Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis

AIM: To investigate acute transient hepatocellular injury in patients with cholelithiasis and cholecystitis but no evidence of choledocholithiasis. METHODS: The medical records of patients with cholelithiasis who underwent cholecystectomy between July 2003 and June 2007 were retrospectively reviewed. Imaging studies to detect common bile duct (CBD) stones were performed in 186 patients, who constituted the study population. Biochemical liver tests before and after surgery, and with the presence or absence of CBD stones were analyzed. RESULTS: In 96 patients with cholelithiasis and cholecystitis without evidence of CBD stones, 49 (51.0%) had an alanine aminotransferase level elevated to 2-3 times the upper limit of normal, and 40 (41.2%) had an elevated aspartate aminotransferase level. Similar manifestations of hepatocellular injury were, as would be expected, even more obvious in the 90 patients with CBD stones. These markers of hepatocellular injury resolved almost completely within 2 wk to 1 mo after cholecystectomy. Compared to 59 patients with histologically less severe cholecystitis in the group undergoing urgent surgery (total 74 patients), the 15 patients with a gangrenous gallbladder had a higher mean level of total bilirubin (1.14 ± 1.27 mg/dL vs 2.66 ± 1.97 mg/dL, P < 0.001) and white cell count (9480 ± 4681/μL vs 12840 ± 5273/μL, P = 0.018). CONCLUSION: Acute hepatocel lular injury in cholelithiasis and cholecystitis without choledocholithiasis is mi ld and t ransient . Hyperbi l irubinemia and leukocytosis may predict severe inflammatory changes in the gallbladder.     

Risk factors of acute cholecystitis after endoscopic common bile duct stone removal

AIM:To evaluate the risk factors of acute cholecystitisafter endoscopic common bile duct(CBD)stone removal.METHODS:A total 100 of patients who underwent en-doscopic CBD stone removal with gallbladder(GB)in situwithout subsequent cholecystectomy from January 2000to July 2004 were evaluated retrospectively.The follow-ing factors were considered while evaluating risk factorsfor the development of acute cholecystitis:age,gender,serum bilirubin level,GB wall thickening,cystic duct pa-tency,presence of a GB stone,CBD diameter,residualstone,lithotripsy,juxtapapillary diverticulum,presence ofliver cirrhosis or diabetes mellitus,a presenting illness ofcholangitis or pancreatitis,and procedure-related compli-cations.RESULTS:During a mean 18-mo follow-up,28(28%)patients developed biliary symptoms;17(17%)acutecholecystitis and 13(13%)CBD stone recurrence.Of patients with acute cholecystitis,15(88.2%)re-ceived laparoscopic cholecystectomy and 2(11.8%)open cholecystectomy.All recurrent CBD stones weresuccessfully removed endoscopically.The mean timeelapse to acute cholecystitis was 10.2 mo(1-37 mo)and that to recurrent CBD stone was 18.4 mo.Of the17 patients who received cholecystectomy,2(11.8%)developed recurrent CBD stones after cholecystectomy.By multivariate analysis,a serum total bilirubin level of<1.3 mg/dL and a CBD diameter of <11 mm at the timeof stone removal were found to predict the developmentof acute cholecystitis.CONCLUSION:After CBD stone removal,there is noneed for routine prophylactic cholecystectomy.However,patients without a dilated bile duct(<11 mm)and jaun-dice(<1.3 mg/dL)at the time of CBD stone removal     

Preoperative MRCP to detect choledocholithiasis in acute calculous cholecystitis

Purpose

There are risks of common bile duct (CBD) stones in acute cholecystitis, and there is a move among surgeons to identify choledocholithiasis before surgery. Magnetic resonance cholangiopancreaticography (MRCP) has the potential to accurately detect choledocholithiasis in patients with acute cholecystitis. The aim of this study was to evaluate the predictive values of MRCP and elevated biochemical predictors for choledocholithiasis in patients with acute cholecystitis.

