选择性术中胆囊-胆管造影在内镜微创保胆中的应用

目的 探讨选择性术中胆囊-胆管造影在保胆取石中的意义及可行性.方法 对于术前患者有黄疸、胰腺炎病史,肝功能检查示直接胆红素升高或GPT、AKP升高,或保胆术中胆汁自胆囊管不能涌入胆囊,显示胆囊管流通不畅者等特殊病例,术前B超或CT、MRI检查无阳性结果43例,术中经胆囊管行胆管造影.结果 内镜保胆取石术中43例行胆道造影,发现2例胆囊管结石,1例取出后保留胆囊,1例因结石取出困难,中转腹腔镜胆囊切除,7例发现胆总管结石,行腹腔镜胆总管切开胆道镜取石并置“T”管引流,术后6～8周经“T”管造影、胆道镜、超声检查显示胆道通畅无残余结石,拔除“T”管.2例十二指肠乳头轻度狭窄,未行特殊处理.结论 合理选择和应用术中胆囊-胆管造影,能提供可靠、直观、清晰的图像,全面了解胆道走向,提高胆囊管、胆总管病变诊断的正确率,减少了不必要的胆道阴性探查,对于手术方式选择有指导意义.     

术中胆囊胆总管造影的临床价值

目的 探讨术中胆囊胆总管造影的临床价值。方法对39例病人术中经胆囊管胆总管造影,胆囊管Ⅰ期缝合术,用一次性静脉输液管头放置胆囊管,注入20％泛影葡胺注入,同时用C型臂（GSP）机观察胆总管全程和肝内胆管。结果对术前B超提示,胆囊急性肿大、胆总管扩张,胆囊颈部结石嵌顿病人,术中经胆囊管、行胆总管造影,未发现胆总管结石及狭窄、肿瘤等。术前B超和CT证实6例有胆总管探查指征,术中经胆囊管,胆总管造影39例,阳性3例,经探查证实有结石。结论术中做胆总管造影,可发现隐匿性胆总管结石,能有效减少胆总管残余结石,减少胆道损伤。     

双镜结合选择性术中胆道造影治疗胆囊炎急性发作65例临床分析

目的评价双镜结合选择性术中胆道造影治疗胆囊炎急性发作的疗效。方法回顾性分析本院2007年1月～2010年12月65例按腹腔镜联合胆道镜结合选择性术中胆道造影方法治疗胆囊炎急性发作的临床资料。结果 43例行腹腔镜下胆囊切除术,6例中转开腹行胆囊切除术,16例发现或证实胆总管内有结石,其中3例中转开腹行胆囊切除+胆总管切开取石,13例腔镜手术成功,其中1例胆道镜经胆囊管切开取石术,胆总管未放置T管;12例行腔镜下胆囊切除+胆总管切开胆道镜取石术,胆总管内放置T管,术后6～8周行纤维胆道镜检查,1例发现残余结石,拔除T管后经窦道取净,11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,术中出血30～130 mL,手术时间90～220 min,术后住院4～8 d,所有病例均无发生并发症。结论腹腔镜联合胆道镜结合选择性术中胆道造影治疗胆囊炎急性发作并胆总管结石,患者创伤小,康复快,胆管结石残留少,安全有效,减少不必要的阴性胆总管切开探查。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。     

选择性术中胆道造影在腹腔镜胆囊切除术中的临床应用观察

回顾性分析2009年1月~2013年12月我院102例行腹腔镜胆囊切除术术中行胆道造影患者资料。结果 102例患者98例成功经胆囊管造影4例经胆总管造影,发现胆总管结石15例,胆囊管异常开口8例,胰、胆管汇合畸形(PBM)6例,右侧副肝管5例,Mirizzi综合征5例,胆囊管结石5例,胆道损伤1例。术中予改相应术式,经处理后患者均康复出院。选择性术中胆道造影在腹腔镜胆囊切除术能清楚显示胆道结构,能发现术前未确诊的胆总管结石、胆囊管结石,对胆管、胰管变异的诊断提供确切依据。胆道造影简便易行,增加术者的信心,值得在广大的基层单位推广。     

