胆总管结石ERCP取石术后结石复发的危险因素分析

目的:探讨胆总管结石经内镜逆行胰胆管手术(ERCP)取石术后结石复发的危险因素。方法:选取2013年3月—2014年3月在行ERCP手术取石的200例胆总管结石患者的临床资料,其中胆总管结石复发者73例(复发组),未复发者127例(未复发组)。采用χ2和t检验初步筛选出胆总管结石ERCP术后复发的危险因素,对筛选出的危险因素进行多因素Logistic回归分析,筛选出胆总管结石ERCP术后复发的独立危险因素。结果:经χ2和t检验结果显示:复发组和未复发组在患者年龄、病程、胆道手术史、乳头旁憩室、胆总管直径、胆道狭窄、结石数量≥2枚,结石直径≥10 mm方面差异均有统计学意义(P0.05)。多因素Logistic回归分析结果显示:年龄(OR=4.523,95%CI=1.945~7.868,P=0.021),有胆道手术史(OR=3.565,95%CI=1.662~7.523,P=0.036),乳头旁憩室(OR=3.873,95%CI=1.759~7.426,P=0.039),结石数量≥2枚(OR=3.925,95%CI=1.905~7.063,P=0.035),胆总管直径(OR=3.431,95%CI=1.656~7.534,P=0.029),是胆总管结石ERCP术后复发的独立危险因素。结论:患者年龄、既往有胆道手术史、合并乳头旁憩室、结石数量≥2枚、胆总管直径是胆总管结石ERCP术后复发的独立危险因素。     

ERCP取石后胆总管结石复发的相关危险因素研究

目的探讨内镜逆行性胰胆管造影术(ERCP)取石后胆总管结石复发的危险因素。方法选择2010年1月~2014年3月期间在我院行ERCP取石的患者380例为研究对象,所有患者随访13~36个月,根据有无胆总管结石复发进行分组,有胆总管结石复发的136例归为复发组,无胆总管复发的244例归为未复发组,对两组患者的一般资料、胆道情况、胆结石情况进行对比,采用Logistic回归模型分析胆总管结石复发的危险因素。结果复发组与未复发组病例资料比较显示,年龄≥70岁、首次病程≥10 d、有胆道手术史、有乳头旁憩室、胆总管直径≥10 mm、有胆道狭窄、结石数量≥2个、结石直径≥10mm是ERCP取石后胆总管结石复发的危险因素;多因素Logistic回归模型分析显示,年龄≥70岁、有胆道手术史、有乳头旁憩室、胆总管直径≥10 mm、结石数量≥2个是ERCP取石后胆总管结石复发的独立危险因素,OR值和P值分别为3.435和0.002、5.820和0.019、3.286和0.022、4.300和0.002、4.244和0.003。结论 ERCP取石后胆总管结石复发的发生率较高,导致胆总管结石复发的危险因素多,其中胆道手术史是影响程度最高的危险因素。     

经内镜逆行胰胆管造影联合腹腔镜胆囊切除术后胆囊结石合并胆总管结石复发的危险因素分析

目的探讨经内镜逆行胰胆管造影（ERCP）联合腹腔镜胆囊切除术（LC）治疗胆囊结石合并胆总管结石复发的危险因素。 方法回顾性分析2012年1月至2015年3月沭阳县人民医院诊断为胆囊结石合并胆总管结石患者87例,均行ERCP联合LC术治疗。根据患者术后结石复发情况分为复发组与非复发组,对比两组患者一般情况、术者经验、胆道情况、结石情况。单因素分析以及多因素Logistic回归分析术后结石复发的危险因素。 结果87例患者术后随访32~60个月,中位随访时间为48个月,未复发组66例,复发组21例,中位复发时间15.0（95% CI=12.5~20.0）个月,术后1、2、3年复发率分别为8.0%、23.0%、24.1%,复发主要集中于术后2年内。单因素分析显示,胆道感染、胆道狭窄、胆总管夹角、结石数量、结石大小、乳头旁憩室情况影响胆囊结石合并胆总管结石复发（均P<0.05）。多因素分析显示,胆总管夹角（OR=0.196,95% CI=0.044~0.877）、胆道感染（OR=6.894,95% CI=1.698~27.984）、乳头旁憩室（OR=10.554,95% CI=2.134~52.197）、胆道口括约肌切开（OR=17.803,95% CI=3.342~94.845）是胆囊并胆总管结石术后复发的独立危险因素。 结论合并胆总管夹角过小、胆道感染、乳头旁憩室及术中括约肌切开的患者,ERCP联合LC术后结石更容易复发,对临床的预防和治疗有一定借鉴意义。     

