Laparoscopic choledochotomy for bile duct stones

In the era of laparoscopic surgery, treatment strategies for common bile duct stones remain controversial. Laparoscopic choledochotomy is usually indicated only when transcystic duct exploration is not feasible. However, laparoscopic choledochotomy provides complete access to the ductal system and has a higher clearance rate than the transcystic approach. In addition, primary closure of the choledochotomy with a running suture and absorbable clips facilitates the procedure. Therefore, to avoid postoperative biliary stenosis, all patients with bile duct stones can be indicated for choledochotomy, except for those with nondilated common bile duct. Placement of a C-tube also provides access for the clearance of possible retained stones by endoscopic sphincterotomy as a backup procedure. C-tube placement, in contrast to T-tube insertion, is advantageous in terms of a relatively short hospital stay. In conclusion, laparoscopic choledochotomy with C-tube drainage is recommended as the treatment of choice for patients with common bile duct stones. Received: February 27, 2001 / Accepted: March 19, 2001     

合并尾状叶结石的肝内胆管结石20例临床分析

目的 探讨合并尾状叶结石的肝内胆管结石的合适的诊治方法.方法 20例合并尾状叶结石的肝内胆管结石,采用肝尾状叶切除联合左外叶切除10例,采用左外叶切除联合尾状叶胆管切开取石T管引流5例,肝右叶切除联合尾状叶切除1例.肝左叶切除联合尾状叶胆管切开取石T管引流2例,肝右后叶切除联合尾状叶切除2例.结果 并发胸腔积液12例,切口感染1例,胆漏2例,死亡1例.随访2年,2例联合尾状叶胆管切开取石T管引流患者仍有胆管结石复发,间断出现胆道感染症状.结论 联合尾状叶切除术可以达到良好的远期效果,是合并尾状叶结石的肝内胆管结石的较好的治疗方法.     

Biliary stones: treatment by shock-wave lithotripsy

Extracorporeal shock-wave lithotripsy has been introduced as a novel nonsurgical therapy for gallstone disease. To substantiate the initial results, more than 400 patients with biliary calculi have been treated. In selected patients with gallbladder stones, complete clearance of all stone fragments can be expected within 1 year in about 80%. In patients with bile-duct stones not amenable to endoscopic measures, sufficient stone fragmentation by extracorporeal shock waves was achieved in about 80%. Extracorporeal shock-wave lithotripsy is a safe and efficient therapy for selected patients with gallbladder calculi. For patients with bile-duct stones not amenable to endoscopic measures it offers a nonsurgical alternative.     

腹腔镜联合胆道镜治疗胆管结石77例临床体会

目的探讨腹腔镜联合胆道镜治疗胆管结石的可行性及临床体会。方法回顾性分析2011年12月~2013年12月77例在我院腹腔镜联合胆道镜下行胆囊切除、胆总管切开取石+T管引流术的病人术中情况、术后临床恢复情况及疗效,对其手术成功率、手术时间、术中失血量、肠功能恢复时间、住院时间、术后胆漏例数及残石例数等指标进行分析。结果77例患者手术均获成功,无中转开腹,其中63例行T管引流,14例行胆总管一期缝合;手术时间75~170min;术中出血40~150ml;胃肠道功能恢复时间为1~3 d;住院时间4~14 d;术后胆漏1例;经腹腔引流治愈;术后胆道残石3例,术后经T管胆道镜下取尽结石。结论腹腔镜联合胆道镜治疗胆管结石安全有效、可靠,损伤小,恢复快,但术者需要掌握熟练的操作技能。     

