Objective:To explore the pathogenesis of gallbladder cholesteryl polyps (GCP) and gallbladder cholesterol calculus (GCC) by studying the different changes of mucin (MUC) expression and reverse cholesterol transporter (RCT) in gallbladder mucosa epithelium.Methods:The data of 10 GCP patients (GCP group), 10 GCC patients (GCC group) and 5 patients with normal gallbladder resection (control group) were retrospectively analyzed, who underwent cholecystectomy in the Department of General Surgery, Xuanwu Hospital, Capital Medical University from January to December 2021. Among the 10 patients in the GCP group, there were 5 males and 5 females, aged (43.40±9.59) years old. Among the 10 patients in the GCC group, 5 males and 5 female, aged (45.00±8.13) years old. Among the 5 patients in the control group, there were 3 males and 2 females, aged (43.80±6.01) years old. Immunohistochemical analysis was used to investigate the expression differences of various subtypes of MUC and RCT [ATP binding cassette transporter G1 (ABCG1) and B group type I scavenger receptor (SR-BI)] among each group.Results:Compared with the control group, the expression of MUC1 (3.40±0.70 vs. 0), MUC5AC (1.50±0.53 vs. 0), MUC6 (4.70±0.48 vs. 0), and ABCG1 (3.50±0.53 vs. 1.60±0.55) in the gallbladder mucosa of the GCP group increased, while the expression score of SR-BI decreased (1.70±0.48 vs. 3.40±0.55), with statistical significance (all P<0.001). Compared with the control group, the expression of MUC1 (4.80±0.42 vs. 0), MUC5AC (4.70±0.48 vs. 0), MUC6 (3.30±0.67 vs. 0), and ABCG1 (3.40±0.52 vs. 1.60±0.55) in the gallbladder mucosa of the GCC group increased, while the expression score of SR-BI decreased (0 vs. 3.40±0.55), with statistically significant differences (all P<0.001). Conclusion:The different expression levels of MUC1, MUC5AC, MUC6, and RCT proteins lead to the differential formation of GCP and GCC on the basis of the co-pathogenesis in high cholesterol in bile.

目的 探索肝胆外科临床实习教学活动中,网络辅助临床案例问题为导向(CBL-PBL)的教学模式提高临床思维能力的教学效果.方法 选取2020年9月至2021年4月在首都医科大学宣武医院肝胆外科病区实习的临床医学系5年级医学生50名作为研究对象,使用随机数字表法将其分为研究组和对照组,每组各25名.研究组采用网络辅助CBL-PBL教学模式,包括网络化的组织管理、CBL为基础的教案设计、PBL为中心的教学实施和网络化课后管理.对照组采用传统教学模式.比较两组学生对临床思维能力学习的满意度.使用临床思维能力教学评估量通用量表评分评估临床思维教学效果.结果 研究组学生对临床思维能力教学满意度高于对照组(P<0.05).研究组学生批评思维、系统思维、循证思维及临床思维能力及总分高于对照组(P<0.01).结论 应用网络辅助CBL-PBL教学模式,在临床医学生肝胆外科的实习中,可以提高学生满意度,改善临床思维能力教学效果,值得深入研究、完善和推广.

Objective To analyze the factors related to gallbladder cholesterol polyp (GCP) and gallbladder adenoma (GA) and establish predictive model for distinction between GCP and GA before surgery. Methods Patients with gallbladder polyps diameter≥10 mm diagnosed by ultrasonography in Xuanwu Hospital Capital Medical University and the First Hospital of Peking University from January 2015 to December 2019 were studied. There were GCP group and GA group based pathological diagnosis. Univariate and multivariate analyses were used to study the factors related to GCP and GA. Logistic linear regression was used to establish a predictive model and to evaluate the diagnostic effect. Results A total of 384 patients with gallbladder polyp were in this study with male to female ratio of 1:1.49 and age of (50.32±14.15) years. There were 250 patients (65.1%) in GCP group and 134 patients (34.9%) in GA group. Univariate analysis showed that five factors in quantitative data including age, blood glucose, low density lipoprotein, albumin, and total bile acid and three factors in count data including age 50 years or older, low density lipoprotein ≥3.1 mmol/L and total bile acid ≥10.0 μmol/L had significant difference statistically between two groups (P<0.05). Three factors were gotten as age, low density lipoprotein and total bile acid with significant difference statistically in multivariate analysis. The sensitivity of predictive regression equation were 74.8%, when P≥0.601 was used to diagnose cholesterol polyps. The regression equation was fitted by ROC curve and the area under curve was 0.662. Conclusions The equation on the factors of age, low density lipoprotein and total bile acid could be used to predict cholesterol polyps and adenomas preoperatively for patients with gallbladder polyps.

胆囊息肉(gallbladder polyp,GBP)是一种常见病和多发病,世界范围内发病率0.3％～9.5％[1].GBP病人的分布有种族和区域性差异.在东亚和南亚地区人群,包括我国的汉族人群中GBP发生率较高.既往报道,我国人群体检GBP发生率2.68％～14.17％[2],近年来有逐渐上升的趋势.一般认为GBP直径≥10 mm有恶变风险,需手术切除,＜10 mm随访观察.但在临床实践中情况较复杂,诊治中仍有一些争议.随着更多GBP相关基础研究的发展和临床循证医学证据的增多,有必要对这些问题进行深入分析和思考.

