【作者】 李桂臣；

【导师】 刘永锋；

【作者基本信息】 中国医科大学 ， 外科学， 2003， 博士

【摘要】 研究背景与目的 Oddi括约肌(SO)主要作用是调节胆汁和胰液向十二指肠的流动，防止十二指肠内容物逆流入胆道和胰管。其运动功能主要包括紧张性收缩引起的基础压力和自发性基础性收缩。神经因素和多种胃肠道激素以及某些药物均可影响其运动功能。SO的运动虽独立于十二指肠，但受后者运动的影响。移植物胰腺炎是膀胱引流式胰腺移植后移植物功能丧失的重要原因，其原因可能与尿液返流或胰液潴留有关。这些与移植物的SO功能密切相关。膀胱引流式胰腺移植后，移植物的SO失去正常神经支配，移植物十二指肠片也丧失了正常的胃肠平行移动复合波(MMC)。此时SO的功能如何变化，对移植胰腺功能会产生什么影响尚无人研究。本研究的目的是探讨膀胱引流式犬胰腺移植后SO功能的变化以及对移植物造成的可能影响。然后针对SO功能的变化采取药物治疗，以期减少膀胱引流式胰腺移植的并发症，提高生存质量。 方法 选用清洁级成年Mongrel犬(中国医科大学实验动物部)，体重13-18kg，主要仪器设备有高分辨多道全胃肠功能监测仪和三通道胆道测压管，全自动化学发光免疫分析仪，GC-1200γ放射免疫计数器。主要药物有胆囊收缩素(CCK)、生长抑素十四肽思他宁、三硝酸甘油，主要试剂有环磷酸鸟苷(CGMP)放免试剂盒和胰蛋白酶原激活肽(TAP)测定试剂盒。 首先建立正常对照犬SO测压模型：术前12小时禁食水，经犬大隐静脉注射5％的戊巴比妥钠30mg/kg进行麻醉。经股静脉建立输液和给药通道，股动脉插管监测血压。清洁级手术，上腹部正中切口入腹，找到胆总管后不做任何分离。经胆总管置入三腔测压导管并送入十二指肠，外接高分辨多道胃肠功能测压仪。三腔测压管外径为1.7mm，内径为0.5mm，每腔远端均有一直径0.5mm的测压侧孔，不在同一水平，孔间角度为120度，可以测定不同方向的压力。孔间距为2mm。最远端距导管顶端3mm。从最远端测压孔向近侧标有6条黑线，每线相距2mm，用来观察导管插入深度。通过低顺应性气压毛细管灌注系统每个管灌注无菌蒸馏水，速度为0.25 xl日/而n。外接压力传感器和计算机记录系统。测压前先调十二指肠内压力为零。然后匀速向外牵拉测压管，每次lmln至50区域，其标志是记录仪上压力升高并出现有规律的收缩波。缓慢牵拉测压管至三条通道均见到有规律的收缩波，静止10分钟，稳定后开始记录至少5分钟。计算基础压力、振幅、收缩频率和动力指数。 建立胰腺离体及移植后犬so测压模型:术前处理同正常对照模型，清洁级手术，正中绕脐切口人腹，于胆囊管汇合处下方切断胆总管并沿之向下方分离至胰腺上方，于幽门下方1。m切断近端十二指肠，远端双重关闭。显露并游离胃十二指肠动、静脉至其根部。于脾动脉供应处之右方切断胰腺，两断端妥善缝合闭锁。主胰管予以缝合结扎。于十二指肠系膜内找到胰十二指肠下动脉，在胰十二指肠下动脉供应胰腺和十二指肠分支的右方切断胰腺和十二指肠，双重缝合两断端。游离右侧的骼内动脉和骼总静脉。上述步骤完成后迅速于胃十二指肠动脉根部结扎切断，于胃十二指肠静脉根部连同部分门静脉壁结扎切断。动脉保留端缝合结扎。缺损的门静脉壁以5一0的无损伤线缝合。移植物经胃十二指肠动脉重力灌注肝素冰凡n-ger液(50IU/祖)至静脉流出端清亮为止，修剪血管断端使适合移植。将移植物的胃十二指肠动脉与右铭内动脉端端吻合、静脉与右铭总静脉端侧吻合，时间大约30一4O分钟。通血后，移植物迅速红润。.将十二指肠与膀胧顶行双层侧侧连续吻合。然后切除剩余的胰腺组织。胃与远端十二指肠端侧吻合，胆囊与距胃肠吻合口20cm之空肠侧侧吻合b移植物的胆管断端缝合于腹壁皮下组织并做标记以备将来测压。冲洗腹腔，留置引流，关腹。术后留置尿管、静脉补液及应用抗生素治疗。2天后进食水。饮食中补充胰酶。每天监测尿淀粉酶、空腹血糖和空腹胰岛素水平。5天后，于腹壁皮下找到预留之胆管，经此置人三腔测压导管，按与对照组同样的方法进行测压。离体测压组在胰头十二指肠切除进行冷灌注后，在常温下经胆总管残端置人三腔测压管用同样方法测压。 实验一14只犬，正常对照和移植组各7只。在正常对照和移植后测压完成后，分别经静脉给予胆囊收缩素(CCK) 20m扩kg后再进行测压并记录。同时监测移植胰腺的内外分泌功能。于移植后犬膀脱和胆管残端内各置一测压管，通过尿管内注水使膀耽内压升高，同时观察胆管残端内压力变化情况。 实验二除了实验一14只犬外，另需7只犬进行移植。在实验一正常对照和移植后测压完成后50运动恢复至应用CCK之前水平时，分别经静脉给予思他宁125ug后再进行测压并记录。另7只犬在移植后第5天经静脉持续滴注思它宁10u扩kg，持续2小时。检测移植前及移植后用药前后尿中激活的胰蛋白酶原激活肤(TAP)和尿淀粉酶水平。 实验三28只犬，正常对照测压14只，移植后测压14只。在正常对照和移植后测压完成后，两组分别有7只犬迅速取下50待测组织中CGMP。另各有7只犬经测压管灌注0.sm扩d的三硝酸甘油(GTN)10血，1分钟后开更多还原