急性胆囊炎行腹腔镜胆囊切除时术中胆道造影35例分析

目的:探讨急诊腹腔镜胆囊切除术(LC)时行术中胆道造影对胆总管结石的诊断价值,了解IOC在急诊LC时的可行性和安全性。方法:37例术前B超或CT未发现胆总管结石的急性胆囊炎病例行LC,均行经胆囊管胆道造影。结果:35例胆道造影成功,发现3例胆总管结石病例,分别为4mm、3mm、3mm大小,于术后行内镜取石成功。该组病例中无胆道损伤,发生1例与胆道造影无关的轻微胆漏。结论:急性胆囊炎行LC时,并发隐匿性胆管结石的情况值得重视,IOC在急诊LC时对胆管结石的诊断是安全可行的。     

经胆囊管纤维胆道镜在小切口胆道术中的应用(附51例治疗体会)

目的 评估经胆囊管行纤维胆道镜在小切口胆道术中的临床应用价值。方法 行小切口胆囊切除后，对于不能明确胆总管内有无残余结石者，经胆囊管置入胆道镜，探查肝内外胆管，并取尽结石。结果 51例病人术中胆道镜检，发现有结石者20例(另外有2例发现胆道絮状物)，经胆囊管胆道镜取石或冲洗入十二指肠17例(2例发现胆道有絮状物者经胆道镜冲洗入十二指肠)，胆总管切开胆道镜取石3例。结论 术中经胆囊管胆道镜检的方法即可降低胆道残余结石发生率，又可避免不必要的胆总管探查，同时还能将部分复杂的胆总管探查手术转化为单纯的胆囊切除手术。     

经胆囊管内镜下处理胆总管结石86例

我院自 1988～ 1998年对 86例胆囊结石伴胆总管结石的患者 ,在胆囊切除术中经胆囊管采用纤维胆道镜行胆总管取石 ,效果满意 ,现报告如下。1　临床资料本组男 37例 ,女 4 9例 ,年龄 16～ 69岁。其中66例为胆囊多发性结石 ,2 0例为单枚结石。术前Ｂ超、ＣＴ发现胆总管结石 4 3例 ,术中胆道镜检查发现 37例 ,术中胆道造影发现 6例。2　方法与结果常规行胆囊切除术 ,胆囊管长度酌情保留约 1.5ｃｍ左右 ,用细线在残留胆囊管呈等距离缝合 3针 ,不同方向牵开 ,并根据胆囊管直径大小与通畅情况决定是否作扩张或胆总管联合切开[1] 。本组有 68例胆囊…     

腹腔镜B超在腹腔镜胆囊切除术中的应用

目的探讨腹腔镜B超在腹腔镜胆囊切除术中的作用，利用腹腔镜B超，对肝胆系统进行探查，代替术中胆道造影，以降低手术难度及风险，减少漏诊及胆道损伤。方法收集并分析2002年6月-2003年6月间69例LC中应用腹腔镜B超进行检查的病例。结果手术过程均顺利，轻易找到胆总管位置及其病变，其中1例发现胆总管变异，1例胆总管癌变，2例胆总管结石，无中转开腹及术后并发症。结论腹腔镜B超对肝外主胆管能作出准确的术中定位，避免术中胆道损伤，也可判断胆总管内有无结石，对指导LC手术和提高诊断准确率有实用价值，可代替术中胆道造影。     

胆道镜在胆道手术中的应用

目的 探讨胆道镜在胆道手术中的应用价值。方法 对经CT、B超、ERCT或MR证实为胆石症的32例胆道手术病人术中进行胆道镜探查,常规开腹切除胆囊或切开胆管将结石取出后,胆道镜经胆囊管残端或胆管切开处插入胆道依次探查左右肝管,肝总管、胆总管。结果 32例病人中发现肝管残留结石1例,胆总管残留结石2例,胆总管末端狭窄2例,胆管癌1例。3例残留结石中2例以取石器将结石取出,1例结石嵌顿在乳头开口处,以胆道镜推送至十二指肠内。2例胆总管末端狭窄,给予胆道镜下扩张治疗,减轻了术后因胆总管末端狭窄而导致的不良后果。1例在探查中发现胆总管下端不光滑,有小结节状隆起,取组织病理检查证实为胆管癌而改变术式,避免了再次开腹手术。结论 胆道手术时行胆道镜探查,可减少残留结石的发生,并能及时发现其它病理情况,给予相应治疗,减少漏误诊的发生。     

