钬激光在胆道镜胆管取石中的应用体会

胆总管切开取石T管引流术后的病人，常出现胆总管内结石残留或再发结石。经T管窦道胆道镜取石是比较简单的方法。但如果结石较大、较硬，取石篮即使套住也难以取出。强行取出会造成窦道断裂而形成胆汁瘘，或难以控制的胆管出血。钬激光经胆道镜碎石后取石，操作简单。笔者总结5例，疗效满意，现总结资料报告如下。     

腹腔镜下胆道探查术取出2枚嵌顿网篮1例并文献复习

背景与目的:经内镜逆行胰胆管造影术(ERCP)联合胆管取石+腹腔镜下胆囊切除术(LC)成为胆总管结石合并胆囊结石的主要治疗方式之一。通过网篮或球囊扩张,ERCP的取石成功率可高达90%。对于较大的结石无法通过网篮拖出时可能发生网篮嵌顿、导丝断裂。本文总结1例ERCP术中网篮嵌顿、导丝断裂继而通过腹腔镜下胆道探查术(LCBDE)取出2枚嵌顿网篮的经验,以期对临床预防和处理该类并发症提供参考。方法:回顾分析1例老年患者ERCP术中网篮嵌顿、导丝断裂继而通过LCBDE取出2枚嵌顿网篮的临床资料,并对近些年相关文献进行复习分析。结果:患者,女,78岁。以"胆总管多发结石并肝内外胆管扩张,急性胰腺炎"收治。对症治疗及术前准备完善后,于入院第10天行ERCP,胆胰管显影后,首先通过十二指肠镜切开乳头括约肌,用碎石网篮套住大结石,拟行机械碎石,取石网篮嵌顿及导丝断裂,立即置入第二个网篮套住结石和网篮,向外无法拉出,剪断嵌顿网篮口腔外导丝,并放置鼻胆管于胆总管。术后按胰腺炎处理,于入院第13天行LC+LCBDE,顺利取出结石和2枚留置网篮,术后60 d经T管窦道取尽残余结石后拔除T管,恢复良好。随访24个月,无胆道狭窄、胆管炎等并发症。近些年文献报道网篮嵌顿发生率约为0.2%～0.8%,对于这种ERCP罕见并发症,目前常用的处理方法主要有:体外震波碎石、液电碎石术、激光碎石、再次网篮套取、球囊扩张术、开腹胆道探查术等。腹腔镜胆道探查术在嵌顿网篮的取出仅少数报道,同时取出2枚嵌顿网篮罕见。结论:ERCP取石术中网篮嵌顿导丝断裂后择期行LCBDE是安全可行的,既控制了外科的损伤,又处理了并发症,患者能快速康复。     

Experience of Calculi extraction by choledochoscope Postoperatively in 1226 cases

目的 探讨经T管窦道胆道镜取石的方法及技巧,评价胆道镜在肝内外胆管结石治疗中的价值.方法 回顾分析我院1990年3月至2011年9月术后胆道镜取石1226例,结石取净后常规行T管造影.结果 共取石2685次,平均2.2次,取石最多次数者为12次.取净1182例,取净率96.4％.除1例为了重新放置T管而扩张窦道时引起出血、2例取石过程中引起窦道破裂外,未发生其它严重并发症.结论 术后胆道镜取石,作为胆道结石特别是肝胆管结石治疗环节中不可或缺的一环,在胆道结石治疗中扮演着十分重要的角色.     

术后胆道镜取石1226例体会

目的探讨经T管窦道胆道镜取石的方法及技巧,评价胆道镜在肝内外胆管结石治疗中的价值。方法回顾分析我院1990年3月至2011年9月术后胆道镜取石1226例,结石取净后常规行T管造影。结果共取石2685次,平均2.2次,取石最多次数者为12次。取净1182例,取净率96.4%。除1例为了重新放置T管而扩张窦道时引起出血、2例取石过程中引起窦道破裂外,未发生其它严重并发症。结论术后胆道镜取石,作为胆道结石特别是肝胆管结石治疗环节中不可或缺的一环,在胆道结石治疗中扮演着十分重要的角色。     

