胆囊造口后内镜下电凝胆囊粘膜消除术

目的：对内镜下电凝消除胆囊管及胆囊粘膜的效果进行评估。方法：12例胆囊造口术后病人在硬膜外麻醉下行宫腔镜检查和治疗。分别用滚球和滚棒电极电凝消除胆囊管及胆囊粘膜，电凝功率为60－70W，滚棒移动速度为10－15mm/s。结果：内镜下操作时间为25－55min（平均35min) ,术后6个月内蛆囊腔完全闭合8例，其余未闭合胆囊已萎缩。结论：内镜下电凝消除胆囊管及胆囊粘膜是胆囊造口后一期胆囊硬化闭塞的可行方法。     

腹腔镜治疗胆囊内瘘7例报告

目的总结腹腔镜手术诊治胆囊内瘘的经验。方法回顾分析2002年1月～2005年12月我院2113例腹腔镜胆囊切除术中遇到的7例（0．3％）胆囊内瘘的诊治经过。结果7例均系术中确诊，其中胆囊十二指肠瘘5例，胆囊横结肠瘘和胆囊胃瘘各1例。6例在腔镜下完成胆囊切除和瘘口关闭，平均手术时间130min（50～180min），术中无意外出血和损伤，术后恢复顺利；1例胆囊十二指肠瘘中转开腹。随访6个月～4年（平均22，6个月），无手术相关并发症发生。结论对于Lc中遇到的胆囊内瘘，可以酌情选择镜下完成手术，同样安全可靠。腔镜下瘘管的处理可以采用：夹闭或套扎、缝合、造疼和内镜切割吻合器切断闭合．     

胆囊造瘘术在胆道疾病治疗中的作用与地位

目的了解胆囊造瘘术在胆道疾病治疗中的作用与发展。方法收集我医院1971.1～2000.12胆囊造瘘术的病历共215例进行回顾性总结分析,登记其年龄、性别,黄疸、胆囊肿大、胆囊穿孔、休克,病因,手术方式及治疗预后等资料;再将其分为1971～1985及1986～2000两个时期进行分析,从中了解胆囊造瘘术的发展状况。结果治愈出院191例,治愈率88.8%,死亡23例,病死率为11.2%,90例术后在1～3个月再次行胆囊切除(41.9%)。80年代胆囊造瘘术占32.9%,90年代为3.1%(P<0.01)。结论胆囊造瘘术在重症胆道疾病中抢救生命仍是一种有用的治疗方法。     

胆囊造瘘术后行LC经验总结

目的 探讨胆囊造瘘术后行LC的手术经验。方法 收集我院自2004年9月至2014年12月胆囊造瘘术后施行LC的33例患者的临床资料进行分析。结果 全组25例顺利完成LC手术,8例中转开腹;手术时间47～210 min,平均（126.0±18.3）min;术中出血量20～260 mL,平均（95.0±28.4）mL;引流管留置时间1～5 d,平均（2.0±1.2）d;住院时间5～10d,平均（6.0±2.1）d。术后并发症：切口感染2例,脂肪液化1例。门诊随访3～56个月,无结石复发。结论 胆囊造瘘术后行LC是安全、可行的,详细的术前评估、仔细的术中操作及术者的经验是手术成功的关键。     

经内窥镜化学性胆囊切除术31例

作者对化学性胆囊切除术中某些关键技术作了较大的改进，首先采用了经内窥镜途径胆囊造瘘、微波闭塞胆囊管、硬化剂加压灌注等操作技术，并使胆囊造瘘、经瘘管取石、闭塞胆囊管和胆囊硬化四个步骤一期完成。本组共治疗３１例患者（５例中转开腹）。随访２～１２个月（平均７．６个月），２５例胆囊腔完全纤维化闭塞，仅１例术后胆囊区仍有２ｃｍ×３ｃｍ的囊腔。所有患者均无并发症。结果表明：该方法在临床上切实可行、疗效满意，明显优于国外同类技术，值得推广应用。     

