超声检查在急性胆囊炎腹腔镜胆囊切除术前的应用价值

目的 评价术前超声检查对预测腹腔镜胆囊切除术(LC)治疗急性胆囊炎难度的价值。方法 对180例因急性胆囊炎接受LC的患者,术前超声检查综合分析胆囊轮廓、胆囊颈部、囊壁厚度、囊壁回声、囊内回声情况,评估胆囊周围、Calot三角区的粘连程度,并与手术病理进行对照。结果 超声检查综合性评估胆囊与周围组织粘连程度的敏感度为92.78%(90/97),特异度为93.98%(78/83),准确率为93.33%(168/180)。结论 术前超声检查对预测LC治疗急性胆囊炎的难度有重要价值。     

术前超声检查预测急性胆囊炎腹腔镜胆囊切除术的技术难度

目的评价术前超声检查预测急性胆囊炎腹腔镜手术技术难度.方法对73例因急性胆囊炎行腹腔镜胆囊切除术的患者行超声检查,超声检测参数:胆囊容积、胆囊壁厚度、胆囊壁增厚类型、结石大小、结石移动性、胆囊与胆囊床的粘连、肝与胆囊间的脂肪厚度、胆囊窝液体、总胆管扩张、总胆管结石、胆囊壁彩色和脉冲多普勒征像、邻近肝脏内的彩色和脉冲多普勒信号.腹腔镜胆囊切除手术分5步,每步根据难易程度记分:困难记1分,容易记0分,总分相加为总的难度分数.评价术前超声表现与总的难度分数、每一步难度分数、手术时间长短是否有显著关系.结果胆囊容积≥50 cm3、胆囊壁厚度≥3 mm、胆囊壁内丰富彩色血流信号与手术总难度分数显著相关;胆囊容积增大使粘连胆囊及Calot'三角分离困难;胆囊壁增厚及胆囊粘连者胆囊取出腹腔时较难;胆囊壁彩色血流丰富、邻近肝脏血流增加与手术时间延长有显著关系.结论术前测定胆囊容积、胆囊壁厚度、胆囊壁彩色血流丰富程度有助于预测急性胆囊炎腹腔镜胆囊切除手术中的技术难度.     

经脐单孔腹腔镜胆囊切除术前超声评估价值

目的 探讨超声检查在经脐单孔腹腔镜胆囊切除术前评估中的应用价值.方法 回顾性分析行经脐单孔腹腔镜胆囊切除术90例结石性胆囊炎患者的超声声像图资料.结果 术前超声示单发结石26例,多发结石64例;90患者均符合经脐单孔腹腔镜胆囊切除术手术适应证,82例完成经脐单孔腹腔镜胆囊切除术,8例中转行多孔腹腔镜胆囊切除术.结论 超声检查在经脐单孔腹腔镜胆囊切除术术前评估中有重要指导意义.     

腹腔镜胆囊切除术96例超声造影评估

目的 探讨超声造影对拟行胆囊腹腔镜切除术患者周围粘连情况的评估.方法 对96例拟行胆囊腹腔镜切除术患者行超声造影检查,观察其造影表现,与术中情况对比分析.结果 72例患者进行了腹腔镜手术,6例患者进行了开腹手术.术中与术前造影提示符合77例(98.71％).结论 超声造影能够准确提示胆囊壁与周围组织粘连情况.     

腹腔镜胆囊切除术治疗急、慢性胆囊炎合并胆囊管结石23例

目的 探讨腹腔镜胆囊切除术治疗急、慢性胆囊炎合并胆囊管结石的临床疗效.方法 对23例急、慢性胆囊炎合并胆囊管结石患者均行腹腔镜胆囊切除术.结果 23例患者中,术前B型超声或CT检查诊断为胆囊管结石1例,术中探查发现胆囊管结石22例.除1例因Mirizzi综合征中转开腹外,22例均顺利完成腹腔镜手术.术后均无胆漏及结石残留,均治愈.结论 腹腔镜胆囊切除术治疗急、慢性胆囊炎合并胆囊管结石,术前诊断明确及术中处理是关键,胆囊管充分游离及伸展、胆囊管剪开及捏挤可有效的预防结石残留.     

