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Objective:To evaluate the effect of different options of preoperative biliary drainage (PBD) on perioperative complications of patients undergoing pancreaticoduodenectomy (PD).Methods:The clinical data of patients undergoing PD for periampullary carcinoma from January 2016 to November 2021 at Third Affiliated Hospital of Naval Medical University (Shanghai Eastern Hepatobiliary Surgery Hospital) were retrospectively analyzed. The 303 patients including 199 males and 104 females, aged (64.2±8.8) years. According to PBD, the patients were divided into two groups: percutaneous transhepatic biliary drainage (PTBD) group ( n=228) and endoscopic retrograde cholangiopancreatography (ERCP) group ( n=75). PBD operation-related complications (including bleeding, biliary leakage, etc.), postoperative complications of PD (including pancreatic fistula, biliary leakage, surgical site infection, etc.) and perioperative complications (PBD operation-related complications + postoperative complications of PD) were compared between the two groups. Univariate and multivariate logistic regression analysis were used to analyze factors influencing perioperative complications of PD. Results:The incidence of PBD operation-related complications in PTBD group was 10.1% (23/228), lower than that in ERCP group 25.3%(19/228), and the difference was statistically significant (χ 2=10.99, P=0.001). The incidence of postoperative complications of PD in PTBD group was 38.2%(87/228), lower than that in ERCP group 69.3%(52/75), the difference was statistically significant (χ 2=22.09, P<0.001). The incidence of total perioperative complications in PTBD group was 44.3% (101/228), lower than that in ERCP group 73.3%(55/75), the difference was statistically significant (χ 2=19.05, P<0.001). Multivariate logistic regression analysis showed that patients with periampullary carcinoma undergoing ERCP biliary drainage and PD had increased risk of surgical site infection ( OR=2.86, 95% CI: 1.59-5.16, P<0.001) and pancreatic fistula ( OR=3.06, 95% CI: 1.21-7.74, P=0.018). Conclusion:ERCP biliary drainage is a risk factor for postoperative pancreatic fistula and surgical site infection in patients with periampullary carcinoma undergoing PD. PTBD should be recommended as the first choice for the patients underwent PD.
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Paraneoplastic pemphigus (PNP) is an autoimmune mucocutaneous disease first named by Anhalt, et al. in 1990. The disease is characterized by such distinctive clinical symptoms and signs as severe, painful mucosal erosions, polymorphous skin lesions, histopathology hallmarks, and immunological findings. The situation typically presents in patients with lymphoproliferative diseases and primarily malignancies. A main challenge of the study is the relationship between the existence of associated tumors and the autoimmune reaction to the skin. Some researchers suspected that the possible expression of foreign antigens on the tumor can cross react with epidermal antigens inducing the auto-reactive clones of T-lymphocytes. Some speculated that the type of tumors associated with PNP may produce plakin proteins that result in initiation of the immune response. Other reports believed the autoimmune reaction is related to the epitope spreading or to the changing of cytokines. We analyzed 12 PNP patients diagnosed in our department in the past few years. An intensive study to the B cells in the PNP associated with tumors demonstrated that the tumors have structural basis to produce antibody. The similar immunoglobulin heavy chain genes of tumor B-cells in 7 patients strongly suggested that the B cell clones were functional and recognized the same antigen epitope. The autoantibodies secreted by the tumor can react against specific plakin proteins in epidermis, lead to the impairment of cell-cell adhesion, and cause the mucocutanous lesions. The clinical significance of the results indicates the importances of early finding and total resection of the associated tumors, and the usage of IVIG pre or during operation to prevent Bronchitis Obliterans. The new finding is also important for the study of other antibody mediated autoimmune diseases.
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Objective To study the diagnosis, treatment and prognosis of hepatolithiasis combined with cholangiocarcinoma. Methods The clinical, pathological and follow-up data of 17 cases of hepatolithiasis combined with cholangiocarcinoma were retrospectively analysed. Results The results showed that the incidence of cholangiocarcinoma in hepatolithiasis was 5% in this series. 17.6% of the patients were diagnosed as cholangiocarcinoma preoperatively. Tumor occurring in intrahepatic ducts was 88.2% and in hepatic porta ducts 11.8%. Nine cases were well-differentiated adenocarcinomas. Only 7(41.2%) cases were radically resected and their average survival time was 26.0 months. Eight(47.1%) patients underwent internal drainage with average survival time 12.4 months. 2(11.7%) cases subject to external drainage with survival time 3.6 months. Conclusions If patients with hepatolithiasis have a long history of recurrent cholangitis, weight-loss in a short period, progressive jaundice or intractable abdominal pain, the possiblility of combined with cholangiocarcinoma should be considered. Resection of the tumor has a better prognosis than that of tumor unresected; and the prognosis of internal drainage is better than that of external drainage.
