推按运经仪对胆石病术后胆道压力的影响

目的监测推按运经仪对胆石病术后患者胆道压力的影响,探讨推按运经仪防治胆石病的作用机制。方法选择120例胆石病术后留置胆道引流管的患者,将胆道引流管与压力换能器连接,由多道生理信号采集系统测定并记录推按运经仪治疗前后胆管压力变化。结果推按运经仪治疗后胆管压力的平均值、最小值、最大值均比治疗前显著升高,并有统计学意义（P〈0.01）。结论推按运经仪治疗能明显提高胆管内压力,从而促进胆管内容物的排出,这一作用可能与刺激胆管的收缩和促进胆汁的持续分泌有关,为推按运经仪的临床应用提供了理论依据。     

肝内胆管结石的外科治疗

目的：探讨肝内胆管结石的治疗方法。方法：回顾性分析160例肝内胆管结石患者的临床资料,对比不同术式的效果,总结各种术式的作用和适应证。结果：肝切除术式采用左外叶切除56例（35％）,左半肝切除29例（18．13％）,肝方叶切除11例（6．88％）,右前叶切除13例（8．13％）,右后叶切除22例（13．75％）,右半肝切除5例（3．2％）,双侧多区段肝切除24例（15％）;其中附加胆肠内引流术69例（43．13％）,经肝实质切开取石6例。结论：根据手术探查胆管狭窄部位及范围和结石分布状况,采用不同的术式。正确选择肝内胆管结石手术方式是减少术后残留结石的关键,而规则性肝叶／段切除是治疗原发性肝胆管结石的有效手段。     

小儿胆囊炎胆石症21例临床分析

[目的]探讨小儿胆囊炎胆石症的临床特点、诊断与治疗方法。[方法]回顾性总结14年间收治的小儿胆囊炎胆石症21例的临床资料,对其临床特点、诊疗方法以及随访资料进行分析。[结论]门诊首诊为胆囊炎12例,误诊率为42.86％。其中7例施行手术治疗,病理检查提示急性胆囊炎5例,慢性胆囊炎2例;胆固醇结石5例,混合性结石2例。2例拒绝手术者经保守治疗症状好转后出院。12例无胆石症的急性单纯性胆囊炎患儿给予短期禁食、纠正水电解质失衡、抗感染、解痉、利胆等治疗,住院10-21d治愈出院。[结论]小儿胆囊炎胆石症发病率低,缺乏典型症状,临床易误诊,诊断明确后应及时治疗。     

Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically

Background: Two recent meta‐analyses suggest that operative common bile duct (CBD) exploration (laparoscopic or open) may be superior to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis when the gall bladder is in situ. Much of the published work regarding laparoscopic exploration comes from enthusiasts of the technique and may not be transferable to other institutions. In our institution, both hepatobiliary and general surgeons carry out cholecystectomy, with differing levels of expertise in laparoscopic bile duct exploration. ERCP and laparoscopic antegrade transampullary endobiliary stents are available. We reviewed the management of choledocholithiasis in this setting. Methods: A retrospective review of all patients undergoing cholecystectomy during 2004 and 2005 at John Hunter and Belmont Hospitals (Newcastle, Australia) was conducted. Results: The overall incidence of choledocholithiasis was 10.3% (70 of 681). Fifty patients underwent preoperative ERCP, with choledocholithiasis confirmed in only 24 patients (therapeutic rate 30%). Thirty‐one patients underwent CBD exploration with 100% clearance through an open approach (12 patients) and 58% clearance through a laparoscopic approach (11 of 19 patients). Hepatobiliary surgeons carried out 22 of 31 CBD explorations (clearance rate 82%) and placed 13 transampullary antegrade endobiliary stents. In comparison, general surgeons carried out nine CBD explorations (clearance rate 56%) and placed only four antegrade stents. Conclusion: This series suggests that preoperative ERCP is significantly overutilized, laparoscopic CBD exploration is less successful than open CBD exploration and that antegrade transampullary intraoperative endobiliary stenting is underutilized by non‐hepatobiliary surgeons.     

Risk factors affecting conversion in patients undergoing laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is the gold standard in the treatment for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy for several factors. The objective of this study was to evaluate preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Methods: One thousand two hundred and sixty‐five laparoscopic cholecystectomies were carried out from January 2005 to January 2006 in our hospital. Preoperative clinical, laboratory and radiographic parameters of these patients were kept prospectively and analysed retrospectively. Results: Conversion to open cholecystectomy was needed in 94 patients (7.4%). The main reason for conversion was inability to safely display and identify anatomical structures of Calot’s triangle correctly secondary to severe inflammation or dense adhesions, Multivariate analysis identified male sex, with Murphy’s sign positive, gall bladder wall thickness > 4 mm and previous upper abdominal surgery as independent predictors of conversion rate to laparotomy. Conclusion: Preoperative risk factors evaluated by the present study confirm the likelihood of conversion. Recognition of these factors was important for understanding the characteristics of patients at a higher risk of conversion. Identifying risk factors will help the surgeon to plan and counsel the patients and introduce new policies.     