经T管窦道纤维胆道镜取石106例体会

目的 评估经T管窦道纤维胆道镜取出胆总管结石的临床价值。方法 肝外胆道结石术后带有T管引流的患者在拔掉T管之后，经T管窦道常规行纤维胆道镜检查，并取净残石。结果 106例病人一次取净结石103例，两次取净结石3例，无并发症发生。结论 术后经T管窦道取出胆总管残石的方法，安全，可靠，痛苦小。现已成为处理有T管窦道的胆总管残石的主要措施之一。     

体外震波碎石治疗术后Vater壶腹嵌性残石

总结我院 1998～ 2 0 0 0年收治 31例胆道术后胆管残石病例 ,其中 3例Ｖａｔｅｒ壶腹嵌顿性残留结石 ,由于结石紧固包嵌 ,胆道镜下取石网难于通过套取 ,为避免再次手术 ,我们采用体外震波碎石技术治疗 ,取得了满意疗效 ,现报告如下。1　临床资料1.1　一般资料　 3例病人均经Ｔ管造影发现胆总管下端梗阻 ,经Ｔ管窦道胆道镜可见结石嵌顿Ｖａｔｅｒ壶腹部 ,取石网无法张网取石 ,活检钳亦无法钳夹碎石 ,导致取石失败。1.2　治疗方法　术前给予度冷丁 5 0ｍｇ肌注 ,经Ｔ管窦道注入造影剂 ,通过体外震波碎石机Ｘ线定位后碎石 ,完毕后注入 10ｍｌ利…     

经T管窦道胆囊管残余结石胆道镜取石1例报告

目的:探究经T管窦道胆囊管残余结石胆道镜取石的可行性.方法:选取1例胆囊管残余结石T管引流术后患者,应用胆道镜结合X线透视取石,观察取石效果.结果:胆囊管结石取石成功,术后X线造影无残余结石.结论:对于存在胆囊管肝总管瘘的胆囊管残余结石患者,应用胆道镜取石安全可靠.     

自制腹腔镜胆道取石钳在腹腔镜治疗胆总管结石中的应用研究 (附64例报告)

目的:探讨自行设计的腹腔镜胆道取石钳在腹腔镜治疗胆总管结石中的取石效果及应用价值。方法:64例患者在腹腔镜下切开胆总管,先用胆道镜探查,取石网篮取石失败后,用胆道取石钳在胆总管内碎石并取出结石,同时可交替使用取石网篮取石。结果:22例胆总管中有<1.0 cm的游离结石,用腹腔镜胆道取石钳直接取出;31例胆总管中有≥1.0 cm的游离结石,由腹腔镜胆道取石钳联合取石网篮顺利在胆总管内碎石和取石;16例胆总管中有嵌顿的难取性结石,用腹腔镜胆道取石钳在胆总管内碎石后单独或联合取石网篮取出结石。3例术后胆总管残余小结石,经胆道镜取净残余结石。无一例因无法取出结石而中转开腹。结论:腹腔镜胆道取石钳用于腹腔镜胆总管探查取石术,缩短了取石时间,降低了取石难度,避免了因难取性结石而中转开腹手术。在腹腔镜治疗胆总管结石术中有实用性。     

胆道镜联合钬激光治疗难取性胆管残余结石的体会

目的:探讨胆道镜联合钬激光治疗难取性胆管残余结石的临床疗效及安全性。方法:对38例胆道术后"T"管引流的患者拔除"T"管后,因嵌顿结石、铸型结石或巨大结石(直径>1.0cm)先行单纯胆道镜取石不成功,联合钬激光碎石后再取石。结果:对38例患者采用胆道镜下钬激光碎石、取石治疗,经过1～3次碎石、取石治疗,共有35例患者的结石取净,3例因结石位于三级以上胆管,胆道镜及光道纤维不能到达,未完全取净。术后有4例出现发热、轻微腹痛、寒战等胆道感染的表现,3例出现胆道出血,出血量均小于100ml,无胆道穿孔,窦道破裂等严重并发症。结论:胆道镜联合钬激光治疗难取性胆管残余结石创伤小,并发症少,安全有效,是目前治疗胆道术后难取性残余结石最有效的补救措施。     