随着微创外科技术的发展,腹腔镜手术中血管和胆管闭合夹的使用有效提高了手术效率,包括金属钛夹、非金属不可吸收闭合夹和可吸收闭合夹等.腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)或胆总管探查(laparoscopic common bile duct exploration,LCBDE)术后钛夹迁移进入消化道、胆道、泌尿道的病例报道较多,金属闭合夹的使用逐渐减少[1～3].非金属闭合夹Hem-o-lok(Weck Closure Systems)作为钛夹的替代物具有更好的安全性,其移位报道较少[4～8].本文回顾性分析我院Hem-o-lok迁移进入胆管4例资料,结合文献对其发生机制、危害、治疗和预防进行总结.

Background The purpose of this study was to assess the risk factors for cholesterol polyp formation in the gallbladder. Methods This was a multicenter retrospective study based on pathology. From January 2016 to December 2019, patients who underwent cholecystectomy and non-polyp participants confirmed by continuous ultrasound follow-ups were reviewed. Patients in the cholesterol polyp group were recruited from three high-volume centers with a diagnosis of pathologically confirmed cholesterol polyps larger than 10 mm. Population characteristics and medical data were collected within 24 h of admission before surgery. The non-polyp group included participants from the hospital physical examination center database. They had at least two ultrasound examinations with an interval longer than 180 days. Data from the final follow-up of the non-polyp group were analyzed. The risk factors for cholesterol polyp formation were analyzed by comparing the two groups. Results A total of 4714 participants were recruited, including 376 cholesterol polyp patients and 4338 non-polyp participants. In univariate analysis, clinical risk factors for cholesterol polyps were age, male sex, higher body mass index (BMI), higher low-density lipoprotein (LDL), lower high-density lipoprotein (HDL), and higher aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. In multivariate logistic analysis, independent risk factors were age > 50 years (odds ratio [OR] = 3.02, 95% confidence interval [CI] 2.33–3.91, P < 0.001], LDL > 2.89 mmol/L (OR = 1.38, 95% CI 1.08–1.78, P = 0.011), lower HDL (OR = 1.78 95% CI 1.32–2.44, P < 0.001), AST > 40 IU/L (OR = 3.55, 95% CI 2.07–6.07, P < 0.001), and BMI > 25 kg/m 2 (OR = 1.32, 95% CI 1.01–1.72, P = 0.037). Conclusions Age, LDL, HDL, AST, and BMI are strong risk factors for cholesterol polyp formation. Older overweight patients with polyps, accompanied by abnormal lipid levels, are at high risk for cholesterol polyps.

目的:探讨日间腹腔镜胆囊切除术(DCLC)的可行性.方法:回顾分析2018年1月1日至2019年12月31日施行腹腔镜胆囊切除术患者的临床资料,分为DCLC组与常规腹腔镜胆囊切除术(RLC)组.对比两组患者一般情况、手术安全性、卫生经济学指标.结果:共纳入1870例患者,其中DCLC组246例,RLC组1624例.计划DCLC患者中13例24 h后延迟出院,原因包括放置腹腔引流管(7.7％)、切口疼痛(15.4％)、进食后恶心呕吐(23.1％)及术后焦虑(53.8％);两组患者性别、病因、伴发疾病、腹部手术病史、手术时间、术中出血、术后并发症差异均无统计学意义(P>0.05).DCLC组年龄、住院时间、住院费用低于RLC组(P<0.05),满意度评分高于RLC组(P<0.05).行DCLC的两个手术组患者年龄、性别、病因、伴发疾病史、腹部手术史、手术时间、术中出血、住院时间、住院费用、满意度评分差异均无统计学意义(P>0.05).结论:熟练掌握LC的术者均可安全施行DCLC,不会增加术后并发症的发生风险,并能显著缩短住院时间、降低住院费用、提升患者满意度.

临床应用解剖学以人体解剖学为基础,用于解决临床诊治相关问题[1].除尸体解剖外,它引入了影像学、手术学等研究方法,深入揭示人体局部解剖的形态结构、胚胎发育、组织构成、生理功能和毗邻关系,关注解剖变异变形,并明确病灶病理状态,包括定性、定位、分型、分期.临床应用解剖学是制定外科诊疗策略和手术操作的基础,与外科手术技术相互促进共同发展.胆道外科疾病复杂,手术技术方法多样,术者需要掌握更多更深入的解剖学知识,并与手术技术相结合.

Acute appendicitis is one of the most common acute abdominal diseases in surgery. Due to its urgent onset and rapid progress, timely diagnosis and early treatment are beneficial to the prognosis of patients. The diagnosis of acute appendicitis should be based on the characteristics of different populations, based on clinical symptoms, physical examination, laboratory examination, and imaging methods. Anti-infection treatment should be started as soon as possible in the early stage, and antibiotics should choose effective drug treatment with both anaerobic bacteria and aerobic bacterial infection. Appendectomy is still the most effective treatment for acute appendicitis. In the case of uncomplicated abdominal infection such as simple and non-perforated appendicitis, antibiotic treatment may be chosen, but the development needs to be closely observed. Laparoscopic appendectomy is the first choice, but in pregnancy patients should be cautious. Emergency surgery is required for acute perforated appendicitis and attention should be paid to intraoperative abdominal flushing. Immediate surgical treatment of appendiceal abscess may involve the risk of partial ileectomy. Antibiotic treatment is recommended, with percutaneous abscess puncture and drainage if necessary.