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目的 探讨内镜在重症急性胆管炎（ACST）急诊治疗中的应用价值。方法 自1997年1月至2002年5月应用十二指肠镜急诊治疗重症急性胆管炎。对于乳头部结石嵌顿用针型刀切开乳头、插管困难者先行乳头括约肌切开术。选择直径＜1.2cm的1－2颗胆总管结石行经内镜括约肌切开术（EST），网篮取石放置鼻胆引流管（ENBD），其余直接行鼻胆引流管引流。结果 156例ACST中148例ENBD治疗成功，内镜治疗成功率94．9％。125例ENBD治疗后24小时内症状减轻。所有良性病变（胆总管结石、胆管良性狭窄）均得到有效引流，5例胆道恶性肿瘤由于胆管的多处狭窄引流失败。平均引流时间为7.3天（1－25天）。无一例消化道穿孔和死亡，术后5例出现急性轻型胰腺炎，3例乳头出血，总的并发症发生率5．1％。结论 急诊内镜治疗ACST操作简便，安全有效，尤其适用于高龄、一般情况较差、肝硬化凝血功能障碍和多次胆道手术病人。     

重症急性胆管炎的急诊腹腔镜治疗

目的总结运用腹腔镜胆总管切开取石T管引流术急诊治疗重症急性胆管炎（acute cholangitis ofsevere type,ACST）的治疗经验。方法1993年9月至2006年12月间,运用腹腔镜胆总管切开取石T管引流术的手术方式（包括胆总管切开,胆管镜取石,T管引流等）有选择地对45例重症急性胆管炎患者进行急诊手术治疗。结果重症急性胆管炎45例中,急诊完成腹腔镜胆总管切开取石T管引流术45例,无中转开腹。术后胆漏2例,应激性溃疡出血1例;术后死亡1例。术后其他多种并发症均经非手术综合疗法治愈。结论只要选择合适的病例,腹腔镜胆总管切开取石T管引流术急诊治疗重症急性胆管炎,对于有较高胆管镜和腹腔镜技术者是可行、有效和安全的。     

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目的探讨利用内镜、腹腔镜治疗高龄病人急性胆管炎的安全有效的治疗方法。方法自1998年5月至2003年6月,收治高龄(>75岁)胆管结石诱发急性化脓性胆管炎病人121例,首先经十二指肠镜行鼻胆管引流术(ENBD),待病情缓解后,根据病人的身体条件和局部结石情况,分别行网篮取石、三镜联合胆总管探查术或经十二指肠镜胆肠内引流术(ERBD)。结果ENBD全部成功。死亡3例;首次急诊内镜取净结石16例;二次内镜取净结石66例;15例行ERBD术;21例行三镜联合胆总管探查术,中转开腹手术1例。118例内镜、腹腔镜治疗病人中无严重并发症发生。结论高龄急性胆管炎病人的早期治疗非常重要。急诊应用ENBD缓解胆道梗阻症状可有效降低病死率。综合利用此3种不同的治疗方式,可达到安全满意的疗效,避免开腹手术。     

重症急性胆管炎26例急诊腹腔镜治疗

腹腔镜在重症急性胆管炎(acute cholangitis of severe type，ACST)急诊治疗中的应用鲜有报道，随着腹腔镜技术的提高和腹腔镜医师经验的积累，腹腔镜在治疗ACST方面的成功率逐步提高，为ACSF的治疗开辟了又一条途径。我院从1993年9月至2003年11月手术治疗ACST149例，其中应用十二指肠镜急诊治疗ACST47例，开腹手     

腹腔镜手术治疗急性胆管炎合理选择及争议

急性胆管炎治疗选择与诊断、分级密切相关。中、重度急性胆管炎须立即行胆道引流,国内外指南均推荐首选内镜下鼻胆管引流术（ENBD）,经皮经肝胆道引流术（PTCD）与外科手术为备选治疗方案。在对急性胆管炎准确分级前提下,行急诊腹腔镜胆总管探查术（LCBDE）治疗胆总管结石引起的轻、中度急性胆管炎安全可靠。急诊行LCBDE时,轻度胆管炎病人的术中情况与择期手术基本相同,特殊情况少见;中度胆管炎病人可能发生出血量偏大、胆管壁菲薄或偏厚缝合困难等情况,须酌情处理,必要时中转开腹手术。对于重度胆管炎病人,应尽可能避免手术引流,如果ENBD和PTCD失败或存在禁忌证时,可考虑行开腹胆道引流术。     