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Objective To investigate the risk factors of gallbladder stone changing to gallbladder carcinoma. Methods The clinical data of 200 patients with gallbladder stone undergoing operation were retrospective analysed. Results (1) In the 200 resected gallbladder specimens, gallbladder mucosa hyperplasia was found in 144 specimens(72%), atypical hyperplasia(AHP) in 38(19%), infiltrative cancer in 7(3.5%). All the paracancer mucosa had midder or severe AHP. The incidence of atypical hyperplasia and canceration had increased with patients' age and the history lenth of cyst stone. (2) The content of DNA, the porpotion of euplpoid cells, the AgNOR content in tissues as follows: hyperplasia<mild AHP<midder AHP<severe AHP<canceration. Conclusions The results of this study indicate that the canceration of gallbladder from cyst stone may be a chronic process which from hyperplasia→AHP→canceration. So the risk factors of canceration including age≥50 years; long term history of cyst stone, espically in women; that for cases of cyst stone with age≥50 years, more long term history, especially in women, therefore periodical examinations should be done, and preventive cholecystectomy should be performed if necessary.
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Objective To study the effect of the modality of subtotal splenectomy with retroperitoneal splenic transposition combined with devascularization on portal hypertensive gastropahy(PHG). Methods Subtotal splenectomy with retroperitoneal splenic transposition combined with devascularization was performed in 48 cirrhotic patients with portal hypertension. Forty seven patients were followed up for 2 years to 13 years (average 91 months). PHG were observed by gastroscopy.Results At 2 months postoperation ,PHG was significantly aggravated compared with that of preoperation (P
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Objective To investigate the diagnosis and treatment of hashimoto′s disease(HD) complicated with thyroid adenomas(TA).Methods Clinical data of 50 cases of HD complicated with TA were analysed retrospectively. Results 8 patients were diagnosed before operation ,misdiagnosis rate was 84.0%.Intra operation frozen section diagnosis rate was 81.4% (35/43).All patients were diagnosed as HD complicated with TA by pathology after operation.Various extension thyroidectomies were performed according to the patients conditions. After operation,27 cases were given small dosage of thyroxine and 2 cases were given small dosage of prednisone. All the 50 patients were followed up for 3 months to 1 year, none presented hypothyroidism.Conclusions Complete serum immunologic examinations,ultrasonography and fine needle aspiration biopsy are helpful for the diagnosis of HD with TA. HD with TA should be treated surgically,and the intraoperation frozen section for the diagnosis is important.The operation procedures,extension of excision and medication after operation should be individulization to avoid the occurrence of postoperative hypothyroidism as possible.
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Objective To study the protective effect and mechanism of lactulose on the renal function in acute cholelithiasis with obstructive jaundice. Methods Fifty five cases of acute cholelithotic obstruction were randomly assigned into lactulose group (group L, n=28) and control group (group C, n=27), and 50% lactulose (group L)or 10% glucose (group C ) was administered orally for 3 days before the operation , respectively. The systemic and portal blood endotoxin (ET), blood urea nitrogen (BUN) and endogenous creatinine clearance rate (Ccr) were measured periodically. Results (1) In group L, the level of systemic vein ET and BUN were significantly lower than that in group C (P0.05); and the systemic vein ET and Ccr decreased significantly on 9d (P
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Objective To discuss the diagnosis and surgical treatment of Takayasu arteritis accompanied with aneurysms. Methods The clinical features and the effect of operation types in 14 patients were reviewed.Results All the 14 patients had history of Takayasu arteritis and had steroid therapy before the formation of aneurysms.Among the 14 patients,aortic aneurysms were found in 13(including 9 thoracoabdominal aneurysms),carotid aneurysm with subclavian aneurysm in 1 and multiple aneurysms in 5.All the 14 patients underwent operations ,including replacement of aorta in 11 cases,bypass of aorta in 3 cases,reconstruction of visceral vessels in 8, renal autotransplatation in 1 and replacement of carotid in 1.1case had heart failure and cured ;1 died postoperatively. Eight cases were followed up for 4 months - 18 years,of which, 1 died of heart failure,2 were excellent, 3 of 5 cases with hypertension preoperatively showed normal blood pressure,and the other 2 were controlled by medicines.Conclusions Operation should be performed as early as possible if the aneurysm is found in patients with Takayasu arteritis.The stenosis of renal artery should be resolved during the operation.
