线阵超声内镜对胆总管结石的诊断价值研究

目的探讨线阵超声内镜对胆总管结石的诊断价值。方法对35例腹部B超发现胆总管扩张,临床怀疑胆总管结石的患者行线阵超声内镜检查,并在3d内再行ERCP及乳头扩约肌切开胆总管取石,以取石的结果计算线阵超声内镜诊断的准确率、灵敏度、特异度、阳性预测值、阴性预测值及Youden指数。结果35例患者中,经线阵超声内镜检查及胆总管取石结石均阳性者22例,阳性率为62.8％（22／35）,均阴性者12例。线阵超声内镜检查有1例假阳性,无假阴性。与胆总管取石比较,线阵超声内镜诊断胆总管结石的准确率为97．1％,灵敏度为100％,特异度为92．3％,阳性预测值为95．6％,阴性预测值100％,Youden指数为92．3％,且未出现并发症。结论线阵超声内镜检查是诊断胆总管结石安全而可靠的方法。     

Diagnosis and therapy of common bile duct stones in a patient with a history of hypersensitivity reaction to radiologic contrast media --a case report]

Common bile duct (CBD) stones may occur in patients who had been previously cholecystectomized because of gallbladder stones. CBD stones occur in 15%-20% of patients with symptoms secondary to cholecystolithiasis. After cholecystectomy they occur in 1%-5% of patients, either in the form of retained or recurrent choledocholithiasis. Endoscopic ultrasonography (EUS) is a novel and excellent diagnostic screening procedure for common bile duct stones. Numerous reports confirm an equal success rate for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). However, unanimity of opinion with respect to the best diagnostic procedure for the detection of CBD stones does not exist to date. We report a 74-year-old female patient with CBD stones, who was shown to have a severe allergy to X-ray contrast medium at a previous examination. In view of the pre-existing contraindication for ERCP, we diagnosed the stones by EUS. The majority of patients would require ERCP for endoscopic treatment, but our patient rejected the administration of contrast medium as well as conventional surgical treatment. After introducing a guide wire into the bile duct to assure its position, endoscopic sphincterotomy (EST) without contrast imaging was performed successfully. The CBD stones were extracted with a basket. Based on our results we believe that EUS ranks as an important procedure in the diagnosis of CBD stones, and that successful endoscopic treatment can be performed without previous ERCP. We do realize that EST without ERCP in unsuitable as a routine procedure, but may be used successfully in specific cases such as that of the patient reported here.     

胆总管结石继发急性梗阻性化脓性胆管炎的急诊内镜治疗

目的：探讨胆总管发急性梗阻性化脓性胆管炎的急诊内镜镜治疗方法,方法：118例胆总管结石继发急性梗阻性化脓性胆管炎患者接受ERCP检查和治疗,112例,人镜括约肌切开（EST）或内镜乳头气囊扩张（EPBD）取石梳 及放置鼻胆管引流（ENBD）,结果：31例经EPBD后取石,39例经EST后取石,或同时放置ENBD,42例单纯放ENBD,105例患者经急诊治疗后症状得到缓解,无严重并发症和死亡,结论：内镜治疗急性胆管炎较传统开腹手术具有操作简单,安全,有效,创伤小和恢复快等优点。     

术后胆道镜下胆管扩张术的临床应用

目的 探讨胆总管探查T管引流术后胆道镜下扩张术在处理Oddi括约肌狭窄中的临床应用。方法 胆总管探查T管引流术后1～6个月采用胆道镜结合扩张导管和球囊导管施行Oddi括约肌扩张术，扩张满意、胆道镜检查结石取净，更换支架或拆除支架后，T管腹壁瘘口纱条堵塞自行愈合。结果 69例中60例获成功(狭窄扩张满意，术后T管腹壁瘘口愈合，随访无特殊)。3例施行胆道镜下电针Vater壶腹戳孔扩张术成功．4例施行十二指肠镜Oddi括约肌切开术成功，2例施行胆道镜扩张导管指引下十二指肠镜Oddi括约肌切开术成功。无胆漏、出血、穿孔、腹膜炎和胰腺炎，无手术死亡。结论 只要选择合适病例，胆总管探查T管引流术后施行胆道镜下扩张术后处理Oddi括约肌狭窄这一术式有效、安全、可行。     