内镜下十二指肠乳头括约肌切开及腹腔镜胆囊切除联合术中胆道造影治疗胆囊合并胆总管结石

目的探讨内镜下十二指肠乳头括约肌切开（endoscopic sphincterotomy，EST）、腹腔镜胆囊切除（laparoscopic cholecystectomy，LC）结合术中经鼻胆引流管（endoscopic nasobiliary drainage，ENBD）胆道造影治疗胆囊合并胆总管结石的可行性。方法总结经EST处理胆总管结石并放置ENBD管，在LC术中经ENBD胆道造影治疗胆囊合并胆总管结石的经验。结果51例病例中，手术成功47例。经术中胆道造影发现胆总管继发结石4例，其中2例术中再用内镜取出结石。结论用EST、LC结合术中胆道造影治疗胆囊合并胆总管结石是一种比较理想的术式；术中胆道造影可及时发现并处理继发性胆总管结石。     

经腹腔镜胆囊切除术选择性术中胆道造影的临床应用价值

目的探讨术中胆道造影在腹腔镜胆囊切除术（LC）中的临床应用价值。方法分析2006年9月至2010年12月北京丰台长辛店医院及东城区第一人民医院180例慢性结石性胆囊炎、急性结石性胆囊炎、胆源性胰腺炎患者行LC患者的临床资料,统计分析其中20患者在术中经胆囊管插管行胆管造影（IOC）的临床数据。结果 20例LC术中胆管造影18例成功,成功率90.0%,术中发现胆总管结石2例,经中转开腹行胆总管切开取石,胆管变异1例;平均造影时间15±10.50 min。结论 LC中胆管造影操作较为简单方便、显影清晰、成功率高,既能发现术前未能发现的胆总管结石,又能发现胆管解剖变异;并能够有效地降低胆管残石率,及时发现术中胆管损伤,提高了LC的手术质量和安全性。     

如何评价腹腔镜胆囊切除术中胆道造影技术的应用价值

目的 评价胆道造影技术在腹腔镜胆囊切除术中的应用价值。方法 腹腔镜胆囊切除术中经胆囊管插管行胆道造影共2503例。结果 2503例中，造影成功2419例，成功率为96.64%。术中造影发现胆总管结石193例，胆管损伤12例，副肝管1例。结论 术中造影操作迅速、安全，显影清晰，成功率高，能降低胆管损伤发生率；提高腹腔镜胆囊切除术的质量，值得推广应用。     

术中胆道造影在LC中应用探讨

目的:探讨选择性经胆囊管胆道造影在腹腔镜胆囊切除术中的应用价值。方法:有选择性地对72例行腹腔镜胆囊切除的病人,在术中经胆囊管胆道造影,并对其临床资料进行分析。结果:术中造影发现胆囊管变异13例(18%),胆总管结石8例(11.1%),中转开腹3例(4.1%),无胆管损伤。结论:腹腔镜胆囊切除术中选择性胆道造影可以减少胆囊残余、残留胆总管结石、胆管损伤,从而提高腹腔镜胆囊切除术的质量和安全性。     

选择性术中胆道造影的合理应用

目的探讨在胆道手术中正确、高效的选择性应用术中胆道造影。方法回顾性分析2000年10月~2004年10月333例术中胆道造影。结果经胆囊管术中胆道造影181例,发现胆道残余结石47例,假阳性3例,Mirizzi综合征3例。经“T”管术中造影152例,胆道结石残余为16例,假阳性2例,胆道解剖异常5例;胆道探查术中结合胆道镜检查取出结石数目与术前B超检查所示一致者92例,行术中胆道造影未发现胆道残余结石。结论术中胆道造影应合理的选择性应用,要避免不必要的术中胆道造影。选择性术中胆道造影可避免胆道结石及不必要的胆道探查,能够提高手术的安全性,在临床手术中有着广泛的应用价值。     

