困难胆总管结石的内镜治疗进展

胆总管结石是一种常见的胆道疾病,首选治疗方式为内镜治疗,但部分胆总管结石难以通过常规内镜治疗清除,被称为困难胆总管结石。困难胆总管结石治疗方法包括内镜下乳头大球囊扩张术、机械碎石术、经口胆道镜辅助碎石和体外冲击波碎石等。就上述技术治疗困难胆总管结石的适应证、临床疗效和不良事件等进展作一综述。     

体外冲击波碎石联合经内镜逆行胰胆管造影对胆总管困难结石的疗效分析

在我国,体外冲击波碎石术（extracorporeal shock wave lithotripsy,ESWL）主要应用于泌尿系统、胰腺,少数报道应用于肝内胆管结石,较少应用于胆总管结石,本研究回顾性分析2016年11月至2017年4月在我科行ESWL联合ERCP治疗的胆总管困难结石患者资料,探讨ESWL联合ERCP治疗胆总管困难结石的有效性、安全性。     

内镜技术在胆总管结石治疗中的应用

1974年经内镜十二指肠乳头括约肌切开术开启了胆总管结石非手术治疗的时代。如今,更多的内镜技术不断推广应用。本文讨论了目前胆总管结石内镜治疗的常规方法,以及内镜取石困难时的治疗技术。     

腹腔镜内镜同步治疗胆囊合并胆总管结石的探讨

在胆囊合并胆总管结石的微创治疗中,对于十二指肠镜下乳头深插管困难导致胆总管取石失败的患者,我们尝试同时应用腹腔镜、超细胆道镜及十二指肠镜互相配合摘除胆囊并取除胆总管结石,取得一定成效。     

腹腔镜内镜联合同步治疗胆囊结石合并胆总管结石10例报道

腹腔镜胆囊切除术(LC)作为胆囊结石的主要治疗手段已被普遍接受.胆总管结石可供选择的手术方式包括内镜逆行胰胆管造影(ERCP)取石术、开腹胆总管探查取石术、腹腔镜胆总管切开取石术等.目前胆囊结石合并胆总管结石最常用的方案为先ERCP去除胆总管结石后再行LC.但LC前ERCP选择性胆管插管困难,常会导致胆管取石失败.本研究采用腹腔镜内镜联合同步治疗胆囊结石合并胆总管结石,现报道如下.     

超声显示胆总管异常:腹腔镜胆囊切除术前预测胆总管结石的最佳方法

在当前腹腔镜胆囊切除术(LC)时代,对胆总管结石的处置取决于诊疗中心的设施和技术条件。前瞻性研究旨在确定LC前预测胆总管结石的最可靠指征。     

胆管支架治疗难治性胆总管结石28例报告

难治性胆总管结石（即大结石、铸型结石以及胆管下端狭窄结石）内镜下取石困难,标准取石技术（球囊扩张和取石篮网）失败后,可用机械碎石、体外震波碎石和激光碎石等方法,但仍有10％左右患者治疗失败。2005～2008年,我们用置入胆管支架的方法治疗难治性胆总管结石28例,疗效满意。现报告如下。     

内镜逆行胰胆管造影术中使用SpyGlass系统联合液电碎石治疗胆总管困难结石的效果及安全性分析

目的评估内镜逆行胰胆管造影(ERCP)术中使用SpyGlass系统联合液电碎石治疗胆总管困难结石的有效性及安全性。方法选取2019年12月—2020年5月于重庆医科大学附属第一医院肝胆外科行经内镜逆行胰胆管造影术中使用SpyGlass系统联合液电碎石治疗胆总管困难结石的20例患者,检测术后肝功能、血淀粉酶、血脂肪酶水平;观察患者体温、腹痛以及合并胆道出血、感染、穿孔情况;术后复查是否存在胆总管残余结石。结果 20例患者中,18例一次性取石成功,无严重手术并发症; 2例患者因术后复查见少许残余结石影,再次行ERCP下网篮取石及球囊胆道清理,二次取尽结石。未见胆道穿孔、大出血发生;术后诱发胰腺炎均为轻度,给予药物治疗后好转;部分患者血淀粉酶及脂肪酶水平升高,但无临床症状;术后肝功能均明显好转。所有患者取石术后3个月复查腹部彩超均未见胆总管残余结石。结论 ERCP术中使用SpyGlass系统联合液电碎石治疗胆总管困难结石一次性取净结石的成功率较高,且无明显手术并发症。     