重症急性胆管炎的急诊腹腔镜治疗22例

腹腔镜在重症急性胆管炎(ACST)急诊治疗中的应用鲜有报道。我们从1993年9月至2003年2月采用腹腔镜胆总管探查术(LCDE)治疗ACST 22例，现报告如下。     

以十二指肠镜为主治疗高龄结石性急性胆管炎

目的 探讨十二指肠镜、腹腔镜治疗高龄结石性急性胆管炎的疗效。方法 1998年5月～2005年6月，我院对年龄〉75岁因胆管结石诱发急性胆管炎273例，首先经十二指肠镜行鼻胆管引流术（endoscopic nasobiliary drainage，ENBD），待急诊情况缓解后，根据患者的身体条件和局部结石情况，分别行网篮取石、三镜联合胆总管探查术或经十二指肠镜胆肠内引流术（endoscopicretrogradebiliarydrainage，ERBD）。结果273例ENBD全部放置成功。ENBD术后死亡3例。余270例中首次急诊内镜取净结石36例；二次十二指肠镜取净结石178例；31例行ERBD；25例行三镜联合胆总管探查术，其中1例中转开腹手术。270例十二指肠镜、腹腔镜治疗中无严重并发症发生。结论高龄急性胆管炎患者，急诊ENBD缓解胆道梗阻症状后，综合利用经十二指肠镜取石、ERBD及三镜联合胆总管探查术，可达到安全、满意的疗效，避免开腹手术。     

重症急性胆管炎26例急诊腹腔镜治疗

腹腔镜在重症急性胆管炎 (acutecholangitisofseveretype ,ACST)急诊治疗中的应用鲜有报道 ,随着腹腔镜技术的提高和腹腔镜医师经验的积累 ,腹腔镜在治疗ACST方面的成功率逐步提高 ,为ACST的治疗开辟了又一条途径。我院从 1993年 9月至 2 0 0 3年 11月手术治疗ACST14 9例 ,其中应用十二指肠镜急诊治疗ACST 4 7例 ,开腹手术急诊治疗ACST 76例 ,选择性腹腔镜急诊治疗ACST 2 6例 (17.4 % )。现报告如下 :1　资料和方法1 .1　一般资料　　本组 2 6例 ,男 11例 ,女 15例。年龄 2 7～ 6 9岁 ,平均4 8岁。无上腹部手术史 ,无严重的内科…     

多镜联合应用治疗急性胆管炎临床研究

目的 探讨利用十二指肠镜、腹腔镜、胆道镜联合治疗急性胆管炎的微创治疗方法. 方法 从2001年10月至2004年12月共收治胆管结石诱发急性胆管炎患者34例,先经十二指肠镜行鼻胆管引流术(ENBD),待病情缓解后,根据患者条件和结石情况分别行十二指肠镜下网篮取石、腹腔镜下胆总管切开取石、腹腔镜下胆总管切开胆道镜下取石等二镜、三镜联合治疗. 结果 ENBD全部成功,本组无死亡,首次急诊内镜取石取净6例,二次内镜取石5例(其中二镜联合9例),三镜联合21例,中转开腹2例. 结论 急性胆管炎早期治疗十分重要,应用十二指肠镜能缓解胆管炎的症状,减少死亡率,采用多镜联合应用治疗急性胆管炎的胆道结石是一种微创、安全、有效的方法,避免了急诊手术的风险.     

