Comparison of emergent versus elective laparoscopic common bile duct exploration for patients with or without nonsevere acute cholangitis complicated with common bile duct stones

Background

Laparoscopic common bile duct exploration (LCBDE) has already been established for the treatment of patients with common bile duct stones (CBDS) in elective situations. However, the effect of emergent LCBDE on those patients with nonsevere acute cholangitis has not been assessed. The aim of this study was to evaluate the effect of emergent LCBDE on patients with nonsevere acute cholangitis complicated with CBDS.

Methods

Seventy-two patients with CBDS admitted from January 2009 to December 2012 were included for this retrospective study. LCBDE of transductal approach for CBDS was performed to all patients. Thirty-seven patients underwent emergent LCBDE for nonsevere acute cholangitis and 35 patients underwent elective LCBDE. Duration of the procedure, complications, retained stone of bile duct, hospital stay, and total charges were compared between the two groups. In addition, the characteristics of patients underwent emergent LCBDE were also compared before and after surgery.

Results

There was no significant difference with regard to the diameter of common bile duct and number of CBDS from imaging and/or operative findings between the two groups. There was no conversion to open common bile duct exploration, no major bile duct injuries, and no mortality in both the group of patients. There was no significant difference in patients with or without acute or chronic cholecystitis, duration of surgery, overall hospital stay (16.41 ± 1.03 versus 14.54 ± 0.94, P > 0.05), and total charges (18,603 ± 1774.64 versus 14,951 ± 1257.09 Yuan in renminbi, P > 0.05) between the two groups. Four cases with retained stones were found in patients with emergent LCBDE and two in elective LCBDE patients. There were four cases of biliary leak in patients with emergent LCBDE and three cases in elective LCBDE group, respectively. However, there was no statistical difference between the two groups. The biliary leak was cured postoperatively after drainage. Control of septic symptoms was achieved in all patients after emergent LCBDE.

Conclusions

Our data indicated that emergent LCBDE is as safe and effective as elective LCBDE for the treatment of patients with nonsevere acute cholangitis complicated with CBDS.     

经肝断面胆道探查取石治疗左肝内胆管结石合并胆总管结石的临床应用

目的评估经肝断面胆道探查替代胆总管切开胆道探查术治疗左肝内胆管结石合并胆总管结石的可行性及效果。方法 回顾性分析笔者所在医院科室收治的122例左肝内胆管结石合并胆总管结石患者的临床资料,其中2007年6月至2010年6月期间的64例患者行左肝切除、胆总管切开取石、T管引流术（对照组）,2011年6月至2013年12月期间的58例患者行左肝切除联合术中经肝断面残端胆管行胆道探查取石术（观察组）,比较2组患者的手术时间、术中出血量、术后住院时间及并发症发生率。结果与对照组相比,观察组患者术后住院时间明显缩短（P〈0．05）,2组的手术时间及术中出血量的差异无统计学意义（P〉0．05）,观察组术后并发症发生率明显低于对照组（P〈0．05）。122例患者中105例获随访,随访率为86．1％,随访期为2年,2组患者均无结石残留及复发。结论术中通过肝断面途径胆道探查是治疗左肝内胆管结石一种有效的方法,简化了操作程序,缩短了住院时间,有效避免胆总管切开和T管引流所带来的并发症。     

经脐入路腹腔镜胆总管探查一期缝合术后胆漏34例分析

目的分析经脐入路腹腔镜胆总管探查一期缝合术后胆漏并发症的发生及其治疗,探讨有效的防治措施。方法回顾性分析2008年11月至2013年3月,本院34例经脐入路腹腔镜胆总管探查一期缝合术后发生胆漏并发症患者的临床资料。结果胆漏发生率为22．7％（a4／150）。34例胆漏患者中,22例在术后24h内出现,12例在术后3～7d出现,经腹腔引流34例患者均治愈。结论严格掌握手术适应证,术中操作轻柔,认真仔细缝合胆总管以及加强营养支持等,是防治经脐入路腹腔镜胆总管探查一期缝合术后胆漏的有效措施。     

腹腔镜手术治疗腹腔镜胆囊切除术后再发胆管结石合并胰腺炎的临床体会

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)后再发胆管结石合并胰腺炎再次行腹腔镜治疗的可行性、手术时机及手术经验。方法:回顾分析2011年5月至2013年5月20例患者LC术后再发胆管结石合并急性胰腺炎行腹腔镜治疗的临床资料。结果:19例患者顺利完成胆总管探查取石引流术,1例中转开腹,中转率5%。5例患者入院时合并急性胆管炎症状(Charcot三联征)急诊手术,3例为重症胰腺炎予以保守治疗效果不佳,1~3 d内行胆管探查的同时行胰包膜切开灌洗引流术。余者均为轻型胰腺炎未合并急性胆管炎,予以对症治疗待腹痛症状缓解,酶学指标正常后行腹腔镜胆总管探查术。术后2例患者胆管仍有残余小结石,术后3个月经胆道镜取出。结论:LC术后再发胆管结石合并急性胰腺炎再次行腹腔镜胆管探查取石术安全、可行。胆管结石合并急性胰腺炎患者内环境紊乱,病情相对复杂,手术时机的把握、腔镜下胰包膜切开灌洗引流对重症胰腺炎的恢复至关重要。     

