经十二指肠镜治疗胆总管大结石

目的 探讨经十二指肠行逆行胆胰管造影（ERCP）及内镜下十二指肠乳头括约肌切开术（EST）取石对胆总管大结石病人的治疗价值。方法 本组21例胆总管大结石病人应用ERCP及EST，采用碎石取石网篮即时取石，较大结石采用机械碎石后取出。结果21例胆总管结石病人全部行EST，一次取尽结石14例（66．7％），二次取尽结石5例（22．8％），因碎石过多难以取尽1例（4．8％），1例因结石过大放弃治疗，取石成功率为90．5％，其中碎石治疗17例（81．0％），一次碎石成功13例（76．5％）。2次碎石成功3例（17．6％），1例因结石过大而放弃，碎石成功率94．1％。结论 经十二指肠镜治疗胆总管大结石是行之有效的好方法，多可避免外科手术治疗。     

机械式碎石术联合胆道母子镜治疗胆道结石

目的采用内镜技术及机械碎石术治疗胆总管结石．方法应用机械式碎石器，在十二指肠乳头括约肌切开基础上，结合胆道母子镜，鼻胆管引流术治疗23例胆道结石患者．其中男10例，女13例、单发结石11例、多发结石12例左肝管结石2例，右肝管结石1例，双侧肝管结石1例，胆道内结石最多者33块，最大结石直径3．0cm×4．5cm．伴有乳头傍憩室5例，胆总管癌1例，结果23例患者全部取石成功．取石次数：单发结石11例均一次取石成功．多发结石12例5例取石二次，3例取石一次，4例肝内胆管结石，网篮在肝管内难以充分张开，在取除胆总管结石后，再次应用子镜取除肝管内结石并发症：①出血，EST时乳头切口出血3例，5d后延迟出血1例．②刀丝断裂，十二指肠乳头括约肌切开刀刀丝断裂1例．③穿孔、感染，黄疸加重．本组病例中，无一例出现发热、黄疸加重，无穿孔．结论对胆道内大结石及肝管内结石的处理方法，胆道内，2cm，5cm以上的结石，虽经乳头切开，采用一般的网篮圈套方法很难奏效，并且操作时患者疼痛明显．采用碎石器将结石粉碎后再取石则要安全的多，我们用碎石器碎石时，无一例发生意外．     

经内镜治疗胆总管结石60例临床分析

目的探讨内镜逆行胰胆管造影术（ERCP）和内镜下十二指肠乳头肌切开术（EST）治疗胆总管结石的临床效果。方法对60例确诊为胆总管结石的患者采用经内镜治疗,其中结石直径〈1．0cm的47例采用取石网篮取结石,泥沙样结石加用气囊取石,结石直径在1．1～2．0cm的8例,用取石网篮,但对稍大、较硬的结石用碎石网篮碎石后取出。结石直径〉2．1cm的5例,用碎石网篮碎石后取出。结果60例经治患者,一次性取净结石者51例,2次取净者6例,共57例取石成功,内镜治愈率95％;出现并发症5例,占8．33％;其中急性胰腺炎1例,其他4例患者为术后轻度的上腹疼痛、恶心、呕吐、及一过性发热和高淀粉酶血症。结论内镜治疗胆总管结石具有创伤小、并发症少、疗效确切、恢复快等优点．是目前胆管疾病较好的微创介入治疗方法。     

内镜下机械碎石术治疗胆总管大结石

目的 探讨内镜下机械碎石术治疗胆总管大结石的价值。方法 32例经ERC证实胆总管结石直径≥1．5cm。其中结石直径1．5～1．9cm17例，2．0～2．4cm9例，≥2．5cm6例，单颗结石24例，2颗结石5例，3颗或以上结石3例。先行乳头肌切开，然后使用机械碎石器于胆管内将结石粉碎取出。结果 机械碎石成功31例，成功率96．9％，失败1例。1次碎石取净结石28例，2次3例，3次1例。发生并发症4例，发生率12．5％，其中切口渗血和出血2例，急性胰腺炎1例．急性胆管炎1例，症状均较轻微。结论 对于直径≥1．5cm的胆总管大结石，单纯使用普通取石网篮难以取出，机械碎石术可不受结石大小限制，是理想、有效的碎石取石方法。     