胆总管取石并胆囊切除术后胆总管结石复发的相关危险因素分析

目的:探讨胆总管结石(CBDS)取石合并胆囊切除患者术后CBDS复发的危险因素。方法:回顾性分析2003年1月—2012年2月我院收治的333例CBDS取石并胆囊切除患者的病例资料,将可能影响CBDS术后复发的因素进行Logistic回归多因素分析,明确CBDS术后复发的相关危险因素。结果:333例患者中297例获得确切随访资料(失访率11%),31例患者CBDS复发,复发率10.4%。伴有壶腹周围憩室(PA D)、多发CBDS、胆总管直径≥15 mm与胆总管取石合并胆囊切除术后CBDS复发相关。结论:胆总管取石合并胆囊切除术后CBDS复发的危险因素为伴PA D,多发CBDS(结石数量≥2),胆总管直径≥15 mm。对于存在复发危险因素的患者,应进行积极干预,并在术后密切随访。     

胆总管结石术后复发危险因素的分析

目的:分析胆总管结石术后复发的危险因素。方法:选择2009年2月—2012年5月胆总管结石患者385例,从一般情况、胆道情况、结石情况、治疗情况4个方面对胆总管结石的复发进行统计分析。结果:385例中胆总管结石复发组58例,未复发组327例,胆总管结石复发率为15.1%。年龄60岁患者胆总管结石复发率明显升高,(P=0.009),乳头旁憩室、胆总管直径≥10 mm、胆总管下段狭窄为结石复发的危险因素(P=0.002,P=0.006,P=0.01),而合并胆囊结石与胆总管结石的复发无相关性(P=0.167),多发结石(≥2)患者的复发率为18.05%,而单发结石患者复发率为6.78%,前者的复发率明显升高(P=0.004);结石直径≥10 mm的患者复发率为21.65%,而结石直径10 mm的患者复发率为12.85%,二者相比具有统计学意义(P=0.036),EST相较于开放或腹腔镜胆总管探查更容易出现结石复发(P0.001),术后给予中药治疗相较于为治疗组可以明显降低胆总管结石的复发率。结论:高龄、有乳头旁憩室、胆总管直径≥10mm、多发结石和行EST治疗是胆总管结石复发的独立危险因素,而术后给予中药治疗可以明显降低胆总管结石的复发。     

复发性胆总管结石治疗选择

复发性胆总管结石,临床较为常见,公认的结石复发高危因素为糖尿病、胆总管扩张、十二指肠乳头旁憩室及前次胆总管结石治疗方法等,无有效预防药物。治疗选择包括内镜治疗与外科手术治疗,内镜治疗为内镜逆行胰胆管造影（ERCP）、内镜括约肌切开术（EST）与内镜乳头球囊扩张术（EPBD）,外科手术治疗包括胆肠吻合术、开放胆道探查术（OCBDE）及腹腔镜胆道探查术（LCBDE）。目前没有复发性胆总管结石针对性治疗指南及共识,多参考胆总管结石相关指南,最佳治疗方案尚无定论,胆囊切除术后的胆总管取石,国内外多首选内镜治疗。无胆肠吻合手术指征的复发性胆总管结石,内镜治疗与LCBDE均是安全有效的治疗方法,LCBDE具有不损伤Oddi括约肌功能、术后结石复发率低等优势,尤其当胆管结石较多或直径较大、铸型结石、胆管明显扩张及合并乳头旁憩室等情况时,建议首选LCBDE。     

