无胆总管结石高危因素的胆囊结石患者行磁共振胆胰管成像的必要性

目的探讨无胆总管结石高危因素的胆囊结石患者行腹腔镜下胆囊切除术(LC)前行磁共振胆胰管成像(MRCP)检查的必要性。方法回顾分析我院450例无胆总管结石高危因素的胆囊结石患者行LC术前常规行彩超、MRCP检查并于术后结果比较。结果 450例无胆总管结石高危因素的患者经MRCP检出胆总管结石38例,术中胆总管探查阳性率100%,无胆道损伤病例,术后随访最少三个月,除一例术后7天因发生胆总管结石再次住院外,无因胆总管结石再次入院及死亡病例。结论对于无胆总管结石高危因素的胆囊结石患者LC术前常规行MRCP检查是很有必要的,可以及时发现隐匿性胆总管结石,减少胆总管结石的漏诊,减少术中胆总管探查阴性率和胆道损伤等并发症。     

腹腔镜联合胆道镜或十二指肠镜治疗胆总管结石合并胆囊结石的对比研究

目的：探讨胆总管探查取石术（laparoscopic common bile duct exploration,LCBDE）联合腹腔镜胆囊切除术（1aparoscopic cholecystectomy,LC）与内镜下括约肌切开取石术（ endoscopic sphincterotomy,EST）联合LC治疗胆总管结石合并胆囊结石的临床疗效。方法2010年7月～2013年10月我院对136例胆总管结石合并胆囊结石分别采用LCBDE＋LC治疗（72例）或EST＋LC治疗（64例）,比较2组手术治疗成功率、术后并发症发生率、结石残留率、胃肠功能恢复时间、住院时间和费用等指标,随访2组远期并发症发生率。结果 LCBDE＋LC组手术时间（186±44） min明显短于EST＋LC组（221±41）min（t＝-4．687,P＝0．024）;LCBDE＋LC组住院时间（10．4±3．2）d,明显短于EST＋LC组（13．6±3．4）d（t＝-5．545, P＝0．000）;LCBDE＋LC组手术费用（8200±376）元,明显少于EST＋LC组（9600±420）元（ t＝-20．130,P＝0．000）;2组术后排气时间分别为（1．3±0．8）、（1．2±0．7）d,无统计学差异（t＝0．756,P＝0．451）;2组手术成功率分别为97．2％（70／72）、95．3％（61／64）,无统计学差异（χ2＝0．018,P＝0．893）;2组结石残留率分别为2．8％（2／70）、3．3％（2／61）,无统计学差异（χ2＝1．728,P＝0．531）,胰腺炎发生率有显著性差异[0 vs．6．2％（4／64）,P＝0．047]。随访1～3年,（2．5±0．5）年,2组反流性胆管炎发生率有统计学差异（χ2＝7．661,P＝0．004）。结论 LCBDE＋LC治疗胆囊结石合并胆总管结石安全、有效,术后并发症如胰腺炎和远期并发症返流性胆管炎比EST＋LC更具优势。     

腹腔镜胆囊切除中转开腹手术的原因分析

目的分析腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中转开腹的原因并探讨其防治措施。方法2005年10月-2007年10月共行LC手术405例,中转开腹37例（9.1%）。结果中转开腹的原因：慢性萎缩性胆囊炎5例、解剖变异3例、术中胆管损伤7例、胆囊动脉或肝右动脉损伤出血6例、胆囊三角解剖不清16例,开腹手术均获成功,均痊愈出院。结论熟悉各种解剖变异、规范操作、正确术前评估、熟练的操作技术是减少LC中转开腹手术的关键。     

Risk Factors for Conversion to Open Surgery in Patients Undergoing Laparoscopic Cholecystectomy

Background Laparoscopic cholecystectomy is the gold standard treatment for most gallbladder diseases. Conversion to open cholecystectomy is necessary in some patients for any of a number of factors. Identifying these factors will help the patient, the surgeon, and the hospital. Methods One thousand laparoscopic cholecystectomies were performed from May 1998 to May 2004 in Changi General Hospital, Singapore; 103 patients (10.3%) required conversion to open cholecystectomy. All data were kept prospectively and analyzed retrospectively. Results The patients who had conversion were mostly men (P < 0.0001), were heavier (P < 0.05), had acute cholecystitis (P < 0.0001), and had a history of upper abdominal surgery (P < 0.001). There were no differences in terms of race (P = 0.315) and presence of diabetes mellitus (P = 0.126). Diabetic patients who had conversion had a significantly higher glycosylated hemoglobin (Hba1c) (8.9% ± 0.6%; P < 0.038). Patients who had conversion had a higher total white count (P < 0.05), but liver function tests were similar between the two groups. There was a higher conversion rate among the junior surgeons than the more experience surgeons (P < 0.032). Conclusions The significant risk factors for conversion were male gender, advanced age (> 60 years), higher body weight > 65 kg, acute cholecystitis, previous upper abdominal surgery, junior surgeons, and diabetes associated with Hba1c > 6. Chronic liver disease was not found to be a risk factor (P = 0.345), and performing laparoscopic cholecystectomy in cirrhotic patients is safe. Identifying risk factors will help the surgeon to plan and counsel the patient and introduce new policies to the unit. Some of the risk factors are similar to those reported from international centers, but others may be unique to our department.     

