腹腔镜胆囊切除术治疗无黄疸急性胆源性胰腺炎95例

目的探讨腹腔镜胆囊切除术（1aparoscopic cholecystectomy，LC）治疗无黄疸急性胆源性胰腺炎可行性及手术时机的选择。方法回顾性分析1996年7月～2004年7月我院收治的无黄疸急性胆源性胰腺炎95例，79例通过非手术治疗胰腺炎缓解后延期行LC，16例非手术治疗后效果不佳而急诊行LC。结果95例LC均获成功。手术时间40—328min，平均103min。术中出血量0～210ml，平均35ml。95例均行术中胆道造影，成功92例，3例失败。造影发现13例胆总管下段结石行逆行性胰胆管造影（endoscopic retrograde cholanginpancreatography，ERCP）联合内镜下十二指肠括约肌切开术（endoscopic sphincterotorny，EST），取石成功。无中转开腹及围手术期死亡，无术后出血及胆漏并发症。术后胆囊内见多发结石，以小结石、泥沙样结石多见。39例随访1个月～5年，均无胰腺炎、胆总管结石复发。结论无黄疸急性胆源性胰腺炎应尽早行LC以去除原发病因，术中造影和术后EST是其成功的重要辅助手段。     

胆囊结石伴急性胆源性胰腺炎的微创治疗

目的 探讨胆囊结石伴急性胆源性胰腺炎（acute biliary pancreatitis,ABP）的微创治疗方法及手术时机。方法 回顾分析我院2008年5月～2013年5月胆囊结石伴ABP122例的临床资料。先保守治疗,磁共振胰胆管成像（MRCP）明确胆总管有无结石梗阻,104例未发现结石者急性胰腺炎恢复后行腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）。18例MRCP发现胆总管下段结石,行内镜逆行胆胰管造影（ERCP）＋十二指肠乳头括约肌切开（EST）取石＋鼻胆管引流（ENBD）治疗成功,再行LC。结果轻型106例,手术时间为发病后7～14天;重型16例,手术时间为发病后15～30天。无中转开腹、胆管损伤及死亡。其中107例随访5～8个月,无胰腺炎复发。结论对胆囊结石伴ABP应常规MRCP检查。未发现胆总管结石者待胰腺炎恢复后行LC;有胆总管结石伴梗阻者72小时内用十二指肠镜取出胆管下端嵌顿结石并ENBD,待胰腺炎恢复后再行LC;无梗阻者保守治疗胰腺炎恢复后,先行ERcP并取石,再行LC。手术时机应遵循“个体化”原则,一般轻型胰腺炎可在发病1～2周内手术。采用上述方法治疗胆囊结石伴ABP安全、有效、微创、可行。     

胆囊结石合并胆总管结石的微创治疗进展

正研究显示,10%~20%的胆囊结石患者同时合并胆总管结石~([1-2]),可诱发急性胆源性胰腺炎、黄疸、急性化脓性胆管炎等并发症,严重者危及生命。胆囊结石合并胆总管结石的微创治疗方式主要包括两大类:腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)+术前、术中或术后行经内镜逆行胆胰管造影(endoscopic retrograde cholangiopancreatogra-phy,ERCP)胆总管取石术,LC+胆总管探查取石术     

轻症急性胆源性胰腺炎合并结石的两种微创术式疗效研究

目的:比较腹腔镜胆总管探查取石术(LCBDE)联合腹腔镜胆囊切除术(LC)与内镜逆行胰胆管造影(ERCP)+LC两种术式治疗轻症急性胆源性胰腺炎(ABP)合并胆囊结石伴胆总管结石的临床疗效。方法:回顾分析2018年1月至2021年1月收治的98例合并胆囊结石伴胆总管结石的轻症ABP患者的临床资料。其中42例行LCBDE+LC(LCBDE组),56例行ERCP+LC(ERCP组),比较两组术前情况、术前准备时间、术中出血量、手术时间、术后肛门排气时间、住院时间、住院费用、术后并发症等指标。结果:两组患者年龄、性别、急性胰腺炎严重程度床边指数评分、BMI差异无统计学意义(P0.05),具有可比性。LCBDE组胆总管直径大于ERCP组,差异有统计学意义(P0.05)。两组ABP患者均痊愈出院,无围手术期死亡病例。两组手术时间、术中出血量、并发症发生率差异无统计学意义(P0.05)。LCBDE组术前准备时间、术后肛门排气时间长于ERCP组,住院时间、住院费用优于ERCP组,差异有统计学意义(P0.05)。结论:LCBDE+LC与ERCP+LC两种方案治疗轻症ABP合并胆囊结石伴胆总管结石均是安全、有效、可行的,需结合患者病情、医院设备条件、技术因素合理选择。     