内镜逆行胰胆管造影术后胆总管结石复发的相关因素研究进展

胆总管结石是消化系统常见病,内镜逆行胰胆管造影(ERCP)是目前治疗胆总管结石的重要手段,但常存在术后结石复发的问题。胆总管结石从清除到复发涉及到复杂的因素,主要包括既往胆道手术史、胆管扩张、壶腹周围憩室、胆道感染等。笔者就ERCP术后胆总管结石复发的相关因素作一综述,以期为临床预防及治疗提供帮助。     

十二指肠乳头旁憩室与胆总管结石及复发结石的关系

目的 本文的目的是研究十二指肠乳头旁憩室是否与胆总管结石的发生及胆道术后胆总管复发结石有关。方法 1980年1月至1996年6月．我科共收治十二指肠乳头旁憩室38例，其中男25例，女13例．年龄21～80岁(57±12)。十二指肠憩室诊断均经X线造影片显示为据。结果 结果显示，十二指肠乳头旁憩室明显与胆总管结石的发生及胆道术后胆总管复发结石有关。结论 十二指肠乳头旁憩室可能是胆总管结石或复发结石的病因之一。因此，对胆囊或胆总管术后复发胆总结石者，应考虑合并有十二指肠乳头旁憩室的可能。     

内镜下胆道塑料支架置入引流术治疗复发性胆总管结石合并乳头旁憩室

目的探讨对内镜逆行性胰胆管造影(ERCP)术后伴有十二指肠乳头旁憩室的患者采用内镜下胆道塑料支架置入引流术(ERBD)治疗复发性胆总管结石的效果。方法将我院2012年8月至2014年8月胆总管结石复发且合并乳头旁憩室的18例患者随机分为支架组和对照组,支架组9例患者内镜下取净结石后留置塑料支架,对照组9例患者取净结石后留置鼻胆管引流,比较两组症状性胆总管结石复发的间隔时间和并发症发生率。结果 18例患者随访至2015年3月,支架组与对照组相比平均复发间隔时间延长[(7.19±1.42)个月vs(6.19±1.31)个月],但差异无统计学意义(P=0.140);两组患者并发症发生率的差异无统计学意义(P=1.000)。结论对于合并乳头旁憩室、ERCP术后反复再生胆总管结石的患者,取净结石后置入胆道塑料支架虽然不能显著延长再次出现症状的间隔时间,但该方法安全有效,可作为无法耐受手术或拒绝手术的患者的一种治疗选择。     

十二指肠乳头旁憩室对胆道疾病与ERCP插管的影响

目的 回顾性探究十二指肠乳头旁憩室对胆道疾病与ERCP插管的影响,以及探究胆总管结石复发的危险因素.方法 对我院行ERCP取石的970例胆石症患者的临床资料进行回顾性分析.按有无PAD分为PAD组和非PAD组,探究PAD对原发性胆总管结石、胆管炎、胆总管直径、结石的个数和大小、及ERCP插管成功率的影响;按有无结石复发...     

