胆道镜下液电碎石术治疗肝内胆管残留结石的研究

肝内胆管结石是胆道外科常见疾病，其术后残留结石发生率可高达30．0％～96．0％。胆道镜的出现使术后残石的治疗有了很大的进步，而胆道镜下液电碎石术（electrohymulic lithotripsy，EHL）则进一步提高了镜下碎石的效果和结石取净率，减少了胆道镜取石次数，并为肝内巨大、嵌顿、铸状结石（常规胆道镜下难取性结石）提供一种简单、有效的方法。我院自1996年5月至2005年12月期间，在胆道镜下应用EHL治疗肝内胆管残留结石56例，报道如下。     

液电碎石在肝内胆管难取性结石中的应用

目的探讨对肝内胆管难取性结石实施液电碎石的方法和安全性。方法回顾性总结２４例肝内胆管难取性结石的液电碎石治疗资料。液电碎石方法是：３例术中经肝外胆管,１８例术后经Ｔ管窦道及３例经胆肠吻合皮下预置空肠盲袢途径,置入电视监视胆道镜至结石处,再经胆道镜送入液电碎石电极直抵结石实施碎石。结果碎石成功率１００％,全部病例未出现明显并发症。结论液电碎石治疗肝内胆管难取性结石是简便、安全和有效的。     

胆道镜配合中药治疗胆道术后残余结石

目的总结胆道术后残余结石应用纤维胆道镜取石并配合中药胆胰和胃冲剂治疗的效果。方法对127例胆道术后残余结石及其胆管狭窄应用纤维胆道镜取石及服用我院研制的中药胆胰和胃冲剂治疗与预防结石复发,观察其效果。结果结石取净率97．64％(124／127),3例因T管脱落或拒绝治疗,未能取净。胆管狭窄经纤维胆道镜扩张,都可以达到取石和解除狭窄的目的。经1～2年的随访,治愈病例无结石复发。结论纤维胆道镜经T管窦道处理术后残石,绝大多数可以解除胆管狭窄,取净结石,服用中药胆胰和胃冲剂可利胆排石,调整胆道内环境,逆转成石胆汁,有预防胆石复发的功效。     

胆道镜下液电碎石术治疗难治性胆管残留结石

胆管结石历来以外科手术为主，但效果并非十分理想．很多复杂的肝内胆管结石、胆总管结石术后残留率高达30％～96％，手术越做越大，效果仍不满意。由于镜技术的发展，胆道治疗内镜术已达到了一个临床能够接受的成熟水平，而胆道镜下液电碎石术则进一步提高了镜下碎石的效果和结石取净率。     

胆道镜下激光碎石术治疗残留胆管结石的临床观察

目的探讨电子胆道镜下激光碎石治疗手术后难取性胆道残留结石的疗效和安全性。方法回顾2007年2月-2009年2月电子胆道镜下激光碎石治疗难取性肝内、外残留结石22例的临床资料,观察治疗情况和效果。结果取石成功率95．5％（21／22）,其中一次性取石成功率86．4％（19／22）,经二次成功取石2例,1例患者因肝内多部位胆管结石且部分结石位于Ⅱ级以上胆管、胆管成角大胆道镜未能进入而无法完成碎石、取石治疗。未发生胆道出血、窦道穿孔、感染等并发症。结论胆道镜下激光碎石治疗手术后难取性胆道残留结石疗效确切,并发症少,安全可行。     

纤维胆道镜给T管窦道取石的护理体会

胆道镜经T管窦道取石是治疗肝内外胆管残余结石的微创而又有效的方法。肝胆管结石大多不能在手术中一次取净，术后残余结石率高达96％。术后4～6周可行纤维胆道镜经T管窦道取石，经B超、CT检查证实无残余结石后才能拔除T管。我院1999—01／2001—06共取石127例，现将护理体会报告如下。     

纤维胆道镜治疗胆管结石（附562例报告）

本院使用导光纤维胆道镜（以下简称纤胆镜）治疗５６２例胆管结石。其中，术中胆道镜检取石６８例，术后胆道镜检取石４９４例。５３８例结石取净，取净率９５．７％。为便于术后纤胆镜检及取石，用Ｔ管由切口引出腹腔，其长臂与总胆管和切口保持垂直；对泥沙样结石和胆管腔内大量絮状物的病人，采用肝素生理盐水Ｔ管滴入；对肝内胆管的嵌顿性结石，先采用活检钳在结石上打洞或开沟，再用生理盐水或双氧水加压冲洗，或使用等离子体冲     