Methods

Between September 2006 and August 2008, of 84 patients with acute cholecystitis based on the diagnosis criteria of the Tokyo guidelines, 57 had MRCP preoperatively. The predictive values of six biochemical predictors for choledocholithiasis were also evaluated.

Results

Of the 57 patients, seven (12.28%) had choledocholithiasis, of whom three had CBD stones in nondilated ducts. The smallest stone detected in a dilated CBD and nondilated duct was 3.19 and 4.55 mm in diameter, respectively. None of our patients whose MRCP showed a clear CBD returned with symptomatic choledocholithiasis during the follow-up period. All biochemical predictors and CBD diameter had limited positive predictive values.

Conclusions

Magnetic resonance cholangiopancreaticography is a reliable evaluation technique for the detection of choledocholithiasis. It reduces the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and prevents the risk of overlooking choledocholithiasis. No single predictor or combined markers have been found to be reliable for including/excluding the presence of choledocholithiasis.     

Cholecystectomy improves long-term success after endoscopic treatment of CBD stones

BACKGROUND/AIMS: The aim was to study prospectively primary endoscopic treatment of CBD stones and further the long-term need for renewed gallstone disease interventions, defined as short- and long-term outcome. METHODOLOGY: Seven years prospective follow-up of 101 consecutive patients with CBD stones who underwent endoscopic treatment with the intent of primarily achieving duct clearance. RESULTS: Many patients underwent several endoscopy sessions before stone clearance was completed in 83%. Eleven patients were treated surgically, 2 patients received a permanent stent, and the remaining 3 became stone free with other means. Complications occurred in 47 patients. During follow-up, 31 patients were readmitted for gallstone disease and 15 of these had recurrent CBD stones. Ten percent (8/78) of patients with the gallbladder in situ had acute cholecystitis during follow-up and late cholecystectomy was carried out in 22%. Risk factors for new gallstone disease were an in situ gallbladder containing stones and previous episodes of CBD stones. CONCLUSIONS: A goal of complete CBD stone clearance with ERC and ES proved to be relatively resource consuming. Subsequent cholecystectomy after duct clearance for CBD should be advised when the gallbladder lodges gallstones, especially in younger patients. Recurrent CBD stones were not influenced by cholecystectomy.     

Is choledocholithiasis a late complication of nonresectional therapies for hepatocellular carcinoma?

We present 3 patients who developed choledocholithiasis 10, 13, and 12 months after percutaneous ethanol injection and/or transcatheter arterial chemoembolization for hepatocellular carcinoma. Since none of these patients had stones in the gallbladder or in the bile ducts before treatment, bile duct stones might have resulted from local injury in the bile ducts by percutaneous ethanol injection and/or transcatheter arterial chemoembolization. Choledocholithiasis may be a late complication of nonresectional and local therapies for hepatocellular carcinoma tumors.     

