腹腔镜、胆道镜、十二指肠镜在胆总管探查一期缝合中的应用

目的探讨腹腔镜、胆道镜、十二指肠镜二镜或三镜联合胆总管探查一期缝合的可行性及疗效。方法对61例胆总管结石患者应用二镜或三镜联合胆总管探查一期缝合的疗效进行了回顾性分析。结果 61例中56例完成了一期缝合,未放置鼻胆管的病例中6例出现胆漏,经腹腔引流管引流治愈。无出血、切口感染等发生。结论掌握好手术适应证,二镜或三镜联合胆总管探查一期缝合安全可行。     

老年胆总管结石患者腹腔镜胆总管探查术后一期缝合与T管引流疗效比较

目的比较腹腔镜胆总管探查术(laparoscopic common bile duct exploration,LCBDE)后一期缝合与T管引流治疗老年胆总管结石患者的临床疗效.方法回顾分析2011-2016年67例接受腹腔镜下胆总管探查术的老年胆总管结石患者的临床资料,其中34例行一期缝合,33例放置T管引流,分析比较两种手术方式的安全性及术后并发症情况.结果两组手术时间、术中出血量及腹腔引流管拔除时间均无统计学差异(P0.05),而一期缝合组肛门排气时间(2.0 d±0.6 d)、术后住院时间(9.6 d±2.2 d)明显短于T管引流组(P0.05).两组术后并发症发生率无统计学差异(P0.05),其中一期缝合组患者术后出现胆漏1例、结石复发1例,T管引流组术后出现水电解质紊乱2例、残余结石1例.结论对于老年胆总管结石患者,在LCBDE后,如严格掌握适应证、操作技术熟练,一期缝合是安全、有效的,且相对T管引流,患者的生活质量较高.     

两种微创术式在胆总管结石合并胆囊结石中的临床应用

目的:比较腹腔镜胆囊切除术(LC)+腹腔镜胆总管切开胆道镜探查取石术(LCBDE)+胆总管一期缝合术与内镜逆行胰胆管造影(ERCP)+内镜下十二指肠括约肌切开取石术(EST)+鼻胆管引流术(ENBD)+LC治疗胆总管结石合并胆囊结石的临床疗效。方法:收集2015年6月至2021年2月间山西白求恩医院普通外科收治的200...     

腹腔镜胆总管探查结合球囊导管扩张即时缝合胆总管切口的探讨

目的 探讨腹腔镜胆总管探查术中,结合球囊导管扩张治疗Oddi括约肌和肝内胆管狭窄,行胆管切口即时缝合的适应证和并发症。方法 采用腹腔镜胆总管探查取石,结合球囊导管行Oddi括约肌或肝内胆管狭窄扩张术,效果满意,经胆道镜检查结石取净后,胆管切口用4-0或5-0可吸收缝线即时缝合,不放置胆道内外引流,Winslow孔附近常规放置腹腔多孔引流管观察渗漏情况。结果 42例中41例获成功（结石取净、狭窄扩张满意及即时缝合术后无胆漏）。8例肝管I、Ⅱ级分支狭窄者经扩张,胆道镜先端可通过狭窄,1例术后从腹腔引流管流出胆汁30-150ml/d,持续4d后减至20ml/d,术后6d拔管,d痊愈出院 。术后3个月门诊B超检查发现1例继发性胆总管结石患者,有胆管积气和胆管炎。1例原发性肝胆管结石有左肝管残留结石。结论 腹腔镜胆管探查术中结石取净后,对合适病例,用斑马导丝引导耐高压球囊导管或抗划损球囊导管扩张Oddi括约肌狭窄和肝内胆管狭窄,胆管切口采用可吸收缝线即时缝合,不放置胆道内外引流是较安全、可行的。     