腹腔镜手术早期治疗急性胆源性胰腺炎18例

目的探讨腹腔镜手术早期治疗急性胆源性胰腺炎(acute biliary pancreatitis,ABP)的可行性及有效性。方法2003年1月~2006年6月对18例急性胆源性胰腺炎分别行单纯腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)3例,LC联合腹腔镜下胆总管切开探查取石术(laparoscopic common bile duct exploration,LCBDE)9例,LC联合胰腺被膜切开引流5例,LC联合LCBDE联合胰腺被膜切开引流1例。结果18例均在腹腔镜下完成手术,无中转开腹手术。手术时间100~150min,(115.3±15.2)min。10例LCBDE术中取净胆管内结石。无皮下气肿、出血、腹腔脓肿及胆道狭窄等严重并发症发生。18例随访4~40个月,平均28.5月,胰腺假性囊肿2例,1例经内引流手术治愈,另1例3个月后逐渐吸收,无胰腺炎及胆总管结石复发。结论对ABP患者早期采用腹腔镜手术治疗可行,疗效好。     

腹腔镜、内镜早期干预急性胆源性胰腺炎

目的观察腹腔镜胆囊切除术(LC)联合内镜(ERCP)早期治疗急性胆源性胰腺炎(ABP)的效果。方法收集2005年6月至2014年12月152例ABP患者,所有患者先行ERCP+十二指肠乳头括约肌切开术治疗,102例合并胆囊结石病例序贯行LC。结果检查发现胆总管结石140例,12例胆总管下端狭窄放置支架(其中7例怀疑恶性占位)。术后未出现十二指肠穿孔及胰腺炎加重等严重并发症。结论 140例胆总管结石术后未出现并发症,102例LC患者治愈出院。腹腔镜联合ERCP早期治疗ABP安全、有效,值得临床推广使用。     

89例急性胆源性胰腺炎治疗体会

目的总结急性胆源性胰腺炎(ABP)的治疗经验。方法我院2005年2月至2009年10月期间收治89例ABP患者,梗阻型ABP 29例,其中2例胆总管下端结石梗阻致坏死型胰腺炎患者,24 h内行开腹或腹腔镜胆囊切除(LC)、胆总管切开取石、T管引流、胰腺被膜切开减压、胰腺坏死组织清除;8例肝外胆管结石患者急诊(24~48 h)行内镜逆行胰胆管造影术(ERCP)+内镜下括约肌切开术(EST)+内镜下鼻胆管引流(ENBD);17例胆囊结石伴胆总管结石及2例胆总管下端占位患者先行内科保守治疗病情得到控制,7 d后行CT、EST或ENBD,择期行LC、胆总管切开取石术、限期内镜胆管内支架放置术或开放根治术。非梗阻型ABP 60例,均为胆囊结石、胆囊炎所致,在入院后3~14 d急性胰腺炎控制后42例行胆囊切除术,18例行保守治疗。结果 29例梗阻型ABP在及时或限时行胆道引流解除梗阻后均使胰腺炎得到控制,病情稳定后行手术治疗,均治愈出院;60例非梗阻型ABP患者中,42例住院行一期胆囊切除术,治愈率达100%,18例保守治疗患者,1个月至1年胰腺炎复发9例,均再次入院,3例保守治疗好转后出院;6例行胆囊切除术,其中LC 4例,开腹胆囊切除术2例,其中5例治愈,1例出现急性呼吸窘迫综合征抢救无效死亡。结论 ABP应根据胆管有无梗阻分型治疗,梗阻型应尽早引流解除胆管梗阻,EST+ENBD能有效解除胆管梗阻控制胰腺炎症;非梗阻型宜积极保守治疗,病情缓解后手术治疗,能有效降低并发症发生率和病死率。     

