经内镜处理胆总管结石

２５例胆总管结石经内镜乳头切开（ＥＰＴ）后，即时用机械碎硬石及取石术，全部取尽结石。结石最大达４．９Ｘ３．２ｃｍ。结石者直径）１．０ｃｍ者常需碎石后取出，直径（１．０ｃｍ可用蓝式和气囊型取石器取出。对于胆总管壶腹段有炎性狭窄并结石嵌顿可用碎石器或气囊导管解除嵌顿；并发症的发生与结石大小及乳头切口大小无明确关系，改进操作技术及术后胆道内注入抗生素可减少并发症。     

微创时代胆总管结石的治疗选择

目的比较腹腔镜胆总管探查取石术（LCBDE）和内镜下十二指肠括约肌切开取石术（EST）治疗胆总管结石的临床效果及医疗费用。方法回顾性分析150例胆总管结石患者经腹腔镜胆总管探查取石术或经内镜十二指肠乳头切开取石术治疗的临床资料。结果本组患者全部治愈。120例患者接受了十二指肠括约肌切开取石术,25例胆囊结石合并胆总管结石患者接受了腹腔镜胆囊切除＋胆总管切开取石术,5例胆囊切除手术史的胆总管结石患者接受了腹腔镜胆总管切开取石术。结论腹腔镜胆总管探查取石术及内镜十二指肠乳头括约切开取石术优于传统手术,但胆囊结石合并胆总管结石患者更适宜腹腔镜手术,有胆囊或胆道手术史的胆总管结石患者更适宜于经内镜途径手术。     

胆总管巨大结石的内镜处理

内镜技术用于胆总管结石的治疗至今已有近30年的历史,随着腹腔镜技术和内镜技术的发展,胆石症病人越来越多地接受内镜治疗。因其创伤小、痛苦少、费用低、恢复快等优点,术前内镜下取出胆总管结石 腹腔镜胆囊切除术已成为治疗胆囊结石合并胆总管结石的“金标准”,但对于直径在2.5cm以上的胆总管结石,单纯的乳头括约肌切开或乳头气囊扩张术无法取出结石,须借助一定的碎石技术,才能实现内镜下取石手术。胆总管巨大结石的内镜处理目前使用较多的是内镜下碎石技术,包括机械碎石(mechanicallithotripsy,ML)、液电碎石(electrohydrauliclithotrips…     

同期腹腔镜、胆管镜、十二指肠镜多入路治疗胆囊结石合并细径胆总管结石71例

目的总结运用同期三镜（腹腔镜、胆管镜、十二指肠镜）多入路手术治疗胆囊结石合并细径胆总管结石的临床经验。方法回顾性分析我院2001年2月至2013年12月期间施行腹腔镜胆囊切除（LC）＋术中胆管镜下取石术及液电碎石术＋术中十二指肠镜下乳头切开术治疗71例胆囊结石合并细径胆总管结石患者的临床资料。首先完成LC后,经胆囊管残端切口插入输尿管导管或斑马导丝并经胆总管下端进入十二指肠腔。在输尿管导管指引下,经胆囊管残端扩张、经汇合处切口、经胆囊管与胆总管联合切口或经胆总管直接切口,插入胆管镜进入胆总管腔内用取石网取石或液电碎石。然后,经口插入十二指肠镜至十二指肠乳头,针刀在输尿管导管指引下对乳头施行切开术,继续用十二指肠镜取石网取石。结果同期三镜治疗胆囊结石合并细径胆总管结石71例,胆总管内径为4～8 mm。经胆囊管途径延长切口放置导管59例,经胆总管切口途径放置导管22例（其中10例因经胆囊管途径插入输尿管导管能够成功进入胆总管末端或十二指肠腔,但不能引导进入十二指肠上段胆总管腔内而失败,从而改为从十二指肠上段胆总管前壁另做一条纵行切口进入胆总管腔内）。经胆管镜下取净胆总管结石64例,联合十二指肠镜下取净胆总管结石7例。71例均取净胆总管结石。无中转开腹。术后发生胆汁漏5例,轻症胰腺炎1例。无胆管残留结石,无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症,无死亡。结论只要病例选择合适,同期三镜多入路手术治疗胆囊结石合并细径胆总管结石可行、有效和安全。     

