本文選題：膽囊切除術(shù) + 迷走神經(jīng)干切斷術(shù)��； 參考：《中國醫(yī)科大學(xué)》2008年博士論文

【摘要】： 前言 圍繞在膽總管壺腹和膽胰管末端的括約肌,統(tǒng)稱為Oddi括約肌(sphincter ofOddi,SO)。正常情況下,SO在維持膽道壓力、促進(jìn)膽汁排泄以及防止十二指腸液和胰液返流方面起重要作用。目前,國內(nèi)外學(xué)者已經(jīng)認(rèn)識到SO異常包括SO功能異常(sphincter of Oddi dysfunction,SOD)和SO解剖形態(tài)異常兩個部分,前者可能不合并形態(tài)的異常變化,而后者可能在形態(tài)異常的基礎(chǔ)上并沒有表現(xiàn)出功能異常。但是,SO測壓(sphincter of Oddi manometry,SOM)是公認(rèn)的檢測SO功能異常的金標(biāo)準(zhǔn)。我們采用多種手術(shù)方法制作SOD的模型,并應(yīng)用SOM的方法觀察實驗組家兔模型的各項壓力指標(biāo),同時與對照組的正常家兔壓力指標(biāo)比較,以便判斷模型制作是否成功。此外,我們應(yīng)用免疫組化鏈酶親和素-過氧化物酶法(SABC法)觀察各組家兔SO和十二指腸乳頭中一氧化氮合酶(Nitric oxidesynthase,NOS)和血管活性腸肽(Vasoactive intestinal polypeptide,VIP)的變化,探討VIP和一氧化氮(Nitric oxide,NO)在SOD發(fā)病機(jī)制中的作用。 論文一 材料 1、分組方法 將77只成年家兔隨機(jī)分為正常對照組8只、膽囊切除組12只、迷走神經(jīng)干切斷組8只、膽總管不完全結(jié)扎組11只、SO不完全結(jié)扎組9只、膽囊不完全結(jié)扎組9只、膽管注入胰酶組12只、SO注射酒精組8只,雄性40只,雌性37只。 2、儀器和藥品 ①三通道測壓管(長2米,外徑1.7mm,3個側(cè)孔徑0.5mm,間隔2mm.) ②PC polygram HR高分辨,多通道胃腸功能測定儀 ③低順應(yīng)性水灌注系統(tǒng) ④20%氨基甲酸乙酯;95%酒精;動物胰酶制劑(粉劑) 方法 1、手術(shù)操作 氨基甲酸乙酯(1.0g/kg)靜脈注射麻醉,全部實驗組均經(jīng)腹中線開腹,且徹底止血后,行兩層關(guān)腹。(1)對照組:僅行開關(guān)腹術(shù);(2)膽囊切除組:結(jié)扎膽囊管和膽囊動脈,逆行切除膽囊;(3)迷走神經(jīng)干切斷組:于腹段食管兩側(cè)游離出左,右迷走神經(jīng)干,用絲線將其懸吊,各切除約1cm的神經(jīng)干;(4)膽總管不完全結(jié)扎組:于十二指腸乳頭開口處對側(cè)緣縱行切開十二指腸約1cm,將無菌硬膜外插管逆行插入膽總管,鈍性分離膽總管周圍組織,4~#絲線繞過膽總管,將膽總管結(jié)扎在硬膜外插管上,然后,拔出插管,縫合十二指腸切口;(5)SO不完全結(jié)扎組:如上述切開十二指腸,應(yīng)用可吸收線橫行縫扎乳頭開口,觀察仍有少量膽汁流出,縫合十二指腸切口;(6)膽囊不完全結(jié)扎組:牽拉肝臟于腹外,顯露膽囊,縫合針帶絲線繞過膽囊體中部,結(jié)扎閉合約50%橫斷面積;(7)膽管注入胰酶組:如上述切開十二指腸,將無菌硬膜外插管逆行插入膽總管,關(guān)閉十二指腸切口,并固定插管在腸壁上,縫合腹膜及腹肌,同時再次固定插管于腹肌上,鈍性分離出一皮下隧道至家兔后頸部,插管沿道至后頸部切口,再次固定插管,關(guān)閉腹部外皮。將配制10%動物胰酶2ml自插管逆行注入膽總管,1hr和2hr后,分別再注入2ml胰酶,每次注入后均閉管10min;(8)SO注射酒精組:如上述切開十二指腸,乳頭周圍2mm內(nèi)均勻四個點各注射95%酒精0.1ml,縫合十二指腸切口。對照組和實驗組均于術(shù)前12hr和當(dāng)日禁食不禁水,除膽管注入胰酶組于注完胰酶24hr后測壓外,其余各組均于術(shù)后1周進(jìn)行壓力測定。 2、測壓步驟 氨基甲酸乙酯(1.0g/kg)麻醉滿意后,經(jīng)原切口進(jìn)腹腔,在十二指腸乳頭開口的對側(cè)緣,縱行切開十二指腸約1cm,暴露乳頭。將高分辨,多通道胃腸功能測定儀接通三通道測壓管,應(yīng)用低順應(yīng)性水灌注系統(tǒng),以十二指腸壓力為曲線零點標(biāo)定后,經(jīng)乳頭將測壓管逆行插入膽總管。觀察曲線,確定插入膽總管后,穩(wěn)定30sec,進(jìn)行測壓3-5 min,然后逐漸撤拉導(dǎo)管達(dá)SO處,直視下并結(jié)合電腦顯示曲線于高壓力區(qū)處可確定測壓管側(cè)孔位于括約肌最佳位置。穩(wěn)定30 sec后進(jìn)行壓力測定3-5 min,記錄壓力曲線以待分析。 