腹腔镜术中联合胆道镜或十二指肠镜治疗胆总管结石

目的总结腹腔镜术中联合胆管镜或十二指肠镜治疗胆囊疾病合并细径胆总管（≤0．8cm）结石的治疗经验。方法首先完成腹腔镜下胆囊切除术。胆管镜法：经胆囊管残端扩张、经胆囊管胆总管汇合部切开或经胆总管前壁切口入路,采用胆管镜取石网取石和液电碎石取净结石,经胆囊管残端输尿管导管胆管引流、T管引流或行胆总管切口即时缝合术。十二指肠镜法：经胆囊管残端插入输尿管导管或斑马导丝至十二指肠腔,经口插入十二指肠镜至十二指肠乳头,针式刀或弓式刀在输尿管导管或斑马导丝指引下对乳头施行切开术,用十二指肠镜取石网或球囊取石。结果191例患者进行了联合治疗。联合胆管镜法治疗117例,术中胆管镜下均取净结石,平均手术时间114min;术后胆漏7例,均经术中常规放置的胆管引流和腹腔引流管引流治愈;术后影像学复查,胆总管切口即时缝合区呈现轻度狭窄影像2例。联合十二指肠镜法治疗74例,68例乳头切开和取石成功,5例乳头切开成功,1例中转为其他术式,平均手术时间97min;术后轻症胰腺炎6例。两组均无肠穿孔、胆管穿孔、大出血、重症胰腺炎等严重并发症,无死亡。结论只要选择病例合适,腹腔镜术中联合胆管镜或十二指肠镜治疗细径胆总管结石是安全、有效且可行的。     

肝内外胆管结石的微创治疗策略

肝内外胆管结石是一种常见、多发疾病,其传统的开腹手术近年来受到微创手术的挑战.本文通过文献检索,结合作者的实践经验,在全面总结肝内、外胆管结石的微创治疗现状基础上,探讨出一种可有效提高其微创治疗效果的策略:(1)对于肝内胆管结石:可根据指征选用腹腔镜肝切除、腹腔镜胆总管探查取石术(laparoscopic common bile duct exploration,LCBDE)、经皮经肝胆道镜取石术;(2)对于胆囊结石合并胆总管结石:可根据指征选用腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)+经内镜十二指肠乳头括约肌切开(endoscopic sphincterotomy,EST)或经内镜乳头气囊扩张术(endoscopic papillary balloon dilatation,E P B D)、L C+经胆囊管胆总管探查取石术(laparoscopic transcystic common bile duct exploration,LTCBDE)、LC+LCBDE+T管引流或一期缝合术;(3)对于肝内合并肝外胆管结石,可根据指征选用腹腔镜肝切除、经肝断面胆管胆道镜取石、LCBDE、EST、经皮经肝胆道镜碎石术.根据上述策略,结合术者的技术和设备条件,合理选择微创治疗方法,对于提高肝内、外胆管结石的治疗效果具有重要意义.     

腹腔镜治疗肝外胆管结石个体化方案的临床应用

肝外胆管结石是外科常见病、多发病,随着腔镜镜技术的发展,腹腔镜治疗肝外胆管结石得到了迅速发展.我院按照个体化方案采用腹腔镜治疗肝外胆管结石患者173例,疗效满意,现总结报道如下.一、资料与方法1.病例资料:2004年6月至2010年12月共173例肝外胆管结石患者在我院接受了腹腔镜个体化方案治疗,所有患者术前明确诊断为结石性胆囊炎合并胆总管结石,无腹腔镜手术禁忌证.其中45例接受腹腔镜经胆囊管胆道探查术(LTCBD)治疗(LTCBD组);53例接受腹腔镜胆总管切开术(LD)+T管引流(TD)治疗(LD+ TD组);25例接受LD+Ⅰ期缝合术(PS)治疗(LD+ PS组);35例接受经内镜乳头括约肌切开术(EST)+腹腔镜胆囊切除术(LC)治疗(EST+ LC组);15例接受经内镜鼻胆管引流术(ENBD)+LD治疗(ENBD+ LD组).     