Ultrasound of the common bile duct in patients undergoing cholecystectomy

One hundred patients undergoing cholecystectomy underwent ultrasonography of the biliary tree on the day prior to surgery. At operation a per-operative cholangiogram was performed unless stones were palpable in the duct. Pre-operative biliary ultrasonography accurately identified dilatation of the common bile duct (sensitivity 96%, specificity 95%) but was less accurate at detecting common duct stones (sensitivity 36%, specificity 98%). Thirty three percent of patients with dilated ducts on ultrasound did not have stones in the duct, while 20% of patients with common duct stones had normal sized ducts. We conclude that ultrasonography alone cannot reliably select patients who require exploration of the common bile duct, or select patients for operative cholangiography. Although pre-operative demonstration of common bile duct dilation is an absolute indication for operative cholangiography, by itself it does not indicate the need for exploration.     

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.     

Assessment of the biliary tract by ultrasonography and cholangiography during laparoscopic cholecystectomy: a prospective study.

OBJECTIVE: The introduction of laparoscopic cholecystectomy (Lap-chol) has induced routine cholangiography to map the biliary tree and identify common bile duct (CBD) stones. However, the use of more selective criteria for performing intraoperative cholangiography (IOC), drawbacks of IOC and experience with laparoscopic ultrasonography (LU) re-introduced intraoperative ultrasonography for the CBD. The purpose of this study was to compare the accuracy of LU and IOC to identify the anatomy of the CBD and the presence of stones. METHODS: A total of 50 unselected patients undergoing elective laparoscopic cholecystectomy were evaluated by LU and IOC. Stones were found in three patients by IOC and could be confirmed by ultrasonography and CBD exploration in two. RESULTS: Anatomic definition of the biliary tract and success of the procedure was better for LU (90 and 98%) than IOC (86 and 72%). CONCLUSION: For Surgical groups with experience in LU this technique appears to become the standard technique to identify the anatomy of the CBD and assessment of CBD stones.     

Laparoscopic ultrasonographic appearance of the common bile duct mucosa: a predictor of choledocholithiasis.

Previously we reported on the use of laparoscopic ultrasonography in detecting common bile duct stones during laparoscopic cholecystectomy. The aim of this study is to describe the laparoscopic ultrasonographic appearance of the common bile duct mucosa in patients with choledocholithiasis. Medical records of 44 patients with an increased risk for common bile duct stones undergoing laparoscopic cholecystectomy between 1993 and 1998 were reviewed. In the operating room, the laparoscopic ultrasonographic appearance of the common bile duct mucosa was scored in real time as normal, mild changes (hyperechoic mucosa), or severe changes (hyperechoic with mucosal thickening). Of the 31 patients (70%) with stones or sludge in the biliary tree, 29 (94%) had either severe (58%) or mild (36%) hyperechoic and 2 (6%) had normal-appearing common bile duct mucosa on laparoscopic ultrasonography. Of the 13 patients (30%) with no documented stones or sludge, 11 (85%) had normal and 2 (15%) had mild hyperechoic common bile duct mucosa on laparoscopic ultrasonography. Both of these patients had laboratory values indicating recent passage of common bile duct stones. The association between common bile duct stones and the presence of hyperechoic common bile duct mucosa was statistically significant (P < .0001, Fisher's exact test). This is the first report of hyperechoic common bile duct mucosa demonstrated by laparoscopic ultrasonography as a predictor of common bile duct stones. This finding is evident in the majority of patients with common bile duct stones and also may be associated with recent passage of a stone into the duodenum.     

选择性胆道造影在胆囊切除术中的临床应用

目的探讨基层医院在胆囊切除手术中选择性胆道造影的应用价值。方法回顾性分析2004年6月至2007年10月26例术中胆道造影（IOC）患者的临床资料。全部选用经胆囊管或经胆总管穿刺行IOC。结果对胆囊切除术中26例具有胆总管相对探查指征患者经胆囊管或经胆总管穿刺IOC,发现胆总管结石9例（34．62％）,假阳性1例（3．85％）,阴性16例（61．53％）。结论选择性IOC在基层医院可预防胆囊切除手术后胆总管残余结石,避免不必要的胆总管切开探查,降低术后并发症;并能在术中直接了解胆道系统解剖,提高手术安全性,在降低术后残余胆总管结石和避免胆道损伤等方面有重要价值。