【Abstract】 Background and objectiveThe major roles of the Oddi sphincter (SO) are to regulate the flow of bile and pancreatic juice into the duodenum and to prevent the reflux of duodenal contents into the biliary and pancreatic duct. The motility of SO was composed of tonic contraction and phasic contraction. Neural factors and hormones and some drugs play important roles in the control of SO motility. The motility of SO was related to migrating motor complex(MMC) of the duodenum. Graft pancreatitis is one of the reasons of graft dysfunction with bladder drainage. The reflux of urine and pancreatic juice can cause graft pancreatitis. After transplantation, the graft was denervated and graft duodenum lost its normal MMC. Little was known about the function of SO and its effect on the graft function after pancreas transplantation with bladder drainage. The objective of this paper was to study the canine SO function after pancreas auto - transplantation with bladder drainage and the effect on the graft. Then drugs that relaxes SO were used to decrease motali-ty caused by SO disorder.MethodsHealthy adult mongrel dogs , either sexes,weighing 13 - 18kg were used. A triple lumen catheter connected via pressure transducer to a computerized recording system with a guide wire channel at its tip was used for SO manometry. The triple lumen catheter,measuring 1.7mm in diameter,with three -holes at 2 -mm intervals,perfused with sterile water at a rate of 0.25ml/min per channel by means of a low - compliance pneumohydraulic pump,connected via transducers to a computerized recording system.Normal canine SO manometry: The dogs were anesthetized with 30mg/kg ofintravenous pentobarbital sodium, and maintained under adequate anesthesia with 15 nag/kg of pentobarbital sodium as required. System blood pressure was monitored through a catheter placed into the femoral artery,The femoral vein was can-nulated and used for systemic administration of solutions and drugs. After an upper medium laparotomy by using aseptic technique, the biliary tree was identified. A small longitudinal incision was made in the common bile duct. A triple lumen catheter was cannulated and tied in the bile duct to avoid any leaks and occlusion of the orifice of the catheters. The catheter was sent into the duodenum. Intraduodenal pressure was taken as zero reference. Via 1 - mm station pull through technique,the catheter was placed just at the site of SO for 10 minutes. A basal recording lasting at least 5 minutes was obtained at the level of SO high pressure zone.Pancreas graft SO and SO in vitro manometry: The dogs were fast and anesthetized the same with the dogs in the control group. After a midline celiotomy with aseptic techniques, the tail of the pancreas was mobilized by division of the veins which drain the distal pancreas into the spleen vein. Then the head of the pancreas was mobilized without cutting the pancreaticoduodenal vessels. After li-gating and dividing the common bile duct at its entry into the duodenum, the lessen omentum was opened. The gastroduodenal artery and vein were dissect out at least 1cm from the bifurcation. The proximal duodenum was cut out 1cm distal to pylorus and closed. The distal duodenum was divided at the end of second part of duodenum. Thus the donor was skeletonized with intact vascular connections. Finally, the gastroduodenal artery and vein was removed and each graft was immediately flushed with cold ringer solution. Reestablishment of vascular connections to the autograft was accomplished by an end - to side anastomosis of the gastroduodenal vein to the right common iliac artery and end - to end anastomosis of the accompanying artery to the internal iliac artery. After reperfusion, the distal pancreas was resected. Gastrointestinal continuity was restored by the Roux -en - Y technique with cholecystojejunal,gastrojejunal and graft - duodenal -host bladder anastomosis. Average graft ischemia time was 30 - 40min. The bile duct residual of graft was placed under the skin. Fluid and antibiotics were given更多还原