复杂性胆囊结石腹腔镜治疗体会

目的总结复杂性胆囊结石的腹腔镜手术治疗体会,探讨其安全性和可行性。方法对2009年5月～2012年5月行腹腔镜胆囊切除术的75例复杂性胆囊结石患者的临床资料进行回顾性分析。其中,急性胆囊炎48例,坏疽性胆囊炎12例,萎缩性胆囊炎5例,合并肝硬化5例,胆囊十二指肠瘘1例,Mirizzi综合征1例,合并腹部手术史3例。结果本组手术时间52～180 min,平均(67.5±35.5)min;术中出血量50～140 ml,平均(75.3±55.5)ml;术后住院时间5～30 d,平均(6.5±2.0)d。完成腹腔镜手术73例,其中腹腔镜下顺行胆囊切除术67例,顺逆结合胆囊切除4例,胆囊大部分切除2例。中转开腹2例,1例为胆总管损伤,行开腹胆囊切除加胆总管T管引流,另1例为右肝管和胆囊管并行过长解剖不清同时合并术中出血;术后并发急性脑梗塞1例。无术后大出血、胆瘘、腹腔脓肿、肠梗阻等并发症发生。结论充分的术前准备,术中仔细操作,及时中转开腹,以及认真细致地术后处理,腹腔镜治疗复杂性胆囊结石是安全可行的。     

腹腔镜胆囊切除术与小切口胆囊切除术在老年患者中的应用体会

目的比较腹腔镜胆囊切除术（LC）与小切口胆囊切除术（MC）在老年患者中的临床效果,以指导临床选择应用。方法回顾性分析笔者所在医院2010年7月至2013年7月期间行LC（LC组,n=109）及MC（MC组,n=111）的老年患者的临床资料,比较2组术中和术后相关指标的差异。结果 LC组和MC组患者的手术时间〔（45.72±6.14）min比（40.67±6.02）min〕、术中出血量〔（10.18±3.31）mL比（11.13±2.93）mL〕、住院时间〔（9±5）d比（10±5）d〕及总并发症发生率〔28.4%（31/109）比31.5%（35/111）〕比较差异均无统计学意义（P〉0.05）;但LC组患者的术后疼痛程度轻、胃肠道功能恢复时间短〔（46.3±10.5）h比（71.4±9.8）h〕、住院费用较高〔（8 010±450）元比（4 800±680）元〕、切口感染发生率较低〔0（0）比15.3%（17/111）〕、肺部感染发生率较高〔17.4%（19/109）比9.9%（11/111）〕,P〈0.05。结论 LC对老年胆囊结石或胆囊炎患者具有更好的临床效果;但对心肺功能异常者,尤其是不能耐受全麻和气腹的患者选择MC更为合适,所以临床上应视患者具体情况加以选择。     

腹腔镜联合内镜微创手术治疗胆囊结石合并胆总管结石的临床观察

目的探讨腹腔镜联合内镜微创手术治疗胆囊结石合并胆总管结石的疗效。方法回顾性分析95例胆囊结石合并胆总管结石病人行腹腔镜联合内镜微创手术治疗的临床资料。结果本组63例先行十二指肠镜下乳头括约肌切开术(endoscopic sphincterotomy,EST)治疗,其中59例成功行EST+腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),但术中并发十二指肠乳头少量出血2例,术后发生胆道感染1例,出现可疑十二指肠漏1例;4例EST取石失败后1周内改开腹手术,术后并发腹腔感染1例,胆漏1例。23例顺利行LC+腹腔镜胆总管探查取石术,其中腹腔镜胆囊管探查取石5例,腹腔镜胆总管切开取石18例。9例因疑诊胆总管结石而先行LC,术后2~4 d再行EST。术后随访6~12个月,均未出现反流性胆管炎、乳头狭窄等并发症,无胆管结石残留。结论腹腔镜联合内镜微创手术治疗胆囊结石合并胆总管结石效果满意。     

