超声引导下双通道置管联合胆道镜保胆取石术治疗高龄急性结石性胆囊炎

目的 探讨超声引导下双通道置管联合胆道镜保胆取石术治疗高龄急性结石性胆囊炎患者的疗效.方法 回顾性分析2012年1月至2013年12月成都军区总医院收治的35例高龄(≥80岁)胆囊结石患者的临床资料,先在B超引导下行经皮胆囊双通道穿刺置管引流,后期联合胆道镜保胆取石术.术后长期口服消炎利胆药物,降低结石复发.采用电话和门诊随访,随访时间截至2014年6月30日.结果 35例患者B超引导下胆囊穿刺置管均一次性成功,1例发生穿刺后出血,经对症治疗止血成功;因置管窦道形成不佳改行胆囊切除术1例;余34例均成功取石;随访4～24个月,结石复发1例.结论 双通道胆囊穿刺置管联合胆道镜保胆取石治疗高龄急性结石性胆囊炎,该手术方式方法简单、疗效可靠,具有推广价值.     

双通道植管联合胆道镜保胆取石治疗高龄结石性胆囊炎

目的：评价B超引导下胆囊穿刺双通道植管联合胆道镜保胆取石治疗高龄高危急性结石性胆囊炎患者的疗效。 方法：回顾性分析2012年1月—2013年12月收治的35例80岁以上急性结石性胆囊炎患者的临床资料。 结果：35例患者均行超声引导下胆囊穿刺双通道植管胆囊冲洗、减压、持续引流,6~8周后,行胆道镜经窦道保胆取石。所有患者超声引导穿刺植管均一次性成功,1例发生穿刺后出血,经对症处理止血成功;1例因植管窦道形成不佳改行胆囊切除术,余34例均成功保胆取石（34/35）;随访4~24个月,结石复发1例（1/34）。 结论：双通道胆囊穿刺植管联合胆道镜保胆取石治疗高龄高危胆囊结石方法简单、疗效可靠,具有推广价值。

     

胆囊穿刺造瘘后双通道胆道镜保胆取石与腹腔镜胆囊切除术治疗老年患者结石性胆囊炎疗效的比较

目的比较超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石与胆囊穿刺造瘘后行腹腔镜胆囊切除术（1aparoscopiccholecystectomy,LC）治疗老年患者急性结石性胆囊炎的临床疗效。方法回顾性分析2012年1～9月接受双通道胆囊穿刺造瘘联合胆道镜保胆取石治疗的30例老年结石性胆囊炎（保胆取石组）和胆囊穿刺造瘘后行Lc治疗的30例老年结石性胆囊炎（Lc组）的临床资料,比较2组手术操作时间、术中出血量、住院时间、消化不良症状发生率等。结果60例均穿刺置管成功,带管时间14d-2个月,平均30d。4～8周后,保胆取石组30例成功行胆道镜取石,结石取净率100％,取石过程中无出血、漏胆、继发胆总管结石、切口感染等手术并发症。LC组28例三孔法完成LC,2例因粘连组织难以分离中转开腹手术,术中、术后均无严重并发症。保胆取石组术中出血量（8．8±1．7）ml,显著少于LC组（18．9±1．2）ml（t=-25．968,P=0．000）;保胆取石组住院时间（4．4±0．6）d,显著短于LC组（5．6±0．5）d（t=-8．243,P=0．000）。保胆取石组术后随访3、6、12个月,B超检查1例复发,5例有上腹部不适、腹泻、食欲不佳等消化不良症状,发生率16．7％（5／30）,LC组术后21例有消化不良症状,发生率70．o％（21／30）,2组比较有显著性差异（x2=17．376,P=0．000）。结论超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石操作简便,在术中出血量、住院时间、远期生活质量等方面均优于胆囊造瘘后行LC。     

介入超声联合胆道镜双通道“一步法”治疗高龄急性结石性胆囊炎的疗效观察

目的 探讨介入超声联合胆道镜双通道“一步法”治疗高龄高危急性结石性胆囊炎的临床可行性。方法 回顾性分析2016年6月至2018年7月于西部战区总医院就诊并接受该技术治疗的54例患者临床资料。结果 54例患者均成功完成双通道置管（超声引导下经皮经肝胆囊穿刺,同期行胆道镜取石）。其中50例患者取石成功,成功率为93%;并发症方面,1例出血,1例术后超声复查疑似胆漏。50例患者随访3～12个月,1例结石复发。结论 超声引导下经皮经肝胆囊穿刺同期胆道镜取石这种双通道“一步法”治疗高龄高危急性结石性胆囊炎安全有效,具有临床可行性。     