胆道镜联合应用在腹腔镜胆总管切开取石一期缝合中的作用

目的探讨胆道镜联合应用在腹腔镜胆总管切开取石一期缝合中的应用价值。方法总结2009年1月至2013年4月,腹腔镜胆总管切开取石一期缝合术61例的临床经验,胆总管直径≥8mm,腹腔镜下胆总管切开,用纤维胆道镜联合胆道直镜行胆总管取石,先用纤维胆道镜探查胆总管、肝总管及左右肝管,吸引器接输血器管反复冲洗胆总管,大部分结石可以被冲出,再用胆道镜检查,用取石网篮取出残余结石,若遇结石嵌顿或大的结石难以用纤胆镜取出时改用胆道直镜碎石、取石。结果61例患者成功行胆总管切开取石一期缝合术,用胆道直镜碎石取石29例,占47．5％;其中17例结石在胆总管下端嵌顿,12例因结石大难以取出。少量胆漏5例,引流量每天10～50m1,术后3～12d拔除腹腔引流管;手术时间90～180（134±22）min。术后住院7～14（8．4±1．5）d,所有患者均治愈。61例中有58例获随访,随访时间4～52个月,无残余结石。结论胆道直镜可以弥补纤维胆道镜的不足,胆道镜的联合应用可以尽可能取净结石,在腹腔镜胆总管切开取石一期缝合中发挥重要的作用。     

Electrohydraulic lithotripsy (EHL) for the treatment of large retained common duct stones

Retained biliary stones may be too large for extraction through the existing T-tube tract. It may be necessary to dilate the tract, crush the stones or use endoscopic papillotomy. There are reports of stones and the extracting basket becoming stuck in the T-tube tract and tract ruptures caused by extracting large stones. In this study electrohydraulic lithotripsy (EHL) is used in combination with T-tube tract choledochoscopy for the fragmentation of large stones prior to basket extraction. T-tube choledochoscopy was performed under IV sedation and sterile conditions no sooner than one month following common bile duct exploration. The Olympus 4.9-mm choledochoscope was passed through the T-tube tract to visualize the stone. A #5 Fr EHL probe was passed through the endoscope and advanced to within 1 mm of the surface of the stone. EHL discharge was started at a low energy level being increased until the spark discharges caused stone fragmentation. The resultant stone fragments were basket extracted under direct vision. The procedure was used in twelve patients with removal of all stones in eleven patients. Eight patients were treated with one endoscopic session. Because of multiple stones, two patients required two sessions and one patient four sessions. In one patient stone position prevented adequate fragmentation and endoscopic papillotomy also failed. Repeat choledochoscopy and EHL were successful. There were no complications of EHL or choledochoscopy in any of the patients. EHL was both effective and safe for fragmentation of large common duct stones when performed under direct vision using a choledochoscope.     

双频激光碎石在腔镜外科难取性胆管结石中的应用(附23例报告)

目的探讨双频激光碎石治疗腔镜外科难取性胆管结石的疗效及安全性. 方法 2002年1月～2004年6月,对23例难取性胆管结石进行双频激光碎石治疗.其中腹腔镜胆道探查术中应用14例,术后胆道镜取石中应用9例. 结果 19例取净胆管中结石,结石取净率为82.6%(19/23),无胆管损伤、窦道损伤等并发症. 结论双频激光碎石具有创伤小、效率高、并发症少的优点,对腔镜外科难取性胆管结石是一种可选择的有效方法.     

自制腹腔镜胆道冲洗器在腹腔镜胆总管取石术中的应用：双中心经验总结

背景与目的 腹腔镜胆总管探查取石术（LCBDE）是治疗胆总管结石的主要治疗方式,但在LCBDE过程中,由于术中缺少窦道支撑,经典的胆道镜下网篮取石相对较为困难,对术者的操作技术要求高,反复的胆道镜取石也容易造成胆道镜损坏或胆管壁损伤。为了更好地提高取石效率,降低手术难度,笔者对胆道镜取石术进行改良,即LCBDE术中采用自制腹腔镜胆道冲洗器配合胆道镜取石。本研究总结两个中心应用该方法的临床效果。方法 回顾2017年1月—2021年1月福建省立医院和福建省浦城县医院收治的313例LCBDE术中应用自制腹腔镜胆道冲洗器治疗的胆总管结石患者的临床资料,分析患者围手术期情况及近期预后。结果 313例患者中,男132例,女181例;平均年龄（56.3±13.2）岁;173例患者为胆总管单发结石,140例患者为胆总管多发结石（结石最多者为10枚）;中位结石直径为0.5（0.2~3.1） cm,中位胆总管直径为1.2（0.6~3.3）cm。手术均顺利完成,无中转开腹。其中281例（89.8%）患者使用自制腹腔镜胆道冲洗器取净结石,32例（10.2%）患者术中联合网篮取石。307例（98.1%）患者一期取净结石,6例（1.9%）患者残留结石;157例（50.2%）术后一期缝合胆总管,156例（49.8%）术后留置T管引流。平均手术时间（109.3±29.4）min,平均术中出血量（42.5±8.4）mL,平均术后住院时间（7.6±3.2）d。术后12例出现胆汁漏,12例出现腹腔感染,9例出现肺部感染,7例出现切口感染,1例出现术后出血,均经保守治疗后痊愈。6例无法一期取净结石患者均于术后1.5个月行经T管窦道胆道镜取净结石。术后随访6~12个月,无胆管结石复发、胆道狭窄等其他并发症。结论 LCBDE术中应用自制腹腔镜胆道冲洗器安全可靠,取石效率高,故推荐使用。     