腹腔镜保胆取石术和息肉切除术临床分析53例

目的:探讨腹腔镜下保胆取石和取息肉的手术适应证、方法和疗效.方法:2009-01/2011-09我们完成了53例腹腔镜下保胆取石和取息肉术.单纯胆囊结石患者39例,其中12例为单发结石,27例为多发胆囊结石;胆囊息肉患者8例,其中3例为腺瘤性息肉,5例为胆固醇性息肉;胆囊结石合并息肉患者6例,均为胆固醇性息肉;胆囊结石合并肝硬化2例,合并肝癌1例;胆囊结石伴急性胆囊炎3例.39例结石患者中37例行胆囊底部切开取石,2例行胆囊颈部切开取石成形术;8例胆囊息肉患者中5例胆固醇性息肉行胆囊底部切开取息肉术,3例腺瘤性息肉患者行息肉周围胆囊部分切除术;6例胆囊结石合并息肉的患者均行胆囊底部切开取石(息肉)术,其息肉均为胆固醇性息肉.胆囊切口采用4-0prolene缝线连续缝合10例,采用3-0可吸收线间断缝合或连续缝合43例.术中使用胆道镜33例,20例未用胆道镜,用腹腔镜代替胆道镜查看胆囊内结石或息肉是否取净.术后放置腹腔引流管19例,其余均未放置腹腔引流管.胆囊结石(包括合并胆囊息肉)患者术后服用利胆药物者33例,服药时间为1wk-1mo不等,另12例未服利胆药物.结果:53例保胆患者手术均获成功,没有1例中转剖腹手术.手术时间80-200min,平均109min±33min.1例颈部切开取石患者术后出现上腹疼痛,腹腔引流管每日引出约15mL淡黄色腹水,超声检查显示小网膜腔少量积液,考虑少量胆漏所致,术后5d腹痛缓解,腹腔引流管无液体引出,拔除腹腔引流管后无不适.其余患者术后均恢复顺利,术后住院2-10d,平均3.8d±2.2d,均治愈出院.所有患者均获随访,随访时间3-36mo,1例患者术后12mo胆囊泥沙样结石复发,给予利胆排石药物治疗1mo后复查腹部超声显示胆囊结石消失.结论:腹腔镜下保胆取石和取息肉术保留了胆囊及胆囊功能,有利于维护患者消化系统的正常功能.只要胆囊大小基本正常、胆囊壁增厚不明显、胆囊功能基本正常,排除了胆囊恶性病变,并且患者及家属保胆愿望强烈,均可进行腹腔镜保胆取石(息肉)术.     

Marked elevation of serum transaminase activity associated with extrahepatic biliary tract disease

Nine patients with choledocholithiasis or cholelithiasis developed transient elevations of serum glutamic oxalacetic transaminase (SGOT) levels of greater than 600 units. Awareness of such transient biliary disease will prevent an unnecessary evaluation of a primary hepatocellular disorder. In our study, we concluded that 1) The SGOT level rose and fell rapidly within a 24- to 72-hour period. 2) Higher SGOT levels were seen in patients with choledocholithiasis in whom the gallbladder had been removed. 3) In patients with choledocholithiasis a fall in SGOT level did not necessarily mean the stone had passed.     

Medium-term effects of endoscopic papillary balloon dilation on gallbladder motility

BACKGROUND: Endoscopic papillary balloon dilation (EPBD) for removal of bile duct stones tends to preserve papillary function. However, EPBD may exert beneficial or deleterious effects on gallbladder motility. This was a prospective, medium-term investigation (2 years) of the effects of EPBD on gallbladder motility. METHODS: Twelve patients with intact gallbladders (6 with and 6 without gallbladder stones) who underwent EPBD for choledocholithiasis were enrolled in this study. Gallbladder motility was examined before EPBD and at 7 days, 1 month, 1 year, and 2 years after EPBD. Gallbladder volumes, measured after fasting and after ingestion of dried egg yolk, were determined by US. RESULTS: All patients were asymptomatic during the 2-year follow-up period. Before EPBD, particularly in patients with cholelithiasis, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction compared with normal control subjects. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, both significantly compared with pre-EPBD values and regardless of the presence or absence of gallbladder stones. At 1 month, 1 year, and 2 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline. CONCLUSION: EPBD does not adversely affect gallbladder motility in the medium-term (2 years). In terms of gallbladder motility, EPBD does not appear to increase the future risk of acute cholecystitis or gallbladder stone formation.     