An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction

Background Endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones. Stone recurrence can, however, occur in up to 25% of cases. Risk factors have been poorly defined, but are believed to be related to bile stasis. This study investigated whether an angulated common bile duct (CBD) that may predispose to bile stasis influences symptomatic stone recurrence after successful endoscopic therapy. Methods This study included 232 consecutive patients (mean age, 64.1 years; 86 men) who had undergone therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones. Data from the follow-up period (36 ± 17 months) were obtained from medical records and patient questioning. Common bile duct angulation and diameter were measured from the cholangiogram after stone removal. Results Symptomatic bile duct stones recurred in 16% of the patients (36/232). Three independent risk factors were identified by multivariate analysis: an angulated CBD (angle, ≤145°; relative risk [RR], 5.2; 95% confidence interval [CI], 2.2–12.5; p = 0.0002), a dilated CBD (diameter, ≥13 mm; RR, 2.6; 95% CI, 1.2–5.7; p = 0.017), and a previous open cholecystectomy (RR, 2.7; 95% CI, 1.3–5.9; p = 0.0117). Gender, age, urgency of procedure, or a periampullary diverticulum did not influence the recurrence rate. Conclusions Angulation of the CBD (≤145°) on endoscopic cholangiography, a dilated CBD, and a previous open cholecystectomy are independent risk factors for symptomatic recurrence of bile duct stones. The findings support the role of bile stasis in stone recurrence. Further studies using these data prospectively to identify high-risk patients are warranted. Part of this work was presented at the Digestive Disease Week in New Orleans, 16–20 May 2004, and published in abstract form in Gastrointestinal Endoscopy 2004;59: AB197     

Extracorporeal shock wave lithotripsy for the treatment of pancreatic duct stones

The purpose of endoscopic therapy in chronic pancreatitis is to decompress the main pancreatic duct and to remove the obstacles that impede the ductal flow of pancreatic juice. The availability of extracorporeal shock wave lithotripsy (ESWL) has improved the results of endoscopic drainage of the main pancreatic duct and has also expanded the indications of endoscopic therapy for chronic pancreatitis. This article briefly reviews ESWL for pancreatic duct stones in patients with chronic pancreatitis, including our experience with ESWL. ESWL is an effective and safe procedure for endoscopically unremovable main pancreatic duct stones, and, in selected patients, ESWL alone may be effective.     

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目的 探讨内镜治疗肝内外胆管残余结石的效果。方法 对1990年1月至2000年1月间的306例胆道残余结石的治疗效果进行回顾性分析,采用十二指肠镜127例,胆道镜116例,经皮经肝胆道镜（PTCS）63例。结果 306例中有286例成功（93.46%）。十二指肠镜治疗127例,成功125例;胆道镜经T管窦道治疗116例,成功109例;PTCS治疗肝内结石63例,成功52例。结论 内镜治疗肝内外胆道结石效果显著,可使绝大多数病人避免再次手术。     

A simple scoring system for predicting bile duct stones in patients with cholelithiasis

A means of accurately predicting the presence of stones in the bile duct in patients undergoing laparoscopic cholecystectomy for gallbladder stones is lacking. With the use of a three-stage analysis, a predictive score was developed from seven common parameters. Initially the score was formulated by using data from a retrospective series of patients undergoing laparoscopic cholecystectomy; the system was then tested prospectively over a l-year period in patients undergoing laparoscopic cholecystectomy for gallbladder stones. This simple scoring system demonstrated an ability to predict bile duct stones with a sensitivity in excess of 70%. The use of such a score may allow the development of preoperative strategies for treating patients undergoing laparoscopic cholecystectomy.     

ERCP与腹腔镜胆总管探查治疗胆囊结石合并胆总管结石的比较

目的比较ERCP与腹腔镜胆总管探查(LCBDE)治疗胆囊结石合并胆总管结石的优、缺点。 方法回顾分析2010年4月至2015年4月5年间诊治的197例胆囊结石合并胆总管结石患者。 结果ERCP组(99例)中有6例患者手术失败,32例合并胰腺炎,1例出现十二指肠壁穿孔。3例患者术后出现胆总管结石复发。LCBDE组(98例)中无手术失败,8例放置T管,无胆总管结石复发,无严重并发症。LCBDE组术后平均住院时间和平均住院费用均低于ERCP组[(5±2) d vs (3±1)d, (2.23±0.85)万元 vs (1.73±0.43)万元]。 结论ERCP＋EST和LCBDE对于胆囊结石合并胆总管结石都是行之有效的处理方法,对于大多数患者应首选LCBDE,对于特殊患者可选择ERCP＋EST＋LC方案。     

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

INTRODUCTION

Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively.