经内镜鼻胆管引流术在腹腔镜胆管探查中的作用

目的：应用经内镜鼻胆管引流术(ENBD)作为腹腔镜胆管探查术(LCBDE)胆管引流方式，探讨其应用价值。方法：对拟行腹腔镜下胆管探查的患者术前进行ENBD，后经胆总管探查切口应用液电碎石、胆道镜取石，将肝内外胆管结石取净，保留鼻胆管于胆管内，将胆总管探查切口一期缝合，常规放置腹腔引流管。术后经鼻胆管造影，肝内外胆管无残余结石，无胆漏，择期拔除腹腔引流管及鼻胆管。结果：共43例患者术前行ENBD，平均6．1d后行LCBDE。36例(83.7％)患者成功进行LCBDE，胆管探查切口一期缝合。术后经鼻胆管造影，发现1例(2．6％)术中胆道镜漏诊--小结石，经内镜取石后痊愈；无胆管狭窄及胆漏等并发症发生。另有7例患者(18．6％)中转开腹手术，其中2例保留鼻胆管，胆管切口行一期缝合，术后顺利拔除鼻胆管。38例患者(88．4％)均成功应用：ENBD进行胆管引流，平均3．2d拔除腹腔引流管，6.7d拔除鼻胆管，无相关并发症发生。结论：ENBD作为LCBDE胆管引流，是安全有效的方式，且术后引流时间短，并发症少，可充分发挥出腹腔镜治疗胆管结石微创的优势。     

应用YAG激光击碎肝内及胆总管结石

作者报道11例肝内胆管及胆总管结石使用Yag激光及纤维胆道镜所作的碎石术。 Yag激光系统的光导纤维导光率达80%;所用胆道镜的直径为4.7～6.0mm。纤维胆道镜先经胆道术后的T管引流瘘管或经皮肝胆管(PTC)引流瘘管插入胆道,然后将石英光导纤维经胆道镜上的导孔插入,使光纤输出端直接贴附于结石上,用40W功率的Yag激光照射,每次5秒钟,每个结石反复照射数次。碎石用胆道镜取出。用本法治疗共11例;年龄40～77岁。8例为肝内胆管结石,3例为胆总管结石。5例为外科手术后残留结石,术后数周经T管引流瘘管应用激光-纤维胆道镜击碎之,6例经PTC引流瘘管进行碎石术。操作每次需15～120分钟。5例经纤维胆道镜通过T管引流     

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．     

1552例胆道镜临床应用体会

自１９７９年１２月至１９９５年３月，应用胆道镜对１５５２例胆道疾患病人进行了检查和治疗。术中使用胆道镜后，胆总管残石率下降至３％，肝内胆管残石率下降至１３％。术后对１２８７例病人经Ｔ管瘘道或皮下空肠盲袢进行了胆道镜检查，胆总管残石取石成功率９４％，肝内胆管残石取石成功率９１％。全组无一例死亡，未发生严重并发症。我们认为胆道镜对胆道残石的处理明显优于其它方法，且具有创伤小和恢复快的优点，是一种值得推广的内镜应用技术。     

Pulsed dye laser lithotripsy of bile duct stones.

Efficacy and safety of pulsed dye laser lithotripsy was tested in 25 consecutive patients in whom bile duct stones could not be extracted after endoscopic sphincterotomy. The patients had one to six (mean, 1.8) bile duct stones (diameter, 10-35 mm; mean, 18 mm) located in the common bile duct (18 cases), the intrahepatic bile ducts (6 cases), or in a long cystic duct stump (1 case). Different approaches were tested depending on the presence of a T tube and on the localization of the bile duct stones. When a T tube was present (7 cases), the lithotripsy was performed under direct vision using a choledochoscope inserted through the T-tube tract. In 18 patients without a T tube in place, the lithotripsy was performed under fluoroscopy using a retrograde approach in case of common bile duct stones (14 cases) or under choledochoscopy using a percutaneous transhepatic approach in case of intrahepatic bile duct stones (4 cases). Fragmentation of all the bile duct stones and a complete bile duct clearance were obtained in all 11 cases with procedures performed under direct vision as compared with only 5 of 14 cases with procedures under fluoroscopic control. Moreover, 6 of the 9 failures using the latter approach were offered another session using a choledochoscope inserted through a percutaneous transhepatic tract and were also successfully treated. No complication related to the laser beam was noted. It is concluded that pulsed dye laser lithotripsy of bile duct stones (that are unable to be removed by standard endoscopic techniques) is safe and efficacious provided that it is performed under direct vision. Technical refinements are needed before this procedure can be reliably performed under fluoroscopy.     

ANALYSIS OF PLASTIC STENTS IN THE TREATMENT OF LARGE COMMON BILE DUCT STONES IN 45 PATIENTS

Background: Although endoscopic plastic biliary stenting is a clinical procedure routinely carried out in patients with common bile duct stones, the effects of stenting on the sizes or fragmentation of large common bile duct stones have not been formally established and the mechanism of this condition is controversial. We compared the stone sizes of common bile duct stones after biliary stenting in order to develop the mechanism. Patients and Methods: Endoscopic plastic biliary stenting was performed in 45 patients with large common bile duct stones or those difficult to extract with conventional endoscopic therapy, including mechanical lithotripsy. The stone diameter was ≥16 mm in all patients. Bile duct drainage and endoscopic placement of 7–8.5 Fr plastic biliary stents were established in all patients. Differences of stone sizes and fragmentations after biliary stenting were compared. The complete stone clearance rate after treatment was obtained. Results: After biliary stenting for 3–6 months, the bile stones disappeared or changed to sludge in 10 (10/45) patients, and fragmentation of the stones or decreased stone sizes were seen in 33 patients, whose stone median size was significantly decreased from 23.1 mm to 15.4 mm in 33 patients (P < 0.05). The stones were removed successfully with basket, balloon, mechanical lithotripsy or a combination in 43 (43/45) patients. The remaining two patients (2/45) demonstrated no significant changes in stone sizes. Conclusion: Plastic biliary stenting may fragment common bile duct stones and decrease stone sizes. This is an effective and feasible method to clear large or difficult common bile duct stones.     