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Objective To study the early prediction of infection in acute pancreatitis in rats by plasma procalcitonin (PCT) and c-reactive (CRP) detection.Methods Eighty SD rats were randomly assigned into acute infected pancreatitis group (I, n=20), pancreatitis control group (C, n=40) and sham-operated group (S, n=20). Blood samples were collected pre- (0h) and post-operatively (12h, 24h and 48h). Plasma CRP was analyzed by ELISA. Plasma and liver PCT was detected by Western blot.Results (1). Ascitic infection occurred in all the group B rats and 16 of 40 rats of group C (analyzed as group C1), and did not occur in the other 20 of 40 rats of group C (analyzed as group C2) and group S. (2). The plasma CRP concentrations elevated gradually after the model setup in group B and C1, which were significantly higher at 48h than those in group C2 and group S. (3). PCT was detected in high levels in plasma and liver tissues in group B and C1 at 48h post-operatively, and they were sighificantly higher than those in group C2 and group S.Conclusions PCT can predict early infection of acute pancreatitis, and detection of PCT combined with plasma CRP may help in the differentiation of acute infected pancreatitis. The liver may be an important organ for synthesis of PCT.
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Objective To explore the prophylaxis and treatment strategies for psychic syndrome in patients after piggyback liver transplantation.Methods The data on the etiology,treatment outcome and prognosis of psychic syndrome occurring in 45 of 235 patients who had piggyback liver transplantation were retrospectively analyzed.Results The incidence of psychic syndrome complication was 19.1%(45/235),22 cases presented as mania(48.9%),5 cases as tristimania(11.1%),3 cases as hallucinosis(6.7%),1 case as suicidal tendency(2.2%),1 case as metamorphopsia(2.2%),8 cases as angst insomnia(17.8%),2 cases as maladjusted disturbance(4.4%),3 cases as affective disturbance(6.7%),and the majority presented as delirious alienation.All the cases were cured,except 1 case of coma,who was confirmed by CT to have intracranial hemorrage,died after failure of resuscitation.Conclusions The incidence of psychic syndrome in patients after piggyback liver transplantation is relatively high.However,most cases have mild symptoms and the prognosis is fine.When the patients have psychogenic symptoms,the prognosis of patients can be improved by some symptomatic treatment strategies directed to their different clinical manifestations.
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Objective To explore the prevention and treatment of early pulmonary infection after liver(transplant).Methods A retrospective analysis was carried out on the clinical data of 34 cases suffered from post-transplant pulmonary infection among 62 cases of liver transplant.Results Among the 34 cases,27 cases recovered and 7 cases died.The sputum of 27 cases was cultured positive for bacteria and fungus(including) Gram-negative bacteria(51.9%),Gram-positive bacteria(29.6%) and fungus(18.5%),cytomegalovirus 1 case,EB virus in 1 case,and pathogens unknown in 5 cases.Conclusions (Gram-negative) bacteria are the main pathogens of pulmonary infection after liver transplant.The critical stage of pulmonary infection is the first week after operation.The perioperative management of respiratory tract and rational use of antibiotics are important for prevention and treatment of post-transplant pulmonary infection.
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Objective To evaluate the methods of diagnosis and treatment of thyroid disease with concomitant focal lymphocytic thyroiditis(FLT), and explore the reasons for its confused with Hashimoto′s disease(HD).Methods During the recent 25 years, 207 patients underwent surgical trearment for pathologically diagnosed HD.Among this group, 143 cases of HD with other concomitant thyroid disease were retrospectively analysed.Results Of the 143 cases, 57 cases were found to have thyroid disease with concomitant FLT, and this was 27.5%(57/207) of the total HD group, or 39.9%(57/143) of the group with thyroid disease and concomitant HD.Intraoperative pathologic section revealed that focal lymphocytic infiltration was positive in 87.7%(50/57) of cases. The postoperative hypothyroidism occurrence rate was 19.3%(11/57), of which, 7 cases(7/57, 12.3%) were subclinical hypothyroidism.Conclusions The character of pathologic changes of thyroid disease with FLT and with HD was different. Intraoperative pathologic section can be helpful in the diagnosis of this condition and can have important significance as a guide to the scope of (surgical) resection of the thyroid gland.