PATIENTS AND METHODS

Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded.

RESULTS

Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation.

CONCLUSIONS

A selective policy for intra-operative cholangiography yields acceptably high positive results. Pre-operatively, asymptomatic bile duct stones rarely present following LC; thus, routine imaging of the biliary tree for occult calculi can safely be avoided. Therefore, a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper, successfully identifies those patients with bile duct stones requiring exploration. Laparoscopic bile duct exploration, performed by an experienced laparoscopic surgeon, is a safe and effective method of clearing the bile duct of calculi, with minimal complications, avoiding the necessity for an additional intervention and prolonged hospital stay.     

腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆总管巨大结石的临床分析

目的:探讨腹腔镜下胆道镜联合液电碎石经胆囊管治疗胆道巨大结石的疗效。方法:回顾分析2005年1月至2013年11月84例因梗阻性黄疸、胆总管巨大结石行腹腔镜下胆道镜联合液电碎石经胆囊管取石患者的临床资料。结果:80例成功完成手术。1例因胆道出血中转开腹行胆总管切开止血、取石+T管引流术;1例患者怀疑胆道下段肿瘤中转开腹探查并行胰十二指肠切除术,术中冰冻病理证实为胆管癌;1例患者经胆囊管取石毕发现乳头下端狭窄,术中行内镜逆行胰胆管造影及乳头肌切开后胆汁流出通畅;1例患者因Mirizzi综合征导致胆囊三角区粘连紧密从而中转开腹行胆总管切开取石、T管引流术。术后均无出血、胆漏、胆总管损伤等并发症发生,术后住院7~11 d。结论:腹腔镜下胆道镜联合液电碎石经胆囊管取石术治疗胆总管巨大结石安全、可靠,手术微创,结石清除率高,并发症少;对于胆囊管粗短直、入口较大的患者,可直接置入胆道镜探查取石,损伤小,优点突出,值得临床应用。     

The endoscopic approach to pancreatic duct stones

Pancreatic duct stones may complicate the course of chronic pancreatitis and be responsible for recurrent episodes of pancreatitis and/or exacerbations of abdominal pain. Endoscopic management of pancreatic duct stones with or without extracorporeal shock-wave lithotripsy (ESWL) is a relatively safe and effective method to treat main pancreatic duct stones in symptomatic patients. Selection of candidates most likely to respond to endoscopic therapy needs further evaluation. Studies comparing medical, surgical, and endoscopic treatment of pancreatic duct stones are still awaited.     

Long-term symptoms following endoscopic sphincterotomy for common bile duct stones

Background: Endoscopic sphincterotomy (ES) has an important role in the management of biliary stones. However, the long-term effects of free duodenobiliary reflux are not established, and it may lead to low-grade morbidity. Methods: We used a questionnaire survey to assess the prevalence of symptoms of biliary disorder in patients who had undergone endoscopic retrograde cholangio pancreatography (ERCP) and ES under the care of a single surgeon (R.J.R.G) between November 1993 and May 1998. Results: ES was carried out on 136 patients during this period. Current addresses were available for 94 patients, and 54 of them (57%) responded. Patients were surveyed a mean of 43 months after ES. Only 42.1% of patients denied having any symptoms. Nausea and pale stools were reported by 28% and 26% of patients, respectively, and nearly one-fifth of patients had symptoms suggestive of cholangitis. In addition, 18.5% of patients experienced one or more symptoms frequently. Conclusion: Severe long-term symptoms are uncommon following ES; however, a significant minority of patients do suffer occasional symptoms that suggest biliary dysfunction.     

内镜下机械碎石术在胆总管结石治疗中的价值

目的 探讨内镜下机械碎石(EML)的临床应用价值.方法 :回顾分析经EML取石治疗的15例临床资料.结果 :15例病人中,14例碎石取石成功,成功率为93.3%(14/15),复发1例,复发率为7.14%(1/14).全组无因EST和EML操作所致的并发症发生.结论 :EML进一步扩展了胆总管结石的内镜治疗范围,具有微创、安全、并发症少、疗效肯定等特点,是治疗胆总管内大结石的重要方法.     