内镜治疗胆总管结石的临床研究

目的 探讨内镜在胆总管探查取石中的应用价值。方法 对227例拟诊胆总管结石 的患者采用经内镜治疗,其中14例直径<1.0 cm的结石采用经内镜乳头球囊扩张术治疗,194例直 径1.0-1.5cm的结石采用内镜乳头括约肌切开治疗,19例直径>1.5cm的结石采用内镜下机械碎 石治疗。结果 15％(34例)胆管造影未见结石,经内镜探查阴性。余193例中,187例取石成功,成 功率为96.9％(187／193)。并发症发生率为5.29%(12／227),其中急性胆管炎3例,急性胰腺炎8 例,消化道出血1例。结论 内镜治疗胆总管结石安全有效,并发症少,应当首选。但对ERCP无法 明确的胆总管结石,不主张行乳头括约肌切开及内镜下的胆管探查,以最大限度地减少并发症。     

Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy. METHODOLOGY: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates. RESULTS: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance. CONCLUSIONS: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.     

内镜下逆行胰胆管造影术治疗老年胆总管巨大结石40例

目的探讨内镜下逆行胰胆管造影术(ERCP)治疗老年胆总管巨大结石的可行性及安全性。方法 40例老年胆总管巨大结石患者完善术前准备,密切监护下经十二指肠镜先行ERCP,发现胆总管结石后行内镜下十二指肠乳头括约肌切开(EST)和机械碎石(EML)取石,视具体情况留置鼻胆管引流及支架置入引流。结果 40例患者37例取石获得成功,成功率92.5%;其中10例经过二次取石。所有患者腹痛症状明显改善,皮肤巩膜黄染迅速消褪,发热患者48 h内体温趋于正常。术后并发轻型胰腺炎4例,乳头肌切口创面轻度渗血2例,均经内科保守治疗痊愈,未发生肠穿孔、胆道撕脱等严重并发症和死亡。结论 ERCP治疗老年胆总管巨大结石是一种安全、有效的治疗方法,应考虑作为治疗的首选方案。     

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。     

De novo stent-stone complex after long-term biliary stent placement: pathogenesis, diagnosis, and endotherapy

BACKGROUND: Long-term and permanent biliary stenting have been reported in many studies and are infrequently practiced in selected patients with irretrievable common bile duct stones and biliary strictures. PATIENTS: Here we report 3 new cases and review 7 other cases of de novo stent-stone complex formation after long-term biliary stent placement. INTERVENTIONS: De novo stent-stone complexes developed in 3 young patients after unintended long-term biliary stent placement of 4.5 to 11 years' duration. The stent-stone complexes were successfully removed during ERCP with electrohydrolic lithotripsy (EHL) in combination with choledochoscopy or extracorporeal shock wave lithotripsy (ESWL) with mechanical lithotripsy (ML). RESULTS: The de novo radiolucent stones formed around and above the stent in the proximal and end part of the stent. The stones were generally large with a diameter>2 to 3 cm. The stent-stone complex usually assumed a 1-sided dumbbell configuration inside the bile duct. The mean duration to clinical presentation after initial biliary stenting is 5.64 years (range 2-11 years). CONCLUSIONS: It is important to keep in mind that a biliary stent can act as a nidus for new biliary stone formation around the stent after long-term placement. We recommend that the optimal endotherapy in this situation is ML for the free-floating complexes with short stents, and choledochoscopy with EHL or laser lithotripsy and ESWL for impacted complexes with longer stents.     

Extracorporeal lithotripsy in the treatment of common bile duct calculi]

Thirty-three patients with common bile duct stones which could not be extracted by routine endoscopic measures were treated with extracorporeal lithotripsy. Two electrohydraulic lithotripters were used: Dornier HM3 and Technomed Sonolith 3000 using fluoroscopy and ultrasonography, respectively, for stone localisation. Twenty-nine patients were treated with only one session and four patients in two sessions. Fragmentation of stones was obtained in 29 patients (88 p. 100) and complete bile duct clearence in 26 patients (79 p. 100). The fragments passes spontaneously through the papilla in 7 cases; in 19 cases complete removal of fragments was achieved with a Dormia basket (16 cases) or after mechanical lithotripsy (3 cases). There were no significant differences in successful fragmentation rates between the two lithotriters. No serious adverse effects or mortality were observed within the 30 days following treatment. In conclusion, extracorporeal lithotripsy is an effective and safe method for the treatment of bile duct stones when, after sphincterotomy, routine endoscopic measures have failed.