【作者】 陈刚；

【导师】 李立；

【作者基本信息】 昆明医学院 ， 外科学， 2009， 博士

【摘要】 第一部分猪胆道缺损修补实验动物模型的建立目的:建立稳定可靠的滇南小耳猪胆道缺损修补模型,为进一步的实验奠定基础。方法:实验动物随机分7组,每组各10只猪。于胆囊管汇入处以下约1cm的胆总管造部分缺损与整段离断缺损,分别以脱细胞真皮基质、膨体聚四氟乙烯及胆肠吻合术修复,脱细胞真皮基质修复为实验组,同时实验组又分为胆囊造瘘与不造瘘组,共4组,即脱细胞真皮基质部分缺损不造瘘组,脱细胞真皮基质整段缺损不造瘘组,脱细胞真皮基质部分缺损造瘘组,脱细胞真皮基质整段缺损造瘘组,膨体聚四氟乙烯（共2组,膨体聚四氟乙烯整段缺损不造瘘组与膨体聚四氟乙烯部分缺损不造瘘组）及胆肠吻合术（1组）修复为对照组。结果:73次正式实验中,70例术后存活超过2周,手术成功率95.9%。脱细胞真皮基质组和膨体聚四氟乙烯组手术时间明显短于胆肠吻合组（P＜0.05）;脱细胞真皮基质不造瘘组中位生存期明显高于其他各组（P＜0.05）,82W以后仍有存活。结论:较短的手术时间,较低的手术后并发症,较长的存活时间均提示脱细胞真皮基质不造瘘组修复胆道缺损效果最佳。同时我们掌握了该模型的制作方法,为下一步的实验提供了基础。第二部分脱细胞真皮基质修复猪胆管缺损的实验研究目的:通过各种技术手段观察研究各组术后胆管修复情况,为其临床表现提供证据,评价脱细胞真皮基质修复猪胆管缺损的实验效果,初步探讨其可能机制方法:不同时间点血清胆红素、磁共振胆道成像（MRCP）观察有无胆道狭窄等胆道并发症出现。血清γ-谷氨酰转肽酶以判断有无微胆道上皮的破坏,血转氨酶以判断肝细胞破坏情况,不同时间点血常规及病理检查以判断有无胆道感染及排斥反应发生,光镜、电镜观察有无胆道上皮、腺体、血管、平滑肌等再生及再生情况,免疫组化CK19测定以判断胆道上皮再生的情况,免疫组化TGF-β₁的测定判断有无胆道狭窄的趋势。并通过不同时间点各项检测情况,初步判断其可能的修复机制。结果:脱细胞真皮基质不造瘘修复组在白细胞计数、总胆红素、γ-谷氨酰转肽酶、TGF-β₁表达均低于其他各组（P＜0.05）,CK19表达均高于其他各组（P＜0.05）,脱细胞真皮基质部分缺损不造瘘组与脱细胞真皮基质整段缺损不造瘘组两组之间无统计学差异（P＞0.05）,脱细胞真皮不造瘘组在术后2周白细胞总数升高（P＜0.05）,其余术后时间点正常,脱细胞真皮不造瘘组总胆红素、γ-谷氨酰转肽酶、转氨酶值各时间点无统计学差异（P＞0.05）,CK19表达随时间增加而升高（P＜0.05）,TGF-β₁表达随时间增加而降低（P＜0.05）;脱细胞真皮基质修复组光镜、电镜观察有胆道上皮、腺体、血管、平滑肌等再生,甚至神经的再生,余组无类似发现。结论:脱细胞真皮基质可能生理性修复胆道并重建其功能,并发症少,是目前为止效果最好的生物人工材料。第三部分脱细胞真皮基质修复人整段胆管缺损目的:在动物实验成功的基础上,我们用脱细胞真皮基质对一例整段缺损的医源性胆道损伤病人予以修复,观察修复效果,探讨最终临床应用推广可能。方法:手术切除损伤段胆管及其周围共约2.5cm长胆管,将脱细胞真皮基质制作成长约2.5cm、直径约1.0cm的管状组织,上下分别用6-0 PDS线连续对端吻合胆管切缘,置8号T管于吻合口支撑,对比手术前后不同时间点的临床表现、血常规、肝功及影像学变化。结果:术后无上腹部绞痛、高热,黄疸逐渐减退,每日引流胆汁300ml-1000ml不等,由淡黄色混浊、内有胆泥过渡到金黄色清亮的正常胆汁,腹腔引流通畅,引流液为淡红色,量从最初的200ml迅速过渡到10ml,血常规、血清谷丙转氨酶、谷草转氨酶、总蛋白、白蛋白、球蛋白等1周内均恢复正常,血清总胆红素、直接胆红素、间接胆红素、谷氨酰转肽酶、碱性磷酸酶逐渐下降,术后12d夹闭T管,术后24d T管造影提示左、右肝管及胆总管下端通畅,无狭窄。术后一月、三月、五月无腹痛、黄疸、发热,复查血常规、血清谷丙转氨酶、谷草转氨酶、总蛋白、白蛋白、球蛋白正常,总胆红素、直接胆红素、间接胆红素、谷氨酰转肽酶、碱性磷酸酶逐渐下降至正常。结论:无胆漏、胆道感染、排异反应发生,血常规、肝功能正常,T管造影无胆道狭窄;手术初步成功。脱细胞真皮基质可能是人理想的整段胆道缺损修复材料。更多还原