Extracorporeal shock-wave lithotripsy prior to laparoscopic cholecystectomy

The extraction of large gallstones in laparoscopic cholecystectomy either requires the enlargement of one of the incisions or intraoperative lithotripsy. Preoperative extracorporeal shock-wave lithotripsy (ESWL) might theoretically solve the problem and facilitate the extraction of the gallbladder.Ten patients with at least one gallstone larger than 20 mm in diameter underwent ESWL treatment within 24 h prior to laparoscopic surgery. Complete pulverization of stones was achieved in one patient. Fragmentation into pieces smaller than 10 mm could be observed in another three cases. Additional mechanical fragmentation employing forceps was necessary in seven and an enlargement of the incision in five of the 10 patients. Compared to a matched group of 10 control patients with gallstones of corresponding size receiving mechanical lithotripsy, the ESWL did not show an advantage, but rather an increase in costs. It therefore cannot be recommended.     

腹腔镜胆道探查胆总管一期缝合术治疗胆管结石的疗效分析

目的探讨腹腔镜下胆道探查术、胆总管一期缝合术的临床疗效与可行性。方法2014年2月至2017年2月收集贵州医科大学附属医院106例胆总管结石病人,男性44例、女性62例,年龄18~75岁,平均(46.5±15.7)岁。106例胆总管结石病人,伴或不伴胆囊结石与肝内胆管结石,其中腹腔镜下胆道探查胆总管一期缝合术67例,腹腔镜下胆道探查T管引流术39例,对两组病例手术适应证、手术时间、术后恢复情况、并发症等进行比较。结果胆总管一期缝合组的手术时间、术后住院天数、腹腔引流管放置时间分别为(72.8±21.0)min、(2.8±1.9)d和(5.5±2.3)d,优于T管引流术组的(95.5±26.5)min、(5.7±1.4)d和(8.1±2.6)d(均P0.05),术后肛门排气时间两组分别为(1.9±0.8)d和(2.1±0.5)d、差异无统计学意义;两组均无肝衰竭、腹腔感染、胆管残余结石、胆道出血及穿孔,胆漏发生率T管引流术组(3例)高于胆总管一期缝合组(0例)(P0.05)。结论腹腔镜胆道探查胆总管一期缝合术治疗胆管结石是安全、可行的,病人明显受益,值得临床推广应用。     

腹腔镜联合胆道镜经胆囊管治疗胆总管结石的疗效观察

【摘要】〓目的〓评价腹腔镜联合胆道镜经胆囊管治疗胆总管结石的疗效。方法〓回顾性分析2012年1月至2014年9月在广东医学院附属福田医院治疗的195例胆总管结石患者,按照术式分为腹腔镜联合术中胆道镜经胆囊管胆道探查取石术(LTCBDE)组(43例)、腹腔镜胆道探查“T”管引流(LCBDE)组(65例)和剖腹胆囊切除、胆总管探查取石、“T”管引流术(OCBD)组(87例)。比较三组患者手术时间、术中出血量、术后肛门排气时间、视觉模拟评分法(VAS)评分、并发症发生率,以及三组治疗前后CRP、PA、TBIL和ALT水平的变化。结果〓3组患者均成功进行手术,LTCBDE组除手术时间比OCBD组长外,术中出血量、术后VAS评分、肛门排气时间、术后住院时间和并发症明显少于LCBDE和OCBD组(P<0.001)。LTCBDE组的并发症发生率为4.7%,明显低于LCBDE组的15.4%和OCBD组的23.0%,差异有统计学意义(P<0.05)。治疗后,三组的CRP、TBIL和ALT水平比治疗前明显降低(P<0.001),而PA水平比治疗前明显升高(P<0.001)。LTCBDE组的降低和升高水平比其余两组更为明显(P<0.001)。结论〓LTCBDE具有创伤小、并发症少、费用低、术后生活质量高等优点,是一种有效、安全及经济的术式。