3、觀察指標(biāo) SO基礎(chǔ)壓;SO收縮幅度;SO收縮頻率;SO收縮間期;膽總管壓力 4、數(shù)據(jù)處理 本實驗計算的壓力指標(biāo)均為計量資料,計量數(shù)據(jù)以均數(shù)±標(biāo)準(zhǔn)差((?)±s)表示。應(yīng)用spss11.5統(tǒng)計分析軟件,采用單因素方差分析的方法行各實驗組與對照組比較。P＜0.05為差異顯著,P＜0.01為差異非常顯著。 結(jié)果 1、膽囊切除組家兔SO功能變化 SO基礎(chǔ)壓較對照組顯著升高,平均為36.61±8.60mmHg(p＜0.01) 2、迷走神經(jīng)切斷干組家兔SO功能變化 SO基礎(chǔ)壓較對照組顯著升高,平均為28.54±7.66mmHg(p＜0.05) 3、膽總管不完全結(jié)扎組家兔SO功能變化 SO基礎(chǔ)壓較對照組均顯著升高,平均為28.45±7.02mmHg(p＜0.05) 4、其余各組家兔SO各項壓力指標(biāo)較對照組均無顯著變化。 結(jié)論 家兔分別行膽囊切除、迷走神經(jīng)干切斷、膽總管不完全結(jié)扎處理后,可以引起SO運(yùn)動功能改變。但是,僅是部分壓力指標(biāo)的變化。 材料 1、分組方法 同實驗一方法,共8組。將上述家兔測壓后,耳緣靜脈注射5-10ml空氣處死后,迅速取出十二指腸乳頭及Oddi括約肌,放到4%多聚甲醛內(nèi)固定。 2、儀器和藥品 ①一抗:血管活性腸肽抗體,一氧化氮合酶抗體;二抗:山羊抗兔IgG ②5%BSA封閉液,SABC,復(fù)合消化液,DAB顯色試劑盒 ③C-7070/BX41采集圖像系統(tǒng) ④MetaMorph顯微圖像分析系統(tǒng) 方法 (1)新鮮組織經(jīng)4%多聚甲醛固定24hr,常規(guī)石蠟包埋,5岬連續(xù)切片,65℃烤25min;(2)常規(guī)脫蠟至水;(3)30%H_2O_2滅活內(nèi)源性活化酶,浸泡10min后,蒸餾水洗3次;(4)熱修復(fù)抗原:將切片浸入0.01M枸櫞酸鹽緩沖液(PH6.0),微波爐加熱至沸騰后斷電,間隔10min后,反復(fù)2次。冷卻后PBS洗滌2次;(5)滴加5%BSA封閉液,室溫20min。甩去多余液體,不洗;(6)滴加適當(dāng)稀釋的一抗兔IgG,4℃過夜,PBS洗滌;(7)滴加二抗生物素化山羊抗兔IgG,37℃孵育20min,PBS洗;(8)0.05%DAB顯色,鏡下控制反應(yīng)時間,流水沖洗終止反應(yīng);(9)蘇木素輕度復(fù)染,脫水,透明,樹脂封片。(10)陰性對照用PBS代替一抗,其余步驟相同。 1、結(jié)果判斷 觀察NOS和VIP時,均以SO平滑肌細(xì)胞、乳頭粘膜柱狀上皮細(xì)胞和粘膜下結(jié)締組織細(xì)胞的胞核藍(lán)色,胞質(zhì)棕黃色染色為陽性。每張切片選擇5個視野,用40×物鏡觀察采集圖像。對于每張圖像,我們應(yīng)用MetaMorph/C-7070/BX41顯微圖像分析系統(tǒng)測定其陽性區(qū)域的積分光密度值。結(jié)果記錄在表格中,準(zhǔn)備統(tǒng)計學(xué)分析。 2、統(tǒng)計處理 本實驗計算的積分光密度值為計量資料,計量數(shù)據(jù)以均數(shù)±標(biāo)準(zhǔn)差((?)±s)表示。應(yīng)用spss11.5統(tǒng)計分析軟件,采用單因素方差分析的方法行各實驗組與對照組比較。P＜0.05為差異顯著,P＜0.01為差異非常顯著。 結(jié)果 1、Oddi括約肌中NOS和VIP的積分光密度值的變化 ①迷走神經(jīng)干切斷組:NOS和VIP的積分光密度值均較對照組顯著升高,分別為34.04±27.24(P＜0.01)和45.82±36.35(P＜0.01)。 ②膽總管不完全結(jié)扎組:NOS和VIP的積分光密度值較對照組顯著升高,分別為29.40±15.99(P＜0.05)和53.06±61.24(P＜0.01)。 ③膽囊不完全結(jié)扎組:NOS和VIP的積分光密度值均較對照組顯著升高, 分別為53.72±47.74(P＜0.01)和71.95±62.34(P＜0.01)。 ④膽管注入胰酶組:NOS的積分光密度值較對照組顯著升高,分別為27.36±24.85(P＜0.05)。 ⑤其余各組家兔Oddi括約肌中NOS和VIP的積分光密度值較對照組均無顯著變化。 2、乳頭粘膜層中NOS和VIP的積分光密度值的變化 膽囊不完全結(jié)扎組,NOS積分光密度值較對照組有顯著升高,為29.78±13.08(P＜0.05)。其余各組較對照組均無顯著變化。 3、乳頭粘膜下層和粘膜肌層中NOS和VIP的積分光密度值變化 膽囊不完全結(jié)扎組和膽管注入胰酶組NOS均較對照組顯著升高,分別為81.28±47.39(P＜0.01)和75.47±73.11(P＜0.05)。膽總管不完全結(jié)扎組VIP較對照組顯著升高,為129.09±182.35(P＜0.01),其余各組較對照組均無顯著變化。 結(jié)論 家兔分別行迷走神經(jīng)干切斷、膽總管不完全結(jié)扎、膽囊不完全結(jié)扎或膽管注入胰酶處理后,其SO平滑肌、乳頭粘膜層、乳頭粘膜下層及肌層中的NOS和(或)VIP的數(shù)量發(fā)生變化,且均呈增多趨勢。