经内镜乳头气囊扩张术治疗胆总管结石

目的探讨经内镜乳头气囊扩张术（ＥＰＢＤ）治疗胆总管结石的安全性和疗效。方法经内镜乳头气囊扩张术治疗胆总管结石８８例。其中单颗结石４５例,２颗结石３３例,３颗以上结石１０例,最多１例１２颗结石,选择结石直径为２～１２ｍｍ。结果治疗成功８５例,占９６．５％,失败３例。８１例采用网篮或取石气囊取出结石,４例采用金属碎石篮碎石后排出,１例改用内镜乳头括约肌切开术（ＥＳＴ）。７９例病人经ＥＰＢＤ后即取出结石,７例经２～３次再次取石后取净。术后出现胆管炎１例、胰腺炎１例,４４例术后行胃肠钡餐Ｘ线检查,胆道内无钡剂反流。结论经内镜乳头气囊扩张术是一种安全有效的方法,有望替代部分括约肌切开术。     

经内镜乳头括约肌切开术治疗胆总管结石108例临床分析

目的 :探讨经内镜乳头括约肌切开术 (EST)治疗胆总管结石的临床效果。方法 :EST治疗胆总管结石 1 0 8例。其中结石直径 <0 .5cm 1 2例 ,0 .6～ 1 .0cm 38例 ,1 .1～ 1 .5cm 30例 ,1 .6～ 2 .0cm 1 3例 ,2 .1～ 2 .5cm 9例 ,>2 .5cm 6例。单颗结石 68例 ,2颗结石2 7例 ,3颗以上结石 1 3例 ,最多的 1例结石 1 4颗。结果 :EST取石成功 1 0 5例 ,成功率 97.2 % ,失败 3例。采用取石网篮、取石球囊和机械碎石网篮取石。EST术后并发症 6例 ,发生率 5 .6 %。其中切口出血 3例 ,急性胰腺炎 2例 ,重症胆管炎 1例。随访 88例 ,时间 1个月～ 2年 ,全身状况良好 ,B超或CT检查无再发结石。结论 :经内镜乳头括约肌切开术是一种治疗胆总管结石安全、有效的治疗方法     

不同内镜术式治疗胆总管结石青年患者的长期随访研究

目的探讨不同的常用内镜治疗方法对胆总管结石青年患者治疗后结石复发的影响以及结石近期复发、远期复发的危险因素。方法选择经一次性治疗性内镜逆行胰胆管术（ERCP）成功取石后随访资料完整的胆总管结石青年（21～45岁）患者,按手术方式分为内镜下乳头球囊扩张术（EPBD）组、乳头括约肌切开术（EST）组、EST（切开〈0．5cm）＋EPBD组,进行随访,统计近期（≤3年）及远期（〉3年）结石复发率,并对复发危险因素进行Logistic回归分析。结果资料完整的327例患者平均随访76．5个月,54例（16．5％）结石复发,其中近期复发35例（10．7％）,远期复发19例（5．8％）。近期胆总管结石复发率EPBD组（11．3％）和EST组（13．2％）均高于EST＋EPBD组（8．1％）,但无统计学差异（P均〉0．05）。远期胆总管结石复发率EPBD组（11．3％）和EST组（6．6％）均显著高于EST＋EPBD组（0．8％）,差异具统计学意义（P均〈0．05）。Logistic回归分析结果表明,胆囊结石、结石最大径、结石个数、机械碎石与近期结石复发显著相关（P〈0．05）,而远期胆总管结石复发则与结石最大径及单纯球囊扩张显著相关（P〈0．05）。结论对于胆总管结石青年患者,单纯EPBD取石固然可保留乳头括约肌功能,但增加了结石的远期复发风险,而乳头括约肌小切开联合EPBD取石可显著降低胆总管结石复发率。     