急性胆源性胰腺炎的微创治疗

目的探讨应用十二指肠镜及腹腔镜治疗急性胆源性胰腺炎(ABP)的有效性。方法回顾性分析5年间对94例ABP患者进行微创治疗的临床资料。ABP合并胆囊结石的59例行行单纯腹腔镜胆囊切除术(LC);胆总管结石14例内镜下乳头括约肌切开取石术(EST),同时置入鼻胆管引流(ENBD),其中3例联合LC;对胆囊结石合并胆总管结石21例行ERCP EST,联合LC治疗。结果全组术后再次发作胰腺炎1例,胆道出血1例,均为ERCP EST患者;另肺部感染2例,切口感染1例,5例均经非手术治疗痊愈。全组有效率100%。结论十二指肠镜及腹腔镜联合应用于治疗ABP效果好。微创技术是目前ABP理想的治疗方法。     

急性胆源性胰腺炎的外科治疗体会

目的:探讨急性胆源性胰腺炎(acute biliary pancreatitis,ABP)的手术时机与治疗方法。方法:回顾分析2009年1月至2013年12月178例ABP患者的临床资料。结果:轻症ABP患者149例,其中非梗阻型121例,早期采用非手术治疗,病情稳定后择期行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),均治愈;梗阻型28例,早期行内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)、内镜十二指肠乳头括约肌切开取石术(endoscopic sphincterotomy,EST)及鼻胆管引流术(endoscopic nasobiliary drainage,ENBD),择期行LC或胆总管切开取石术,均痊愈。中-重症ABP患者29例,其中非梗阻型16例,先行非手术治疗,4周后行胆道手术或外科介入处理重症ABP并发症,均痊愈;梗阻型13例,3例出现腹腔间隔室综合征而行急诊手术,8例行ERCP+EST(或+ENBD)后择期行胆道手术、胰腺坏死组织清除术或外科介入处理并发症,11例均治愈;另2例为爆发性重症胰腺炎未行手术死亡。结论:ABP的治疗应遵循分型而治、个体化治疗的原则。梗阻型术前应尽早解除胆道梗阻,轻症患者当次入院期间行LC,重症患者4周后行胰腺坏死组织清除术与局部并发症引流术。     

急诊腹腔镜手术治疗急性胆源性胰腺炎

目的探讨急诊腹腔镜手术治疗急性胆源性胰腺炎（acute biliary pancreatitis，ABP）可行性及疗效。方法2001年5月～2005年12月对87例ABP行急诊腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）；对胆总管结石和（或）胆总管增宽者，行腹腔镜胆总管探查术（laparoscopic common bile duct exploration，LCBDE）并置T管引流。结果手术成功75例，其中单纯LC 20例，LC联合LCBDE 55例（49例同时行胰腺被膜切开、腹腔置管灌洗引流术）；中转开腹手术12例。87例随访3～58个月，平均28．2月，无手术并发症和（或）胰腺炎及胆总管结石复发。结论急诊腹腔镜手术治疗ABP安全可行，疗效明确。     

Laparoscopic cholecystectomy for complicated gallstone disease

After performing selectively 25 laparoscopic cholecystectomies (LC) to determine the place of LC in the management of complicated gallstones, all patients presenting with gallstones were evaluated by the authors for LC. Eighty-six consecutive patients were evaluated and 84 were studied. Follow-up in every case exceeded 6 months. In three of 10 patients with acute cholecystitis, LC was not possible; each had a history longer than 48 h and all had gangrene of the gallbladder. In four patients with empyema, LC was successful, but operative cholangiography failed. Operative cholangiography was successful in 76 of the remaining 77. Of eight patients suspected of having stones in the CBD, cholangiography excluded stones in six and confirmed them in two. Cholangiography identified three other patients with totally unsuspected CBD stones. Of the five patients with CBD stones, four had them flushed to the duodenum at LC following transcystic balloon dilatation of the papilla and one had a post-op. ERCP. Of four patients with acute pancreatitis, three had LC in the same admission. LC was possible in all three patients with morbid obesity. We conclude that with experience, LC is possible for complicated gallstones. In acute cholecystitis, the probability of success is higher with earlier operative intervention. Operative cholangiography is essential. It not only identifies unsuspected CBD stones but also allows LC without ERCP in those with suspected CBD stones and with modification it allows treatment of those stones.     