[Abstract]:Preface
Around the end of the tube in the common bile duct ampulla and biliary pancreatic sphincter, referred to as Oddi sphincter (sphincter ofOddi, SO). Under normal circumstances, SO in the maintenance of biliary pressure, promote bile excretion and prevent duodenal and pancreatic juice back flow plays an important role. At present, domestic and foreign scholars have been aware of abnormal SO including SO function abnormal (sphincter of Oddi dysfunction, SOD SO) and anatomic abnormalities of two parts form, the abnormal changes of the former may not be combined form, the latter may be based on morphological abnormalities and showed no abnormalities. However, SO (sphincter of Oddi manometry, pressure SOM) is the gold standard accepted detection of SO dysfunction. We use a variety of methods to build SOD model, and using the method of SOM the pressure observation index of rabbit model of experimental group, while the control group in the normal rabbit pressure index, in order to judge The success of model making. In addition, we used immunohistochemical streptavidin peroxidase method (SABC method) of all rabbits SO and duodenal papilla synthase (Nitric oxidesynthase, NOS) and vasoactive intestinal peptide (Vasoactive intestinal, polypeptide, VIP) changes of VIP and nitric oxide (Nitric oxide, NO) in the role of SOD in pathogenesis.
Paper 1
Material Science
1, grouping method
77 adult rabbits were randomly divided into normal control group 8, cholecystectomy group 12, vagotomy Group 8, bile duct ligation incomplete group 11, SO group 9 incomplete ligation, gallbladder incomplete ligation group 9, bile duct injection pancreatin group 12, SO group of 8 alcohol injection only, male 40, female 37.
2, instruments and drugs
(1) three channel pressure tube (2 meters long, outer diameter 1.7mm, 3 side aperture 0.5mm, interval 2mm.)
