【作者】 胡海；

【导师】 蔡秀军；

【作者基本信息】 浙江大学 ， 临床医学， 2009， 博士

【摘要】 第一部分支架法修复胆道缺损的动物实验研究目的探索支架法修复胆道缺损的可行性和安全性。材料和方法利用医用硅胶管设计了一种简易的胆道支架模型。以巴马小型猪为实验对象,随机分为两组,每组15头。构建胆总管缺损1.0cm的动物模型为实验组1;构建胆总管缺损2.0cm的动物模型为实验组2。两实验组行支架法恢复胆道连续性:将设计的支架与胆管两端捆绑连接,同时允许支架中间1.0cm或者2.0cm的胆管缺损。术后观察动物黄疸和胆漏情况;术后1,3,6月每个实验组各处死5头动物,分别比较动物自身术前和术后1,3,6月肝酶(ALT、AST、ALP)和血总胆红素的变化,观察两实验组大体标本、肝脏组织病理切片HE染色、新生胆管组织以及新生胆管组织旁的正常胆管组织病理形态学改变:包括HE染色、Masson染色和α-SMA免疫组化;术后6月两实验组随机抽取动物经胆囊行胆管造影。结果两实验组均顺利完成手术。两实验组动物术后无黄疸。实验组1动物术后无胆漏发生,术后因应激性溃疡大出血动物死亡1例(7%,1/15);实验组2术后因胆漏动物死亡1例(7%,1/15)。两实验组动物肝酶(ALT、AST、ALP)和血总胆红素自身术前和术后1,3,6月比较均无显著性差异(P>0.05)。术后1月,两实验组新生胆管已覆盖支架上胆总管缺损部分,但存在充血水肿;镜下可见散在不规则的新生胆管上皮细胞,伴有杯状细胞,同时可见大量腺体;胶原纤维增生、排列紊乱。术后3月,两实验组新生胆管充血水肿消退;镜下可见新生胆管上皮细胞开始逐渐形成规则的单层粘膜,仍可见杯状细胞和增生的腺体;胶原纤维增生明显、排列紊乱。术后6月,两实验组新生胆管外观与正常胆管相同;镜下可见新生胆管上皮细胞排列为整齐的单层粘膜,与正常胆管上皮细胞形态、排列方式相似,仍可见杯状细胞和增生腺体;胶原纤维增生明显、排列紊乱,部分排列相对有序。实验组2相同时间点的胶原纤维增生表现同实验组1,但排列更加紊乱。术后1,3,6月两实验组肝脏切片镜下未见淤胆和炎性细胞浸润。两实验组术后1月分别与术后3月以及6月相比,α-SMA阳性表达评分均没有显著性差异(P>0.05);术后6月α-SMA阳性表达评分明显低于术后3月(P<0.05)。正常胆管组织镜下仅观察到少量的腺体、未见杯状细胞;胶原纤维层较薄,纤维排列整齐有序。两实验组动物术后6月经胆囊造影提示:胆管和支架捆绑处无造影剂渗漏,肝内胆管显影未见扩张,胆总管引流通畅,十二指肠显影佳。结论在保护胆管血供、实现无张力修复的前提下,整段缺损2.0cm以内的胆总管具有再生形成新生胆管的能力。支架法修复胆道2.0cm以内的缺损是一种操作简易、安全可行的胆道重建方法。第二部分支架法延期修复胆道损伤的动物实验并临床应用1例目的探索支架法延期修复胆道损伤的可行性和安全性。方法以巴马小型猪为实验对象,制成5例胆管损伤后胆漏动物模型。在胆漏动物模型建立48小时后实施支架法重建胆道连续性。术后观察动物胆漏情况;比较重建胆道时和术后1月动物的肝酶(ALT、AST、ALP)和血总胆红素的变化情况;术后1月动物经胆囊行胆管造影。回顾性分析胆管急性炎症期行支架法重建胆道的临床病例1例。结果5例胆漏动物模型建立后均顺利完成手术。ALT、AST和血总胆红素术后1月比重建胆道时明显降低(P<0.05);ALP术后1月和重建胆道时无显著性差异(P>0.05)。术后无胆漏发生,术后1月胆道造影胆管和支架捆绑处未见造影剂渗漏。1例胆管急性炎症期的患者成功切除胆道肿瘤后行支架法重建胆总管连续性,术后黄疸明显减退,术后半月经T管造影胆管和支架捆绑处未见造影剂渗漏。结论动物实验和初步临床研究显示支架法延期修复胆道损伤简便、可行,但需动物实验和临床进一步验证和完善。更多还原