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice

AIM: To study the practical applicability of the American Society for Gastrointestinal Endoscopy guidelines in suspected cases of choledocholithiasis.METHODS: This was a retrospective single center study, covering a 4-year period, from January 2010 to December 2013. All patients who underwent endoscopic retrograde cholangiopancreatography(ERCP) for suspected choledocholithiasis were included. Based on the presence or absence of predictors of choledocholithiasis(clinical ascending cholangitis, common bile duct(CBD) stones on ultrasonography(US), total bilirubin > 4 mg/d L, dilated CBD on US, total bilirubin 1.8-4 mg/d L, abnormal liver function test, age > 55 years and gallstone pancreatitis), patients were stratified in low, intermediate or high risk for choledocholithiasis. For each predictor and risk group we used the χ2 to evaluate the statistical associations with the presence of choledocolithiasis at ERCP. Statistical analysis was performed using SPSS version 21.0. A P value of less than 0.05 was considered statistically significant. RESULTS: A total of 268 ERCPs were performed for suspected choledocholithiasis. Except for gallstone pancreatitis(P = 0.063), all other predictors of cho-ledocholitiasis(clinical ascending cholangitis, P = 0.001; CBD stones on US, P ≤ 0.001; total bilirubin > 4 mg/dL, P = 0.035; total bilirubin 1.8-4 mg/dL, P = 0.001; dilated CBD on US, P ≤ 0.001; abnormal liver function test, P = 0.012; age > 55 years, P = 0.002) showed a statistically significant association with the presence of choledocholithiasis at ERCP. Approximately four fifths of patients in the high risk group(79.8%, 154/193 patients) had confirmed choledocholithiasis on ERCP, vs 34.2%(25/73 patients) and 0(0/2 patients) in the intermediate and low risk groups, respectively. The definition of "high risk group" had a sensitivity of 86%, positive predictive value 79.8% and specificity 56.2% for the presence of choledocholithiasis at ERCP. CONCLUSION: The guidelines should be considered to optimize patients’ selection for ERCP. For high risk patients specificity is still low, meaning that some patients perform ERCP unnecessarily.     

Selection criteria for pre-operative endoscopic retrograde cholangiography and endoscopic-laparoscopic treatment of biliary stones.

OBJECTIVE: Pre-operative endoscopic retrograde cholangiography (ERCP) prior to laparoscopic cholecystectomy (LC) is the most common treatment of gallbladder and common bile duct (CBD) stones. In this study we evaluate our selection criteria for pre-operative ERCP and the results of endoscopic-laparoscopic treatment in patients with CBD stones. DESIGN: Consecutive adult patients admitted to the department of surgery because of symptomatic cholelithiasis were included in a prospective open trial. PARTICIPANTS: Between January 1996 and December 1996, 841 patients underwent LC at our hospital. ERCP pre-LC was performed in 95 of the 841 patients, on the basis of our selection criteria. INTERVENTIONS: The indication to perform ERCP was suggested by a dilatated CBD (> 10 mm) or ductal stones, abnormal serum liver tests, persisting for more than 3 days, jaundice, cholangitis or pancreatitis. Twelve months after surgery, all patients were contacted by telephone to exclude symptoms related to residual stones. RESULTS: Cannulation of the CBD was successful in 94 of 95 patients submitted to pre-LC ERCP. CBD stones were found in 87 patients (95.6%) in 22 of whom (25.2%) they were in the form of small stones or sludge. In only three of 94 patients (3.2%) no alterations of the CBD or papilla were found. Complications occurred in eight of 98 patients (in five after endoscopic sphincterotomy (ES), and in three after LC). CONCLUSIONS: Pre-operative ES in selected patients with coexisting gallbladder and CBD stones has been a good approach and the criteria that we used for selection of patients to be submitted to pre-operative ERCP/ES seem to be effective.     

磁共振胆胰管成像对老年性胆总管扩张患者诊断价值

目的老年性胆总管扩张患者磁共振胆胰管成像（magnetic resonance cholangiopancreatography，MRCP）的诊断和鉴别诊断价值评估。方法回顾性分析197例老年性胆总管扩张患者MRCP检查及临床诊断与治疗结果进行比较。结果MRCP诊断为胆总管下端结石68例，急性胆囊炎，胆囊结石伴胆总管扩张57例，胆囊切除术后改变38例，胆囊颈管结石22例，胆道系统肿瘤7例，胰腺占位性病变5例，诊断符合率99．5％结论MRCP在老年性胆总管扩张的病因诊断和鉴别诊断中有重要价值。     