十二指肠镜、电子胆道镜和腹腔镜序贯治疗胆总管结石合并胆囊结石834例临床观察

目的探讨十二指肠镜、电子胆道镜和腹腔镜序贯治疗胆总管合并胆囊结石的临床疗效。方法回顾性分析1999年6月至2010年6月间本院采用十二指肠镜、腹腔镜和电子胆道镜序贯治疗的834例胆总管结石并胆囊结石患者。结果 834例接受"二镜"(即腹腔镜、十二指肠镜)治疗,成功793例(95.08%)。41例"二镜"治疗困难转入选择"三镜"(即腹腔镜、十二指肠镜、电子胆道镜)治疗,成功39例(95.12%),"三镜"治疗未取得成功的2例患者因肝门部及小网膜口严重黏连,无法显露胆总管,遂转为开腹手术治疗。834例患者共出现并发症28例。结论序贯性多镜联合技术治疗胆总管结石合并胆囊结石切实可行,并发症率低,安全可靠,值得临床推广。     

内镜逆行胰胆管造影治疗取石困难胆总管结石64例

目的:探讨内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)在取石困难胆总管结石中的应用价值.方法:连续收集64例取石困难胆总管结石患者,分析在ERCP术中操作的难点,巨大结石采用机械碎石、激光碎石、体外震波碎石法;胆总管畸形采用变换体位、反复吸引、网篮体外塑形法;胆管过度扩张或狭窄采用吸引或柱状气囊扩张法;结石坚硬采用反复缓慢加压碎石法再进行胆管取石.结果:64例取石困难者,经ERCP取石成功53例,总体取石成功率为82.81%.其中巨大结石者18例,取石成功15例,成功率83.33%;胆总管畸形者18例,取石成功14例,成功率77.78%;胆总管过度扩张或狭窄者19例,取石成功16例,成功率84.21%;结石坚硬者9例,取石成功8例,成功率88.89%.结论:ERCP术可以有效地治疗取石困难胆总管结石.     

ANALYSIS OF PLASTIC STENTS IN THE TREATMENT OF LARGE COMMON BILE DUCT STONES IN 45 PATIENTS

Background: Although endoscopic plastic biliary stenting is a clinical procedure routinely carried out in patients with common bile duct stones, the effects of stenting on the sizes or fragmentation of large common bile duct stones have not been formally established and the mechanism of this condition is controversial. We compared the stone sizes of common bile duct stones after biliary stenting in order to develop the mechanism. Patients and Methods: Endoscopic plastic biliary stenting was performed in 45 patients with large common bile duct stones or those difficult to extract with conventional endoscopic therapy, including mechanical lithotripsy. The stone diameter was ≥16 mm in all patients. Bile duct drainage and endoscopic placement of 7–8.5 Fr plastic biliary stents were established in all patients. Differences of stone sizes and fragmentations after biliary stenting were compared. The complete stone clearance rate after treatment was obtained. Results: After biliary stenting for 3–6 months, the bile stones disappeared or changed to sludge in 10 (10/45) patients, and fragmentation of the stones or decreased stone sizes were seen in 33 patients, whose stone median size was significantly decreased from 23.1 mm to 15.4 mm in 33 patients (P < 0.05). The stones were removed successfully with basket, balloon, mechanical lithotripsy or a combination in 43 (43/45) patients. The remaining two patients (2/45) demonstrated no significant changes in stone sizes. Conclusion: Plastic biliary stenting may fragment common bile duct stones and decrease stone sizes. This is an effective and feasible method to clear large or difficult common bile duct stones.     

Structure and composition of common bile duct stones in relation to duodenal diverticula, gastric resection, cholecystectomy and infection

BACKGROUND: Common bile duct stones represent a clinical problem often involving severe infection, cholangitis and cholestasis. Stasis and infection are thought to play a part in the pathogenesis of choledocholithiasis. Investigations on the etiology of common bile duct stones are, however, scarce because of the difficult access to common bile duct stones and bile. In a clinical series of common bile duct stones, we studied the gross appearance of stones extracted endoscopically from the common bile duct and measured the cholesterol and bilirubinate content in order to elucidate factors of importance to etiology. METHODS: In 135 patients treated endoscopically for bile duct stones, the stones or parts of the stones were collected. Appearances of the cut surface of the stones were studied and described. Cholesterol and bilirubinate content were analyzed enzymatically and with infrared spectroscopy. The growth in bile of gas-producing bacteria previously shown to be correlated with enterobacteriacea was investigated. RESULTS: Seventy-five percent of the stones were pigment stones, the majority with concentric pigmented layering. There was good agreement between cholesterol measurements. With a cutoff at 50% for the infrared measurements and 25% for the enzymatic assay only 3 stones were discordant between cholesterol measurements and visual inspection. Twenty-one of 23 patients with a previous Billroth-II gastric resection had pigment stones (p < 0.05). Gas-producing bacteria were significantly more prevalent in the bile from patients with layered pigment stones. CONCLUSION: Pigment stones with concentric layering highly suggestive of a cyclic process of crystallization were recovered from the common bile duct in 70% of the patients in our series.     