经内窥镜化学性胆囊切除术31例

作者对化学性胆囊切除术中某些关键技术作了较大的改进，首先采用了经内窥镜途径胆囊造瘘，微波闭塞胆囊管，硬化剂加压灌注等操失技术，并使胆囊造瘘，经瘘管取石，闭塞胆囊管和胆囊感化四个步骤一期完成，本组共治疗３１例患者（５例中转开腹）。随访２￣１２个月（平均７．６个月），２５例胆囊腔完全纤维化闭塞，仅１例术后胆囊区仍有２ｃｍ×３ｃｍ的囊腔。所有患者均无并发症。结果表明：该方法在临床上切实可行，疗效满意，明     

腹腔镜手术治疗胆囊结石致胆囊肠道内瘘17例报告

目的：探讨腹腔镜手术治疗胆囊结石致胆囊肠道内瘘的疗效。方法2008年1月～2013年6月,行腹腔镜手术治疗胆囊结石致胆囊肠道内瘘17例,均在腹腔镜下切除胆囊和瘘管,肠道瘘口腔镜下单纯修补为主,其中1例因胆囊十二指肠瘘口较大,行十二指肠瘘口T管引流术。对合并胆总管结石的6例,均在胆道镜取石后行一期缝合或T管引流术。结果胆囊肠道内瘘的类型：单纯胆囊十二指肠瘘8例,胆囊胃瘘1例,胆囊横结肠瘘1例,胆囊十二指肠瘘合并胆囊横结肠瘘1例,胆囊十二指肠瘘合并胆总管结石5例,胆囊十二指肠瘘合并胆囊横结肠瘘、胆总管结石1例。手术时间50～150 min,平均95 min。术中出血量20～240 ml,平均55 ml。17例术后随访7～12个月,平均11个月,无肠漏、胆漏、胆道感染及肠梗阻等并发症发生。结论重视胆囊肠道内瘘患者的术前诊断和准备,术中仔细解剖操作,胆囊肠道内瘘腹腔镜下手术处理安全有效。     

弃用夹子及超声刀的无异物腹腔镜胆囊切除术

目的：探讨腹腔镜胆囊切除术(LC)中使用可吸收缝线、电凝钩取代夹子和超声刀进行手术的可行性。 
方法：对554例LC术中采用可吸收缝线结扎胆囊管和胆囊动脉，用分离钳、电凝钩显露胆囊,根据胆囊三角情况采用顺行或逆行方式切除胆囊。解剖出胆囊管和胆囊动脉，用分离钳将长约10 cm的可吸收缝线送入腹腔,腹腔内打结结扎胆囊管及胆囊血管的近端，远端用电凝钩电凝直接离断。 
结果：554例中除1例因胆囊穿孔，致胆囊三角结构不清，1例因与结肠形成内瘘而中转开腹外，其余552例手术均获成功。手术时间10～70 min，平均32 min；术中出血量5～200 mL，平均13 mL。术后无出血、胆瘘和腹腔感染等并发症发生。503例术后随访1个月至1.5年，平均7个月，未发生腹痛、黄疸及发热等症状。每例住院节余费用平均约2 000元。 
结论：LC术中使用可吸收缝线、电凝钩取代夹子和超声刀进行胆囊切除的方法经济、安全、可靠，能有效地避免使用夹子所致的并发症，可减少患者的医疗费用。

     

改良胆囊造瘘术治疗老年坏疽性胆囊炎的体会

我院1990～1997年采用改良胆囊造瘘术治疗老年坏疽性胆囊炎的高危患者12例．取得了满意的疗效,报告如下。临床资料一、一般资料本组12例．男4例．女8例。年龄67～85岁,平均73岁。其中急性结石性胆囊炎11例．急性非结石性胆囊炎1例．合并胆总管结石者3例．胆囊坏疽穿孔者2例。全部病例伴有严重疾病或并发症,其中中毒性休克6例．糖尿病酮症酸中毒1例．房颤3例．肺心病3例．肾功能不全2例。12例术后均行胆囊病检．证实为坏疽性胆囊炎。二、手术方法进腹后分离胆囊周围的粘连．探查胆管及周围器官．用生理盐水纱布围于胆囊周围后切开胆囊底部…     