Common bile duct stones: management strategies in the laparoscopic era

We reviewed our experience with the treatment of common bile duct (CBD) stones in 70 patients by sequential endoscopic-laparoscopic management and single-stage laparoscopic treatment during the past 7 years. The advantages, disadvantages, and feasibility of the two procedures are discussed to elucidate therapeutic strategies for patients harboring gallbladder stones and associated choledocholithiasis. In 44 patients, sequential endoscopic-laparoscopic management was indicatedd, and was successful in 37 of them but, in seven patients endoscopic stone extraction could not be accomplished. Single-stage laparoscopic treatment was attempted in 26 patients. In practice, laparoscopic transcystic common duct exploration or choledochotomy may not always be feasible if the cystic duct or CBD are not dilated; there is a high risk of intraoperative CBD injury in such circumstances. Laparoscopic management was considered to be especially useful for the treatment of numerous, large or difficult stones, because stone removal could be succesfully performed without any injury to the papilla of Vater. This last issue is of particular importance in patients with dilated CBD, because insufficient opening of the ampulla of Vater made by endoscopic sphincterotomy (EST) may lead to stasis and reflux-related complications such as cholangitis and recurrent stones. We conclude that the most rational management of CBD stones should be decided according to the size of the CBD, which depends on the size, number, and location of stones. Patients with dilated CBD are indicated to under-go laparoscopic single-stage treatment and combined endoscopic-laparoscopic treatment may be best for patients with non-dilated CBD.     

Hypointense gallbladder on MR cholangiopancreatography

A few patients show a gallbladder of poor visibility on magnetic resonance cholangiopancreatography (MRCP) images due to various reasons. A 45-year-old man was referred with abdominal pain and fever. In contrast enhanced computed tomography, several calcified gallstones were observed in the gallbladder. Although a solitary calcified stone was seen in the neck of the gallbladder, neither stones in the common bile duct (CBD) nor dilatation of CBD were observed. On MRCP, hypointense gallbladder with no filling defect in the CBD was observed. Histopathological analysis of the gallbladder, which was obtained by laparoscopic cholecystectomy, confirmed severe chronic cholecystitis with several calcified gallstones up to 0.5 cm in diameter. In conclusion, the finding of hypointense gallbladder on MRCP in patients with cholecystitis and its underlying condition, though rare, should be kept in mind.     

腹腔镜下胆道造影术

为探讨腹腔镜下胆道造影的方法和价值，对６００例胆囊结石并慢性或急性胆囊炎（其中４例伴阻塞性黄疸，６例为胆源性胰腺炎）病人行无选择性腹腔镜胆囊切除和常规术中经胆囊管插管胆道造影术。５６８例（９４．７％）完成了术中胆道造影。术中造影发现胆总管病变４２例，其中３２例为术前未曾检查出的胆管异常。全组共发生胆管损伤３例（０．５％）。表明腹腔镜下经胆囊管插管胆道造影成功率高，术中胆道造影具提高手术质量和防止或减少胆管损伤的作用。     

Endoscopic sphincterotomy--experience with 110 patients

During the last two years, 116 endoscopic sphincterotomies (ES) were attempted in 110 patients. The indication for ES was choledocholithiasis in 102 (93%) patients, including 37 (36.2%) with gallbladder in situ and 65 (64%) post-cholecystectomy patients; the other 8 (7%) were performed for stricture of the lower end of the common bile duct (CBD) with cholangitis (2), insertion of nasobiliary drain (2), restenosis after previous sphincterotomy (1), stone in the cystic duct stump causing cholangitis (1), papillary stenosis (1) and post-cholecystectomy cholangitis with no obvious cause (1). ES was achieved in 113 (97.4%) attempts in 107 (97%) patients and was overall successful in 81% of patients. Of the 95 patients with choledocholithiasis in whom ES could be performed and a follow-up was available, 79 (83%) cleared their CBD. Of 98 patients with choledocholithiasis, 79 (80.6%) finally cleared their CBD of stones. Three patients developed complications, one needing emergency operation. There were no deaths. ES was found to be effective in patients with retained stones and also in patients with choledocholithiasis with gallbladder in situ, especially those who were poor surgical risk.     

