急性结石性胆管炎的腹腔镜治疗

目的 总结应用腹腔镜行胆总管切开取石加T管引流术治疗急性结石性胆管炎的临床经验.方法 回顾性分析北京世纪坛医院普外科2007年3月至2011年7月间98例急性结石性胆管炎急诊行腹腔镜胆总管切开取石术的临床资料.结果 93例患者急诊施行腹腔镜胆总管切开取石加T管引流术,2例经胆囊管胆总管探查术,3例行胆总管探查置塑料内引流管胆道一期缝合术.98例手术顺利,无中转开腹,平均手术时间96 min,平均住院时间12d.术后主要并发症:残石8例,胆漏4例,腹腔出血1例,经保守方法治愈.结论 对绝大多急性结石性胆管炎患者而言,急诊行腹腔镜胆总管切开取石加T管引流术是安全、有效、可行的.     

华支睾吸虫性胆管炎的临床特点及治疗

目的 探讨华支睾吸虫性胆管炎的临床特点、诊断标准和治疗策略.方法 回顾分析57例华支睾吸虫性胆管炎临床诊疗资料.结果 华支睾吸虫性胆管炎均有反复发作的急性胆管炎表现:B超和CT检查肝脏边缘胆管细枝样扩张分别为72%和58%,边缘胆管和肝门部胆管成比例扩张分别为47%和42%;胆汁、十二指肠液和粪便检测华支睾吸虫卵阳性率分别为96%、79%和18%;经内镜乳头切开鼻胆引流术、腹腔镜胆囊切除胆总管探查T型管引流术、开腹胆囊切除胆总管探查T管引流术或胆肠吻合术等方法,结合术后吡喹酮驱虫治疗,胆汁中华支睾吸虫卵和虫体转阴率为100%,57例患者均临床治愈,随访1~5年症状无复发.结论 华支睾吸虫性胆管炎有其临床特征;胆汁中华支睾吸虫卵的检测是确诊华支睾吸虫性胆管炎的金标准,治疗策略是先行抗感染保守对症治疗,病情稳定后采用内镜、腹腔镜和手术等个体化治疗,术后行驱虫治疗.胆汁中华支睾吸虫卵转阴是判断驱虫治疗效果的指标.     

腹腔镜胆总管探查T管引流在急性结石性胆管炎治疗中的应用

目的:探讨腹腔镜胆总管探查术治疗急性结石性胆管炎的安全性与可行性。方法:回顾分析2014年1月至2016年12月为50例轻、中度急性结石性胆管炎患者行腹腔镜胆总管探查T管引流术的临床资料。结果:50例均顺利完成手术,无一例中转开腹;手术时间62~185 min,平均(119.1±31.6)min;术中出血量10~90 ml,平均(31.5±14.9)ml;术后胃肠功能恢复时间1~6 d,平均(2.7±1.0)d;术后腹腔引流时间2~12 d,平均(4.1±2.0)d;术后住院5~16 d,平均(10.1±3.1)d;术后发生胆漏4例,均保守治疗痊愈;T管脱落二次手术1例;残余胆总管结石6例,术后7~10周经T管窦道行胆道镜取石成功。术后随访12~48个月,无胆总管结石复发及胆总管狭窄。结论:在熟练掌握腹腔镜与胆道镜操作技术的前提下,腹腔镜胆总管探查T管引流术治疗轻、中度急性结石性胆管炎是安全、可行的。     

重症急性胆管炎的急诊腹腔镜治疗

目的总结运用腹腔镜胆总管切开取石T管引流术急诊治疗重症急性胆管炎（acute cholangitis ofsevere type,ACST）的治疗经验。方法1993年9月至2006年12月间,运用腹腔镜胆总管切开取石T管引流术的手术方式（包括胆总管切开,胆管镜取石,T管引流等）有选择地对45例重症急性胆管炎患者进行急诊手术治疗。结果重症急性胆管炎45例中,急诊完成腹腔镜胆总管切开取石T管引流术45例,无中转开腹。术后胆漏2例,应激性溃疡出血1例;术后死亡1例。术后其他多种并发症均经非手术综合疗法治愈。结论只要选择合适的病例,腹腔镜胆总管切开取石T管引流术急诊治疗重症急性胆管炎,对于有较高胆管镜和腹腔镜技术者是可行、有效和安全的。     

华支睾吸虫致急性梗阻性胆管炎的治疗(附8例报告)

探讨华支睾吸虫引起急性梗阻性胆管炎的诊断、治疗。报道1990年以来，由大量华支睾吸虫和粘液团引起急性梗阻性胆管炎8例，均经手术证实。B型超声、CT检查示：以肝内小胆管扩张为主，大多从肝门向被膜方向均匀扩张。均行急诊胆道探查或经抗感染、护肝后胆道探查、T管引流，术后给予吡喹酮口服，痊愈。分析认为，华支睾吸虫所致急性梗阻性胆管炎有相对特征性的肝脏B型超声和CT改变，如能确诊，大多数病例可免于急诊胆道探查。     