高龄老年人重症急性胆管炎内镜治疗的护理

目的探讨高龄老年人重症急性胆管炎内镜治疗的护理策略。方法对137例75岁以上老年ACST病人,行急诊内镜治疗的护理进行回顾分析和总结。结果 137例中有6例插管未成功,131例成功行内镜治疗,成功率95.6%。内镜治疗术后8例出现高淀粉酶血症,5例出现轻症急性胰腺炎,2例出现消化道出血,均经保守治疗后痊愈。45例经一次内镜治疗后痊愈出院,83例在病情稳定后分别选择再次内镜或联合腹腔镜或开腹手术治疗,3例死于多脏器功能衰竭,死亡率2.18%。无护理相关并发症发生。结论术前加强沟通,做好充分准备,术后细致观察,精心护理,配合积极有效的治疗,同时重视高龄患者的安全护理,对于提高手术成功率、减少并发症具有极其重要的意义。     

单中心腹腔镜胆囊切除术预防胆管损伤的体会

目的:探讨如何预防腹腔镜胆囊切除术(LC)胆管损伤。方法:回顾分析37 781例LC的临床资料。结果:胆管损伤25例(0.066%),其中术中发现8例,术后发现17例。胆管横断伤12例,其中离断+缺损8例(1例是中转开腹损伤),钛夹夹闭无胆管缺损4例;胆总管部分剪切伤4例;肝总管电损伤2例,分离损伤2例;右肝管损伤3例;副肝管损伤2例。胆管修补(端端吻合)+T管支撑引流5例、胆肠Roux-en-Y吻合16例,腹腔穿刺+鼻胆管引流1例(ENBD)、损伤胆管修复,置管引流3例。无死亡病例。结论:熟悉肝门解剖,仔细处理Calot三角,适时中转开腹,避免盲目自信可以有效的降低胆管损伤的发生率。     

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。     

腹腔镜和内窥镜联合治疗复发性胆总管结石

目的 :探讨腹腔镜和内窥镜联合治疗复发性胆总管结石的方法。方法 :回顾总结经内窥镜鼻胆管引流术 (ENBD)配合实施腹腔镜胆总管探查 (LCBDE)、Ⅰ期缝合术 (内衬ENBD导管 )治疗胆道术后复发性胆管结石 2 2例的临床资料。结果 :2 1例手术成功 ,1例中转开腹 ,全部Ⅰ期缝合胆总管探查切口。术后无残石及胆瘘等并发症。手术时间 1 5 7± 31 4min ,术后住院 9 6± 1 2d。随诊 1 7例未见复发。结论 :应用腹腔镜和内窥镜联合治疗胆总管复发结石安全、可行 ,体现了微创治疗的优点 ,但分离粘连及解剖、缝合胆总管较困难 ,治疗初期应适当放宽中转开腹手术的指征     

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目的 总结运用腹腔镜与十二指肠镜、胆道镜联合，微创治疗内镜取石失败的胆管结石病人的治疗经验。方法 从1998年4月至2002年5月，运用三镜联合的手术方式（术前内镜下经鼻胆管引流，腹腔镜胆总管探查术，术中胆道镜），对251例胆总管结石病人进行微创治疗。结果 240例手术均获成功，11例中转开腹、无残余结石及严重并发症。术后住院时间明显缩短，操作熟练后手术时间也短于开腹手术。194例随访半年以上未见远期并发症。结论 三镜联合胆总管探查术对于有较高内镜、腹腔镜技术的医疗单位是切实可行和安全可靠的。十二指肠镜、胆道镜及腹腔镜的联合应用优势明显，可基本取代开腹胆总管探查术。     

经十二指肠镜治疗胆道疾病387例

目的探讨如何提高十二指肠镜治疗胆道疾病的疗效及减少并发症的发生. 方法对1995年2月～2003年2月经内镜行Oddi括约肌切开术(endoscopic sphincterotomy,EST)292例、鼻胆管引流术(endoscopic nasobiliary drainage,ENBD)104例(其中9例EST后引流)的临床资料作回顾性分析. 结果 EST成功269例,成功率92.1%(269/292).272例胆总管结石中235例取尽结石(86.4%);15例肝内胆管结石,4例取尽;5例胆管异物,3例当即取尽.EST治疗发生并发症16例,发生率5.5%(16/292),包括急性胰腺炎7例和乳头切开处出血5例,继发重症胆管炎2例,十二指肠穿孔1例,碎石时钢索末端断裂1例.ENBD疗效满意92例.所有病例均未发生与操作相关的死亡. 结论严格EST适应证选择、提高EST技术是提高疗效、减少并发症的关健.     