Biliary lithiasis: combined endoscopic and surgical treatment

A combined endoscopic and surgical procedure was performed in 69 patients suffering from gallbladder lithiasis with suspected associated lithiasis of the common bile duct (CBD). The procedure was spread over two days: Day 1 - Endoscopic retrograde cholangiopancreatography (ERCP) revealed choledocholithiasis in 50 cases and papillary sclerosis in 4 cases. In 15 patients, the common bile duct was found to be normal. Fifty-four endoscopic sphincterotomies were performed. Among the 50 cases of choledocholithiasis, endoscopic removal of the stones was judged complete in 44 cases and incomplete in the other 6. Day 2 - Cholecystectomy was carried out in all the patients. Peroperative cholangiography confirmed the results of the pre-operative ERCP with respect to the CBD in all the patients except one, and a choledochotomy was necessary in 6 patients. Results were as follows: The average length of hospitalization was 12.4 days. No residual choledocholithiasis was noted. The morbidity of the procedure was 7.2%, and the mortality 1.4% unrelated to the technique. The diagnostic and therapeutic significance of the procedure is discussed.     

Percutaneous transhepatic sphincterotomy

Endoscopic sphincterotomy (ES) is a highly successful and preferred method for common bile duct (CBD) stone removal. In the rare instance when ES is unsuccessful and CBD stones are removed percutaneously, improved biliary drainage remains desirable to prevent stone recurrence. To this end, percutaneous transhepatic sphincterotomy (PTS) has been performed in nine patients. All patients presented with ascending cholangitis due to biliary obstruction from CBD stones. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy was unsuccessful due to previous upper Gl reconstructive surgery (n = 8) and technical failure (n = 1). Percutaneous biliary drainage (PBD), followed by transhepatic stone removal, was performed prior to the transhepatic sphincterotomy using a standard endoscopic papillotome. Fluoroscopic guidance was used in the first three patients and in the remainder both fluoroscopy and percutaneous choledochoscopy were used. Sphincterotomy was successfully performed in all nine patients; post-procedure cholangiograms showed improved biliary drainage. In two patients, the choledochoscope was passed through the sphincter with ease. One patient bled soon after the procedure (fluoroscopic control only) and responded quickly to treatment with blood transfusion. No complications have occurred since choledochoscopy was incorporated into the procedure. All patients remained free of biliary symptoms for an average follow-up of 19 months (range 12-45 months). Our early experience shows that PTS is efficacious in improving biliary drainage and that it offers a therapeutic alternative to surgery in highly-selected patients.     

Do normal findings at biliary endoscopic ultrasonography obviate the need for endoscopic retrograde cholangiography in patients with suspicion of common bile duct stone? A prospective follow-up study of 238 patients

BACKGROUND AND STUDY AIMS: Biliary endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC) are equally accurate for the diagnosis of common bile duct (CBD) stone. The aim of this prospective 1-year follow-up study was to determine whether normal findings at initial EUS obviated the need for ERC. PATIENTS AND METHODS: During a 17-month period, all patients referred for biliary EUS because of suspicion of CBD stone, in whom EUS findings were normal were included in the study. Early (1-month) and late (1-year) follow-up details were obtained by mail or telephone. The clinical course and need for ERC were recorded. RESULTS: 238 patients were enrolled. During follow-up, 59 (25 %) patients underwent cholecystectomy, with (n=31) or without (n=28) cholangiography, and 30 patients underwent ERC (13 %). CBD stone was found in 14 (6 %) patients. Of these 30 patients, ERC was done in 15 cases in the first week after EUS, because of persistent suspicion of a CBD stone which was found in 10 patients. The 15 late ERC procedures (carried out more than 1 week after EUS) revealed only one CBD stone. The negative predictive value of EUS for the diagnosis of CBD stones was 95.4 %. CONCLUSIONS: Patients with suspicion of CBD stones but normal EUS findings have a low risk of needing ERC in a 1-year period.     

ROUTINE USE OF ULTRASOUND 24 HOURS BEFORE LAPAROSCOPIC CHOLECYSTECTOMY CAN PREDICT THE NEED FOR INTRAOPERATIVE CHOLANGIOGRAM: RESULTS OF A 12-MONTH PROSPECTIVE AUDIT

Intraoperative cholangiograms and exploration of the common bile duct (CBD) during laparoscopic cholecystectomy are technically more demanding than during open cholecystectomy. This has led to many surgeons using a selective policy for cholangiography. In this study we prospectively assessed whether biliary ultrasound (CBD diameter ≥6 mm) or one or more abnormal liver function tests (LFTs) performed in the 24 hours preoperatively could predict the need for cholangiography. Forty-five patients were studied (14 male, 31 female), mean age 47.8 years. All patients with one or both tests abnormal preoperatively (19 patients) underwent intraoperative cholangiograms. Seven CBD stones were identified (16%). There was no evidence of CBD stones in patients not undergoing cholangiography at a median follow-up of 18 months. In patients with stones, three underwent open CBD exploration, and four underwent endoscopic retrograde choledochopancreatography (ERCP) and sphincterotomy in the early postoperative period without complications. CBD diameter ≥6 mm is a useful predictor of CBD stones. These may be treated successfully by postoperative ERCP.     

