内镜十二指肠乳头切开联合腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石

目的 :探讨胆囊结石合并胆总管结石的微创术式及几种术式的优缺点。方法 :回顾总结采用十二指肠乳头切开取石 ,再行腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石 32例的治疗经验 ,分析该术式的优点。结果 :32例中 2例行十二指肠乳头切开取石失败 ,行开腹胆囊切除术加胆总管探查取石、十二指肠乳头成形术。余者均采用内镜十二指肠乳头切开取石后腹腔镜胆囊切除术方法治愈 ,均取得良好疗效 ,无 1例出现胆囊结石脱落致胆总管结石复发。结论 :绝大多数胆囊结石合并胆总管结石病例适用于此术式。比先行腹腔镜胆囊切除再行内镜十二指肠乳头切开取石更为安全可靠。     

Esophagogastroduodenoscopy prior to laparoscopic cholecystectomy

BACKGROUND: Peptic ulcer disease and gallstones are common causes of upper abdominal pain. The benefits of routine gastrostroscopy before laparoscopic cholecystectomy have been controversial. Some cases of persistent abdominal pain after laparoscopic cholecystectomy have been attributed to peptic ulcer disease. MATERIALS AND METHODS: We reviewed the significance of preoperative esophagogastroduodenoscopy in patients scheduled for laparoscopic cholecystectomy. We compared a group of patients who underwent esophagogastroduodenoscopy before laparoscopic cholecystectomy and a group of patients who underwent laparoscopic cholecystectomy with no preoperative esophagogastroduodenoscopy. Postoperative residual abdominal pain, esophagogastroduodenoscopy findings, hospital stay, and other variables were examined. RESULTS: There were 400 patients in this study: 218 (54.5%) patients underwent esophagogastroduodenoscopy while 182 (45.5%) did not. The mean age was 49.8 years, 311 were female and 89 were male patients. One hundred and twenty seven (31.7%) patients were diagnosed with acute cholecystitis and 273 (68.2%) were nonacute. In the esophagogastroduodenoscopy group, there were normal findings in 98 (45%) patients. Disorders such as hiatus hernia (21%), acute duodenal ulcers (3.6%), esophagitis (3.6%), gastric ulcer (0.4%), and Barrett's esophagus (0.4%) were among the findings. Laparoscopic cholecystectomy was avoided in six patients with chronic cholecystitis. Preoperative esophagogastroduodenoscopy did not reduce the incidence of postoperative residual abdominal pain; in fact, patients who underwent esophagogastroduodenoscopy had longer hospital stays (P = 0.02). Unlike chronic cholecystitis, esophagogastroduodenoscopy did not change the course of the planned surgery in acute cholecystitis. CONCLUSION: Esophagogastroduodenoscopy prior to laparoscopic cholecystectomy does not have an impact on postoperative residual abdominal pain; however, it can disclose other gastroesophageal disorders with similar symptoms to gallstones and may change the course of the planned surgery in chronic cholecystitis.     

Endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy is safe and effective

Management strategy for common bile duct (CBD) stones is controversial with several treatment options if stones in the CBD are recognized intraoperatively. The aim of this study was to report our experience with same-session combined endoscopic-laparoscopic treatment of gallbladder and CBD stones. We retrospectively evaluated 31 patients with cholecystolithiasis and CBD stones undergoing same-session combined endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and endoscopic stone extraction and laparoscopic cholecystectomy. Same-session ERCP and sphincterotomy were performed in all patients, and stone extraction was successfully performed in 29 patients (93%) with 2 failures (7%) due to impacted stones. In 8 patients (26%), the laparoscopic procedure was converted to open cholecystectomy because of dense adhesions or unclear anatomy. Two patients (7%) developed mild pancreatitis postoperatively and no other morbidity or mortality. In conclusion, same-session ERCP with stone extraction and laparoscopic cholecystectomy seems to be a safe and effective treatment strategy for CBD stones.     

The impact of laparoscopic cholecystectomy on the treatment of symptomatic cholelithiasis

Background: There has been a debate about the cost-effectiveness of laparoscopic cholecystectomy (LC), as well as a concern regarding its possible overutilization and changes in the indication for surgery. Methods: A retrospective analysis of all cholecystectomies performed at UCDMC from 1988 to 1994 was done. The annual rate of cholecystectomy increased by 50% in 1990 when LC was introduced but has since stabilized at a rate 11% higher than the rate before LC. The disease status and severity did not change. Results: The incidence of nonelective surgery remained stable at 31.2% to 37.5%. Elective cholecystectomy had lower mortality (0.16% vs 1.8%, P=0.029), morbidity (2.6% vs 11.2%, P=0.0001), and conversion rate (2.6% vs 16%, P=0.0001) and a shorter length of stay (2.1 days vs 5.4 days), compared with nonelective procedure. Conclusions: The indication for surgery in cholelithiasis has not changed since the introduction of LC. In patients with symptomatic gallstones, early elective surgery is recommended and may be more cost-effective.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, FL, March 12–14, 1995     

Endoscopic sphincterotomy permits interval laparoscopic cholecystectomy in patients with moderately severe gallstone pancreatitis