经内镜治疗大于1.0 cm的胆总管结石

直径≤1．0cm的胆总管结石行经内镜乳头括约肌切开（EST）后可用取石网篮直接取出，操作较简单，取石成功率高，并发症少。而直径大于1．0cm的结石，必须碎石后取出，增加了操作难度、手术风险，并发症的发生率高。本文总结本院近年来37例1．0cm以上胆总管结石患者的治疗结果，报告如下。[第一段]     

内镜下治疗胆总管扩张的疗效及临床意义

目的 探讨内镜下治疗胆总管扩张的疗效及临床意义。方法 将22例胆总管扩张病人行内镜下逆行胰胆管造影(ERCP)后做十二指肠乳头括约肌切开(EST)。诊断为胆总管结石16例，EST后经网篮取出结石；十二指肠乳头炎性狭窄2例，行EST，为预防并发症，8例病人行鼻胆管引流(ENBD)；诊为胆管癌3例、壶腹癌1例均行胆道支架置入(EMBE)。术后观察随访6个月。结果 18例结石、炎症病人痊愈，其中8例行ENBD，术后7天拔除引流管，恢复好；术中诊为胆管癌3例，壶腹癌1例行ENBE，3例胆道扩张解除、黄疸消退，1例转外科手术治疗，2月后死亡。结论 内镜下治疗胆总管扩张效果确切，能诊断结石、炎症及肿瘤，并根据病因进行针对性治疗，有重要的临床意义。     

胆囊切除术后胆总管继发和残留结石的内镜治疗

目的 探讨经内镜乳头括约肌切开术(EST)治疗胆总管术后继发和残留结石的方法和价值。方法 经内镜逆行胰胆管造影(ERCP)证实为胆道术后残留或继发结石的患34例，单枚结石13例，2枚结石6例，多枚结石15例，结石直径0．3～2．5cm不等，32例行EST成功，全部经予网蓝碎石、取石、气囊取石等治疗。结果 32例行EST成功，成功率93．9％，31例经网蓝和气囊取石成功，成功率96．8％，其中1例取石失败。术中3例乳头切口有出血，1例术后血淀粉酶升高，经非手术治疗控制，无严重并发症发生。结论 EST是治疗胆总管术后残留和继发结石安全、有效的重要方法之一。     

内镜扩约肌切开术治疗胆总管继发性结石

目的评价逆行胰胆管造影术（ＥＲＣＰ）和内镜括约肌切开术（ＥＳＴ）在腹腔镜胆囊切除前后诊断和治疗胆总管继发结石中的作用．方法采用ＥＲＣＰ和ＥＳＴ在ＬＣ术前或术后诊断和治疗胆总管继发结石２２８例,其中包括ＬＣ术前发现的１８５例和术后确诊的４３例．常规ＥＲＣＰ检查,证实胆总管内有结石后行ＥＳＴ．然后根据结石形态、大小和数目不同采取不同方法处理结石．①自然排石,适合于直径在０３ｃｍ～０８ｃｍ的结石;②取石网篮取石,适合于直径在０９ｃｍ～１５ｃｍ的结石;③碎石篮碎石,适宜直径大于１５ｃｍ以上的结石．结果全部２２８例患者中,ＥＳＴ成功２１７例（９５２％）,胆总管结石完全排出２０９例（９１７％）,发生各种并发症１９例（８８％）,主要并发症为急性胰腺炎、急性胆管炎和Ｏｄｄｉ扩约肌切口渗血,全部经非手术治疗愈合,无死亡病例．结论ＥＲＣＰ和ＥＳＴ是ＬＣ术前和术后诊治胆总管结石安全有效的方法之一．     

十二指肠乳头旁憩室与胆胰疾病的关系

目的：探讨十二指肠乳头旁憩室与胆胰疾病的关系。材料和方法：作者采用三种检查方法确诊乳头旁憩室１４１例，根据憩室的部位和类型分为乳头上憩室、乳头下憩室、憩室内乳头。结果：全组并发结石者１２０例，其中胆囊结石４３例，占３０．５％。肝外胆管结石７４例，占５２．５％。肝内胆管结石３例，占２％。２１例有憩室而无结石者占１５％。３５例曾行胆囊切除术，有３０例并发胆管结石，占８６％。再次手术后又有２３例再生胆管结石，复发率７７％。结论：乳头旁憩室与胆胰疾病有关，尤其与胆管结石有显著关系。     