ERCP在胆囊切除术后黄疸诊治中的应用

目的：探讨经内镜逆行胆胰管造影（endoscopicretrogradecholangiopancreatograp11y,ERCP）在胆囊切除术后黄疸患者的诊断和治疗中的应用价值。方法：对53例胆囊切除术后不明原因或考虑为外科原因的黄疸患者行ERCP检查,明确黄疸的原因并在内镜下采取相应的治疗措施。对于胆总管结石的患者行乳头括约肌切开（endoscopicsphincterotomy,EST）或乳头球囊扩张（endoscopicpapillaryballoondilation,EPBD）取石,对胆漏和胆道狭窄患者行内镜引流术,对乳头狭窄或括约肌功能异常的患者行EST或EPBD。结果：53例患者均成功行ERCP检查,结果显示胆总管结石38例、胆道损伤8例、乳头狭窄或括约肌功能异常3例、乳头癌1例、肝门胆管癌1例、未见异常2例。经相应治疗后,所有患者均未出现严重并发症。结论：对于胆囊切除术后出现黄疸的患者,ERCP是理想的诊断方法,同时还可以进行内镜下治疗。     

Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: a systematic review

Background: There is still no consensus on the ideal management of common bile duct (CBD) stones. This article aims to review the management of concomitant gallbladder stones and CBD stones in the laparoscopic era. Method: A PubMed database search was performed to identify MEDLINE articles from 1986 to 2010 using the key terms “common bile duct stones,”“cholecystectomy,”“bile duct exploration,”“ERCP” (endoscopic retrograde cholangiography), and “endoscopic sphincterotomy.” Results: There were five randomized comparative trials (RCT) comparing sequential preoperative ERCP and laparoscopic cholecystectomy (LC) to laparoscopic common bile duct exploration (LCBDE). Two RCTs showed similar stone clearance rates and shorter hospital stays in the LCBDE group, while three RCTs showed similar stone clearance rates and hospital stays in sequential preoperative ERCP, LC and LCBDE groups. There were two RCTs comparing LCBDE to sequential LC and postoperative ERCP. One showed similar stone clearance rate and shorter hospital stay in LCBDE group, while the other showed similar stone clearance rate and hospital stay. There were three RCTs comparing sequential preoperative ERCP and LC against LC with intraoperative ERCP. All three studies showed similar stone clearance rates and shorter hospital stays in the intraoperative ERCP group. There was only one RCT comparing sequential preoperative ERCP and LC against sequential LC and postoperative ERCP. This showed a similar stone clearance rate and shorter hospital stay in the postoperative ERCP group. Conclusion: Different management approaches of concomitant gallbladder stones and CBD stones were equivalent in efficacy. However, one‐stage management had the advantage of providing a shorter hospital stay.     

经胆道镜治疗胆道难取性残留结石

目的：对碎石结合胆道镜取石治疗胆管难取性结石的有效性和安全性作出初步评估。方法：采用碎石后经胆道镜取石的方法治疗１５０例胆道难取性残留结石。其中活检钳碎石５５例,压电冲击波碎石１７例,液电冲击波碎石３８例,碎石篮碎石４０例。对取石失败者联合应用十二指肠镜括约肌切开或乳头气囊导管扩张术（ＥＳＴ／ＥＰＴ）。结果：活检钳碎石、压电冲击波、民冲击波和取石篮碎石取石成功率分别为９０．９％、９４．１％、９４．     

Selective endoscopic cholangiography for the detection of common bile duct stones in patients with cholelithiasis