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??Laparoscopic transcystic common bile duct exploration??A clinical analysis of 68 cases SUN Min??LIU Xun-qiang??TENG Yi-shan et al. Department of Hepatopancreatobiliary Surgery 3, the 2nd Affiliated Hospital of Kunming Medical University??Kunming 650101, China
Corresponding author?? TENG Yi-shan??E-mail??liuxunqiang1001@163.com
Abstract Objective To explore the curative effect and safety of laparoscopic transcystic common bile duct exploration in treating the small stones in common bile duct. Methods A total of 68 cases of laparoscopic transcystic common bile duct exploration were performed from August 2009 to August 2012 in Department of Hepatopancreatobiliary Surgery 3, the 2nd Affiliated Hospital of Kunming Medical University. The therapeutic effects of cases were studied. Results Among them, 62 cases were performed operation successfully. The success rate of operation was 91.12%. The mean operation time was 86 minute. Six cases were changed to laparoscopic common bile duct incision exploratory stone operation. Four cases were performed laparoscopic common bile duct exploration and primary suture, and 2 cases were performed T tube drainage. The transfer rate was 8.88%. All cases were placed abdominal cavity drainage tube pulled out after 2-6 days. The average hospitalization time was 6 days. No bile leak, stone residue, biliary tract infection, biliary tract bleeding complications occurred. Conclusion Laparoscopic transcystic common bile duct exploration has many advantages such as small trauma, short time??less complications, quick recovery??safe??low cost, safety and effective, etc. It is the ideal common bile duct exploration and stone operation. But its indications must be grasped strictly.     

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??Roles of ERCP in the treatment of disorders at pancreaticobiliary junction QIN Ming-fang. Department of Minimally Invasive Surgery??Tianjin Nankai Hospital??Tianjin 300100, China
Abstract With the development and evolution of duodenum endoscopy devices and instruments, endoscopic retrograde cholangiopancreatography (ERCP) has been playing more and more important roles in the treatment of disorders at pancreaticobiliary junction, which includes: benign bile stones, Oddi’s sphincter stenosis, anomalous pancreaticobiliary junction and malignant lesions. The topics are discussed in detail with hand-on experience of the author in the article. The impacted bile stones at the pancreaticobiliary junction can be evacuated by endoscopic sphincterotomy (EST). Surgically incurable malignant lesions can be intraluminally drained by endoscopic retrograde biliary drainage (ERBD) or expandable metallic biliary endoprothesis (EMBE). Severe jaundice can be relieved by endoscopic nasobiliary drainage (ENBD). Oddi’s sphincter stenosis is effectively managed by EST. In addition, the treatment of anomalous pancreaticobiliary junction without dilated common bile duct is still under investigation.     

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??Biliary leakage after laparoscopic cholecystectomy (LC) treated with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic naso-biliary drainage (ENBD)??An analysis of 10 cases WANG Rui-guan, LI Wei-min, ZHENG Fang, et al. Department of Hepatobiliary Surgery, the 309th Hospital of PLA, Beijing 100091, China
Corresponding author: LI Wei-min, E-mail: liweimin1964@263.net
Abstract Objective To explore the safety and effectiveness of endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic naso-biliary drainage (ENBD) in the treatment of biliary leakage after laparoscopic cholecystectomy(LC)??Methods The clinical data of 10 cases of biliary leakage after LC received ERCP and ENBD between May 2010 and June 2014 in the 309th Hospital of PLA were analyzed retrospectively. Results All the cases were operated with ERCP successfully and confirmed with biliary leakage. There were 4 cases of common hepatic duct leaks, 2 cases of right hepatic duct leaks and 4 cases of cystic duct stump leaks. Residual stones occurred in 3 cases, which were operated with endoscopic sphincterotomy(EST) and calculus removed. ALL the cases were placed with naso-biliary drainage tube. The operative time ranged from thirty minutes to sixty minutes with a mean of forty minutes. No intraoperative and postoperative complication occurred. The blood amylase and urinary amylase were normal at the first day postoperatively. The patients could eat liquid diet at the second day postoperatively. All the cases were cured completely. The healing time for biliary leakage ranged from seven days to ten days with a mean of nine days. Conclusion ERCP and ENBD are safe and effective diagnosis and nonoperative methods to treat biliary leakage after LC. It can be used as the preferred treatment for bile leakage.