中国病人内镜取石后胆总管结石复发相关危险因素的Meta分析

目的用循证医学的方法探讨中国病人内镜取石后胆总管结石复发的相关危险因素,为预测和预防结石复发提供理论依据。方法检索中国知网、维普和万方等数据库,收集自建库至2016年12月期间公开发表的有关内镜取石后胆总管结石复发危险因素的相关文献,运用固定或随机模型对各个因素进行合并分析。结果共纳入11项研究,6 137例内镜治疗病人。Meta分析结果显示,复发组中有胆道手术史的病人比例高于未复发组(OR=8.70,95%CI:5.22~14.50;P0.01);复发组中有乳头旁憩室的病人比例高于未复发组中的病人(OR=3.14,95%CI:2.32~4.25;P0.01);复发组中多发结石的病人比例高于未复发组(OR=1.57,95%CI:1.11~2.22;P0.05);复发组中结石直径10 mm的病人比例高于未复发组(OR=7.12,95%CI:4.98~10.19;P0.01);复发组中碎石的病人比例高于未复发组(OR=2.03,95%CI:1.66~2.49;P0.01)。结论既往有胆道手术史、合并乳头旁憩室、多发结石、结石直径10 mm和机械碎石是内镜治疗后胆总管结石复发的危险因素。     

Evaluation of perioperative cholangiography in one thousand laparoscopic cholecystectomies

We analyzed a teaching institution's experience with intra-operative cholangiography (IOCG) and endoscopic retrograde cholangiopancreatography (ERCP) and established an algorithm for their timing and use. The records of all patients undergoing LC during a five year period were reviewed. Patients with a history of jaundice or pancreatitis, abnormal bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence suggestive of choledocholithiasis were considered "at risk" for common bile duct stones (CBDS). The remaining patients were considered to be at low "risk." LC was attempted on 1002 patients during the study period and successfully completed on 941 (94% of the time). The major complication rate was 3.1% and the common bile duct injury rate 0.1%. Eighty eight (9.5%) patients underwent ERCP, 67 in the preoperative period and 19 in the postoperative period. IOCG was attempted in 272 (24%) patients and completed in 234 for a success rate of 86%. Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs Twelve of the 21 patients (57%) with IOCG positive for stones underwent successful laparoscopic clearance of the common duct, and did not require postop. ERCP. No patients were converted to an open procedure for common bile duct exploration. Because postoperative ERCP was 100% successful in clearing the common duct, reoperation for retained common bile duct stones was not necessary. IOCG is an alternative procedure to ERCP for patients at risk with biochemical, radiological, or clinical evidence of choledocholithiasis. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. Preoperative ERCP is recommended in cases of cholangitis unresponsive to antibiotics, suspicion of carcinoma, and biliary pancreatitis unresponsive to supportive care. Although IOCG leads to a similar percentage of nontherapeutic studies as preoperative ERCP, it often allows for one procedure therapy.     

Laparoscopic common bile duct stone clearance with flexible choledochoscopy

Background Laparoscopic common bile duct exploration (LCBDE) is as safe and efficient as endoscopic retrograde cholangiopancreatography (ERCP) in achieving bile duct clearance from stones. No clear guidelines are available on LCBDE with respect to indications for trans-cystic approach versus choledochotomy, or regarding when to use either flexible choledochoscopy (FCD) or intraoperative cholangiography (IOC) guidance. Methods From January 2001 until November 2006, 113 consecutive patients with common bile duct stones (CBDS) and gallbladder in situ were enrolled in a prospective non-randomized study to undergo laparoscopic cholecystectomy with LCBDE on an intention-to-treat basis. Twenty-three patients were aged 80 years or older with severe comorbidity. Preoperative ERCP with attempted stone clearance was performed in 24 patients. Laparoscopic common bile duct exploration was attempted for CBDS in the presence of acute cholecystitis in 24 patients. Laparoscopic common bile duct exploration was performed via the trans-cystic approach in 83 patients and via choledochotomy in 30 patients. Flexible choledochoscopy was used in 79 patients and IOC guidance in 34 patients. Results No mortality occurred. Postoperative complications were encountered in nine patients. Laparoscopic stone clearance of the bile duct was successful in 91.8% of the patients. Median length of hospital stay (LOS) was two days (range, 0 to 24 days) after trans-cystic LCBDE and six days (range, 2 to 34 days) after stone clearance via choledochotomy (p < 0.0001). Choledochotomy was performed for CBDS measuring an average of 11.5 mm (range, 5 to 30 mm) in diameter while trans-cystic LCBDE was successful for stones measuring an average of 5 mm (range, 2 to 14 mm) (p < 0.0001). Mean duration of surgery was 75 minutes (range, 30 to 180 minutes) when FCD was used, and 107 minutes (range, 45 to 240 minutes) in patients undergoing LCBDE under IOC guidance (p < 0.0001). Conclusion Laparoscopic cholecystectomy and LCBDE with stone extraction can be performed with high efficiency, minimal morbidity and without mortality. A trans-cystic approach is feasible in most patients, whereas choledochotomy should be restricted to large bile duct stones that cannot be extracted through the cystic duct. The use of flexible choledochoscopy is preferable to IOC guidance.     