急性胆源性胰腺炎的手术时机和术式探讨

目的探讨急性胆源性胰腺炎（acute biliary pancreatitis,ABP）的手术时机和术式选择。方法123例ABP患者,梗阻性31例,其中9例重症者在观察治疗24—48h后病情恶化,急诊行内镜逆行胰胆管造影术（ERCP）、内镜下十二指肠乳头括约肌切开（ES）或取石术（EST）、鼻胆管引流（ENBD）;余22例轻症者经非手术治疗病情得到控制,10d后行磁共振胰胆管造影（MRCP）、EST、ENBD,择期行腹腔镜胆囊切除术（LC）、胆总管切开取石术、限期内镜胆管内支架放置术或开放根治术。非梗阻性ABP92例,均为胆囊结石、胆囊炎所致,在入院10～14d急性胰腺炎控制后行胆囊切除术60例,32例未行手术。结果31例梗阻性ABP在及时和限时行胆道引流解除梗阻后均控制了胰腺炎的进一步发展,为以后二期手术创造了良好的条件;非梗阻性ABP患者中,60例住院行一期胆囊切除术,治愈率100％。余32例保守治疗患者,1个月到1年内胰腺炎复发24例（75．0％）,均再次入院行胆囊切除术。结论ABP应根据胆道有无梗阻分型论治：梗阻性应尽早引流解除胆道梗阻,EST＋ENBD是目前理想的治疗方法;非梗阻性宜积极保守治疗,病情缓解后在同一住院期内手术。     

Diagnosis of severity as a basic parameter in the treatment of acute biliary pancreatitis

BACKGROUND: Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial to clearly assess the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and to establish their severity in order to plan the appropriate treatment. METHODS: 58 ABP patients were diagnosed by ultrasound (77.5%) or by laboratory findings (22.4%). Following Ranson and APACHE II scoring 17 cases (29.3%) were classified as severe, 41 (70.6%) as mild. All patients with severe ABP, had emergency ERCP + ES (within 24-48 hrs) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. RESULTS: In severe cases operative endoscopy cured pancreatic inflammation in 12 cases. Subsequent LC never showed serious morbidity, apart from subcutaneous emphysema in one case. In 5 cases laparotomy was required since pancreatic necrosis was present, with 60% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 7.3% morbidity. IOC showed choledochal stones in 31.7% of cases, while in severe cases stones in the biliary tree were shown in 88.2% of cases. CONCLUSIONS: In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hrs as well as in mild cases (LC + IOC) when surgery is done within 10 days.     

Comparative evaluation of early laparoscopic cholecystectomy for mild gallstone pancreatitis vs acute cholecystitis

Aim-Background

Laparoscopic cholecystectomy (LC) during index admission for acute cholecystitis (AC) is now an established procedure, but timing for LC in gallstone-induced acute biliary pancreatitis (ABP) is still controversial. Interval cholecystectomy is justified in cases of severe pancreatitis, however, in patients with mild disease, which constitute the majority (80%) of the cases, patients can safely be operated during the index admission. The profile of patients with mild gallstone pancreatitis and AC appears to be similar, since both are complications of gallstone disease. The LC in both situations is equally challenging, due to risk of inflammation and adhesions. However, both conditions are likely to benefit from early LC, in terms of rapid recovery and shortened hospital stay. But no author has compared the outcome of LC in these two similar clinical entities in the past. Hence the present study compares the outcome of LC in case of mild ABP versus AC.

Materials and Methods

This prospective study was conducted on 77 patients undergoing LC for AC with or without pancreatitis, during index admission. Cases were divided into two groups of mild ABP (n=25) and AC (n=52). Both groups were compared with respect to the clinical presentation, timing of cholecystectomy, operative findings, duration of surgery, difficulty in dissection, intra-operative or postoperative complications, duration of hospital stay and outcome at time of discharge.