PTGD联合小切口胆道镜取石治疗高龄、高危急性梗阻性结石性胆囊炎

目的探讨B超引导下经皮经肝胆囊穿刺引流(PTGD)联合二期小切口胆道镜取石术治疗高龄、高危急性梗阻性结石性胆囊炎患者的疗效。方法回顾性分析2009年1月至2013年12月期间接受PTGD联合小切口胆道镜取石治疗的124例高龄、高危急性梗阻性结石性胆囊炎患者的临床资料。结果 124例均穿刺置管成功,置管引流后3~5 d出院。除2例引流管脱出;其余122例6~8周后行右上腹小切口胆囊切开胆道镜取石术,其中91例取净结石后一期缝合胆本+更换PTGD管,31例行胆囊切除。继发胆总管结石6例,其中4行经胆囊管胆道镜取石,2例行经胆囊管残端胆道镜取石。手术顺利,未发生胆管损伤、胆漏等重大并发症或死亡。结论 PTGD联合二期小切口胆道镜取石治疗高龄、高危急性梗阻性结石性胆囊炎,符合损伤控制理念,是一项有效、简便、微创的方法。     

两镜联合微创保胆取石术治疗胆囊颈部结石嵌顿的临床体会

目的:总结胆囊颈部结石嵌顿行两镜联合微创保胆取石术的临床体会.方法:回顾分析2008年3月至2010年3月为73例胆囊颈部结石嵌顿患者施行两镜联合手术的临床资料.结果:51例一次性保胆取石成功;18例行胆囊造瘘术,其中17例Ⅱ期经瘘道胆道镜胆囊探查成功保胆,1例因术后一直无胆汁,胆囊无功能,Ⅱ期施行腹腔镜胆囊切除术(l...     

双镜联合保胆取石术126例报告

目的:探讨腹腔镜与胆道镜联合行保胆取石术的手术指征、方法及技巧。方法:回顾分析2010年5月至2012年5月为126例患者行腹腔镜联合胆道镜保胆取石术的临床资料。结果:122例顺利完成保胆取石术;2例因胆囊内泥沙样结石取石不满意改行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),2例因术中切开胆囊后见白色胆汁流出,胆囊管基本闭锁,改行LC。术后均无并发症发生,出院后服用熊去氧胆酸6个月,随访3～15个月,未见结石复发。结论:把握手术适应证,双镜联合行保胆取石术安全、可行,保留了功能较好的胆囊,满足了患者对保胆的需求。     

胆囊内嵌顿结石应用钬激光碎石保胆取石35例临床分析

目的探讨胆囊内嵌顿结石应用硬质胆囊镜、胆道镜联合钬激光碎石保胆取石的有效性及安全性。方法选取35例胆囊内嵌顿结石患者,应用钬激光碎石行保胆取石术。回顾性分析患者的临床资料。结果本组35例患者均成功碎石、取石及保胆。手术时间25~110 min。均放置腹腔引流管,其中3例放置胆囊造瘘管。术后未发生胆漏、胆道出血等并发症。随访1~3 a,腹部彩超或CT、MRI检查,除1例近期有絮状物沉积,1例远期出现泥沙样结石外,其余未见结石残留或复发。结论对胆囊内嵌顿结石患者,应用硬质胆囊镜、胆道镜联合钬激光碎石保胆取石,可提高保胆取石的成功率,手术操作易掌握,而且安全性较高。但必须严格掌握手术适应证。     

腹腔镜胆囊造瘘术联合术后胆道镜取石在高龄急危重症胆囊结石患者的临床观察

探讨腹腔镜胆囊造瘘术联合术后胆道镜取石对高龄急危重症胆囊结石患者的疗效。分析山东省立三院以腹腔镜胆囊造瘘术结合术后胆道镜取石治疗的高龄急危重症胆囊结石并胆囊炎患者33例的临床资料。33例患者全部为腹腔镜胆囊切除困难、中转为腹腔镜胆囊造瘘术者,术后1月患者行胆道镜检查,7例患者结石消失;24例患者取净胆囊内结石,拔除造瘘管;2例患者因胆囊颈部结石嵌顿,无法取净结石,给予二期胆囊切除,术后恢复良好。对于腹腔镜胆囊切除困难的急危重症胆囊结石患者,腹腔镜胆囊造瘘术可迅速缓解患者危急症状,术后通过胆道镜取净胆囊内结石,保留胆囊部分功能;减少手术并发症,更安全、有效,值得推广。     