【Abstract】 Part 1:Model of common bile duct repair in Diannan small-ear pig establishedObjectives:To establish a stable and credible model of common bile duct repair in Diannan small-ear pig and lay the foundation for further experiment.Methods:70 pigs were randomly divided into seven groups,ten pigs each group. Common bile duct were removed partly and completely,and then had their common bile duct repaired by acellular dermal matrix（ADM） and ePTFE respectively.ADM group was experimental group.ADM group was divided into ADM no fistula gallbladder group and ADM fistula gallbladder group.Four groups involved ADM-partial defect-no fistula group,ADM-complete defect-no fistula group, ADM-partial defect-fistula group and ADM-complete defect-fistula group.Other three contrast groups consisted ePTFE-complete defect-no fistula group, ePTFE-partial defect-no fistula group and choledochojejunostorny group.Results:In 73 normal experiments,70 pigs survived over 2 weeks postoperation. Success rate of operation was 95.9%.Operation time of ADM group and ePTFE group were obviously shorter than choledochojejunostomy group（P＜0.05）.Median survival time of ADM complicated normal gallbladder group was obviously longer than other groups（P＜0.05）.Some of them are still alive 82 weeks later.Conclusion:Shorter operation time,lower complication and longer survival time all implied the effect of ADM for repairing common bile duct.We have grappled manufacture of model and supplied the base for further experiment. Part 2:Repair of Bile Duct Injuries With ADM Grafts: Experimental Study in pigsObjectives:To observe repair of common bile duct through kinds of approach, provide evidence for clinical manifestation,evaluate the experimental effect of common bile duct repair and probe into the possible mechanism.Methods:Whether complication or not were observed through serum bilirubin and MRCP at different time point.Whether breakage of micro biliary epithelial cell or not were observed through serumγ-GT.Injury of hepatic cell was observed through serum transaminase.Whether infection of biliary tract and reject reaction or not were judged through whole blood cell test.Regeneration of biliary epithelial cell,gland, vascular endothelial cell and smooth muscle were observed under light microscope and electron microscope.Regeneration of biliary epithelial cell were observed through expression of CK19.Trend of biliary stricture was observed through expression of TGFβ1.To investigate the possible repair mechanism from regeneration of biliary epithelial cell at different time point.Conclusion:White blood cell,total bilirubin,γ-GT and expression of TGFβ1 in ADM groups were lower than other groups.They were statistical significance （P＜0.05）.Expression of CK19 in ADM groups was higher than other groups.There were no statistical significance between ADM-partial defect-no fistula group and ADM-complete defect-no fistula group（P＞0.05）.White blood cell of ADM groups increased at second week post-operation（P＜0.05）,however,was normal at other time point.Total bilirubin,γ-GT and serum transaminase of ADM groups at different time point were no statistical significance（P＞0.05）.Expression of CK19 increased with time,however,expression of TGFβ1 decreased with time（P＜0.05）.Regeneration of biliary epithelial cell,gland,vascular endothelial cell and smooth muscle,even nerve of ADM groups were detected under light microscope and electron microscope.No similar detection in other groups. Conclusion:Acellular dermal matrix could be used to physiologically repair bile duct defect with less complication.It is the best artificial material to date.Part 3:Repair of Bile Duct Injuries With ADM Grafts in a patientObjectives:On the basis of success of animal experiment,we have completed successfully a bile duct repair with acellular dermal matrix in a patient of iatrogenic bile duct injury.The purpose of research is to observe the effect and popularize the clinical application of the procedure.Methods:Injured bile duct was resected.Acellular dermal matrix was made into a tubular tissue with 2.5cm length and 1.0cm diameter.Both ends of ADM were anastomosed to proximal end and distant end of common bile duct respectively with 6-0 PDS.T-tube was placed into common bile duct to bolster stoma.Clinical manifestation,whole blood cell test,liver function and iconography were compared perioperatively at different time point.Results:There were no abdominal pain and fever,jaundice faded away gradually postoperation.Biliary drainage was 300ml-1000ml/d more or less.Colour of bile changed into normal by degrees.Intra peritoneal drainage was open and the colour was light bloody.Amount of drainage dropped off day after day.Whole blood cell test, serum glutamic pyruvic transaminase,serum glutamic oxalacetic transarninase,total serum protein,serum albumin and serum globulin returned to normal in first week postoperation.Serum bilirubin,serum glutamyltranspetidase and serum alkaline phosphatase declined gradually in first week postoperation.T-tube was clipped at twelfth day postoperation.T-tube Cholangiography was clear at 24^th day postoperation. Condition of the patient got well and laboratory test returned to normal at 1^st month, 3^rdmonth and 5^th month postoperation. Conclusions:No bile leakage,infection of biliary tract and reject reaction occurred.Whole blood cell test and liver function declined to normal gradually. T-tube Cholangiography displayed no biliary stricture postoperation.Operation was successful preliminary.It’s possible that acellular dermal matrix is a perfect material to repair bile duct defect.更多还原