天津自然人群胆石发病率普查与胆石症易患因素的研究

作者等在28319名正常人年度健康查体时用 B 超方法对天津胆石自然发生率作了研究。结果如下:1.共2325例发现有胆石,自然发生率为8.2%。其中1883例胆石位于胆囊,发生率6.6%,163例胆石位于胆管,发生率0.6%,273例胆囊及胆管均有胆石,发生率1.0%。2.胆石发生率与年龄、性别的关系:50岁以下男人胆石发生率为6%,女性50岁以下者为7%。但50岁以上男性发生率为11.3%,女性为20.2%。3.工作性质与发生率的关系:干部及知识份子发生率最高,为9.6%,农民最低为5%。胆囊结石的差别更为明显,干部、知识份子为8%,农民为2.4%。但胆管结石呈相反趋势,农民、工人、干部分别为2.0%、0.3%和0.2%。4.营养与发生率的关系:营养较好,其食物中含肉量较多者发生率为13.7%,营养较差即食物中食肉量较少者发生率为7.4%。胆囊结石发生率分别为12.1%和5.6%,胆管结石则呈相反情况,分别为0.1%和0.7%。5.居住地点与发生率的关系:居住在市区者发生率高于居住在农村者(10.5%和3.7%)。胆管结石亦相反(0.2%和1.2%)。天津胆石自然发生率普查为8.2%。居住地区、性别、年龄、工作性质和营养条件与发生率有关,经统计学处理在以上各因素中以居住地和性别为最重要的因素。     

急性胆石性胰腺炎的外科治疗（附45例临床分析）

目的 探讨急性胆石胰腺炎诊断和手术治疗的经验。方法 回顾性分析了４５例行手术治疗的急性胆石胰腺炎病人的临床资料和治疗。结果 术前Ｂ超检查在发病２４小时内施行的２１例中９例显示胆总管结石，而发病超过２４小时的２４例中仅显示３例（Ｐ〈０．０２５）。本组手术包括单纯胆囊切除３３例，合并胆总管切开探查９例，合并胆总管探查和胰周引流３例，４例病人发生术后并发症（８．９％），仅１例手术死亡，术后第５天死于呼吸     

Laparoscopic cholecystectomy for asymptomatic cholelithiasis

Background: Laparoscopic clolecystectomy is now the most appropriate treatment for most patients with symptomatic cholelithiasis (S‐Chole). However, the management of patients with asymptomatic cholelithiasis (A‐Chole) remains controversial. Our research is aimed at determining whether laparoscopic cholecystectomy for patients with A‐Chole is safer, more effective and more convenient than laparoscopic cholecystectomy for patients with S‐Chole. Methods: We retrospectively conducted a review of 254 patients with A‐Chole who underwent laparoscopic cholecystectomy in an effort to compare the intraoperative course, postoperative recovery and morbidity and mortality with 432 patients with S‐Chole who underwent laparoscopic cholecystectomy. Results: The mean operative time in the A‐Chole group was significantly shorter than that in the S‐Chole group at 92.1 min versus 106.0 min, respectively. The mean intraoperative blood loss was not significantly different between the two groups. There were no significant differences between the two groups, regarding the postoperative recovery. Conversion rate to open laparotomy in the A‐Chole group was significantly lower than that in the S‐Chole group, at 1.57% versus 4.6%, respectively. The morbidity rates were 4.72% in the A‐Chole group and 8.80% in the S‐Chole group, the morbidity rate in the A‐Chole group being significantly lower than that in the S‐Chole group. There was no death in the A‐Chole group. Gallbladder cancer was incidentally diagnosed in two patients with A‐Chole after laparoscopic cholecystectomy. They underwent an additional operation and were alive with no recurrence. Conclusion: Laparoscopic cholecystectomy for patients with A‐Chole is a safe procedure with a low rate of morbidity and mortality.     

肝段(叶)切除治疗肝内胆管结石疗效分析

目的探讨肝段(叶)切除治疗肝内胆管结石的临床价值。方法回顾性分析1997年1月～2004年1月采用肝段(叶)切除治疗肝内胆管结石的115例病例资料。结果肝段(叶)切除 胆管空肠Roux-en-Y吻合28例(24．3％)；肝段(叶)切除 胆道探查72例(62．6％)；肝段(叶)切除 胆肠吻合口切开探查10例(8．7％)；肝段(叶)切除 胆道探查 右肝表面切开取石术5例(4．3％)，术后胆道常规留置T管。其中肝段(叶)切除手术包括左外叶88例，左半肝12例，右前叶7例，右后叶1例。不规则左和(／或)右肝切除术7例。病人均治愈，无死亡。术后发生并发症10例(8．7％)，其中切口感染7例，切口裂开3例，均治愈。术后均经T管行胆道造影及胆道镜检，发现结石15例，残石率13．0％。结论肝段(叶)切除术治疗肝内胆管结石具有疗效较好。残石率较低，并发症较少的优势。     

中医治疗胆系多发性结石并阻塞性黄疸7例

运用中医综合疗法,即中药以茵陈蒿汤、四金排石汤、大柴胡汤加穿山甲化裁,耳穴压豆取肝、胆、胰、十二指肠等13个穴位,并在中、晚餐配合食用适量猪蹄,平均疗程1～2个月,治疗胆系多发性结石并阻塞性黄疸7例,治愈2例,显效5例。排出最大结石为1.9cm×1.5cm×1.2cm。临床证明,本疗法具有明显的利胆、排石、消炎和解痉作用。