy population (0.538 vs.1.571,P＜0.05).The serum let-7a level was significantly associated with the formation of tumor emboli (P＜0.05),but was irrelevant to all other studied factors that included sex,age,HBV infection,cirrhosis,tumor diameter,tumor number,lymph node metastasis,TNM stage,pathological grade and AFP level (all P＞0.05).At an optimal cut-off value of 0.529 of let-7a for diagnosis of HCC,the sensitivity was 79％,the specificity was 71％ and the area under the curve (AUC) was 0.77 (95％ CI=0.624-0.839) respectively;in combined detection of serum let-7a and AFP for diagnosis of HCC,the sensitivity was 83％,the specificity was 97％ and the AUC was 0.92 (95％ CI=0.866-0.987),respectively.Conclusion:The serum let-7a level is decreased in HCC patients,which may be potentially used as a newmolecular marker for diagnosis of HCC,and its diagnostic efficacy for HCC can be enhanced by combinationdetection of AFP.

目的:探讨梗阻型轻症急性胆源性胰腺炎(MABP)的最佳治疗方案.方法:回顾性分析2008-2014年收治的132例梗阻型MABP患者的临床资料.其中35例行以内镜逆行胆胰管造影为基础的微创治疗(内镜组),43例行腹腔镜下胆囊切除、胆总管探查术(腹腔镜组),54例行开腹手术(开腹组).比较各组的相关临床指标.结果:内镜组、腹腔镜组、开腹组间的腹痛缓解时间(3.31 d vs.3.84 d vs.7.65 d)、白细胞恢复正常时间(4.20 d vs.5.35 d vs.8.72 d)差异均有统计学意义(均P＜0.05);内镜组与腹腔镜组的血淀粉酶恢复正常时间(3.26 d vs.3.53 d)、住院时间(9.49 d vs.9.30 d)差异无统计学意义(均P＞0.05),但均短于开腹组(4.35 d、9.30 d)(均P＜0.05).3组的治愈率均为100％,均无死亡病例,并发症发生率差异无统计学意义(P＞0.05);内镜组术后1年内胰腺炎复发率(42.86％)明显高于腹腔镜组(0.00％)和开腹组(1.85％)(均P＜0.05),但后两组间差异无统计学意义(P＞0.05).结论:对于梗阻型MABP,在大多数情况下,腹腔镜途径是解除胆道梗阻的首选方法.

Objective:To investigate the applying value of regional hepatopetal blood flow occlusion in resection of hepatocellular carcinoma.Methods:We retrospectively reviewed the clinical data of 69 patients undergoing resection of hepatocellular carcinoma,38 patients of them received hepatic carcinectomy with regional hepatopetal blood flow oc-clusion,the other 31 patients received hepatic carcinectomy with total hepatic vascular exclusion(Pringle method). The operative time,intraoperative blood loss,rate of intraoperative blood transfusion,incidence of postoperative com-plications,postoperative aspartate transaminase(AST)level,postoperative drainage volume,time to flatus,length of postoperative hospitalization and satisfactory rate of operation margin of the two groups were compared.Results:The intraoperative blood loss,postoperative drainage volume,AST level and incidence of postoperative complications were significantly reduced but the rate of satisfactory resection margin was significantly increased in regional hepatopetal blood flow occlusion group compared with Pringle method group(all P <0.05).No differences between the two groups were noted of the rate of intraoperative blood transfusion,time span for flatus,length of postoperative hospital stay(all P >0.05).Conclusion:Resection of hepatocellular carcinoma with regional hepatopetal blood flow occlusion has the advantages of less intraoperative blood loss,minimum surgical trauma,increased rate of satisfactory resection margin as well as reduced exudation and less complications.

目的:探讨壶腹周围癌发病的相关危险因素,为有效预防和控制壶腹周围癌提供理论依据.方法:采用1:1配对病例对照研究,收集湖南省人民医院肝胆外科2003-2014年间122例壶腹周围癌患者(病例组)和同期122例非肿瘤、非消化系统疾病患者(对照组),对可能的危险因素进行条件Logistic回归分析.结果:在控制了混杂因素后,壶腹周围癌的危险因素为吸烟、饮酒及乙肝感染.其结果为,随着每日吸烟量(支)的增加壶腹周围癌的患病率随之增加,其中现在不吸烟者、＜20支/d、20～39支/d、≥40支/d者的优势比(OR)分别为0.450(95％ CI=0.205～0.988)、0.500(95％CI=0.092～2.730)、2.571(95％ CI=1.074～6.156)、3.000 (95％CI=0.312～28.841);每日饮酒＜40 g、40～99 g、≥100 g者患壶腹周围癌的OR值分别为3.000(95％ CI=0.312～28.841)、65.289(95％ CI=0.006～70.239)、4.50(95％ CI=0.972～20.827);乙肝感染者患壶腹周围癌的危险性是无乙肝病史者的3.25倍(95％ CI=1.060～9.967).结论:大量吸烟、饮酒以及乙肝感染是壶腹周围癌的危险因素.