经胆道镜冲击波碎石治疗胆道残余结石的体会（附75例报告）

目的探讨应用体内冲击波碎石机，经胆道镜碎石治疗手术后胆道残余结石的疗效和安全性。方法对我院2009年8月至2010年3月间75例带T管胆道残余结石的患者，在胆道镜直视下，应用冲击波碎石机将结石击碎后，用取石篮取出，并用生理盐水反复冲洗胆道。结果75例中31例1次取净结石（占41．3％），35例2次取净（46．7％），9例3次以上取净（12％）。取石成功率100％，取石次数1—3次，平均1．7次，无胆道穿孔等严重并发症，有12例（10％）患者发生术中胆道少量出血，2例（2．7％）患者呕吐，5例（6．7％）患者术中有疼痛感，均经保守治疗后缓解。结论体内冲击波碎石机与胆道镜配合，将能窥见的难取性胆道残留结石击碎取出，安全易行，疗效确切，大大提高了取石成功率，值得临床广泛推广应用。     

胆道镜联合钬激光经T管窦道治疗肝内外胆管残余结石

目的:探讨胆道镜联合钬激光经T管窦道碎石治疗肝内、外胆管残余结石的临床价值和安全性。方法:回顾性分析2010年2月—2011年6月经术后T管窦道置入胆道镜联合钬激光碎石治疗300例肝内、外胆管残余结石患者的临床资料。结果:292例经胆道镜下钬激光碎石治疗结石全部取净,碎石时间4~12 min,碎石次数1~5次,13例经5次碎石;8例患者结石位于III,IV级肝管碎石未成功,带管2个月后经等离子体冲击波碎石,6例患者成功取出结石,2例患者结石未取出。碎石总数568枚,结石排净率97.3%(292/300)。术中无胆道大出血、穿孔、胆管壁灼伤、胆瘘等严重并发症发生;15例术后出现低热。268例随访6~18个月,平均10个月,未发现结石复发及残留,无胆道狭窄。结论:胆道镜联合钬激光碎石可显著提高肝内、外胆管残余结石的治疗效果,是一种简便、安全、有效的方法,值得临床应用推广。     

腹腔镜、内镜在Mirizzi综合征I型患者中的应用(附11例报告)

目的探讨腹腔镜、内镜等微创技术在Mirizzi综合征(MS)Csendes I型患者"个体化诊疗"中的应用。 方法纳入成都中医药大学附属医院2013年11月至2015年12月施行腹腔镜胆囊切除术(LC)的患者900余例,进行回顾性分析。对病史中有黄疸、生化检查提示血胆红素升高和超声检查提示胆囊结石且肝总管或胆总管直径大于0.8 cm的患者,术前全部进行MRCP及ERCP,发现符合MS的患者24例,占同期LC患者的2.7%(24/900)。将其中Csendes I型11例纳入本研究,分析其临床特征及诊治特点。 结果11例Csendes I型患者中,Csendes Ia型6例,3例合并继发性胆总管结石,其中2例发生急性胆管炎;Csendes Ib型5例,2例合并继发性胆总管结石,其中1例发生急性胆管炎。所有患者行ERCP时一并清除胆总管内取石,留置ENBD管引流胆道,以改善肝功能。11例患者在ERCP后3～7 d成功施行了LC,仅1例Ia型患者胆囊管结石嵌顿,于LC中中转开腹,经胆囊管行胆道镜下的碎石取石。 结论怀疑MS的患者应行MRCP和ERCP,采用Csendes(1989,2008)标准进行准确分型,以便对肝外胆道的受损程度进行评估、合理抉择治疗策略。Csendes Ia型和Ib型患者均可行LC,但术中应利用胆道镜进行胆囊管探查及碎石取石,尽可能避免胆道探查,以防止医源性胆管狭窄。     