Patients with moderately severe gallstone pancreatitis with substantial pancreatic and peripancreatic inflammation, but without organ failure, frequently have an open cholecystectomy to prevent recurrent pancreatitis. In these patients, prophylactic endoscopic retrograde cholangiography (ERC) with endoscopic sphincterotomy (ES) may prevent recurrent pancreatitis, permit laparoscopic cholecystectomy, and decrease risks. The medical records of all patients with pancreatitis undergoing cholecystectomy from 1999–2004 at the University of North Carolina Memorial Hospital were reviewed. Data regarding demographics, clinical course, etiology of pancreatitis, operative and endoscopic interventions, and outcome were extracted. Moderately severe gallstone-induced pancreatitis was defined as pancreatitis without organ failure but with extensive local inflammation. Thirty patients with moderately severe gallstone pancreatitis underwent ERC and ES and were discharged before cholecystectomy. Mean interval between ES and cholecystectomy was 102 ± 17 days. Cholecystectomy was performed laparoscopically in 27 (90%) patients, open in three (10%) patients, and converted to open in two (7%) patients, with a morbidity rate of 7% (two patients). No patient required drainage of a pseudocyst or developed recurrent pancreatitis. Interval complications resulted in hospital readmission in seven (23%) patients. In conclusion, recurrent biliary pancreatitis in patients with moderately severe gallstone pancreatitis is nil after ERC and ES. Hospital discharge of these patients permits interval laparoscopic cholecystectomy, but close follow-up is necessary in these potentially ill patients. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

内镜在腹腔镜胆囊切除术后胆漏治疗中的应用

目的:探讨内镜在腹腔镜胆囊切除术(LC)术后胆漏治疗中的应用价值。方法:10例胆漏患者均先行内镜下十二指肠乳头切开经鼻胆管引流术,继续保留原有胆道、腹腔引流。胆道、腹腔引流停止1~2周且证实胆漏愈合后拔管。结果:10例胆漏患者经鼻胆管引流2~3周后,胆漏处均闭合,无严重并发症发生。结论:内镜治疗可作为LC术后胆漏早期治疗的有效方法。     

术中经鼻胆管胆道造影在两镜联合治疗胆囊合并胆总管结石中的应用

目的探讨内镜下十二指肠乳头括约肌切开术（endoscopic sphineterotomy，EST）联合腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）治疗胆囊合并胆总管结石术中经鼻胆引流管（endoscopic nasobiliary drainage，ENBD）胆道造影的价值。方法EST处理胆总管结石并放置ENBD管，在LC术中经ENBD管行胆道造影。结果46例术中经ENBD胆道造影均成功，造影时间5—15min，平均8．2min。术中经ENBD管胆道造影发现胆囊脱落至胆总管形成胆总管继发结石4例，其中2例术中再次内镜取出结石，2例结石直径〈3mm术中未处理，术后随访未见胆管结石及胆管炎发生。43例随访6—36个月，平均22个月，未发现胆总管再发结石及胆道逆行感染。结论两镜联合治疗胆囊结石合并胆总管结石，术中经ENBD胆道造影可及时发现并通过术中内镜及时处理继发性胆总管结石，减少术后胆管残余结石的发生。     

联合应用LC与EST治疗胆囊胆总管结石

目的: 探讨联合应用腹腔镜胆囊切除术(LC)与内镜十二指肠乳头括约肌切开术(EST)治疗胆囊和胆总管结石的疗效. 方法: 对18例病人术前按常规行B超或CT检查,证实为胆囊结石合并胆总管结石.11例先行LC,一个月后行ERCP检查并做EST治疗;7例先行B超、ERCP检查及EST,一周后行LC. 结果: 全组18例均获成功,无中转开腹及严重并发症. 结论: 联合应用LC和EST治疗胆囊结石合并胆总管结石的方法切实可行,具有创伤小、效果好、并发症少、恢复快等优点.     

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.     

两镜法治疗胆囊合并胆总管结石36例疗效分析

目的探讨十二指肠镜乳头括约肌切开术(endoscopic sphincterotomy, EST)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy, LC)治疗胆囊合并总胆管结石的疗效. 方法胆囊合并胆总管结石36例,首先经EST取出胆管结石,然后采用LC切除胆囊. 结果 EST成功34例(94.4%); 失败2例,均因胆管末端狭窄,开腹行胆管空肠吻合术治愈.腹腔镜手术34例,成功32例(94.1%),2例中转开腹. 结论 EST联合LC是治疗胆囊合并胆管结石的优选术式,EST失败者主要原因为胆管狭窄,应首选胆管空肠吻合术.     