经内镜诊治肝移植术后胆道远期并发症

目的：探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植患者胆道远期并发症中的应用。方法：肝移植术后出现胆道远期并发症患者6例，共行ERCP 12次，根据患者的情况进行扩张、内镜下乳头切开取石、内支架置入等治疗。结果：1例胆总管结石行乳头切开后取石成功，1例胆道狭窄在胆道扩张后胆道梗阻症状解除，4例胆道狭窄合并胆总管结石的狭窄近端结石经乳头切开取出，狭窄远端结石行胆道扩张、内支架置入等治疗后取出。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度的下降，无严重并发症发生。结论：ERCP是诊断和治疗肝移植患者胆道远期并发症安全、有效的手段。     

改良内镜下乳头气囊扩张术应用的可行性研究

目的探讨改良内镜下乳头气囊扩张术（EPBD）治疗胆管结石的可行性。方法对226例肝外胆管结石的患者应用肠道型柱状气囊行乳头扩张并在此基础上展开治疗，并比较2299例内镜乳头切开术（EST）的治疗效果及术后并发症情况。结果226例患者均顺利完成取石或碎石取石术，术后无胆道感染、穿孔等并发症，发生轻型急性胰腺炎4．7％（10例），与EST（5．2％）比较，差异无统计学意义，术后消化道出血0．47％（1例），与EST（1．2％）比较，差异有统计学意义。结论对EST困难或易发生并发症者用肠道型柱状气囊行EPBD术，能有效地钝性切割乳头，并在此基础上展开较大结石的取石或碎石取石术，同时并发症明显减少。EPBD是内镜下处理胆管结石安全有效的方法之一。     

Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy.

BACKGROUND: Endoscopic biliary sphincterotomy (EST) is a well-established procedure for bile duct stone extraction. Bile duct stones can be classified as primary or secondary. However, few data are available on the recurrence of primary and secondary bile duct stones after EST. Therefore risk factors for the recurrence of primary bile duct stones after EST were prospectively studied. METHODS: Between 1991 and 1997, 61 patients underwent EST for primary bile duct stones. All met the following criteria: (1) previous cholecystectomy without bile duct exploration, (2) detection of bile duct stones at least 2 years after initial cholecystectomy. Mean follow-up was 2.2 years. Fourteen patients were lost to follow-up. The recurrence of primary bile duct stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of primary bile duct stones. RESULTS: The overall recurrence rate of primary bile duct stones was 21% (10 of 47). Two significant risk factors for recurrence were identified by multivariate analysis: (1) patients with a bile duct diameter of 13 mm or greater after stone removal had recurrences more frequently than those with a duct diameter of 13 mm or less, and (2) patients whose papilla was located on the inner rim or deep within a diverticulum, so that the papillary orifice was not visible endoscopically, had more frequent recurrences than patients with a papilla outside the diverticulum, or no peripapillary diverticulum. CONCLUSION: The independent risk factors for recurrence of primary bile duct stones were sustained dilation of the bile duct even after complete removal of stones and location of the papilla on the inner rim or deep within a diverticulum.     

The clinical study on the utility of endoscopic electrohydraulic lithotripsy of common bile duct stone

Using the cholangiofiberscope, electrohydraulic lithotripsy was performed in 20 patients with biliary tract stones. In all cases, stones were destroyed and removed without any serious complications. Since these treatments no recurrence of stones has been recognized (average 8.6 months, longest 16 months). The average period of PTCD needed for the treatments was 34.3 +/- 8.1 days, and the average number of treatments needed was 1.7 +/- 1.0. The average time taken was 91 +/- 26 minutes, and the period from PTCD until hospital discharge was 39.8 +/- 6.1 days for cases of common bile duct stone, and 46.3 +/- 8.8 days for common bile duct and gall bladder stone. This period for cases of common bile duct stone is equivalent to that taken by surgical procedures in our hospital. This treatment seems to be at least as good as EST or surgery for cases of common bile duct stone. It is especially appropriate for those patients who reject surgery, are elderly, poor risks, or recurrent cases.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