LC、胆总管探查及一期胆管缝合术治疗胆囊结石合并胆总管结石

目的观察腹腔镜胆囊切除术（Lc）、胆总管探查及一期胆管缝合术治疗胆囊结石合并胆总管结石的疗效。方法将85例胆囊结石合并胆总管结石患者随机分为观察组45例和对照组40例,对照组行LC、胆总管探查及T管引流术,观察组行Lc、胆总管探查及一期胆管缝合术。结果观察组术中出血量为（100±15）ml,手术时间为（136．5±25．0）min,住院时间为（10．5±2．0）d;对照组分别为（110±20）ml、（152．0±27．5）min、（13．5±2．5）d。两组比较,P均〈0．05。结论LC、胆总管探查及一期胆管缝合术治疗胆囊结石合并胆总管结石可有效减少术中出血量,缩短手术和住院时间。     

气囊鼻胆管在治疗细径胆总管结石中的临床应用59例

目的:探讨腹腔镜、十二指肠镜、气囊鼻胆管探查术(laparoscopic duodenoscopic balloon nasobiliary exploration,LDBNE)同期治疗胆囊结石合并细径胆总管结石的应用体会.方法:回顾性分析2010-04/2015-07成都市第二人民医院运用LDBNE的手术方式,对59例胆囊结石合并细径胆总管(胆总管内径约2-8mm)结石的患者进行治疗的临床材料.结果:LDBNE治疗59例,成功切除胆囊59例;乳头切开取净结石42例(成功率71.2%),联合气囊鼻胆管下取净结石11例(成功率18.6%),中转为经胆囊管汇合部切口和胆总管前壁切口胆管镜下取净结石5例(中转率8.5%);术后胆管残留结石1例(1.7%),排石治愈.术后胆漏1例(1.7%),经术中放置的鼻胆管引流和腹腔引流自愈.术后轻症胰腺炎3例(5.1%),经保守治愈.术后总并发症发生率为8.5%(5/59).术后其他并发症均经非手术综合疗法治愈.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,LDBNE治疗胆囊结石合并细径胆总管结石是可行、有效和安全的.     

自制新型鼻胆管在胆总管探查术中的应用

对34例胆石症患者(观察组)行胆总管探查术,术中置自制新型鼻胆管、行胆总管一期缝合,并与同期32例行传统T管引流术患者(对照组)比较.结果观察组置新型鼻胆管成功率100%,无1例发生胆漏;拔管时间[(5.0±1.5)d]、术后住院时间[(9.2±1.3)d]较对照组[(15.2±3.6)d]、[(17.1±5.6)d]短,P均<0.05.证明术中采用新型鼻胆管引流、胆总管一期缝合操作简单、安全可靠,可避免T型管引流所致胆漏等并发症,缩短住院时间.     

A Case of Post-Laparoscopic Cholecystectomy Bile Leakage from the Cystic Duct Treated by Endoscopic Nasobiliary Drainage without EST

Abstract: The patient was a 45 year old female with cholelithiasis who had undergone laparoscopic cholecystectomy. Bile leakage was detected from the site of Penrose drain insertion immediately after the operation. As no improvement of bile leakage was subsequently observed, ERCP (endoscopic retrograde cholangiopancreatography) was performed on the third postoperative day. Neither choledocholithiasis nor choledochal stricture was found and the diagnosis of bile leakage from the cystic duct stump was made. A 5Fr ENBD (endoscopic nasobiliary drainage)-tube without EST (endoscopic sphincterotomy) was inserted into the common bile duct, and bile leakage disappeared completely on the third day after insertion of the ENBD tube. Additional laparotomy, EST or biliary stenting was thereby avoided. Choledo-chography, via the ENBD-tube, showed no leakage of contrast material, the ENBD-tube was removed and the patient was discharged. ENBD should be considered as a method of treatment for management of bile leaks from the cystic duct stump.     