Value of echotomography for the diagnosis of lithiasis of the common bile duct

The accuracy of ultrasonography (US) for the diagnosis of cholelithiasis and for dilatation of the intra- and extra-hepatic biliary tree is well known. However, the value of US for the diagnosis of common bile duct stones remains poorly defined. We performed a prospective study in 100 patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP); all the examinations were carried out by the same sonographist in the 24 h preceding the ERCP. Fifty patients had choledocholithiasis, 20 patients had obstruction of the bile ducts without lithiasis and the common bile duct (CBD) was free in 30 patients. The sensitivity of US for the diagnosis of choledocholithiasis was 40 p. 100, the specificity 90 p. 100. The positive and negative predictive values of the "CBD stone" sign was 80 p. 100 and 60 p. 100 respectively. In a total of 30 false negatives, the CBD could not be explored in 4 cases, dilatation of the CBD was missed in one case, and obstruction of the CBD by an other disease was diagnosed in 2; in all the other cases, US was able to appreciate the CBD size as well as the ERCP. In the 20 patients with an obstructed CBD but without choledocholithiasis, US diagnosed a stone in 5 cases. Age, serum bilirubin, existence of a previous cholecystectomy, technical difficulties, stone size were comparable in patients with true positive tests and in patients with false negative tests. However the diagnosis of choledocholithiasis was more frequently achieved in patients with dilated CBD over 10 mm (p less than 0.05) and in patients with multiple stones.(ABSTRACT TRUNCATED AT 250 WORDS)     

Usefulness of Intraductal Ultrasonography in Icteric Patients with Highly Suspected Choledocholithiasis Showing Normal Endoscopic Retrograde Cholangiopancreatography

Background

Choledocholithiasis is one of the causes of jaundice and may require urgent treatment. Endoscopic retrograde cholangiopancreatography (ERCP) has been the primary management strategy for choledocholithiasis. However, small stones can be overlooked during ERCP.

Aim

The aim of this study was to evaluate the accuracy of intraductal ultrasonography (IDUS) for detecting choledocholithiasis in icteric patients with highly suspected common bile duct (CBD) stones without definite stone diagnosis on ERCP.

Methods

Ninety-five icteric (bilirubin ≥3 mg/dL) patients who underwent ERCP for highly suspected choledocholithiasis without definite filling defects on cholangiography were prospectively enrolled in the present study. We evaluated the bile duct using IDUS for the presence of stones or sludge. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge.

Result

Bile duct stones were detected with IDUS in 31 of 95 patients (32.6 %). IDUS findings were confirmed by endoscopic stone extraction in all patients. The mean diameter of CBD stones detected by IDUS was 2.9 mm (range 1–7 mm). IDUS revealed biliary sludge in 24 patients (25.2 %) which was confirmed by sludge extraction in 21 patients (87.5 %). In dilated CBD, detection rate of bile duct stone/sludge based on IDUS was significantly higher than in non-dilated CBD (p = 0.004).

Conclusion

IDUS is useful for the detection of occult CBD stone on ERCP in icteric patients with highly suspected CBD stones.     

Wait-and-see policy versus cholecystectomy after endoscopic sphincterotomy for bile-duct stones in high-risk patients with co-existing gallbladder stones: A prospective randomised trial

Background and study aimsEndoscopic sphincterotomy (ES) is one of the most important advances in the treatment of common bile duct (CBD) stones. However, the use of ES to remove CBD stones in high-risk patients without cholecystectomy is still debatable. The aim of this study was to compare the efficacy of a wait-and-see policy versus cholecystectomy after ES for CBD stones in high-risk patients with co-existing cholelithiasis.Patients and methodsA total of 162 patients after undergoing ES with the clearance of CBD stones were randomised after informed consent to cholecystectomy or conservative management of their gallbladder stones.ResultsThe results indicated that cholecystectomy after ES for CBD stones significantly reduced the biliary complications in high-risk patients.ConclusionEvery patient who has both CBD stones and gallstones with significant co-morbid illnesses, after clearance of CBD stones by ES, should undergo early cholecystectomy.     