精索扭转的循证诊断与治疗

目的:系统评价精索扭转的诊断及处理方法。方法:计算机检索Cochrane图书馆、PubMed、维普资讯、CNKI,查找有关精索扭转的随机对照研究,检索时限均为1990~2012年,研究者对文献质量进行严格评价和资料提取,采用盲法分析。结果:共纳入27篇文献,3 541例患者纳入研究。结果表明:多普勒彩超在诊断阴囊急症明显优于常规超声,成为阴囊急症的首选影像学诊断方法;对任何年龄段的急性阴囊疼痛的患者均应行手术探查,没有足够的证据支持单侧精索扭转行对侧睾丸固定;精索扭转对于患侧睾丸生育功能的影响会随着患者年龄的增长而增加,对于健侧睾丸的影响尚存在争议。结论:对于有阴囊症状的患者应及时行阴囊多普勒彩超筛查,对于已确认精索扭转患者及阴囊急症患者应立即行阴囊手术探查,根据具体情况以决定是否行双侧睾丸固定术,对患者生育功能应加强随访。     

腹腔镜和胆道镜双镜联合治疗胆总管结石临床疗效观察

目的探讨腹腔镜联合纤维胆道镜双镜治疗胆总管结石的临床疗效。方法选取2011年11月至2013年4月我院行手术治疗胆总管结石患者72例,其中行腹腔镜联合胆道镜治疗40例作为观察组,开腹手术治疗32例作为对照组。观察并比较两组临床疗效结果。结果 72例手术均获成功。其中观察组在术中出血量、胃肠功能恢复时间、住院天数、术后并发症发生率方面均优于对照组(P0.05)。结论腹腔镜和胆道镜双镜联合治疗胆总管结石具有损伤小、恢复快、术中出血少、疼痛反应轻、住院时间短及术后并发症少等优点,是目前治疗胆道结石较理想的微创术式,临床上值得推广。     

腹腔镜探查诊治腹部闭合性损伤的价值

目的探讨腹腔镜探查在腹部闭合性损伤中的应用及可行性。方法回顾性分析福建医科大学附属闽东医院61例腹部闭合性损伤患者行腹腔镜探查的临床资料。结果经过腹腔镜探查,21例（34.4%）避免开腹探查,17例（27.9%）在腹腔镜下完成手术,22例（36.1%）诊断明确后中转开腹取相应部位小切口或腔镜辅助下手术,1例（1.6%）漏诊,经过观察引流管引流液性状开腹探查,最终康复出院。结论腹腔镜探查腹部闭合性损伤符合微创的原则,兼诊断和治疗的优点,对病情允许的患者,主张选择腹腔镜探查。     

祛痰消脂益肝汤治疗脂肪肝的临床探索

目的：探索祛痰消脂益肝汤治疗脂肪肝。方法：将84名50～60岁检查出脂肪肝的机关工作人员，随机分为两组，治疗组服祛痰消脂益肝汤治疗，对照组服降血脂西药治疗，连续治疗3个月，经血脂检查和B超判断治疗效果。结果：在上述各项检查中治疗组的效果都优于对照组。结论：祛痰消脂益肝汤治疗脂肪肝有肯定的疗效。     

腹腔镜胆总管探查和开腹胆总管探查术后胆道压力变化的对比研究

目的对比分析腹腔镜胆总管探查和开腹胆总管探查术后胆道压力的变化,为胆总管探查可行性提供参考依据。方法 68例胆结石患者随机分成腹腔镜胆总管探查术组和开腹胆总管探查术组,均于术中、术后24、48、72、96小时分别测量两组患者取石后胆道压力的变化情况,并进行统计学分析。结果①两组患者手术后24小时总胆管压力变化较手术中升高,与术中比较有统计学意义(P<0.05或<0.01);②术后48、72小时,OCBDE组胆总管压力变化与术中比较仍有统计学意义(P<0.05),而LCBDE组无统计学意义(P>0.05);③组间比较,OCBDE组术后24、48、72小时胆总管压力变化与LCBDE组比较也有统计学意义(P<0.05或<0.01)。结论腹腔镜胆总管探查较开腹总管探查胆道压力变化小,更适合于患者。     

老年胆总管结石合并2型糖尿病患者腹腔镜胆总管探查术胆总管一期缝合与T管引流的疗效比较

目的比较腹腔镜胆总管切开探查术(LCBDE)胆总管一期缝合和T管引流治疗老年胆总管结石合并2型糖尿病(T2DM)患者的疗效。方法腹腔镜下胆总管切开探查+纤维胆道镜取石治疗老年胆总管结石合并T2DM患者65例,其中术后采用胆总管一期缝合33例为A组,采用T管引流术32例为B组。比较两组手术时间、术中出血量、术后住院时间、补液量、住院费用及并发症发生率。结果与B组比较,A组手术时间短、术后住院时间短、补液量少、住院费用少、发热时间短,两组比较差异均有统计学意义(t分别=2.13、2.61、3.78、3.29、3.02,P均<0.05);A组并发胆漏、胆管狭窄、腹腔感染、结石残余和胆管炎的发生率与B组比较,差异均无统计学意义(χ2分别=3.58、2.61、4.27、3.88、3.51,P均>0.05)。结论与术后采用T管引流术比较,胆总管探查术后一期缝合对于老年胆总管结石合并T2DM患者是安全可靠的。