鼻胆管注入溶石中药治疗胆总管较大结石疗效观察

[目的]观察内镜介入配合鼻胆管注入中药溶石治疗胆总管较大结石的疗效。[方法]依据体外碎石结果,自拟溶石方,收集因无法行内镜下胆总管取石的10例患者,行内镜下鼻胆管引流术,通过鼻胆管注入溶石中药20~50 ml,封闭鼻胆管末端1~2 h后恢复正常引流,2次/d,5~7 d后复查B超及内镜下逆行胰胆管造影术(ER-CP)。[结果]10例患者中1例结石完全溶解,复查B超胆总管结石消失;9例结石明显变小或裂解。ERCP除1例结石消失直接拔除鼻胆管外,9例复查ERCP检查发现结石均明显变小,其中2例铸形结石分散、裂解成多块。该9例直接行网篮取石均1次成功,胆总管结石全部取净。[结论]鼻胆管注入中药溶石治疗胆总管较大结石安全、可靠,疗效显著。     

腹腔镜联合内镜胆总管探查术

目的 探讨运用多种微创治疗手段,治疗经内镜取石失败的胆总管结石患者。方法 运用三窥联合的手术方式（术前内镜下经鼻胆管引流、腹腔镜胆总管探查术及术中胆道镜（对３９例胆总管结石患者进行微创治疗。结果 ３９例手术均获成功,无中转开腹,无残留结石及严重并发症。术后住院时间明显缩短,而手术时间与开腹手术相似。部分病例随边半以上未见远期并发症。结论 三镜联合行胆囊切除、胆总管探查术对于有较高内镜、腹腔镜技术水     

难取性胆管结石内镜综合治疗的探讨

目的探讨肝内外胆管多发性结石、巨大结石、壶腹部嵌顿性结石、小乳头及乳头旁憩室切开禁忌者、T管引流术后残余结石ERCP困难者等难取性胆管结石内镜治疗。方法分别采用术中、术后胆道镜、EST后机械碎石、胆道子母镜、鼻胆／胆肠引流等方法。结果 149例难取性胆管结石中。术中胆道镜取净率95％(19／20),术后经T管胆道镜取净率(35／40)87．5％,机械碎石率94．7％,(72／76),肝外胆管结石取净率94．6％(122／129)。结论应用内镜下综合治疗难取性胆管结石大大提高了结石取净率、减少了残石率。达到去除病灶、通畅引流,值得推广。     

改良鼻胆管与普通鼻胆管引流在经胆囊入路治疗细径胆总管结石患者疗效研究

目的 探讨使用内镜下改良的鼻胆管引流(ENBD)在经胆囊入路治疗细径胆总管结石(CBDS)患者的疗效。方法 2015年12月～2018年6月我科诊治的54例细径CBDS患者(对照组),采用腹腔镜胆囊切除术(LC)后,在腹腔镜下经胆囊管行胆总管探查术,再在十二指肠镜协助下经腹顺行安置常规鼻胆管引流;2018年7月～2020年12月我科诊治的54例细径CBDS患者(观察组),手术方法同前,只是使用改良的鼻胆管进行引流。常规检测血清C反应蛋白(CRP)、白介素-6(IL-6)和肿瘤坏死因子-α(TNF-α)。结果 观察组术后胆汁引流量和鼻胆管拔管时间分别为(281.6±52.5)mL和(5.9±1.3)d,显著多于或长于对照组【分别为(228.7±53.2)mL和(4.0±1.4)d,P<0.05],而住院日为(6.1±1.1)d,显著短于对照组[(8.1±1.3)d,P<0.05】;观察组术后并发症,如胰腺炎、胆漏和鼻胆管滑脱发生率为7.4%,显著低于对照组的25.9%(P<0.05);在术后1周,观察组血清CRP、IL-6和TNF-α水平分别为(42.8±11.1)mg...     