Results

The majority of patients in both groups underwent successful LC. Both groups were comparable, with respect to demographic profile, mean duration of surgery, gallbladder adhesions (32% vs 29%), thickened edematous gallbladder (76% vs 71%), difficult dissection (32% vs 29%) and need of conversion to open procedure (16% vs 17%). Both groups were also comparable, with respect to intra-operative complications (8% vs 10%). Post operative recovery was prolonged in case of ABP, in comparison to AC, but was not significant statistically (p >0.05). Total post-operative complications were significantly more in ABP group (p <0.01). Post operative stay (mean days 2.76 vs 2.34), as well as total hospital stay (mean days 7.24 vs 5.15) was significantly prolonged in cases with ABP (p <0.05).

Conclusion

LC can be safely performed during index admission in patients with mild ABP as can be done in cases of AC.

     

Treatment of acute biliary pancreatitis in the aged in the endolaparoscopic era

BACKGROUND: Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial to clearly assess the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and to establish the severity in order to plan the appropriate treatment. METHODS: In this study we have considered 61 patients divided into 2 groups. Group 1 had 29 ABP patients aging less than 65 years, group 232 patients aging more than 65 years; the diagnosis was made by ultrasound and serological values in 78.5% of cases, while in the remaining 21.5% was only serological. Following Ranson and APACHE II scoring 18 cases (29.5%) were classified as severe [6 (20.6%) in group 1; 12 (37.5%) in group 2: p < 0.01], 43 (70.4%) as mild. All patients with severe ABP had emergency ERCP + ES (within 24-48 hrs) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. RESULTS: In severe cases operative endoscopy cured pancreatic inflammation in 13 cases. Subsequent LC never showed serious morbidity, apart subcutaneous emphysema in one case. In 5 cases laparotomy was required since pancreatic necrosis was present, with 60% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 6.9% morbidity. IOC showed choledochal stones in 32.5% of cases, while in severe cases stones in the biliary tree were showed in 88.8% of cases. No significant differences were detected between group 1 and 2. CONCLUSIONS: In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hrs as well as in mild cases (LC + IOC) when surgery is done within 10 days, independently from the age of the patients.     

胆源性胰腺炎行腹腔镜胆囊切除术及手术时机（附78例报告）

目的：探讨急性胆源性胰腺炎腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的可行性及手术时机选择。方法：回顾分析急性胆源性胰腺炎78例患者在两周内行LC的临床资料和治疗结果。结果：全组患者均行LC,8例术中粘连较重,经仔细分离,平均手术时间约90min,其余手术难度不大,平均手术时间40min,术后无并发症发生,均治愈出院。随访1年,无一例胰腺炎复发。结论：胆源性胰腺炎患者行LC应选择在两周内,手术安全可行。     

胆囊结石伴急性胰腺炎的腹腔镜胆囊切除术

目的探讨胆囊结石伴急性胰腺炎实施腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）的可行性及手术时机。方法回顾性分析我院1999年1月-2003年8月行LC治疗胆囊结石伴急性胰腺炎21例的临床资料。结果2l例均在急性胰腺炎发作后20—40d，血、尿淀粉酶正常15d后，成功实施LC，9例放置腹腔引流管。术后19例恢复顺利，当日或次日下床活动，12h后进食，术后24—72h拔除腹腔引流管，无并发症。2例术后3d又发作急性胰腺炎，经保守治疗后症状缓解。住院4—20d，平均7d。21例随访6个月一5年，平均19个月，均无复发。结论对胆囊结石伴急性胰腺炎患者在急性胰腺炎发作后20—40d，如能慎重选择病例，做好必要的围手术处理，术中仔细操作，术后适当引流，实施LC是安全的。     

急性非梗阻性胆源性胰腺炎的腹腔镜手术时机探讨

目的:探讨急性非梗阻性胆源性胰腺炎患者施行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的可行性及手术时机。方法:回顾分析2004年4月至2008年2月37例急性非梗阻性胆源性胰腺炎患者实施LC的临床资料。结果:37例经非手术保守治疗2～11d后,血、尿淀粉酶恢复正常,成功实施了LC,术后均恢复顺利,当日或次日下床活动,36～72h后进食,无并发症发生。住院10～24d,平均13d。随访3～12个月,均无复发。结论:急性非梗阻性胆源性胰腺炎经非手术治疗病情控制后如能慎重选择病例,做好必要的围手术期处理,实施LC是安全的。