膀胱造瘘穿刺针结合气囊导尿管在经皮胆囊造瘘术中的应用

目的：探讨膀胱穿刺针结合气囊导尿管在高危急性胆囊炎患者中胆囊造瘘的价值。 方法：回顾性分析2001—2010 年收治的42 例高危急性胆囊炎患者临床资料。42 例不能进行急诊 胆囊切除术的高危急性胆囊炎患者在超声引导下应用气囊导尿管经皮穿刺胆囊造瘘术,在胆囊内 放置直径为16 F 气囊导尿管引流胆汁和结石,观察胆囊造瘘前后患者临床症状、体征及白细胞计 数的变化情况。 结果：42 例患者在超声引导下应用膀胱穿刺针和气囊导尿管经皮胆囊造瘘均获得成功。所有患者 术后1~2 d 临床症状、体征缓解。6 例患者获得终末性治疗,4 例术后择期行胆囊切除术,5 例胆 囊小结石通过窦道行胆道镜取石,27 例胆囊结石直径超过窦道直径患者行气压弹道碎石并结合胆 道镜取石。 结论：超声引导下应用气囊导尿管经皮胆囊造瘘术是一种操作简单、安全有效的胆囊造瘘方法, 对于高危的急性胆囊炎患者能缓解症状,且为后续的治疗提供良好的取石通道。     

Percutaneous cholecystostomy for acute cholecystitis in high-risk patients

Seventeen high-risk critically ill patients with suspected cholecystitis underwent percutaneous transhepatic cholecystostomy between 1981 and 1986 using Hawkins' needle guide system for gallbladder intubation. Acute cholecystitis was documented in 15 patients, including 1 with common bile duct obstruction. Two other patients had common bile duct obstruction secondary to metastatic cancer (one patient) and chronic pancreatic fibrosis (one patient). There was rapid resolution of the signs and symptoms of cholecystitis, sepsis, or both in 16 of the 17 patients. One critically ill patient with positive findings on blood culture and an organism resistant to triple antibiotic therapy died soon after percutaneous cholecystostomy. In the entire group of 17 patients, there was no evidence of bile leaks or other catheter complications. Six patients subsequently underwent successful cholecystectomy and two underwent common bile duct exploration without complications. One patient underwent cholecystojejunostomy, and in three patients, the catheter was removed with no sequelae of cholecystitis. Two remaining patients had the catheter in place and were awaiting operation at last follow-up. Three of four patients who died within 30 days of percutaneous transhepatic cholangiographic cholecystostomy died either from the terminal malignant condition (two patients) or from arrhythmia (one patient with cirrhosis). This review suggests that percutaneous cholecystostomy is a safe and effective procedure for resolving acute cholecystitis in high-risk patients. In addition, the technique of percutaneous transhepatic cholangiographic cholecystostomy appears well suited for percutaneous dissolution of stones, sclerosis of the gallbladder, or both in selected high-risk critically ill patients.     

Percutaneous cholecystostomy for acute cholecystitis in high-risk patients

AIM OF THE STUDY: The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia. PATIENTS AND METHODS: From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases. RESULTS: Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without). CONCLUSION: Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.     

Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis

HYPOTHESIS: Tube cholecystostomy followed by interval laparoscopic cholecystectomy is a sale and efficacious treatment option in critically ill patients with acute cholecystitis. DESIGN: Retrospective cohort study within a 4 1/2%-year period. SETTING: University hospital. PATIENTS: Of 324 patients who underwent laparoscopic cholecystectomy, 65 (20%) had acute cholecystitis; 15 of these 65 patients (mean age, 75 years) underwent tube cholecystostomy. INTERVENTION: Thirteen patients at high risk for general anesthesia because of underlying medical conditions underwent percutaneous tube cholecystostomy with local anesthesia. Laparoscopic tube cholecystostomy was performed on 2 patients during attempted laparoscopic cholecystectomy because of severe inflammation. Interval laparoscopic cholecystectomy was attempted after an average of 12 weeks. MAIN OUTCOME MEASURES: Technical details and clinical outcome. RESULTS: Prompt clinical response was observed in 13 (87%) of the patients after tube cholecystostomy. Twelve patients (80%) underwent interval cholecystectomy. Laparoscopic cholecystectomy was attempted in 11 patients and was successful in 10 (91%), with 1 conversion to open cholecystectomy. One patient had interval open cholecystectomy during definitive operation for esophageal cancer and another had emergency open cholecystectomy due to tube dislodgment. Two patients (13%) had complications related to tube cholecystostomy and 2 patients died from sepsis before interval operation. One patient died from sepsis after combined esophagectomy and cholecystectomy. Postoperative minor complications developed in 2 patients. At a mean follow-up of 16.7 months (range, 0.5-53 months), all patients were free of biliary symptoms. CONCLUSIONS: Tube cholecystostomy allowed for resolution of sepsis and delay of definitive surgery in selected patients. Interval laparoscopic cholecystectomy was safely performed once sepsis and acute infection had resolved in this patient group at high risk for general anesthesia and conversion to open cholecystectomy. Just as catheter drainage of acute infection with interval appendectomy is accepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy should have a role in the management of selected patients with acute cholecystitis.     

Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis

Background: Percutaneous cholecystostomy is a valuable alternative temporary measure for acute cholecystitis in elderly patients with severe underlying cardiopulmonary disease, but the subsequent management of gallbladder calculi is still controversial. Methods: Eleven patients treated with percutaneous endoscopic cholecystolithotripsy after percutaneous cholecystostomy were evaluated retrospectively. Results: All patients showed clinical improvement after percutaneous cholecystostomy. Tract dilation succeeded in 9 patients. Complete stone clearance was achieved in seven patients over one to four sessions (average, two sessions). Stone extraction could not be completed in two patients because gallbladder access was lost in one patient, and the other refused further procedure. There were three complications, with two biliary fistulas and one major bile leakage leading to emergency cholecystectomy. The duration of the entire procedure ranged from 30 to 126 days (mean, 58 days). During the follow-up (mean 17.2 months), one patient had recurrent cholangitis and the others remained asymptomatic. Conclusions: Percutaneous cholecystolithotripsy after percutaneous cholecystostomy is a safe alternative in the management of high-risk elderly patients with acute cholecystitis. Received: 26 February 1998/Accepted: 17 July 1998     

An alternative approach to acute cholecystitis

Background: The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 5–30% in high-risk patients such as the elderly or critically ill. An alternative treatment option in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy (PC) followed by interval laparoscopic cholecystectomy. Percutaneous cholecystostomy yields 10–12% mortality in high-risk patients and is therefore a safe temporizing measure, allowing delayed, elective cholecystectomy when the patient is in better condition for surgery. Methods: Hospital charts and radiology films were reviewed for all 50 patients who underwent PC for acute cholecystitis between January 1990 and September 1993. Most patients were high risk for emergency cholecystectomy by virtue of their critical illness or underlying medical condition. Twenty-five patients went on to have interval cholecystectomies. We recorded whether they underwent laparoscopic or open cholecystectomy, as elective or emergency procedures, and we recorded direct complications, mortality, and postoperative length of hospital stay. Results: Relief of symptoms occurred within 48 h of PC in 90% of patients, and two patients had complications of PC. Laparoscopic cholecystectomy was attempted in 13 patients and competed in nine. Four patients (31%) required conversion from laparoscopic to open cholecystectomies due to extensive adhesions (3) or bleeding (1). Three patients had direct complications of laparoscopic cholecystectomy. There was no mortality or major bile duct injury. Conclusion: Percutaneous cholecystostomy followed by interval laparoscopic cholecystectomy is a safe, minimally invasive approach which can be employed safely in the critically ill patient when contraindications to emergency surgery exist.     

Tube Cholecystostomy Before Cholecystectomy for the Treatment of Acute Cholecystitis

Methods:This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012.Results:During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1–59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1–6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump.Conclusions:In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.     

Laparoscopic cholecystostomy with delayed cholecystectomy as an alternative to conversion to open procedure

Background: Acute cholecystitis carries the highest incidence of conversion from planned laparoscopic cholecystectomy to open surgery due to unclear anatomy, excessive bleeding, complications, or other technical reasons. Methods: Laparoscopic tube cholecystostomy was performed instead of immediate conversion to laparotomy in 9 patients with acute cholecystitis after unsuccessful attempts at laparoscopic dissection. Elective laparoscopic cholecystectomy was done 3 months later. Results: Following this approach eight patients were treated successfully. After 3 months the acute process had subsided sufficiently to allow a safe laparoscopic cholecystectomy. One additional patient died of acute leukemia 6 weeks after cholecystostomy. Before adopting this technique we subjected 171 patients with acute calculous cholecystitis to laparoscopic cholecystectomy; there was an 11% (19 cases) rate of conversion. Since cholecystostomy has begun to be offered as an alternative to conversion, 121 patients with acute cholecystitis have had laparoscopic cholecystectomy and only 2 cases (1.5%) have been converted to immediate open cholecystectomy. Conclusions: We recommend the alternative of performing a cholecystostomy with delayed laparoscopic cholecystectomy instead of conversion to open procedure when facing a case of acute cholecystitis not amenable to laparoscopic cholecystectomy.