BACKGROUND AND STUDY AIMS: The detection and management of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy continues to be controversial. Several diagnostic and therapeutic strategies have been suggested. These include intraoperative cholangiography, selective endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. The aim of this study was to evaluate the efficacy of selective ERCP in detecting CBD stones in patients with cholelithiasis before laparoscopic cholecystectomy. PATIENTS AND METHODS: In a prospective study, patients with cholelithiasis who presented during a 6-year period were assessed on a selective basis with ERCP for suspected CBD stones before laparoscopic cholecystectomy. ERCP was carried out if the patient had any of the following criteria: a dilated CBD on ultrasound, gallstone pancreatitis, or abnormal liver function tests. Intraoperative cholangiography was not performed in any of the patients. Long-term follow-up was undertaken. RESULTS: The study included 427 patients. On the basis of selective criteria, ERCP was carried out in 41 patients (9.6 %), with confirmed CBD stones in 22 cases (53.7 %). The most useful predictor of CBD stones on ERCP was the presence of a dilated CBD in association with abnormal liver function tests. In this situation, CBD stones were identified in 14 of 17 cases (82 %). Abnormal liver function tests alone had a sensitivity of 50 % (four of eight). All other parameters used in isolation had a lower detection rate. During a median follow-up period of 6 years (range 1-10 years), six of 386 patients (1.6 %) with initially normal imaging and biochemical tests presented again with retained stones. All were successfully managed by ERCP and sphincterotomy. There were no major complications. CONCLUSIONS: Preoperative selective ERCP is effective in detecting clinically significant CBD stones. However, there is a high false-negative rate when a single criterion is used to guide therapy. Multivariate analysis of preoperative parameters for risk stratification, in conjunction with other imaging modalities, may make it possible to minimize unnecessary ERCPs.     

胆道微结石在急性胆管炎中的临床意义

目的:探讨胆道微结石在急性胆管炎中的临床意义。方法:收集54例急性胆管炎患者,通过经内镜逆行胰胆管造影(ERCP)或内镜鼻胆管引流术(ENBD)收集胆汁,通过普通和偏振光显微镜查找微结石。结果:54例急性胆管炎患者中,3例ERCP失败,其余均插管成功。其中35例胆总管结石或扩张,4例胆总管下端炎性狭窄,12例未见明显异常。在35例胆总管结石中,29例发现胆道微结石,4例胆总管炎性狭窄的患者中,3例发现胆道微结石。在12例ERCP阴性胆管炎患者中,9例发现了胆道微结石(大多为胆固醇单水结晶),3组之间两两比较,差异无显著性(P>0.05)。结论:(1)在急性胆管炎中,ERCP联合微结石检测可以提高胆道结石的诊断率。(2)胆道微结石与急性胆管炎的发病密切相关。     

Intraductal ultrasonography in the diagnosis of Mirizzi syndrome

BACKGROUND AND STUDY AIMS: Common bile duct (CBD) compression can be caused by stones in the cystic duct (Mirizzi syndrome) which can be difficult to diagnose even with endoscopic retrograde cholangiopancreatography (ERCP). Conventional imaging often gives insufficient information and endoscopic ultrasonography (EUS) and magnetic resonance imaging may improve diagnostic accuracy, but often the final diagnosis is made during exploratory surgery. PATIENTS AND METHODS: All patients undergoing ERCP during a 3-year period were prospectively analyzed if they fulfilled the inclusion criteria: gallbladder in situ; obstructive jaundice with CBD stenosis, demonstrated at endoscopic retrograde cholangiography (ERC), but unexplained at ultrasonography; and inability to demonstrate the cystic duct during ERC. Intraductal ultrasonography (IDUS) was carried out over a guide wire using a 20-MHz probe. Prior to ERCP, patients were evaluated with abdominal ultrasonography and computed tomography (CT), as well as by magnetic resonance cholangiopancreatography (MRCP) or EUS in some. RESULTS: 74 patients out of 2089 undergoing ERCP fulfilled the entry criteria. Final diagnoses, from surgical exploration (n = 41), cytology (n = 21), or endoscopic extraction of stones from the cystic duct (n = 12), were Mirizzi syndrome (type I) in 30 patients and other causes in 44 patients (gallbladder carcinoma [n = 16], pancreatic carcinoma [n = 9], metastatic compression [n = 9], other [n = 10]). CT had shown suspected Mirizzi syndrome in 1/30 cases (3 %) and MRCP in 12/19 evaluated cases (63 %). EUS allowed a correct diagnosis in 11 of 15 evaluated cases (73 %). IDUS required an additional 8 +/- 3 min and showed a sensitivity of 97 % and specificity of 100 %. CONCLUSION: IDUS is a sensitive and specific method for the diagnosis of Mirizzi syndrome.     