Difficult bile duct stones

Opinion statement Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.     

柱状大水囊扩张术治疗合并十二指肠乳头旁憩室者胆总管较大结石的初步探讨

目的初步探讨内镜下十二指肠乳头柱状大水囊扩张术对合并十二指肠乳头旁憩室胆总管较大结石患者的安全性和治疗价值。方法对21例合并十二指肠乳头旁憩室且胆总管结石直径较大的患者先行EST,切开3～6mm,用直径10mm的球囊扩张,再根据胆总管直径以及结石大小分别应用直径16～20mm的柱状水囊扩张器行乳头扩张,随后予以取石网篮和（或）取石气囊将结石完整取出。结果所有患者均经一次操作取出结石,均未使用碎石器碎石。取出结石直径1．3～2．0cm,平均1．6cm,单发结石患者15例,2枚结石患者4例,3枚结石患者2例。2例患者术后并发轻型急性胰腺炎,2例术后有一过性血淀粉酶升高,但均低于正常值上限3倍;未发生穿孔、明显出血、感染等并发症。结论对于合并十二指肠乳头旁憩室且胆总管结石较大的患者,十二指肠乳头柱状大水囊扩张术是一种安全有效的治疗方法。     

Endoscopic balloon dilatation is a safe method in the management of common bile duct stones

BACKGROUNDS AND AIMS: Endoscopic sphincterotomy is a widely accepted treatment for patients with common bile duct stones. Despite improvement in this technique, endoscopic sphincterotomy is still associated with some biliary complications. Endoscopic balloon dilatation is a less traumatic and sphincter preserving method for removal of common bile duct stones. However, the results of controlled studies in comparison with these two methods are contradictory. The aim of this study is to compare the safety and efficacy of endoscopic balloon dilatation and endoscopic sphincterotomy in Chinese patients. PATIENTS AND METHODS: A total of 104 patients with common bile duct stones on endoscopic retrograde cholangiopancreatography were enrolled. They were randomly assigned to endoscopic balloon dilatation or endoscopic sphincterotomy. Endoscopic balloon dilatation was performed by using a balloon dilator to dilate the sphincter for 5 min. The common bile duct stones were then removed by a Dormia basket after endoscopic balloon dilatation or endoscopic sphincterotomy. Mechanical lithotripsy was performed if the stones were difficult to remove by Dormia basket. After discharge, patients were regularly followed up for biliary complications. RESULTS: The successful bile duct stone clearance rate was 94.1% in endoscopic balloon dilatation group and 100% in endoscopic sphincterotomy group. Post-procedural significant haemorrhage was higher in endoscopic sphincterotomy group than in endoscopic balloon dilatation group (14/53 versus 1/48, P < 0.001). The bleeding patient from endoscopic balloon dilatation group was a case of uremia and bleeding occurred 48 h after endoscopic balloon dilatation. All the patients with post-procedural haemorrhage were controlled endoscopically. The post-procedural serum amylase level showed no significant difference in both groups and none of them developed clinical pancreatitis. After a mean 16 months follow-up, three patients (6.3%) in endoscopic balloon dilatation group and four patients (7.5%) in endoscopic sphincterotomy group developed recurrent common bile duct stones. The recurrent common bile duct stones were multiple and muddy in consistency. They were successfully removed endoscopically. CONCLUSION: Both endoscopic balloon dilatation and endoscopic sphincterotomy are safe and effective techniques for the treatment of common bile duct stones. Endoscopic balloon dilatation can be safely applied in patients with coagulopathy and does not increase the incidence of pancreatitis or bleeding.     