腹腔镜胆囊切除术后胆囊管瘘的诊断和处理

目的 探讨腹腔镜胆囊切除术(LC)后胆囊管瘘的诊断和处理方法。方法 回顾性分析3例LC术后胆囊管瘘病例的临床资料。结果 3例均为女性，因慢性结石性胆囊炎行LC。临床表现分别为原有心律失常的加重，腹腔引流管引流出胆汁，以及脐部穿刺孔溢出胆汁样液。确定诊断的时间分别是术后第1天、第2天和第20天。2例再次行腹腔镜手术，套扎关闭开放的胆囊管，腹腔冲洗并引流；1例行腹腔穿刺置管引流，并经内镜乳头切开及置入胆道支架。3例均获治愈。结论 LC术后胆囊管瘘临床表现多样，B超可以发现腹腔积液，确定诊断依赖于MRCP和ERCP。微创手术可以安全有效地处理这一并发症。腹腔镜再手术可以有效地关闭开放的胆囊管；内镜下引流的方法要有有效的腹腔引流的配合。     

Endoscopic removal of the gallbladder mucosa after cholecystostomy

The authors have developed a new method of radical treatment of patients with acute obstructive cholecystitis after cholecystostomy. The endoscopic removal of the mucosa was proposed using hysteroresectoscope GYI-525-12 (Circon-ACM1). The method was used in 5 elderly patients with high anesthesia risk in whom surgical cholecystectomy was not possible. The removal of the mucosa resulted in the replacement of the gallbladder with the connective tissue giving the effect of radical operation.     

Long-term effects of cholecystostomy on gallbladder function

In eight patients without a history of gallbladder disease, cholecystostomy was performed for acute pancreatitis (four patients) and blunt abdominal trauma (four patients). In one case only, acute cholecystitis developed after discontinuation of the cholecystostomy. Six patients were followed for a mean period of 3.9 years, after which the gallbladder function was evaluated. Cholecystography and ultrasonography demonstrated good visualisation of the gallbladder without signs of gallstones. The contraction of the gallbladder produced by cholecystokinin varied. This could be due to adhesions impairing the motility of the gallbladder. After cholecystostomy in a previously normal gallbladder, its function will become normal in most patients. If no signs of gallbladder disease develop within the first year after cholecystostomy, the risk of late complications is minimal.     

Ultrasound-guided percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis

Ultrasound-guided percutaneous transhepatic cholecystostomy was performed in six critically ill patients who had acute acalculous cholecystitis. The clinical conditions of all six patients improved dramatically following transhepatic cholecystostomy. No complications of this bedside procedure occurred. Cholangiography via the inserted pigtail catheter was normal in four patients. Their catheters were removed after ten to 21 days. At follow-up examinations at four to 30 months they were free of signs of gallbladder disease. In one patient, ultrasonography showed desquamation of the mucosa in the gallbladder, which led to the decision to perform cholecystectomy two days after cholecystostomy. One patient, suffering from cholangiocarcinoma, died 120 days after cholecystostomy with the catheter in situ. In our experience, ultrasound-guided percutaneous transhepatic cholecystostomy is the treatment of choice to overcome a critical period in patients with acute acalculous cholecystitis. When post-drainage cholangiography is normal, cholecystectomy at a later stage is not indicated in the majority of these patients.     

Endoscopic and sparing surgical interventions in the treatment of patients with acute cholecystitis and high surgical risk]

Laparoscopic gallbladder drainage was performed as an alternative intervention to an emergency operation in 97 patients with acute cholecystitis whose ages ranged from 60 to 89 years. One patient died from thromboembolism of the pulmonary artery. After acute inflammation was arrested, 37 patients underwent cholecystectomy. The risk of a radical operation was ascertained to be very high in 58 cases. In 19 of these cases endoscopic cleansing of the cystic cavity was performed through cholecystostomy formed during laparoscopic drainage of the gallbladder. In 39 cases the therapeutic process was completed by a sparing operation--sanative cholecystostomy which was carried out under local anesthesia. There were no fatal outcomes in these groups. Endoscopic papillosphincterotomy was conducted in 17 patients, with stones in the gallbladder and choledocholithiasis, after which the stones were removed. The performance of endoscopic and surgical interventions which cause minimal injury provides for adequate sanative treatment of the gallbladder in cases in which cholecystectomy is an extremely high risk.     

Therapeutic tactics after laparoscopic cholecystostomy in patients with acute cholecystitis]

Laparoscopic cholecystostomy was undertaken in 178 elderly and old-aged patients with acute cholecystitis. Dynamic cholecystoscopy with biopsy of the cystic mucosa and bacteriologic study of the bile was conducted for objective appraisal of the inflammatory process in the gallbladder. Concluding operations on the bile tract were carried out in 147 patients. New methods were applied in 10 patients: filling of the gallbladder and contact solution of the stones in the gallbladder and bile ducts.     