纤维胆道镜取石术后并发症的处理

目的探讨纤维胆道镜取石术后并发症的处理方法。方法总结我院1999年10月-2005年12月应用纤维胆道镜取石治疗362例的病例资料,对引起各种并发症的28例进行回顾性分析。结果取石术后出现发热（38℃以上）,经引流及抗生素等治疗体温降至正常者11例;胆道出血,经冰肾、双氧水冲洗后出血停止者3例;窦道穿孔胆漏,重新置管者4例;T管脱落、重新置管成功者7例,失败1例;网篮套取结石嵌顿,通过体外冲击波碎石后成功取石者2例。结论胆道术后纤维胆道镜取石可出现多种并发症,只要处理及时、方法妥当,均可避免产生严重后果。     

Choledochoscopic electrohydraulic lithotripsy and lithotomy for stones in the common bile duct, intrahepatic ducts, and gallbladder.

Choledochoscopic lithotomy with the aid of electrohydraulic lithotripsy was performed in 40 patients, including 16 patients with choledocholithiasis, 15 with hepatolithiasis, and 9 with cholecystolithiasis. As a route for the choledochoscopy, a T-tube tract, external cholecystostomy, or jejunal limb of hepaticojejunostomy was used in nine patients, while percutaneous transhepatic biliary drainage followed by dilatation of the track was established in 31 patients. The largest cholesterol stone measured 55 mm by 33 mm and the largest bilirubinate stone measured 52 mm by 37 mm. The stones were disintegrated in all but one patient in whom choledochoscopic access to a gallstone was difficult due to deformity of the gallbladder. Complete removal of the stones was achieved in 38 of 39 patients. In a patient with hepatolithiasis, small stones located deep in inaccessible branches of the intrahepatic duct remained unremovable. There were no serious complication. Minor complications occurred, including bleeding from the bile duct mucosa in four patients and postprocedure chills and fever in three. Choledochoscopic lithotomy with electrohydraulic lithotripsy is efficient and useful to remove biliary calculi in patients who are poor surgical risks.     

Nonoperative removal of giant common bile duct calculi

Endoscopic sphincterotomy has allowed us to extract relatively large stones from the common bile duct as compared with other methods utilizing a T-tube tract or the percutaneous transhepatic route. Twenty-four patients with large stones over 20 mm in diameter were selected and reviewed from a series of 469 sphincterotomy patients. Eleven stones passed into the duodenum spontaneously, the maximal size of which was 30 by 43 mm. Passage occurred within 4 days after sphincterotomy in 27 percent, 5 to 7 days after the procedure in 55 percent, and 8 to 13 days after the procedure in 18 percent and was accompanied by cholangitis in 55 percent of the patients. The small diameter of the stone and common bile duct dilatation down to the distal end seemed to be the factors favoring stone delivery. Five stones were removed using ordinary basket catheters by duodenoscopy; however, the largest one required 28 attempts. More recently, four stones were efficiently extracted after destruction by electrohydraulic or mechanical lithotripsy. Failure of removal in five patients was mainly due to a lack of space around the stone for basket manipulation or occurrence of severe cholangitis. Further refinements in technique in this regard are needed.     

Postoperative T-tube tract choledochoscopy.

One hundred twenty-six patients underwent postoperative fiberoptic T-tube tract choledochoscopy for the management of retained biliary calculi as demonstrated by T-tube cholangiography. Extraction was successful in 94% of patients with retained stones. Thirty-nine patients had more than 1 stone, 20 patients had heptic duct stones, and 14 patients had large stones requiring electrohydraulic lithotripsy or laser fragmentation. Stone removal was not possible in six patients, secondary to either slippage of the T-tube with obliteration of the tract, inability to remove the stones with available instruments, a tortuous tract, or choledochoscope malfunction. Minor complications, most commonly transient fever, occurred in 12 patients. No serious complications or deaths occurred. The advantages of T-tube tract choledochoscopy include direct visualization of the biliary tree, avoidance of radiation exposure, and easy access to hepatic duct stones. This is the preferred method for treating retained biliary calculi in patients with a T-tube in situ.