PC Polygram HR high resolution, multichannel gastrointestinal function measuring instrument
Low compliance water perfusion system
(4) 20% ethyl carbamate; 95% alcohol; animal pancreatin (powder)
Method
1, operation
Ethyl carbamate (1.0g/kg) intravenous anesthesia, the experimental group were all abdominal midline laparotomy, and complete hemostasis, two layer closed abdomen. (1) control group: only switch abdominal surgery; (2) cholecystectomy group: ligation of the cystic duct and the cystic artery, retrograde cholecystectomy; (3) the vagus nerve cut off the stem group in the abdominal segment of esophagus on both sides of the free left and right vagus nerve, with the wire suspension, the removal of about 1cm neural stem; (4) common bile duct ligation group: incomplete in the duodenal papilla at the opening on the side edge of the duodenal longitudinal incision about 1cm, there will be no epidural catheterization retrograde insertion of bile bacteria duct, blunt dissection around the bile duct, 4~# silk around the common bile duct, common bile duct ligation in the epidural catheter, then pull the plug, suture the duodenal incision; (5) SO incomplete ligation group: cutdown the duodenum, application of absorbable suture line with the papilla, observe still A small amount of bile flow, suture the duodenal incision; (6) gallbladder incomplete ligation group: traction in the abdominal liver, gallbladder exposed, suture needle with thread around the central body of gallbladder, ligation of closed about 50% cross-sectional area; (7) bile duct injection pancreatin group: cutdown the duodenum, the sterile epidural cannula inserted retrograde bile duct, closed duodenal incision and fixed intubation in the intestinal wall, closure of peritoneum and abdominal muscles, and again fixed to facilitate intubation, blunt dissection of a subcutaneous tunnel to rabbit neck, along the road to the neck incision after intubation, intubation again fixed, closed abdominal skin. The preparation of 10% animal trypsin 2ml since retrograde intubation injected into the common bile duct, 1hr and 2hr, respectively, and then injected into 2ml pancreatin, close the pipe 10min after each injection; (8) SO alcohol injection group: cutdown the duodenum, even four points around the nipple 2mm within the injection of 95% ethanol 0.1ml, ten suture Two fingers intestinal incision. The control group and the experimental group were all fasted before 12hr and the day of the experiment. Except for the bile duct injected into the pancreatin group, the pressure was measured at 1 weeks after the injection of trypsin 24hr.
2, the step of pressure measurement
Ethyl carbamate (1.0g/kg) after the anesthesia satisfaction, through the original incision into the abdominal cavity, the side edge of the opening of duodenal papilla, longitudinal incision of duodenal papilla. The exposure of about 1cm, high resolution, instrument on three channel multi channel pressure tube determination of gastrointestinal function, using low compliance water perfusion system, the duodenal pressure curve of zero after calibration, the nipple will pressure tube retrograde into the common bile duct. The observation curve, determine the insertion of common bile duct after 30sec were stable, pressure 3-5 min, then gradually withdraw pulling catheter of SO, and combined with the computer display under the open curve in high pressure can be determined at the pressure tube side hole located in the best position of sphincter pressure measurement. 3-5 min were stable after 30 sec analysis, record pressure curve for.
3, observation index
SO base pressure; SO contraction amplitude; SO contraction frequency; SO contraction interval; choledochal pressure
4, data processing
The pressure index calculation for measurement data, measurement data to mean + standard deviation ((?) + s). Using SPSS11.5 statistical analysis software, using the method of single factor analysis of variance for each experimental group compared with control group.P < 0.05, P < 0.01 for the difference, difference is very significant.
Result
1, the changes of SO function in the cholecystectomy group
The base pressure of SO was significantly higher than that of the control group, with an average of 36.61 8.60mmHg (P < 0.01).
2, the changes of SO function in the rabbits with vagotomy
The base pressure of SO was significantly higher than that of the control group, with an average of 28.54 7.66mmHg (P < 0.05).
3, the changes of SO function in the rabbits with incomplete ligation of common bile duct
The base pressure of SO was significantly higher than that of the control group, with an average of 28.45 7.02mmHg (P < 0.05).
4, there was no significant change in the pressure index of SO in the rest of the rabbits compared with the control group.
conclusion
Cholecystectomy, vagotomy, and incomplete ligation of common bile duct can cause changes in motor function of SO in rabbits.
Material Science
1, grouping method
There were 8 groups in the same experiment method. After the above rabbits were given the 5-10ml pressure, the duodenal papilla and Oddi sphincter were quickly removed and placed into 4% paraformaldehyde.
2, instruments and drugs
1 antibody: vasoactive intestinal peptide antibody, nitric oxide synthase antibody; two anti: Goat anti rabbit IgG
(2) 5%BSA sealing solution, SABC, compound digestive juice, DAB chromogenic Kit
C-7070/BX41 acquisition image system
MetaMorph microscopic image analysis system
Method
(1)鏂伴矞緇勭粐緇，

本文編號：1753417