The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis

BACKGROUND: The risk of damage to the bile duct and structures in the hilum of the liver is significant when Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy, and conversion to an open procedure often is performed. This is more common during emergency surgery, but may not render the procedure any easier. Traditionally, open subtotal cholecystectomy was performed, but with the advent of laparoscopic surgery, this has fallen from favor. The authors report their experience using laparoscopic subtotal cholecystectomy to avoid bile duct injury and conversion in difficult cases. METHODS: Laparoscopic subtotal cholecystectomy, performed when the cystic duct cannot be identified safely, consists of resecting the anterior wall of the gallbladder, removing all stones, and placing a large drain into Hartmann's pouch. The notes for all patients who underwent a laparoscopic subtotal cholecystectomy between 1 September 2001 and 31 December 2004 were retrospectively analyzed. RESULTS: Subtotal cholecystectomy was performed in 26 cases including 13 emergency and 13 elective procedures. The median age of the patients (15 women and 11 men) was 68 years (range, 36-86 years). The indications were severe fibrosis in 16 cases, inflammatory mass or empyema in 8 cases, and gangrenous gallbladder or perforation in 2 cases. The median postoperative inpatient stay was 5 days (range, 2-26 days). Five patients underwent postoperative endoscopic retrograde cholangiopancreatography: four for persistent biliary leak and one for a retained common bile duct stone. One patient required laparotomy for subphrenic abscess, and one patient (American Society of Anesthesiology [ASA] grade 4, presenting with biliary peritonitis) died 2 days postoperatively. One patient required a subsequent completion laparoscopic cholecystectomy for a retained gallstone. One patient had a chest infection, and two patients experienced port-site hernias. CONCLUSIONS: Laparoscopic subtotal cholecystectomy is a viable procedure during cholecystectomy in which Calot's triangle cannot be dissected. It averts the need for a laparotomy.     

腹腔镜胆囊切除术和内镜括约肌切开术治疗胆囊胆总管结石的观察

目的:探讨腹腔镜胆囊切除术和内镜括约肌切开术联合治疗胆囊胆总管结石的临床效果。方法:胆囊胆总管结石21例先行腹腔镜胆囊切除术,再行内镜括约肌切开术取出胆总管结石。结果:除1例腹腔镜胆囊切除术中转开腹手术外,余者内镜括约肌切开术取出胆总管结石均获成功。结论:腹腔镜胆囊切除术和内镜括约肌切开术联合治疗胆囊胆总管结石的临床效果可靠。     

胆囊结石伴急性胆囊炎的腹腔镜手术时机

目的 :探讨胆囊结石伴急性胆囊炎的腹腔镜手术时机。方法 :回顾分析 12 2例患者的临床资料。结果 :115例顺利完成腹腔镜胆囊切除术 (LC) ,7例中转开腹。全组并发胆漏 1例 ,粘连性肠梗阻 1例。结论 :只要掌握正确的手术时机 ,及时中转开腹 ,急性胆囊炎行LC是安全可行的。     

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.     

腹腔镜胆囊切除术前逆行胆管造影的临床价值

目的探讨在腹腔镜胆囊切除术 (LC)前 ,行内镜逆行胆管造影 (ERC)对判断胆总管并存病变的价值。方法对 43例病史中有黄疸、胰腺炎 ,肝功能异常 ,B超怀疑或证实胆管结石的患者 ,经ERC排除或取石后 ,再行LC。结果 43例ERC造影均获成功 ,ERC成功取出胆管结石 34例 ,LC成功 39例 (91 % )。术前有黄疸史 (P <0 0 1 ) ,胆总管扩张≥ 1cm(P <0 0 0 1 ) ,肝功能异常 (P <0 0 0 1 ) ,有胰腺炎史 (P <0 0 5) ,提示存在胆管结石。发生并发症 1例 (3 % ) ,无死亡。随访 1～ 3个月 ,未发现胆管残余结石。结论LC与ERC联合应用可有效治疗胆囊疾病合并总胆管结石     

Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones.

BACKGROUND: To assess the outcome of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy (LC) for symptomatic gallbladder and suspected duct stones. METHODS: During 3 years, one or more of four criteria led to ERC: jaundice, choledocus >8 mm, cholestasis, and severe biliary pancreatitis. Endoscopic extraction (ESE) of ductal stones was attempted before LC. RESULTS: In all, 990 patients were prospectively included. There were no exclusions. There were no deaths. A multivariate logistic regression analysis identified jaundice (P = 0.001), pancreatitis (P = 0.001), and cholestasis (P = 0.001) as statistically significant predictors of ductal stones. Choledocus >8 mm was not a significant predictor (P = 0.12). A total of 155 (16%) patients underwent ERC for suspected stones: 21 of 155 (13%) patients had no stones; and 6 of 134 (4%) patients had stone impaction cleared at open surgery. ERC clearance rate was 95% (128 of 134). LC was performed in 149 of 155 patients after a median interval of 3 days (range 1 to 7). Morbidity rates were 3% (4 of 134), 2% (3 of 149), and nil (0 of 6) after ESE, LC, or open surgery, respectively. Median hospital stay was 11 days. A total of 835 patients underwent LC with a 1.5% complication rate. Laparoscopic fluoro-cholangiography showed < or =3 mm-sized stones in 10 of 835 (1.2%) patients. No stones were reported at a median follow-up of 4 months including 990 patients. CONCLUSIONS: Ninety-five percent of patients with ductal stones can be successfully and safely managed by ERC prior to LC.