目的:探讨PROX-1及Ki-67在胆管癌中表达及意义.方法:用免疫组化法检测46例肝门部胆管癌患者(伴淋巴结转移29例,无淋巴结转移17例)癌组织与23例胆管良性病变患者胆管组织中PROX-1及Ki-67的表达,分析PROX-1及Ki-67的表达与胆管癌淋巴转移及其他临床病理因素的关系.结果:PROX-1与Ki-67两者的阳性表达率在良性病变胆管组织、无淋巴结转移胆管癌组织、伴淋巴结转移胆管组织中依次增高,差异均有统计学意义(均P＜0.05);两者的阳性表达率均与胆管癌的分化程度有关(均P＜0.05),而与患者的性别、年龄无关(P＞0.05);胆管癌组织中PROX-1与Ki-67表达正相关(r=0.831,P＜0.05).结论:PROX-1与Ki-67的高表达与胆管癌的恶性生物学行为密切相关,且两者表达量之间存在关联性.

Objective To investigate the diagnosis and treatment of delayed arteriorrhagia after pancreaticoduodenectomy.Method The data of 5 DAP patients were analyzed retrospectively.Result There were 3 patients accompanied with blood hypertension or coronary atherosclerosis.After operation,there were 4 patients suffered from pancreatic leakage and abdominal abscess.All patients were diagnosed and cured by transcatheter arterial angiography and embolization.Conclusion Blood hypertension,coronary atherosclerosis,pancreatic leakage and abdominal abscess are the risk factors for delayed arteriorrhagia after pancreaticoduodenectomy.It plays an important role of the transcatheter arterial angiography and embolization in diagnosis and treatment for the delayed arteriorrhagia after pancreaticoduodenectomy.

To compare effects and life cycle of simple surgical treatment and surgery combined with trans-catheter arterial chemo-embolization(TACE) on patients with advanced un-resectable hepatocellular carcinoma(HCC).Clinical data of 260 consecutive patients who underwent hepatectomy for HCC in our hospital from 2006 to 2009 were analyzed retrospectively.According to the different treatment modalities,these patients have been divided into simple surgical group(control group) and group of surgery combined with TACE(combined group) to proceed controlled studies and to compare the Disease Control Rate(DCR) three months after patients'operation,to compare 3 year survival rates and analyzed using Kaplan-Meier survival curves.For control group and combined group,the 3-month DCR were 75.70% and 85.62% respectively(P=0.043) there was a statistically difference.For control group,1,2 and 3 year survival rates were 55.14%,15.89%,9.35% respectively;for combined group,the rates were 66.01%,27.45%,18.95% accordingly.There was no significant differences for 1 year survival rates(P=0.076),but 2 and 3 year survival rates of combined group were apparently higher than control group(P=0.029,P=0.033).The long-term effect of surgery combined with TACE on patients with advanced un-resectable HCC has a distinct advantage over those of simple surgical treatment.

[目的]探讨医用生物胶用于肝胆管结石肝叶切除术中应用的临床效果.[方法]180例肝胆管结石部分肝切除患者以术中有无使用创面封闭胶分为A组(使用封闭胶)与B组(不使用封闭胶),每组90例.观察术后1～3 d腹腔引流管引流情况,记录引流量(mL),常规待腹腔引流管无液体引出时拔管,记录留置引流管时间(h);观察比较两组患者的并发症发生率.[结果]A组d1、d2、d3引流量明显小于B组,拔管时间明显短于B组(P<0.05).术后A组有2例膈下积液,B组有9例膈下积液(P<0.05);术后A组无一例胆漏发生,B组有2例患者发生胆漏.[结论]创面封闭胶能明显减少肝切除患者术后腹腔渗液及减少膈下积液的发生率,适合在临床推广应用.

胰头慢性肿块型胰腺炎及胰头部铸型结石常引起患者难以忍受的上腹部及腰背部疼痛,常需行胰头十二指肠切除术才能缓解疼痛症状,但此类患者常因胰头周围反复炎症粘连,无法沟通胰颈与肠系膜上静脉及门静脉之间的解剖间隙,但考虑到胰头为良性病变,在辨清肠系膜上静脉、门静脉右缘基础上,行胰头次全切除、解除主胰管梗阻而达到缓解症状的目的.笔者于2006年3月至2007年10月期间为3例难切的胰头部良性病变(1例胰头肿块型胰腺炎和2例胰头结石)患者施行了胰头次全切除术.

尽管肝切除技术已取得相当大的进步,但手术的风险性仍较大,肝切除术中肝血流阻断、出血、肝脏缝扎、挤压等多重因素都会对正常肝细胞产生不同程度的损害,导致术后易发生肝功能代偿不全,甚至肝功能衰竭而危及生命.本研究回顾性分析在围术期使用乌司他丁对不同肝门阻断时间肝切除术后肝功能损害的影响.