腹腔镜下经胆囊管的胆总管探查取石术治疗肝外胆道结石

目的探讨腹腔镜下经胆囊管的胆总管探查取石术治疗肝外胆道结石的临床应用效果。方法应用该方法治疗胆囊结石合并胆总管结石26例，总结其临床资料。结果经胆囊管途径取石成功率为24／26，1例因胆囊管变异，1例导丝插入胆总管未成功，中转为胆总管切开术。术中扩张时无胆管撕裂，术后无腹腔出血、胆漏发生，无围手术期死亡。术后住院时间4-8d.结论对于胆囊结石合并继发性肝外胆管结石的病例，在采用腹腔镜下1次手术的方式治疗时，应首先考虑经胆囊管途径，以争取更小创伤以便更快地恢复。     

胆囊切除术后残留胆总管结石的内镜诊治

目的：探讨经内镜逆行胰胆管造影（ERCP）在胆囊切除术后残留胆总管结石诊治中的应用价值。方法：对胆囊切除术后腹痛、发热、黄疸或肝功能异常而经B超、CT或磁共振胰胆管造影（MRCP）证实或怀疑残留胆总管结石的患者进行ERCP检查，对发现胆总管结石的患者行EST或EPBD后取石。结果：ERCP检查的成功率为96．4％（108／112）。85例证实胆总管结石的患者行EST或EPBD后取石，79例（92．9％）取石治疗成功；6例因合并肝内胆管多发结石而行外科手术治疗。并发症发生率为4．5％，其中消化道出血2例，急性胰腺炎3例。结论；对于胆囊切除术后残留胆总管结石的患者，ERCP是理想的诊断方法，而且还可以同时进行治疗。     

胆总管下段癌的腔内超声与ERCP诊断价值比较

目的比较内镜超声(EUS)、胆管腔内超声(IDUS)与内镜下逆行胰胆管造影(ERCP)对胆总管下段癌的诊断价值.方法回顾分析上海长海医院1999年8月至2003年8月期间,同期施行EUS、IDUS和ERCP检查,并经手术标本病理证实的42例胆总管下段癌患者的病例资料,比较EUS、IDUS和ERCP的诊断价值.结果 42例患者中,男24例,女18例,平均年龄53.9岁.EUS检出39例(92.9%),IDUS检出42例(100%),ERCP检出40例(95.2%),三者检出率差异无统计学意义(P>0.05).EUS漏检的3例病灶均局限于胆管壁,但被IDUS确诊.结论 EUS与ERCP对胆总管下段癌具有相当的检出率, EUS和ERCP联合IDUS可提高早期胆总管下段癌的诊断水平.     

腹腔镜胆道镜十二指肠镜联合治疗原发性肝管结石31例报告

目的：探讨三镜联合治疗原发性肝胆管结石和肝胆管狭窄的手术方法,提高治愈率和避免多次开腹手术。方法：采用腹腔镜、胆道镜、十二指肠镜（三镜）联合治疗原发性肝胆管结石31例。经十二指肠镜手术治疗肝外胆管尤其是胆总管下端结石及狭窄。经腹腔镜手术行胆囊切除（ LC）及结石胆道镜行肝胆管探查术（LCDE）和耐高压球囊导管扩张术（LPBD）,解除肝门部胆管梗阻及狭窄。术后2月行胆道镜和／或十二指肠镜治疗残余结石及肝内外胆管内支撑引流术。结果：31例均获成功,未再施行开腹手术,经IVC和ERC随访30例结石取净,1例左外叶肝管残石。结论：病例选择恰当,三镜联合治疗原发性肝胆管结石具有创伤小、结石除净率高,获窄胆管球囊导管扩张安全有效。     

Preliminary experience using endoscopic ultrasonography in the diagnosis of choledocholithiasis.

Twenty patients with symptomatic cholelithiasis and suspected choledocholithiasis were evaluated in an ongoing prospective trial using endoscopic ultrasonography (EUS), standard abdominal ultrasonography (US) and ERCP for the detection of choledocholithiasis prior to laparoscopic cholecystectomy. EUS was used successfully to image the extrahepatic bile duct in all patients. EUS detected three of four proven bile duct stones and correctly identified 16 bile ducts as stone free, thus being more accurate than standard abdominal US. The preliminary results of this ongoing prospective trial and the experience reported by other authors suggest that EUS may be as sensitive as ERCP in the detection of choledocholithiasis.     

胆囊切除术后胆总管下端狭窄的内镜诊断与治疗

目的探讨胆总管下端炎性狭窄的内镜诊断与治疗。方法174例胆囊切除术后综合征患者行内镜下逆行胰胆管造影(ERCP)，对发现的73例(41．95％)胆总管下端狭窄患者行内镜下治疗。结果上腹痛缓解率在单纯胆总管下端狭窄者、合并急性胰腺炎者、合并结石者分别为83．33％、73．81％、80．95％，胆总管内径恢复率在单纯胆总管下端狭窄者、合并急性胰腺炎者、合并结石者分别为100％、88．89％、100％，术后所有患者血AIT，AST，ALP及r-GT恢复正常。结论EST可作为治疗胆总管下端狭窄有效和首选的治疗方法之一。