肝吸虫性胆管炎误诊为胆管癌病例分析

目的报道3例肝吸虫性胆管炎的诊治经过,总结临床经验教训。方法对3例肝吸虫性胆管炎误诊为胆管癌临床资料进行回顾性总结分析。结果 3例肝吸虫性胆管炎病人均为男性,年龄50～65岁,均有食鱼生史,1例因"上腹部疼痛4天"入院,1例因"反复上腹痛1月余"入院,1例因"反复上腹疼痛半年"入院,3例术前均误诊为胆管癌,行手术探查,手术方式为胆囊切除、胆总管切开探查、胆道镜检查、T管引流术,术中胆管内均可见大量华支睾吸虫虫体,其中1例形成化脓性胆管炎,术中胆道镜探查肝内外胆管未见明显肿物以及狭窄,术后无明显并发症,均痊愈出院。结论对于高度怀疑胆管癌的肝吸虫性胆管炎患者先驱虫治疗后观察胆管系统情况再决定是否手术探查是比较合适的治疗方案。     

腹腔镜经胆囊管胆道探查术手术技巧的探讨

目的探讨经胆囊管途径行腹腔镜胆道探查取石术的手术操作技巧。方法总结2003年12月至2012年12月开展的897例腹腔镜经胆囊管胆总管探查术的手术经验,分析手术适应证、手术操作步骤及要领。结果841例顺利完成腹腔镜经胆囊管胆总管探查术,56例改行腹腔镜胆总管切开探查术、T管引流术。行腹腔镜经胆囊管胆总管探查术组的平均手术时间为（98．1±38．1）min,术后住院天数为（3．5±1．9）d,胆漏4例,无其他严重并发症;平均随访时间18．6个月（3～36个月）,无胆道狭窄发生。结论切开胆囊管胆总管汇合部、适度扩张切口加上熟练的胆道镜操作技术是完成腹腔镜经胆囊管胆总管探查取石术的关键所在。     

非流行区华支睾吸虫感染致胆道急症诊治研究

目的探讨非流行区华支睾吸虫感染导致胆道外科急症的临床特点及诊治方法。方法对1998年1月至2007年4月中国医科大学附属盛京医院普外科收治的华支睾吸虫感染导致胆道外科急症21例临床资料进行回顾性分析。结果5例直接确诊,行经内镜下鼻胆管引流(ENBD)或内镜乳头括约肌切开术(EST),未行外科手术。其余的手术中或术后确诊,7例行胆囊切除术,6例行胆囊切除、胆总管切开取石、T管引流术,2例行胆总管空肠Roux-en-Y吻合术,1例行胰十二指肠切除术。全部手术病人术中或术后均发现胆汁内有华支睾吸虫成虫和(或)虫卵。结论非流行区胆道外科急症的病人应注意病因诊断。华支睾吸虫感染病人常具有典型的病史和辅助检查改变,一经确诊,除必要的外科治疗外均应进行驱虫治疗。     

腹腔镜联合胆道镜胆总管探查取石和T管引流术治疗胆总管结石并急性胆管炎的效果

目的观察腹腔镜联合胆道镜(双镜)胆总管探查取石和T管引流术治疗胆总管结石并急性胆管炎的效果。方法 2014-01—2018-01间商城县人民医院对48例胆总管结石并急性胆管炎患者实施双镜胆总管探查取石和T管引流术。回顾性分析患者的临床资料。结果本组48例均成功完成双镜胆总管探查取石和T管引流术。手术时间68～168 min,平均121.1 min;术中出血量15～88 mL,平均32.6 mL;术后肛门恢复排气时间1～5 d,平均2.4 d;术后腹腔引流管留置时间2～10 d,平均4.3 d;术后住院时间6～14 d,平均9.5 d。术后腹腔引流管引流出胆汁2例(4.2%),分别经通畅引流后第4天、第6天自行停止后拔管。出院后8～12周返院复查,期间未发生T管非计划拔脱。经T管造影检查未发现结石残留,造影剂可顺利进入十二指肠,常规拔除T管。术后随访1～5 a,期间定期复查超声及MRCP,未发现结石复发及胆总管狭窄。结论双镜胆总管探查T管引流术治疗胆总管结石并急性胆管炎,安全、可行,但手术团队必须具备熟练的双镜手术操作技巧、经验和良好的配合。     