B超对慢性胆囊炎行腹腔镜胆囊切除术难度的预测

目的：利用术前Ｂ超预测腹腔镜胆囊切除术难度。方法：收集我科１９９５年４月至１９９８年４月,２５６例胆囊炎行腹腔镜胆囊切除术患者术前２４小时Ｂ超及手术的详尽资料。以Ｂ超中各参数为自变量,手术总难度计分为因变量,采用多元回归分析法,评估术前Ｂ超对腹腔镜胆囊切除术难度预测作用。结果：胆囊壁厚度、胆囊管长度有预测作用。结论：术前超声检查对预测腹腔镜胆囊切除术难度有价值     

超声造影对胆囊术前胆囊周围粘连评估的价值研究

目的 探讨利用超声造影评估胆囊术前胆囊周围粘连状态的可行性及判断要点.方法 102例胆囊结石患者在行胆囊切除术前进行胆囊区超声造影检查,并根据术中胆囊周围粘连情况分为无粘连组及粘连组;分析两组超声造影增强特点及差异,总结粘连组的胆囊区增强特征.结果 3个超声造影增强特征有助于诊断胆囊周围粘连:(1)胆囊壁不均匀增强;(2)胆囊游离缘与周围组织间正常平行低增强带的消失;(3)囊壁游离缘周边存在不规则的条片状高低混杂增强区.该3项指标在两组间差异有显著统计学意义(P＜0.001).结论 超声造影检查可于胆囊切除术前较准确地判断有无胆囊周围粘连,对手术难度判断和术式选择等有一定的临床指导意义.     

术前超声预测腹腔镜胆囊切除术难度的受试者工作特征曲线分析

目的建立术前超声预测腹腔镜胆囊切除术(laparoscopiccholecystectomy,LC)难度评分表,并评价其科学性。方法连续选择118例接受LC患者,随机分为两组:训练样本100例,验证样本18例。采用自身前后对照试验方案,术前应用超声检测胆囊大小(长x胆囊底宽)mm2,胆囊壁厚度(mm),胆囊颈有无结石嵌顿,单个胆囊结石数目及最大长径(mm),脐孔及胆囊周围有无粘连;术后登记手术时间(min),术中出血量(mL),有无中转开腹,手术并发症以及术后住院时间(d)。根据100例训练样本LC实际难度分为容易和困难两级,应用t检验和χ2检验统计筛选出有统计学意义的超声检测指标,建立术前超声预测LC难度评分表,进行受试者工作特征曲线(receiveroperatorcharacteristiccurve,ROC)分析。结果胆囊大小、胆囊壁厚度、胆囊颈有无结石嵌顿、脐孔粘连及胆囊周围粘连5项超声检测指标在LC容易和困难两级之间的差异有显著性,P均<0.05。应用5项指标建立术前超声预测LC难度评分表,经ROC分析,曲线下面积为0.922,与完全随机情况下获得的曲线下面积(0.5)相比,差异有显著性,P<0.05。经18例检验样本前瞻性误判概率评估,结果显示术前超声预测LC难度误判率约5.6%。结论术前超声预测LC难度评分表可以正确预测LC难度。     

超声对胆囊周围粘连的诊断价值

目的探讨超声检查对胆囊周围粘连的诊断价值。方法通过超声观察胆囊壁的厚度、胆囊周围片状高回声结构以及胆囊与周围肠管网膜的错位滑动来判断胆囊周围有无粘连。结果90例行腹腔镜胆囊切除术患者,39例经手术及病理证实有胆囊周围粘连,其中超声检出37例,漏诊1例,误诊1例;超声对其诊断敏感性为94．8％,特异性为97．2％。结论超声通过实时动态观察胆囊与周围肠管网膜之间有无错位滑动,结合观察胆囊壁的厚度及胆囊周围片状高回声来判断胆囊周围有无粘连是有效可行的。     