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10 000mL. Six cases developed ascites postoperatively. There was no mortality or bile duct injury. The average hospital stay was 15d.Conclusions Intraoperative bleeding and bile duct injuries are the major dangers of (cholecystectomy) in patients with liver cirrhosis, and packing of gallbladder bed with pedicle of greater omentum is a satisfactory method of hemostasis.
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ObjectiveTo investigate the clinical results of hepatectomy for bleeding of spontaneous rupture of hepatocellular carcinoma (HCC). MethodsThe clinical data of 24 cases admitted to our hospital from Jan 1990 to Mar 2004 was analyzed retrospectively.ResultsSurgical hemostasis was achieved successfully in 100.0% (24/24) of patients. The postoperative mortality rate was 4.1% (1/24), and the (complication) rate 12.5%(4/24). Liver function recovered within two weeks after operation. The length of hospital stay was 14.756.25 days.Twenty-one patients were followed-up from 6 month to 36 months. 8 patients died from recurrence within 10 months postoperatively; 10 patients survived over 1 year, 1 patient over 2 years and 1 over 3 years. The overall 1-year survival rate was 58.3%(13/24).ConclusionsIn the management of bleeding of spontaneous rupture of HCC, hepatectomy can effectively stop the bleeding and excise the tumor at the same operation. In some patients, a radical excision can be achieved, and, if the (patient)s condition permits it, hepatectomy should be the treatment of choice.
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20) were analyzed.ResultsMODS was staged according to "Lu shan conference" diagnostic criteria.In this group of patients there were 27 deaths(24.7%),of which 1 patient(3.9%) was stage I,7 patients(15.6%) stage II,9 patients(45%) stage III,and 10 patients(90.9%) stage IV.Prognosis varied with stage of MODS.The incidence of MODS increased with higher scores of body injury, and mortality rate increased with the increase of the number of failured organs.Conclusions The diagnostic classification of MODS has obvious clinical significance. It (provides) clinicians with an important basis for early diagnosis and treatment of MODS.
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Objective To investigate a rational treatment for severe gallstone pancreatitis(SGP) and evaluate therapeutic effect.Methods A retrospective study was made on the clinical data of 97 cases with SGP.(Results) Among 97 SGP patients,54 cases were in severe grade I, 43 cases were Grade II;77(79.4%) cases were cured and 20(20.6%)died.The morbidity rates of endoscopic therapy(EST),delayed surgery and early surgery were 24.1%,25.0% and 65.5% respecticely,while the mortality rates in the 3 groups were 10.3%,13.9% and 37.5% respectively.The morbidity and morality rates in the first 2 groups were significanty lower than the early surgery group(P
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Objective To investigate the role of hepatic Kupffer cells in acute hemorrhagic necrotizing pancreatitis associated lung injury(AHNP LI) and the therapeutic effects of gadolinium chloride(GdcI_3). Methods Forty-two Wistar rats were randomly divided into four groups:(I) sham operation group;(II) AHNP group;(III) Gdcl_3 (protection) group(Gdcl3 10mg/kg);(IV) Gdcl_3control group(Gdcl_3 10mg/kg).In the sham operation group, the (abdominal) vescera were shifted around for several times and the abdomen was closed.The AHNP model was induced by retrograde intraductal administration of 5% sodium taurcholate(1ml/kg,0.1ml/min).In the Gdcl_3 protection group,Gdcl_3 solution was admmistered by caudal vein injection one day before the AHNP model was made.In these 3 group of animals,specimens were obtained in order at 3h and 6h postoperatively:(1)Blood was withdrawn from the abdominal aorta to determine serum amylase,TNF?,IL-1(in addition,in the sham operation group,blood AST and ALT were determined);(2)A portion of liguefied right lung was obtained to determine MPO;another portion was fixed with 10% formalin for tissue pathological examination;(3)Bronchoalveolar lavage fluid of excised left lung was obtained ,and then alveolar macrophages were isolated,collected and purified.After removal of their nuclear (proteins),the alveolar macrophages were tested to determine NF-?B activation with the use of chemical illumination ELISA method;and (4)pancreatic tissue was reserved for pathological examination.In the Gdcl_3 control group, Gdcl_3 was administered by caudal vein injection,the animals were sacrificed 24h later,and blood was obtained to determine blood AST and ALT. Results In the Gdcl_3 prevention group,the level of MPO in lung tissue,serum (levels) of TNP? and IL-1,and NF-?B activation of alveolar (macrophages) were all significanfly reduced as compared with the AHNP model group(in all,P