Biliary navigation surgery using endoscopic nasobiliary drainage tube for the prevention of bile duct injury in laparoscopic cholecystectomy

Bile duct injury is the most troublesome complication in laparoscopic cholecystectomy (LC). The identification of the anatomical relationship between the cystic duct and common bile duct is one of the most important points for the safe LC. Therefore, we introduced a biliary navigation surgery using endoscopic nasobiliary drainage (ENBD) tube to avoid bile duct injury during LC. The benefit of intraoperative cholangiography using an ENBD tube is that the identification of the anatomical relationship between the cystic duct and common bile duct can be confirmed by using intraoperative cholangiography through the ENBD tube. We consider that ENBD tube is useful for identifying the biliary tract by repeated intraoperative cholangiography and, thus, for preventing injury to the bile duct in LC.     

三种外科疗法治疗老年胆囊结石并发肝外胆管结石病人的疗效比较

目的 探讨3种外科疗法治疗老年胆囊结石并发肝外胆管结石病人的疗效与并发症.方法 选取我院2016年7月至2019年6月收治的178例胆囊结石并发肝外胆管结石的老年病人作为研究对象,其中63例采用腹腔镜胆囊切除术联合腹腔镜胆总管探查术(LC+LCBDE),61例采用内镜逆行胰胆管造影联合腹腔镜胆囊切除术(ERCP+LC)...     

Choledocholithiasis treated by ethylenediaminetetraacetic acid infusion through an endoscopic nasobiliary catheter

A 64 year old man was admitted to the National Cheng Kung University Hospital for obstructive jaundice. He had received cholecystectomy 5 years previously. Sonography revealed common bile duct stones. He was treated with endoscopic nasobiliary drainage (ENBD) for 5 days for concomitant cholangitis. The muddy pigment stones disappeared completely after 10 days of infusion of ethylenediaminetetraacetic acid (EDTA) via the ENBD tube. There were no adverse effects, and he was stone-free 4 months later.     

Endoscopic nasobiliary drainage for treating bile leak after laparoscopic cholecystectomy.

BACKGROUND/AIMS: Bile leaks are common complications of laparoscopic cholecystectomy. We evaluated the diagnosis and endoscopic treatment of bile leaks. METHODOLOGY: A total of 436 patients underwent laparoscopic cholecystectomy with infrahepatic drainage. We performed immediate endoscopic retrograde cholangiopancreatography (ERCP) on all patients with bile discharge from an infrahepatic drain, and treated bile leaks which were not due to a major ductal injury by endoscopic nasobiliary drainage (ENBD) without endoscopic sphincterotomy (ES). RESULTS: Ten patients developed bile leaks which were recognized within 18 hours of operation. ERCP, on post-operative day 1 or 2, showed a bile leak from the cystic duct (9 patients) or the liver bed (1 patient). All patients underwent ENBD. Only 1 patient, who had a retained stone, had ES. In all patients, the bile leak resolved promptly and both the infrahepatic and nasobiliary drains were removed within 6 days of cholecystectomy. All patients were asymptomatic at a mean follow-up of 30 months. CONCLUSIONS: Routine placement of an infrahepatic drain is recommended for the early detection of bile leaks. Bile leaks can be successfully treated by prompt ENBD without ES.     

Laparoscopic choledochotomy for bile duct stones

In the era of laparoscopic surgery, treatment strategies for common bile duct stones remain controversial. Laparoscopic choledochotomy is usually indicated only when transcystic duct exploration is not feasible. However, laparoscopic choledochotomy provides complete access to the ductal system and has a higher clearance rate than the transcystic approach. In addition, primary closure of the choledochotomy with a running suture and absorbable clips facilitates the procedure. Therefore, to avoid postoperative biliary stenosis, all patients with bile duct stones can be indicated for choledochotomy, except for those with nondilated common bile duct. Placement of a C‐tube also provides access for the clearance of possible retained stones by endoscopic sphincterotomy as a backup procedure. C‐tube placement, in contrast to T‐tube insertion, is advantageous in terms of a relatively short hospital stay. In conclusion, laparoscopic choledochotomy with C‐tube drainage is recommended as the treatment of choice for patients with common bile duct stones.