【Abstract】 PartⅠThe experimental study of repairing bile duct defect with intraluminal stentObjective To assess the feasibility and safety of repairing bile duct defect with intraluminal stent.Methods We designed a simple bile duct stent model with medical use silicone tubes. A total of 30 Bama minipigs were randomly divided into two groups,15 pigs in each group.Two groups were formed as Group 1 with a 1.0cm segment of the common bile duct(CBD) resected and Group 2 with a 2.0cm segment of the CBD resected.Animals in both groups underwent biliary reconstruction with intraluminal stent.Both bile duct ends were bound to the stent,allowing a 1.0 cm or 2.0cm gap between them.Incidence of jaundice and bile leakage was evaluated in both groups.Five animals were sacrificed each time at 1,3,6 months postoperatively in both groups.Liver enzymes(ALT,AST, ALP) and serum total bilirubin were determined preoperatively and at 1,3,6 months. Pathomorphologic changes of the neo-bile duct and the native bile duct beside the neo-bile duct were observed by HE and Masson staining,α-SMA immunohistochemistry.Liver tissue slides with HE staining were analyzed. Cholangiography was performed for the randomly selected animals at 6 months.Results All operations were accomplished successfully.There was no postoperative jaundice in both groups.There was no bile leakage and one death(7%,1/15) because of postoperative hemorrhea caused by stress ulcer in Group 1.One animal died because of bile leakage(7%,1/15) in Group 2.There was no significant difference comparing liver enzymes(ALT,AST,ALP) and serum total bilirubin tested preoperatively with those tested in the same animal at 1 month or 3 months or 6 months postoperatively in both groups(P>0.05).The neo-bile duct with edema and congestion covered the gap between both of the CBD ends at 1 month.The scattered and irregular neo-bile duct epithelial cells were observed.Hyperplasia of collagen fiber arranged in disorder was observed.The neo-bile duct showed disappearance of edema and congestion at 3 months.The neo-bile duct epithelial cells began to form a regular mucosal monolayer. More disorderly arranged fibers were observed.The neo-bile duct resembled the native bile duct at 6 months.The neo-bile duct epithelial cells formed a flat mucosal monolayer,appearing as the native bile duct.Disorderly arranged fibers were still observed,with some orderly arranged hyperplastic fibers.Goblet cells and accessory glands were also observed at 1,3,6 months.The appearance happened in both groups. But fibers arranged much more disorderly in Group 2 than those in Group 1 at each time point.No cholestasis and infiltrating inflammatory cells were found in the liver in both groups at 1,3,6 months.The a-SMA positive expression scores showed no significant difference at 1 month comparing with those at either 3 months or 6 months in both groups(P>0.05).However,scores showed a significantly lower at 6 months than those at 3 months in both groups(P<0.05).The native bile duct showed a few accessory glands and no goblet cells under microscopy,with orderly arranged fibers forming thin layers.Cholangiography performed for the randomly selected animals at 6 months showed no bile leakage,no dilation of intrahepatic bile ducts,the CBD drainage unobstructed,and good development of the duodenum.Conclusion After the CBD resected within 2.0cm,the rest can regenerate the neo-bile duct if the bile duct blood supply well protected and repairing with free of tension.Repairing bile duct defect within 2.0cm with intraluminal stent is a safe, feasible,and easy of doing technique. PartⅡThe experimental study of delayed repairing bile duct injury with intraluminal stent and a case reportObjective To assess the feasibility and safety of delayed repairing bile duct injury with intraluminal stent.Methods A total of 5 Bama minipigs were included to establish an animal model of bile leakage.Animals underwent biliary reconstruction with intraluminal stent after 48 hours when the animal model of bile leakage established.Incidence of bile leakage was evaluated postoperatively:Liver enzymes(ALT,AST,ALP) and serum total bilirubin were determineed preoperatively and at 1 month postoperatively.Cholangiography was performed for the treated animals at 1 month.A retrospective analysis was conducted of a patient who underwent biliary reconstruction with intraluminal stent under the circumstances of acute bile duct inflammation.Results All operations were accomplished successfully.ALT,AST and serum total bilirubin tested at 1 month decreased significantly as compared with those tested preoperatively(P<0.05).There was no significant difference comparing ALP tested at 1 month with that tested preoperatively(P>0.05).There was no bile leakage after operation.Cholangiography performed for the treated animals showed no bile leakage at 1 month postoperatively.A patient under the circumstances of acute bile duct inflammation received operation for biliary tumor and underwent biliary reconstruction with intraluminal stent successfully.A remarkable alleviation of jaundice was seen in the patient postoperatively.Cholangiography performed for the patient showed no bile leakage at half a month postoperatively.Conclusion The experimental study and the preliminary clinical study show that delayed repairing bile duct injury with intraluminal stent for biliary reconstruction is a feasible and easy technique.More experimental and clinical investigations should be done.更多还原