Risk Factors Associated With Residual Stones in Common Bile Duct Via T Tube Cholangiography After Common Bile Duct Exploration

Open surgery with common bile duct (CBD) exploration and T tube drainage are still traditionally performed in a large amount of selected patients with cholelithiasis and choledocholithiasis. Confirmation of CBD clearance via T tube cholangiography after surgery is a routine procedure before T tube removal. The present study aims at investigating potential risk factors associated with residual stones in CBD via T tube cholangiography.Patients undergoing open CBD exploration and T tube drainage for choledocholithiasis in the hospital were enrolled retrospectively from January 2011 to December 2013. The clinical data were reviewed and analyzed based on computer database. Patients undergoing laparoscopic CBD exploration were excluded. Patients with CBD exploration and primary choledochotomy or choledochojejunostomy were also excluded from the study. T tube cholangiography was regularly performed 4 to 8 weeks postoperatively.Two hundred seventy-five patients undergoing open CBD exploration and T tube drainage were enrolled in the study. Thirty-five patients (12.7%) were found to have gallbladder stones but without bile duct stones intraoperatively (Group A). One hundred sixty-five (Group B) and 77 patients (Group C) were diagnosed with choledocholithiasis and hepato-choledocholithiasis in operation, respectively. Disease of hepato-choledocholithiasis, size of the previous stones, and CBD exploration without intraoperative choledochoscopy were identified as risk factors associated with residue stones via T tube cholangiography (P < 0.001, P = 0.034, and P = 0.047, respectively). Patients with residual stones had a higher incidence of cholangitis during cholangiography than those without residual stones (8.9% vs 7.8%, P = 0.05). A scoring system based on the 3 risk factors has been set up. The incidence of residual stones were 5.6% in patients with score 0 to 1, 27.4% in patients with score 2 to 3 and 80.0% in patients with score 4 (P < 0.001). Abdominal distension after T tube clamp might be a strong predictor of cholangiography-associated choloangitis (P < 0.001).Intraopearative choledochoscopy should be strongly recommended as a routine procedure during CBD exploration to confirm the clearance of CBD, which could significantly lower the risk of residual stones postoperatively.     

胆石症患者Oddi括约肌压力表现及其意义

目的探讨胆石症与Oddi括约肌（SO）功能的关系。方法对已行外科胆总管探查术患者术后6周进行胆道镜经T管窦道胆道测压,项目包括s0基础压、s0收缩幅度、sO收缩频率、胆总管压力。探查术原因71例为胆石症,分为胆囊结石组（20例）、胆总管结石组（22例）和肝内胆管结石组（29例）;9例因外伤,作为正常对照。胆道镜先明确有无胆道结石,如有结石在取石前后分别测压,如无结石则直接测压。结果胆道镜检查50例存在胆管结石者取石前后各测压指标均无统计学差异。胆囊结石组、胆总管结石组各指标与对照组无明显差异（P〉0．05）;但肝内胆管结石组的S0基础压、s0收缩幅度、胆总管压力均较对照组明显降低[（8．92±-5．87）mmHg比（16．21±3．27）mmHg、（58．89±26．40）mmHg比（106．30±54．28）mmHg、（8．49±6．89）mmHg比（13．56±2．93）mmHg],差异均有统计学意义（P〈0．05）,SO收缩频率无统计学差异（P〉0．05）。结论胆道测压不能作为判断胆管内有无结石的可靠依据;肝内胆管结石患者存在SO功能异常,其SO基础压和收缩幅度、胆总管压力均明显下降。