腹腔镜联合胆道镜行胆总管切开取石探查术156例临床体会

目的:总结腹腔镜联合胆道镜行胆总管切开探查取石、T管引流术的临床体会。方法:先行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),再切开胆总管,用特制的腹腔镜胆总管取石钳取石,胆道镜主要观察胆总管及肝内外胆管有无结石残余及是否通畅,必要时经胆道镜取石。结果:术后拔T管时出现胆漏3例,1例术后10d T管自胆总管脱出至腹腔,1例术后24h胆漏达400ml,6例中转开腹,余均痊愈出院,无残石及术后胆管狭窄等并发症发生。结论:腹腔镜联合胆道镜行胆囊切除、胆总管切开探查取石、T管引流术具有安全可靠、患者损伤小、康复快、住院时间短等优点,是治疗胆囊结石、胆总管结石的有效术式。     

腹腔镜下经胆囊管取石及胆囊管内置管(C管)在胆道外科中的应用

目的:对比研究腹腔镜下胆总管切开取石术与腹腔镜下经胆囊管取石术,胆囊管置管(C管)在胆道外科中的应用。方法:回顾调查1995年10月至2004年12月术前经影像学证实为胆总管结石的89例患者。结果:腹腔镜下胆总管切开取石T管引流35例,术后残留结石2例,胆漏4例,放置T管(24±5.6)d。经胆囊管取石C管引流39例,术后残留结石2例,无胆漏,C管放置(8±4.5)d,与T管引流组差异有统计学意义(P<0.001)。结论:腹腔镜下经胆囊管取石是值得推荐的方法。经胆囊管路径,不仅可用胆总管取石后的引流,且可在胆道外科诸方面发挥作用。     

急性胆管炎腹腔镜胆总管探查后一期缝合与T管引流的临床研究

目的 探讨急性胆管炎腹腔镜胆总管探查后一期缝合与T管引流两种手术方式的特点,评估其可行性与安全性.方法 回顾性分析首都医科大学宣武医院普外科2012年1月-2014年12月100例急性胆管炎患者行腹腔镜胆囊切除+胆总管探查术患者的临床资料,其中54例(54％)患者行一期缝合,46例(46％)患者行T管引流.结果 100例患者均成功行手术治疗,手术时间缝合组显著短于T管组(96.72 minvs123.00 min,P=0.001),术中出血量缝合组与T管组相比显著减少(27.13 mlvs38.48 ml,P=0.009).缝合组术后胃肠功能恢复时间(1.57 dvs2.33 d,P=0.003)与术后住院时间(6.19 dvs9.20d,P=0.000)均显著短于T管组.两组术后腹腔总引流量(309.22mlvs212.46ml,P=0.070),引流时间(3.96 dvs4.02 d,P=0.875),术后胆漏发病率(9.3％ vs0,P=0.060),出血率(5.1％vs2.2％,P=0.622)差异均无统计学意义.结论 急性胆管炎腹腔镜胆总管探查后一期缝合严格掌握适应证后,与T管引流相比,同样安全有效.     

腹腔镜胆道探查胆总管一期缝合术治疗胆管结石的疗效分析

目的探讨腹腔镜下胆道探查术、胆总管一期缝合术的临床疗效与可行性。方法2014年2月至2017年2月收集贵州医科大学附属医院106例胆总管结石病人,男性44例、女性62例,年龄18~75岁,平均(46.5±15.7)岁。106例胆总管结石病人,伴或不伴胆囊结石与肝内胆管结石,其中腹腔镜下胆道探查胆总管一期缝合术67例,腹腔镜下胆道探查T管引流术39例,对两组病例手术适应证、手术时间、术后恢复情况、并发症等进行比较。结果胆总管一期缝合组的手术时间、术后住院天数、腹腔引流管放置时间分别为(72.8±21.0)min、(2.8±1.9)d和(5.5±2.3)d,优于T管引流术组的(95.5±26.5)min、(5.7±1.4)d和(8.1±2.6)d(均P0.05),术后肛门排气时间两组分别为(1.9±0.8)d和(2.1±0.5)d、差异无统计学意义;两组均无肝衰竭、腹腔感染、胆管残余结石、胆道出血及穿孔,胆漏发生率T管引流术组(3例)高于胆总管一期缝合组(0例)(P0.05)。结论腹腔镜胆道探查胆总管一期缝合术治疗胆管结石是安全、可行的,病人明显受益,值得临床推广应用。     