腹腔镜下治疗胆囊结石合并胆总管结石的疗效影响因素分析

目的:探讨影响腹腔镜手术治疗胆囊结石合并胆总管结石疗效的相关因素。方法:回顾分析2009年6月至2011年6月为128例胆囊结石合并胆总管结石患者行腹腔镜手术的临床资料,根据患者术后是否复发将其分为复发组及未复发组,分别采用单因素及Logistic回归模型分析影响胆囊结石合并胆总管结石术后复发的相关因素。结果:24例术后复发,复发率18.75%。经单因素分析得出,年龄、胆总管直径、结石数量、胆总管扩张、胆囊管扩张、胆管炎、总胆红素异常、胰腺炎、结石残留、术后合并症、黄疸、结石直径及手术类型与胆囊结石合并胆总管结石术后复发相关。经Logistic回归模型分析可知,胆总管直径、胆囊管扩张、胆总管扩张、结石数量、胆管炎、结石残留、术后合并症及手术类型是影响胆囊结石合并胆总管结石患者术后复发的独立危险因素。结论:腹腔镜手术治疗胆囊结石合并胆总管结石术后复发的影响因素较多,临床应根据患者具体情况制定相应的预防控制措施,以降低术后复发率。     

Laparoscopic endobiliary stenting significantly improves success of postoperative endoscopic retrograde cholangiopancreatography in low-volume centers

Background: Occult common bile duct stones (CBDS) discovered during laparoscopic cholecystectomy with intraoperative cholangiography are most often managed by postoperative endoscopic retrograde cholangiopancreatography (ERCP). Expert endoscopists at high-volume centers achieve common bile duct cannulation in nearly all patients undergoing ERCP, but cannulation rates of less than 80% have been observed in low-volume centers. As many as 20% of patients with CBDS referred for postoperative ERCP in low-volume centers may require repeated attempts at ERCP, referral to a high-volume center, percutaneous transhepatic techniques, or reoperation for clearance of CBDS when postoperative ERCP fails. Methods: Laparoscopic cholecystectomy with intraoperative cholangiography performed in 511 consecutive patients over 80 months at a community hospital showed occult CBDS in 66 patients (12.9%). Laparoscopic endobiliary stent placement was successful in 65 patients (98.5%). As part of an earlier study, 16 patients underwent laparoscopic common bile duct exploration with clearance of CBDS before stent placement. Laparoscopic endobiliary stent placement failed in one patient for whom CBDS were cleared with intraoperative ERCP. Results: Initial postoperative ERCP was successful in clearing CBDS in all 65 patients (100%) with laparoscopically placed stents. During the same period, 611 patients underwent ERCP for various indications including CBDS (43%). Selective cannulation was achieved in 78% of all patients during initial ERCP. Conclusions: Laparoscopic endobiliary stent placement is an effective adjunct to the management of occult CBDS. Laparoscopic endobiliary stenting ensures selective cannulation during postoperative ERCP and eliminates the need for repeated attempts at ERCP, referral to specialty centers, use of transhepatic techniques, or reoperation for retained CBDS. Laparoscopic endobiliary stent placement for treatment of occult CBDS significantly improves the success of postoperative ERCP in low-volume centers and eliminates the morbidity and expense of repeated procedures.     

Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder

Background  The probability that a patient has common bile duct stones (CBDS) is a key factor in determining diagnostic and treatment strategies. This prospective cohort study evaluated the accuracy of clinical models in predicting CBDS for patients who will undergo cholecystectomy for lithiasis. Methods  From October 2005 until September 2006, 335 consecutive patients with symptoms of gallstone disease underwent cholecystectomy. Statistical analysis was performed on prospective patient data obtained at the time of first presentation to the hospital. Demonstrable CBDS at the time of endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography (IOC) was considered the gold standard for the presence of CBDS. Results  Common bile duct stones were demonstrated in 53 patients. For 35 patients, ERCP was performed, with successful stone clearance in 24 of 30 patients who had proven CBDS. In 29 patients, IOC showed CBDS, which were managed successfully via laparoscopic common bile duct exploration, with stone extraction at the time of cholecystectomy. Prospective validation of the existing model for CBDS resulted in a predictive accuracy rate of 73%. The new model showed a predictive accuracy rate of 79%. Conclusion  Clinical models are inaccurate in predicting CBDS in patients with cholelithiasis. Management strategies should be based on the local availability of therapeutic expertise.     

Laparoscopic endobiliary stenting: a simplified approach to the management of occult common bile duct stones

Three years ago we described laparoscopic placement of biliary stems as an adjunct to laparoscopic common bile duct exploration (LCBDE) in 16 patients. We now present a modification of our technique and experience with 48 additional patients. Laparoscopic cholecystectomy with intraoperative fluorocholangiography (LC/IOC) performed in 372 consecutive patients during a 36-month period revealed common bile duct stones (CBDS) in 48 patients (12.9%). In this series, LCBDE was not performed and no attempt was made to clear CBDS prior to transcystic stent placement. Stent placement added 9 to 26 minutes of operative time to LC/IOC alone. Forty-four patients (92%) were discharged after surgery and four (8%) were observed overnight. Outpatient endoscopic retrograde cholangiopancreatography 1 to 4 weeks later succeeded in clearing CBDS in all patients. All stents were retrieved without difficulty and 3- to 36-month follow-up demonstrates no surgical, endoscopic, or stent-related complications to date. Laparoscopic biliary stent placement for the treatment of CBDS is a safe, rapid, technically less challenging alternative to existing methods of LCBDE. It preserves the benefits of minimally invasive surgery for patients, and virtually assures success of postoperative endoscopic retrograde cholangiopancreatography with complete stone clearance. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2l–24, 2000 (poster presentation).     

经内镜乳头括约肌小口切开并放置塑料支架分期治疗巨大或多发胆总管结石

【摘要】目的探讨经内镜逆行胰胆管造影术（ERCP）Ⅰ期先行乳头括约肌小口切开并放置塑料支架解除梗阻,一月后再Ⅱ期取石,分期治疗巨大或多发胆总管结石的临床应用的安全性及有效性。方法回顾性分析2010年1月至2015年12月在我科住院首次行ERCP治疗的72例直径≥20mm或结石数量≥3粒的胆总管结石患者,分为观察组（一期ERCP放置支架,1月后二期取石,n=36）;对照组（一期治疗组,n=36）。观察和比较两组病例术后结石清除率,ERCP后胰腺炎（PEP）、重症胰腺炎发生,术后出血、胆道感染发生情况。结果在术后结石清除率方面观察组34例（94.4%）与对照组31例（91.2%）,比较差异无统计学意义（P>0.05）;观察组ERCP术后胰腺炎1例,对照组有8例（P<0.05）;观察组无重症胰腺炎发生,对照组发生2例;观察组1例发生术后出血,对照组则有6例发生（P<0.05）;观察组没有发生术后胆道感染,对照组发生5例（P<0.05）。结论内镜下乳头括约肌小切开并放置塑料支架分期取石术治疗巨大或多发胆总管结石是安全、有效、可行的。