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Objective To evaluate the therapeutic approach for patients with periampullary carcinoma (complicated) with acute cholangitis. Methods A comparative analysis of the clinical data of cases of (periampullary) carcinoma with acute cholangitis who were admitted and treated in our hospital during a 12-year period.They included 25 cases who underwent primary resection, and 12 cases who underwent a two-stage resection with initial bile duct drainge. Results After conservative procedures, the preoperative temperature and WBC of patients in primary resection group were much lower than when admitted(P0.05). Total bilirubin and albumin levels showed no significant changes. Compared with the two-stage resection group,the primary resection group had shorter preoperative preparation time, shorter operation time, lesser intra-operative blood loss, but higher postoperative infection complication rate and prolonged length of hospital stay(P0.05). Conclusions Patients with periampullary carcinoma complicated with acute cholangitis can initially be treated conservatively . After biliary infection is controlled, primary (pancreatoduodenectomy) is performed.
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Objective To investigate the morbidity of cholecystic disease in renal transplant candidates and study the indications of prophylactic laparoscopic cholecystectomy(LC) for renal transplant candidates with cholecystic disease. Methods The incidence of cholecystic disease in 286 renal transplant candidates in our institution in recent four years was retrospectively reviewed.All the candidates had received one or more ultrasonographic examinations. Results Cholecystic disease was found in 32 of 286 candidates ((11.1)%), including cholelithiasis in twenty(62.4%, 20/32), sludge in six(18.8%, 6/32)and polypoid lesion in six(18.8%, 6/32). Cholecystectomy had been performed in twenty candidates with symptomatic chronic cholecystitis before transplantation, including LC in fourteen and open cholecystectomy with small incision in six .Five of twelve candidates without symptoms received prophylactic LC electively .In three of the other 7 candidates acute cholecystitis occured within six month after transplantation.There was no death of the (candidates) and no grafts function loss occurred in this series. Conclusions Cholelithiasis is the major cause of cholecystic disease in renal transplant candidates. Electively prophylactic LC is recommended for the (candidates) with or without symptomatic cholecystitis before transplantation or before acute cholecystitis has (occured).
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Objective To investigate the reasonable operation timing for patients with acute pancreatitis without obvious infectious manifestation. Methods The findings during the operation and pathological changes in 27 pantients with necrotic pancreatitis were analysed retrospectively.Results Six patients underwent surgical treatment with in 3 weeks. The delimitation between non-necrotic pancreas and necrotic pancreas was not very clear, and the abdominal adhesion and edema were serious. Other 14 cases were subjected to the surgical treatment 3-4 weeks after the onset of illness. The delimitation was clear in 9 cases without obviously infectious signs, but the adhesion of the pancreas bed to the greater omentum or the transverse mesocolon was evident. Various degrees of necrosis was found in 3 cases, and the infection together with pancreatic necrosis developed in the other 2 cases. The rest 7 patients were operated on 5-7 weeks after the disease onset, different degrees of infection and necrosis developed in 3 cases, and local pancreatic abscess formation could be observed.There was a lot of necrosis of fatty tissues on the peri-pancreas and the root of mesentery. Conclusions Clear away of necrotic pancreatic tissue is suitable in 3-4 weeks after the onset of illness in patients with non-infectious necrosis of pancreas.If operation is performed in the initial 3 weeks, intraoperative bleeding may be severe because the detachment between the non-necrotic tissues and necrotic tissues of pancreas was not yet formed completely, which may lead to hard to do the operation and result in increasing intraoperative bleeding and even increasing reoperation .If operation was done after 5 weeks, the infection of the necrotic pancreatic tissues can be seen in most of the cases, and the infection degree in the abdominal cavity may also be serious, which may need more operations to treat.