Laparoscopic cholecystectomy after open cholecystostomy for gallbladder empyema: a case report

The case of a patient with gallbladder empyema initially drained through a minilaparotomy procedure under local anesthesia with a tube cholecystostomy is reported in this paper. Eight weeks later, the patient underwent an elective interval laparoscopic cholecystectomy. At laparoscopy, the gallbladder and the cholecystostomy tube were dissected free from the abdominal wall and the greater omentum, which was attached to the gallbladder. The tube was removed from the gallbladder fundus, and the operation was completed laparoscopically without any major problems.     

胆囊化学灭活的临床应用和远期疗效观察

目的探讨胆囊化学灭活的临床应用可行性和远期疗效.方法胆囊造瘘21人,微波热凝闭塞胆囊管后,向胆囊内注入95%酒精灭活胆囊粘膜,1次/4小时,连续6次.如灭活1周后造影胆囊腔闭合,胆囊管不显影;或引流量＜10ml,无胆汁,则为灭活成功.灭活前后分别测定血肝肾功能指标和心电图.结果1次微波热凝闭塞胆囊管的成功率为76%(16/21),2次为95%(19/20);95%酒粗完全灭活胆囊粘膜的成功率为85%(17/20),另3例灭活后胆囊区仍有小的液性暗区.所有病人无结石再生,灭活中及灭活后无严重并发症.灭活前后血生化和ECG无明显变化(P＞0.05).结论胆囊化学灭活临床应用安全有效,远期疗效满意.     

Use of endoscopic and surgical methods in the treatment of patients with acute cholecystitis

Laparoscopic gallbladder drainage (LGBD) was undertaken to arrest acute inflammation in 121 patients suffering from acute cholecystitis and serious concomitant diseases. Their ages ranged from 30 to 89 years. Cholecystectomy was carried out in 78 patients after complete abatement of the inflammatory process. When the risk of a radical operation was very high treatment was restricted to cleansing of the gallbladder cavity (CGBC). In 9 patients stones were removed from the gallbladder through a cholecystostoma, formed during LGBD, using a choledochoscope. Cleansing cholecystostomy under local anesthesia was conducted in 19 cases. Fifteen patients who were treated by CGBC had choledocholithiasis; they were subjected to endoscopic papillosphincterotomy. The death rate was 1.6%.     

Laparoscopic reintervention for residual gallstone disease

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.     

胆囊穿刺造瘘后双通道胆道镜保胆取石与腹腔镜胆囊切除术治疗老年患者结石性胆囊炎疗效的比较

目的比较超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石与胆囊穿刺造瘘后行腹腔镜胆囊切除术（1aparoscopiccholecystectomy,LC）治疗老年患者急性结石性胆囊炎的临床疗效。方法回顾性分析2012年1～9月接受双通道胆囊穿刺造瘘联合胆道镜保胆取石治疗的30例老年结石性胆囊炎（保胆取石组）和胆囊穿刺造瘘后行Lc治疗的30例老年结石性胆囊炎（Lc组）的临床资料,比较2组手术操作时间、术中出血量、住院时间、消化不良症状发生率等。结果60例均穿刺置管成功,带管时间14d-2个月,平均30d。4～8周后,保胆取石组30例成功行胆道镜取石,结石取净率100％,取石过程中无出血、漏胆、继发胆总管结石、切口感染等手术并发症。LC组28例三孔法完成LC,2例因粘连组织难以分离中转开腹手术,术中、术后均无严重并发症。保胆取石组术中出血量（8．8±1．7）ml,显著少于LC组（18．9±1．2）ml（t=-25．968,P=0．000）;保胆取石组住院时间（4．4±0．6）d,显著短于LC组（5．6±0．5）d（t=-8．243,P=0．000）。保胆取石组术后随访3、6、12个月,B超检查1例复发,5例有上腹部不适、腹泻、食欲不佳等消化不良症状,发生率16．7％（5／30）,LC组术后21例有消化不良症状,发生率70．o％（21／30）,2组比较有显著性差异（x2=17．376,P=0．000）。结论超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石操作简便,在术中出血量、住院时间、远期生活质量等方面均优于胆囊造瘘后行LC。