D-Glucaric Acid in Common Duct Bile and Relation to Choledocholithiasis

Background: The aim was to investigate a possible association between D-glucaric acid (DGA), biliary bilirubin glucuronidation and brown pigment stones in the common bile duct. Methods: A high performance liquid chromatography method with a strong cation resin (HPX-87H) was developed for measuring biliary DGA. Bile was obtained during ERCP by deep cannulation of the common bile duct in 100 patients with suspected biliary disease. Results: The concentration of DGA in common bile duct bile was 60 (1.1-633) μmol l -1 (median, range). The values were lower than previously reported. There were no differences in DGA concentrations in patients with common bile duct stones compared to patients without common bile duct stones, irrespective of stone type, cholesterol or brown pigment stones. Bilirubin conjugates in common duct bile did not vary with DGA concentrations. Conclusion: DGA is probably insignificant in the pathogenesis of common bile duct stones.     

D-glucaric acid in common duct bile and relation to choledocholithiasis

BACKGROUND: The aim was to investigate a possible association between D-glucaric acid (DGA), biliary bilirubin glucuronidation and brown pigment stones in the common bile duct. METHODS: A high performance liquid chromatography method with a strong cation resin (HPX-87H) was developed for measuring biliary DGA. Bile was obtained during ERCP by deep cannulation of the common bile duct in 100 patients with suspected biliary disease. RESULTS: The concentration of DGA in common bile duct bile was 60 (1.1-633) micromol l(-1) (median, range). The values were lower than previously reported. There were no differences in DGA concentrations in patients with common bile duct stones compared to patients without common bile duct stones, irrespective of stone type, cholesterol or brown pigment stones. Bilirubin conjugates in common duct bile did not vary with DGA concentrations. CONCLUSION: DGA is probably insignificant in the pathogenesis of common bile duct stones.     

Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation

BACKGROUND: Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography. METHODS: Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge. RESULTS: Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully. CONCLUSIONS: Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.     

Triple non-invasive diagnostic test for exclusion of common bile ducts stones before laparoscopic cholecystectomy

AIM： To evaluate the impact of a preoperative ＂triple non-invasive diagnostic test＂ for diagnosis and/or exclusion of common bile duct stones. METHODS： All patients with symptomatic gallstone disease, operated on by laparoscopic cholecystectomy from March 2004 to March 2006 were studied retrospectively. Two hundred patients were included and reviewed by using a triple diagnostic test including： patient＇s medical history, routine liver function tests and routine ultrasonography. All patients were followed up 2-24 mo after surgery to evaluate the impact of triple diagnostic test. RESULTS： Twenty-five patients were identified to have common bile duct stones. Lack of history of stones, negative laboratory tests and normal ultrasonography alone was proven to exclude common bile duct stones in some patients. However, a combination of these three components （triple diagnostic）, was proven to be the most statistically significant test to exclude common bile duct stones in patients with gallstone disease. CONCLUSION： Using a combination of routinely used diagnostic components as triple diagnostic modality would increase the diagnostic accuracy of common bile duct stones preoperatively. This triple non-invasive test is recommended for excluding common bile duct stones and to identify patients in need for other investigations.     

Association between common bile duct stones and treated hypothyroidism

BACKGROUND/AIMS: The purpose of this study was to investigate the frequency of diagnosed hypothyroidism in patients with common bile duct stones. METHODOLOGY: The common bile duct stone group (Group I) consisted of all the patients who had verified gallstones in the common bile duct in endoscopic retrograde cholangiopancreatography during 1995. The control group (Group II) was matched for age, sex, and hospital admission. These patients did not have diagnosed gallbladder or common duct stones. In both groups there were 86 patients (56 women and 30 men). The median age in these groups was 73 (range: 22-92) years at the time of common bile duct stone diagnosis. Medical records of all patients were reviewed. RESULTS: In Group I the prevalence of previously diagnosed hypothyroidism was 7/86 (8%) compared with 1/86 (1%) in Group II (P = 0.01). Hypothyroidism was previously diagnosed only in the common bile duct stone patients (Group I) of over 60 years of age, where the prevalence was 7/66 (11%). In addition, we studied 36 consecutive gallbladder stone patients (Group III) of over 60 years, who had no evidence of common bile duct stones. Hypothyroidism had been diagnosed in them less frequently (2/36 = 6%) than in the age and hospital admission matched common bile duct stone patients (P = 0.01). Other diagnosed endocrine disorders did not differ between the study groups. CONCLUSIONS: There is a significant association between the common bile duct stones and previously diagnosed hypothyroidism. There stronger association between the common bile duct stones and hypothyroidism compared to gallbladder stones and hypothyroidism suggests a mechanism other than merely the cholesterol metabolism mediated mechanism. The 11% prevalence of previously diagnosed hypothyroidism in the common bile duct stone patients of over 60 years of age suggests all patients with common bile duct stones be screened for current thyroid dysfunction.