Laparoscopic primary choledochorrhaphy over endonasobiliary drainage tubes

Background The T-tube is widely used in laparoscopic choledochotomy to decompress the biliary tree. However, there are high morbidity rates related to the T-tube. This study reviewed the results of laparoscopic primary choledochorrhaphy over endonasobiliary drainage (ENBD) tubes to find an effective alternative to the T-tube for the performance of laparoscopic choledochotomy. Methods From March 2003 to September 2005, 23 patients (9 men and 14 women) with choledocholithiasis underwent laparoscopic choledochotomy over ENBD tubes. The mean age of these patients was 47 years (range, 32–73 years). At admission, six patients had cholangitis. All the patients had ENBD tubes placed preoperatively after the failure of endoscopic sphincterotomy. Results There was no conversion to open surgery. The mean operative time was 90 min (range, 70–150 min). There were no biliary complications such as bile leaks, biliary peritonitis, or pancreatitis. No residual stones were found by postoperative cholangiograms. The ENBD tubes were removed between postoperative days 7 and 9. The hospital stay ranged from 8 to 14 days, with 16 patients (70%) discharged on postoperative day 8. The complications were limited to one umbilical infection and one case of pneumonia. The median follow-up period was 24 months (range, 8–36 months), and none of the patients were readmitted with biliary symptoms. Conclusion Laparoscopic choledochotomy over ENBD tubes proved to be technically feasible and safe. The ENBD tube decompresses the biliary tree and allows for cholangiography after surgery. Its removal does not need to wait for tract maturation, which allows an earlier removal of the tube and a shorter postoperative hospital stay. Laparoscopic choledochotomy over ENBD tubes is an effective alternative to the T-tube in laparoscopic choledochotomy.     

腹腔镜胆总管切开取石一期缝合术(附29例报告)

目的:探讨腹腔镜胆总管切开取石一期缝合术的优点、方法及适应证。方法:应用腹腔镜手术设备及纤维胆道镜为29例胆总管结石患者行腹腔镜胆总管切开取石术,不置T管引流,一期缝合胆总管壁。结果:26例手术成功,平均手术时间98.2m in,术中平均出血15.3m l,术后平均肛门排气时间19.6h,术后平均住院8.3d,无胆漏等严重并发症发生,3例中转行腹腔镜胆总管切开取石T管引流术。结论:应用腹腔镜胆总管切开取石一期缝合术治疗胆管结石具有创伤小、住院时间短及并发症少的优势,对符合适应证的患者是一种安全、有效的术式,但应掌握操作技巧以提高手术成功率、防止胆漏的发生。     

Laparoscopic management of common bile duct stones: transcystic approach and choledochotomy

The purpose of this study was to review our experience with laparoscopic common bile duct (CBD) exploration by the transcystic approach and choledochotomy. We selected the transcystic approach for patients whose CBD stones were less than five in number and smaller than 9 mm in diameter, and whose CBD was less than 15 mm in diameter on cholangiograms. Among 217 patients with CBD stones treated laparoscopically, the transcystic approach was performed successfully in 91 of 104 patients in whom it was attempted (87.5%). The other 126 patients underwent laparoscopic choledochotomy, followed by ductal closure with transcystic drainage in 59, T-tube drainage in 46, primary ductal closure in 19, and choledochoduodenostomy in 1. Choledochotomy was converted to open surgery in only 1 patient. The transcystic approach was associated with shorter hospital stay and less morbidity than choledochotomy. However, choledochotomy also had an acceptably low rate of complications. Bile leaks occurred more frequently in those with primary ductal closure than in those with transcystic drainage or T-tube drainage. Residual stones were found in 2 patients with the transcystic approach and in 10 with choledochotomy. The residual stones were removed through the T-tube tract by choledochoscopy in 7 of these 10 patients. From these results we conclude that laparoscopic management of CBD stones is feasible for almost all patients with CBD stones. It is considered to be safe and effective and has the advantage of being a single-stage procedure. Received: July 7, 2000 / Accepted: October 26, 2000     

Delayed cholangitis resulting from a retained T-tube fragment encased within a stone: a rare complication

Inserting a T-tube after choledochotomy for the removal of bile duct stones remains a time-honored practice. Biliary drainage after bile duct exploration has some advantages. It minimizes bile leakage, provides access for cholangiography, and removes occasional retained stones. The use of T-tubes also has been associated with significant complications. Biliary sepsis, bile duct trauma during removal, bile leakage leading to peritonitis, retention of a fragment, stricture formation after removal have been reported. We report an unusual case of cholangitis caused by a T-tube fragment within a large stone, occurring 11 years after bile duct exploration. A 39-year-old woman underwent common bile duct exploration with insertion of a T-tube. Cholangiography was normal, but as the T-tube was removed, its horizontal limb was missing. The patient failed to present for endoscopic removal a few weeks after surgery Five years later, she presented with recurrent biliary pains and a mild episode of cholangitis. This last episode was associated with severe pain and jaundice. After initial conservative treatment, endoscopic retrograde cholangiopancreatography was performed, and endoscopic removal of the fragment and stone material was successful. Despite the declining numbers of bile duct explorations in the laparoscopic era and the tendency to use transcystic drainage or primary closure of a choledochotomy, the T-tube will continue to be a useful tool in biliary surgery, subject to consideration of the indications and the available alternatives. The reported case highlights the importance of careful tube preparation to prevent partial separation at removal, and early removal of a missing fragment to avoid potential serious complications.