腹腔镜下逐级导管扩张术治疗胆总管结石合并胆总管远端梗阻146例

[摘要] 目的 探讨在腹腔镜胆总管探查术中采用经腹顺行引导法逐级扩张导管乳头扩张术（LPCD）治疗胆囊结石、胆总管结石及合并十二指肠乳头部梗阻的应用价值。方法 回顾性分析成都市第二人民医院1998年10月至2017年5月期间,符合入选标准的146例患者的临床资料。先游离胆囊至胆总管汇合部,经胆囊管汇合部切开或经胆总管前壁切开,采用胆管镜取石网取石或液电碎石术。经切口插入斑马导丝进入肠腔,引导逐级扩张导管顺行扩张乳头。结石取净后,行一期缝合术,切除胆囊。结果 腹腔镜下成功切除胆囊146例。胆管镜取石、逐级扩张导管扩张乳头并行一期缝合术74.6%（109/146）,胆管镜取石、逐级扩张导管扩张乳头和推挤胆总管下端及乳头部结石入肠腔并行一期缝合术8.2%（12/146）,因胆总管残石于腹腔镜下留置T形管3.4%（5/146）,因胆总管末端狭窄未解除而于腹腔镜下留置T形管6.2%（9/146）,因胆总管末端狭窄未解除而中转为腹腔镜下内镜乳头切开术和鼻胆管引流术5.5%（8/146）,因腹腔镜下取石失败而中转开腹胆总管探查取石T管引流术2.1%（3/146）。一期缝合术后无残留结石,胆汁漏9例（6.2%）,轻症胰腺炎3例（2.1%）。无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症,无围手术期再手术和死亡病例。术后总并发症发生率为8.2%（12/146）。结论 只要病例选择合适,在腹腔镜胆总管探查术中采用LPCD治疗胆囊结石、胆总管结石及合并十二指肠乳头部梗阻是可行、有效和安全的。     

腹腔镜联合胆道镜治疗胆囊结石并胆总管结石

目的:探讨分析腹腔镜联合胆道镜治疗胆囊结石并胆总管结石的方法。方法:我院2008年3月至2009年12月收治26例胆囊结石并胆总管结石患者,腹腔镜胆囊切除术中切开胆囊管或胆总管,行纤维胆道镜胆总管取石术。结果:26例患者均按常规行腹腔镜胆囊切除术,12例行胆囊管切开取石术,胆总管未放置"T"管;14例行胆总管切开取石术,其中8例未放置"T"管,行一期缝合,6例胆总管内放置"T"管,术后6~8周行纤维胆道镜检查,2例发现残余结石,并取净,4例未发现胆总管残余结石,再次行胆道造影后未发现结石,拔除"T"管。所有病例均无并发症发生。结论:腹腔镜胆囊切除联合纤维胆道镜取石术治疗胆囊结石并胆总管结石,患者创伤小,康复快,安全有效。术中不能取净胆总管结石者,术后可通过"T"管窦道行纤维胆道镜取石。     

胆总管结石的内镜治疗

目的总结内镜下乳头括约肌切开术（endoscopic sphincterotomy，EST）治疗胆总管结石的疗效及随访结果，分析可能导致取石失败的危险因素。方法2001年4月～2006年1月我院96例经内镜逆行胰胆管显影（endoscopic retrograde cholangiopancreatography，ERCP）证实胆总管结石后行EST及内镜下取石。通过随访术后疗效．对可能影响EST取石结果的因素进行分析。结果第1次EST未取出或未取净结石15例，第1次EST结石清除率84．4％（81／96）。第1次取石失败后5例再次行EST取净结石，3例自发排石，2例服中药或其他药物后排石，术后B超或ERCP检查证实结石已经排出，总结石清除率为94．8％（91／96）。术后近期并发症10例，其中急性胰腺炎5例、明显出血3例、急性胆囊炎和（或）急性胆管炎2例。5例因并发症或结石未取净行开腹手术。单因素和多因素分析表明，胆总管结石〉1．5cm和既往有胆总管探查手术史是取石失败的危险因素。85例随访10—59个月，胆总管结石复发3例、急性胆管炎1例；19例单纯胆总管结石在EST取净结石后没有切除胆囊，随访未见异常。结论EST是治疗胆总管结石安全有效的方法。结石〉1．5cm和既往有胆总管探查手术史时，应警惕EST有取石失败的可能。对于单纯性胆总管结石，在EST清除胆总管结石后不必预防性切除胆囊。     