残存胆囊21例的超声诊断

目的探讨超声在残存胆囊诊断中的作用和临床应用价值。方法分析21例残存胆囊的超声表现,结合残存胆囊的病因,总结残存胆囊的超声影像特征及诊断中的注意事项。结果 21例均经超声检查(或联合内镜造影检查)被诊断为残存胆囊,包括胆囊管残留11例、胆囊管残留并残留结石4例、残端小胆囊并残留结石6例。超声检查结果显示:11例胆囊窝部位见无回声区,囊状,较为规则,形似胆囊;大小1.8 cm×1.0 cm~4.5 cm×3.0 cm,边界清晰、壁厚(0.3~0.5 cm),不光滑;其中10例显示有残留的结石。1例于囊内可见强回声,长度0.4~0.8 cm,后方伴声影。2例于囊内可探及不规则低回声团。4例囊壁光滑,囊腔内未探及异常回声。3例超声检查未提示胆囊区域存在异常回声。患者均经再次择期手术治疗后痊愈。结论超声检查可较好地诊断残存胆囊,对于及时发现和防治胆囊切除术后残存胆囊等并发症具有重要临床意义。     

Ultrasound in postoperative acalculous cholecystitis

Eleven patients were examined by ultrasound before undergoing cholecystectomy (n=9) or cholecystostomy (n=2) for acalculous cholecystitis after abdominal surgery. The ultrasound images were analyzed retrospectively and compared with the surgical and histologic findings. The results indicate several established ultrasound criteria of cholecystitis to be less reliable than usual. Although 10 of 11 patients were on parenteral hyperalimentation, gross distention of the gallbladder was observed in only 3. In 4 of 7 patients, in whom pericholecystic fluid was observed, no gallbladder perforation was found at surgery. However, thickening of the gallbladder wall was displayed in 10 of 11 cases, combined with a sonolucent intramural layer in 6. Furthermore, intraluminal nonshadowing echogenic densities correlated with empyema or hemorrhage in 5 of 8 cases. In conclusion, despite several limitations, ultrasound can be of considerable help when one is deciding to perform repeat laparotomy when acalculous cholecystitis is suspected.     

腹腔镜胆囊切除术后胆囊窝异常回声的超声鉴别和治疗后随诊

目的探讨超声对腹腔镜胆囊切除术后胆囊窝出现异常回声诊断鉴别和治疗的价值。方法对24例经腹腔镜胆囊切除术后出现胆囊窝液性异常回声的患者进行超声观察或介入治疗。结果胆囊窝液性回声区在胆囊床范围内的有19例;积液区大于胆囊床范围合并邻近部位或腹腔积液5例。临床处理为:保守治疗19例,超声介入胆囊窝穿刺及置管引流各1例,腹腔穿刺置管引流2例,胆囊窝、腹腔及膈下均穿刺置管1例。24例患者均未再行手术,痊愈出院。讨论超声在胆囊窝液性异常回声的诊治中有重要价值。     

Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis

A positive sonographic Murphy sign, the presence of maximal tenderness elicited over a sonographically localized gallbladder, has been reported to be a helpful adjunctive finding in patients with proven acute cholecystitis who are evaluated with ultrasonography. We evaluated 200 patients with right upper quadrant pain, thought to be acute cholecystitis. Results of ultrasound examinations and subsequent follow-up were tabulated. The sensitivity of the sonographic Murphy sign in acute cholecystitis was 86% with a specificity of 35%, positive predictive value of 43%, and negative predictive value of 82%. The sensitivity of the sonographic findings, including stones, gallbladder wall edema, and pericholecystic fluid collections, was 93%, a specificity of 53%. The combination of the Murphy sign accompanied by gallstones yielded a specificity of 77%. The large number of false positives, and only moderate improvement in specificity when accompanied by gallstones, makes this sign unreliable in separating acute from chronic cholecystitis. © 1995 John Wiley & Sons, Inc.     