胆胰疾病行治疗性内镜逆行性胰胆管造影术811例临床分析

目的探讨治疗性内镜逆行性胰胆管造影术(ERCP)在胆胰疾病中的应用价值及其并发症的防治。方法回顾性分析上海中医药大学附属普陀医院2001年9月至2006年9月行治疗性ERCP的811例胆胰疾病患者的临床资料。结果562例胆总管结石患者中行乳头切开术(EST)474例,行乳头气囊扩张术(EPBD)88例,结石总清除率为95%;244例恶性胆道梗阻患者中183例行鼻胆管引流(ENBD),61例行胆道内支架引流术(ERBD);5例恶性胆胰管梗阻患者行胆胰管双支架引流术。行胆道内支架引流可使血清胆红素明显下降,胰管支架置入可使上腹部疼痛有一定程度减轻。并发症:乳头切开处出血13例(1.6%),均发生于EST术后;急性胰腺炎43例(5.3%),其中发生于EST术后32例,EPBD术后7例,ENBD术后2例,ERBD术后2例;EST术后发生急性胆囊炎4例(0.5%);全组死亡2例(0.2%)。结论应用十二指肠镜行治疗性ERCP去除胆管结石,控制胆道炎症,解除胆胰管恶性梗阻是一种理想的微创外科方法,熟练的技术与细致的围手术期处理是防治并发症关键。     

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones. METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed. RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P=0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P=0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P=0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P=0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P=0.00). CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.     

Perioperative fluorocholangiography with routine indication versus selective indication in laparoscopic cholecystectomy

BACKGROUND: The use of routine or selective peroperatory cholangiography in cholecystectomy is a matter of controversy in literature. AIM: To compare the efficacy of selective or routine fluorocholangiography in diagnostic of common bile duct stone in patients underwent to laparoscopic cholecystectomy based on selective indication criteria. METHOD: Two hundred and fifty four patients with cholelithiasis were prospectively studied. The patients were divided in two groups: to the first 127 patients perioperative fluorocholangiography was indicated as routine (group 1), and to the other 127 patients perioperative fluorocholangiography indication followed clinical criteria (jaundice, choluria, fecal acholia and history of pancreatitis), laboratory criteria (increase in seric alkaline phosphatase, bilirubins, amylase) or ultra-sonographyc criteria (less than 6 mm diameter calculi, common bile duct stone, common bile duct diameter more than 6 mm). A comparative assessment of the difference in common bile duct stone diagnosis, fluorocholangiography success index and reliability of the selective criteria of indication for perioperative fluorocholangiography was compared between the two groups. RESULTS: Perioperative fluorocholangiography was successfully performed in 102 of the 127 patients from group 1 (a rate of 80.3%), and in 59 of the 71 patients from group 2 (a rate of 83.1%). In the 102 patients of group 1 who underwent perioperative fluorocholangiography, 11 (10.8%) presented common bile duct stone, 4 (3.9%) presented common bile duct dilatation, and 1 (1%) had a false-positive image. In the 59 patients from group 2, 7 (11.7%) presented common bile duct stone and one (1.7%) presented a common bile duct diatation. In another situation, when application of selective indication criteria to perioperative fluorocholangiography was simulated in group 1 patients, we observed that only in one patient with common bile duct stone the diagnostic would not have been made. Fluorocholangiography selective indication criteria presented sensitivity of 90.9% and specificity of 46.2%. The main causes of fluorocholangiography failure were biliary pedicle inflammation and cystic duct size and caliber variations. CONCLUSION: There was not a significant difference in common bile duct stone diagnostic through perioperative fluorocholangiography between the groups of patients with selective and routine indication, validating the examination selective indication criteria, with a sensitivity of 90.9%, despite the specificity of 46.2%--43 patients were selected to the flourocholangiography and common bile duct stone was not diagnosed.