腹腔镜胆囊切除术前行 ERCP 胆总管结石取除术

腹腔镜胆囊切除术前行ＥＲＣＰ胆总管结石取除术Ｌｕｃａ，Ｓ．ＡｍＪＧａｓｔｒｏｅｎｔｅｒｏｌｏｇｙ，１９９６；９１（７）：１３２６有症状的胆囊结石目前首选腹腔镜胆囊切除术（ＬＣ）。大约有１０％的胆囊结石病人合并胆总管结石，而大多数外科医生认为经ＬＣ不能...     

胆道手术中十二指肠多处损伤胆总管下段损伤一例的处理

胆道手术中十二指肠多处损伤胆总管下段损伤一例的处理罗喆用患者：男，４０岁。２５天前在外院因胆总管多发性结石并急性梗阻性化脓性胆管炎行胆总管切开取石，Ｔ管引流术，未切除胆囊，结石也未取净带管转我院。经Ｔ管造影，造影剂不能到达肠腔，胆总管内径１．８ｃｍ，...     

胆囊结石合并胆总管结石术后复发的危险因素分析

目的：探讨内镜手术治疗胆囊结石合并胆总管结石患者复发的相关影响因素。 方法：回顾性分析2010年1月—2012年12月应用内镜治疗胆囊结石合并胆总管结石99例患者（51例行腹腔镜下胆囊切除+胆总管切开取石术,48例行腹腔镜下胆囊切除+十二指肠镜乳头切开取石术）的临床与随访资料,对影响结石复发的相关因素行单因素与多因素分析。 结果：术后共19例患者复发,复发率为19.19%。单因素分析显示,术后结石复发与年龄、黄疸、胆管扩张、胆总管直径、结石最大直径、结石数目、胆管、胰腺炎症以及手术类型等因素有关（均P<0.05）,Logistic多因素回归分析发现,年龄（OR=2.692,P=0.011）、胆总管直径（OR=2.249,P=0.022）、结石数量（OR=2.647,P=0.017）、结石最大直径（OR=2.348,P=0.009）、合并炎症（OR=2.801,P=0.013）、手术类型（OR=2.421,P=0.018）是结石复发的独立危险因素。 结论：内镜手术治疗胆囊结石合并胆总管结石术后结石复发受多种因素影响,应当根据具体情况采用有针对性措施降低复发率。     

Endoscopic cholangiography and stone removal prior to cholecystectomy. A more cost-effective approach than operative duct exploration?

Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85,526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.     

EST联合LC治疗胆囊结石胆总管结石

目的：探讨EST联合LC联合治疗胆囊、胆总管结石的可行性及优越性。方法：先行EST（经内镜十二指肠乳头括约肌切开术）取出胆总管结石,再行LC（腹腔镜胆囊切除术）,EST失败或不宜行EST者置ENBD（鼻胆管）再行LC+腹腔镜下胆道探查、胆道镜取石,或开腹行胆道探查术。结果：全组99例,91例LC术前EST取石成功,3例LC术后EST取石成功,3例EST取石失败。2例年龄小于15岁者未行EST改行LC+腹腔镜下经胆囊管胆道镜胆道探查取石。3例EST取石失败,改行腹腔镜下胆道探查胆道镜取石、胆总管一期缝合或T管引流+LC,或开腹胆道探查一期缝合胆总管未置T管（已置ENBD）。无严重并发症,患者均治愈出院。结论：EST联合LC联合治疗胆囊结石胆总管结石是安全、可靠的方法,软硬镜联合充分体现了“微创”治疗的优势。     

腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石效果分析

目的 探讨腹腔镜胆囊切除术(LC)联合内镜Oddi括约肌切开取石术(EST)治疗胆囊结石合并胆总管结石的临床效果.方法 回顾性分析2003年5月-2009年6月,LC与EST联合治疗胆囊结石合并胆总管结石78例临床资料.首先经EST取出胆管结石,5 d内行LC.结果 EST成功76例(97%),失效2例,1例因胆管末端狭窄,开腹行胆肠吻合术治愈;1例胆总管结石直径1.6 cm,质硬,机械性碎石失败,开腹行胆总管切开取石T管引流术.76例腹腔镜手术成功,无明显出血、胆漏等严重并发症.结论 EST+LC联合治疗胆囊结石并胆总管结石具有创伤小、恢复快、并发症少及无需T管引流等优点,是一种安全有效的治疗方法.     

Endoscopic management of bile duct stones

Endoscopic sphincterotomy is the procedure of choice for choledocholithiasis in patients who have had a cholecystectomy. The bile duct is cleared of stones in about 80 to 90 percent of patients. Available data, largely retrospective, suggest that surgery and endoscopic sphincterotomy are about equal with respect to removal of stones, morbidity, and mortality. Certain technical problems are discussed, including inability to insert the papillotome, the large stone, and problems relating to anatomy such as peripapillary diverticulum and prior gastrectomy. The treatment of patients with bile duct stones who have not had a cholecystectomy, with and without cholelithiasis, is controversial. Endoscopic sphincterotomy without subsequent cholecystectomy is adequate treatment for the majority of patients who are unfit for surgery, even if there are stones in the gallbladder, provided they are asymptomatic after endoscopic removal of stones from the bile ducts. Endoscopic sphincterotomy has been performed in the treatment of gallstone-induced pancreatitis, acute obstructive cholangitis, and sump syndrome. The complication rate for endoscopic sphincterotomy ranges from 6.5 to 8.7 percent, with a mortality rate of 0 to 1.3 percent. The most common serious complications are perforation, hemorrhage, acute pancreatitis, and sepsis.     

Extracorporeal shock-wave lithotripsy and endoscopy: combined therapy for problematic bile duct stones

Summary Endoscopic treatment of bile duct stones is currently successful in 86% of patients. We prospectively studied the efficacy and complication rate of extracorporeal shock-wave lithotripsy (ESWL) of problematic bile duct stones combined with endoscopy. When stone removal was not possible, patients were subjected to ESWL, Fragmented stones were removed endoscopically. During 1 year, 220 patients presenting with choledocholithiasis were diagnosed and 188 were successfully treated endoscopically. In all, 3 subjects received alternative treatmenl and the remaining 29 (13%) constituted our study group: 19 (65%) were women and the mean age was 76.7 years. Overall, 22 (76%) were high-risk patients; 23 (79%) were jaundiced and 9 (31%) had cholangitis at admission. The most frequent indication for ESWL was stone size. Stone fragmentation was achieved in 80% of cases. Complications were mild and were managed conservatively. No patient died. Complete stone clearance was possible in 23 (80%) cases. The association of ESWL and endoscopy enhanced the success rate of endoscopic stone clearance from 86% to 96%. During the same period, open surgery was performed in 4 cases for residual common bile duct (CBD) stones and in 32 cases in association with simultaneous cholecystectomy.     

内镜下乳头气囊扩张术治疗胆囊切除术后胆总管结石

目的　探讨经内镜乳头气囊扩张术 (EPBD)治疗胆囊切除术后胆总管结石的安全性和疗效。方法　对胆囊切除术后出现黄疸或胆管炎的 31例患者 ,利用EPBD结合取石篮、取石球囊或总攻方法 ,使梗阻于胆总管下段的结石排入肠道。结果　 31例患者全部顺利实施EPBD ,共排除结石37颗 ,4例行 2次扩张术 ,术后患者均痊愈出院 ,复查B超无结石残存或胆管扩张。结论　经内镜治疗胆囊切除术后胆总管结石 ,安全、无创、有效 ,有望成为治疗LC术后胆总管结石的首选方法     

The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis.

BACKGROUND AND OBJECTIVES: Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution. METHODS: A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998. RESULTS: Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth. CONCLUSIONS: Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary.     

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis

Summary Six hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.