超声在腹腔镜胆囊切除术中建立气腹的价值

目的 探讨超声在腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中安全建立气腹的应用价值。方法 应用超声检测110例行LC的患者建立气腹前脐下周围腹壁与肠管间滑动征象诊断有无粘连，并与术中诊断结果比较，同时与术者共同标定最佳第一入腹点，计算超声诊断粘连的敏感性、特异性、准确性、阳性预测值和阴性预测值，记录并发症例数。结果 比较110例行LC的患者超声诊断和术中诊断脐下周围粘连发生率，两者间差异无显著性（P〉o．05），超声诊断脐下周围粘连的敏感性为100％，特异性为98．7％，准确性为99％，阳性预测值为97％，阴性预测值为100％。该组LC成功率为100％，第1孔穿刺并发症为0例。结论 超声可准确地检测脐下周围有无粘连，标定最佳第1入腹点，有效避免第1孔穿刺并发症的发生。     

术前超声检测胆囊周围粘连的方法及其临床价值

目的 探讨术前超声判断胆囊周围有无粘连的方法，观察指标及对预测腹腔镜手术难度的临床价值。方法 采用自身对照研究方案，选择2003年6月～2003年9月间我院26例因胆囊结石拟行腹腔镜胆囊切除术的患。通过超声观察胆囊与肝脏、胆囊周围肠管及脐孔处腹膜与肠管有无错位滑动，判定有无胆囊周围粘连，并在手术中验证。结果 (1)超声检测出12例胆囊与周围肠管或网膜发生粘连，其中1例误诊，另有1例漏诊，本组病例中超声判定胆囊周围肠管粘连的敏感性与特异性均为91．7％，假阳性与假阴性均为8．3％；(2)超声仅见1例脐孔处粘连，并经手术证实；(3)超声及手术均未见胆囊与肝脏发生粘连。结论 通过超声观察胆囊与其周围脏器间有无错位滑动判断胆囊周围有无粘连，是一种简便易行，结果可靠的预测腹腔镜手术难度的方法之一，它能帮助手术医师正确估价手术难度，合理选择病例和手术方式。     

Bedside diagnostic laparoscopy to diagnose intraabdominal pathology in the intensive care unit

Introduction

Delayed diagnosis of intraabdominal pathology in the intensive care unit (ICU) increases rates of morbidity and mortality. Intraabdominal pathologies are usually identified through presenting symptoms, clinical signs, and laboratory and radiological results; however, these could also delay diagnosis because of inconclusive laboratory tests or imaging results, or the inability to safely transfer a patient to the radiology room. In the current study we evaluated the safety and accuracy of bedside diagnostic laparoscopy to confirm the presence of intraabdominal pathology in an ICU setting.

Methods

This retrospective study, carried out between January 2006 and June 2008, evaluated the diagnostic accuracy of bedside diagnostic laparoscopy performed on patients with a suspicion of ongoing intraabdominal pathology. Clinical indications for bedside diagnostic laparoscopy were: ultrasonography (US) images of gallbladder distension or wall thickening of more than 3 to 4 mm, with or without pericholecystic fluid; elevation of laboratory tests (bilirubin, transaminases, myoglobin, lactate dehydrogenase, creatine phosphokinase, gamma-glutamyltransferase); high level of lactate/metabolic acidosis; CT images inconclusive for intraabdominal pathology; or inability to perform a CT scan. Patients did not undergo bedside diagnostic laparoscopy if they presented clear indications for open surgery, coagulopathy, abdominal wall infection or high intraabdominal pressure.

Results

Thirty-two patients underwent bedside diagnostic laparoscopy (Visiport Plus, Autosuture, US), 14 of whom had been admitted to the ICU for major trauma, 12 for sepsis of unknown origin and 6 for complications after cardiac surgery. The procedure was performed on an average of eight days after ICU admission (95% confidence interval = 5 to 15 days) and mean procedure duration was 40 minutes. None of the procedures resulted in complications. Bedside diagnostic laparoscopy was diagnostic for intraabdominal pathology in 15 patients, who subsequently underwent surgery, except in two cases of diffuse gut hypoperfusion. Diagnosis of cholecystitis was obtained in seven cases: two were treated with laparotomic cholecystectomy and five with percutaneous gallbladder drainage positioning.

Conclusions

Bedside diagnostic laparoscopy represents a safe and accurate technique for diagnosing intraabdominal pathology in an ICU setting and should be taken into consideration when patient transfer to radiology or the operating room is considered unsafe, or when routine radiological examinations are not conclusive enough to reach a definite diagnosis.     

胆囊结石患者微创保胆取石术前超声诊断效能及术后复发的高危因素

目的  分析胆囊结石患者微创保胆取石术前彩色多普勒超声（CDFI）诊断效能及术后复发的高危因素。方法  选取2017年1月~2020年1月本院收治的90例拟行微创保胆取石术的胆囊结石患者为研究对象,所有患者在术前均接受CDFI检查,观察胆囊结石患者CDFI表现,并以手术结果为金标准,采用Kappa检验评价其诊断结果的一致性,采用ROC曲线评估CDFI诊断胆囊结石的效能,计算曲线下面积;术后随访2年,统计胆囊结石复发情况,采用单因素和多因素Logistic回归分析影响患者术后复发的高危因素。结果  术前,胆囊内结石表现为不规则形、圆形或类圆形低信号影;胆囊保肝取石术后,大小约4.9 cm×1.8 cm,壁增厚,约1.3 cm,内壁见点状强回声附着,后方伴彗星尾,腔内透声好,胆囊未见明显积液;90例患者中,金标准诊断显示阳性81例,阴性9例,CDFI诊断显示阳性74例,阴性16例,其诊断结果与手术一致性较好（Kappa值=0.524）;ROC曲线显示,CDFI诊断胆囊结石的曲线下面积为0.840,敏感度为90.12%,特异性为77.78%;术后随访2年,有12例患者复发,单因素和多因素Logistic回归分析结果显示,胆石症家族史、胆囊壁厚度、结石数量均是影响胆囊结石患者术后复发的高危因素（P < 0.05）。结论  CDFI对胆囊结石患者微创保胆取石术前诊断具有较好的效能,胆石症家族史、胆囊壁厚度、结石数量均是胆囊结石患者术后复发的高危因素。     

Endoscopic sonography in the diagnosis of gallbladder wall lesions in patients with gallstones

PURPOSE: The purpose of this study was to evaluate the diagnostic accuracy of endoscopic sonography (EUS) in the detection of gallbladder wall lesions in patients with and without gallstones. METHODS: We retrospectively reviewed the medical records, sonograms, and sonographic reports of 62 patients who underwent cholecystectomy for gallbladder wall lesions evaluated by EUS. We assessed the accuracy of EUS in diagnosing gallbladder wall lesions in the presence or absence of gallstones and on the basis of the size and number of stones and the size of the gallbladder wall lesions. We also evaluated the effect of acoustic shadowing. The EUS results were compared with the histopathologic results. RESULTS: EUS correctly diagnosed the gallbladder wall lesions in 17 (71%) of 24 patients with gallstones and in 34 (89%) of 38 patients without gallstones. The diagnostic accuracy of EUS was 86% in patients with gallbladder wall lesions smaller than 20 mm and 79% in patients with gallbladder wall lesions 20 mm or larger. The diagnostic accuracy was 75% in patients with gallstones smaller than 5 mm and 67% in patients with stones 5 mm or larger. The accuracy was 67% in patients with 1-5 stones and 83% in patients with 6 or more stones. None of these differences was statistically significant. Acoustic shadowing did not affect the diagnostic accuracy of EUS. CONCLUSIONS: The diagnostic accuracy of EUS for gallbladder wall lesions is not affected by the presence of gallstones. However, better diagnostic criteria must be established based on larger studies, and technical refinements of the equipment are needed to increase the accuracy of EUS in the diagnosis of gallbladder wall lesions.