术前扩容对腹腔镜胆囊切除术后患者恶心呕吐的影响

目的观察术前补充10ml/kg6%中分子羟乙基淀粉(HES130/0.4,万汶)或10ml/kg乳酸钠林格液对腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)术后恶心呕吐的影响。方法60例ASAⅠ~Ⅱ级择期LC随机均分为三组,A组入手术室后至麻醉诱导前给予静脉输注2ml/kg乳酸钠林格液,B组静脉输注10ml/kg乳酸钠林格液,C组静脉输注10ml/kg羟乙基淀粉。记录术前、诱导时及诱导后5、10、15min及术毕时血压和心率,3组麻醉时间、手术时间,术后第1天随访患者恶心呕吐情况及需要补用止吐药例数。结果3组年龄、体重、麻醉时间、手术时间差异无显著性。诱导后3组平均动脉压较诱导前显著下降(P<0.05),A、B两组下降较C组明显(P<0.05)。术后24h恶心呕吐发生率B组(7/20)和C组(6/20)明显低于A组(14/20)(χ2=4.912、6.400,P<0.05),而B、C两组差异无显著性(χ2=0.114,P=0.736)。但3组间恶心呕吐分级无显著性差异(P>0.05)。需要给予止吐药的患者比例C组(1/20)低于A组(7/20)(χ2=3.906,P=0.04...     

双镜联合一期治疗胆囊结石合并胆总管结石27例

目的探讨内镜下乳头扩约肌切开取石（endoscopic sphincterotomy,EST）联合腹腔镜胆囊切除术（laparoscopiccholecystectomy,LC）一期治疗胆囊结石和胆总管结石的可行性。方法 2010年10月～2011年10月对27例胆总管结石合并胆囊结石在基础麻醉下行EST取石成功置入ENBD后改全麻下行四孔法LC。结果 25例成功施行EST联合LC一期手术,成功率92.6%（25/27）;1例EST取石未成功改开腹胆囊切除、胆总管取石、T管引流;1例EST成功后,LC术中见胆囊炎症明显,胆囊床渗血不止改开腹止血。术后发生胰腺炎1例,保守治疗治愈;迟发上消化道出血3例,经鼻胆管滴入去甲肾上腺素后血止;高淀粉酶血症13例,未处理自愈。残留结石3例,二次取石后痊愈。术后住院5～7 d,平均6 d。27例随访3～12个月,平均9个月,B超和肝功能检查均未见明显异常。结论 EST联合LC一期治疗胆囊结石合并胆总管结石可行。     

腹腔镜胆囊切除术后呼吸功能训练效果观察

将腹腔镜胆囊切除术后病人随机分为呼吸功能训练组(观察组)和对照组,各30例.对照组术后采用一般常规护理,观察组在此基础上进行深呼吸训练.分别于手术前后检测病人的动脉血气分析和肺功能.结果两组手术前后VC、FVC及FEV1%比较,均P＜0.05,差异有显著性意义.提示腹腔镜胆囊切除术后病人接受呼吸功能训练后肺功能的恢复效果明显.     

腹腔镜与开腹胆囊切除术治疗急性胆囊炎的效果比较

目的比较腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)与开腹胆囊切除术(opencholecystectomy,OC)治疗急性胆囊炎的效果。方法回顾性比较行胆囊切除术治疗的急性胆囊炎患者114例,其中LC 53例,OC 61例,比较两种手术的手术时间、术中出血量、下床活动时间、术后排气时间、住院时间、住院综合费用、切口感染率和置引流管率的差异。结果与OC组比较,LC组手术时间、下床活动时间和术后排气时间短,术中出血量少,住院时间短,住院费用低,切口感染率低,置引流管的比率低,差异均有统计学意义(P0.05)。两组患者中均无胆道损伤、胆漏病例。均获随访,平均时间13.3(2~48)个月,均未发现胆管损伤、胆漏损伤、胆囊残株炎、胆囊切除术后综合征等并发症。结论与OC相比,LC治疗急性胆囊炎具有创伤小、并发症少和综合费用少等优点,是治疗急性胆囊炎可行的手术方式。     

经腹腔镜逆行胆囊切除术治疗复杂胆囊结石术后并发症的危险因素分析

目的：探究经腹腔镜逆行胆囊切除术（LRC）治疗复杂胆囊结石（CGS）术后并发症的危险因素。方法：选择2019年3月—2021年3月我院收治的237例行LRC治疗的CGS患者作为研究对象,根据术后并发症发生情况分为无并发症组（220例）和并发症组（17例）。比较两组患者的一般资料;采用单因素及多因素Logisitic回归分析影响患者术后并发症发生的危险因素;构建风险评分模型,并评价其预测价值。结果：本研究中有17例CGS患者行LRC治疗后出现并发症,发生率为7.17%(17/237),包括胆管损伤3例,胆囊管过长3例,结石4例,胆漏7例;糖尿病、胆囊壁厚度> 5 mm、胆囊颈部结石、周围脏器粘连、Calot三角粘连、急诊手术均是影响CGS患者行LRC后并发症发生的危险因素（P <0.05）;将上述危险因素纳入风险评分模型,分别赋予19、35、42、31、38、27分的权重,将总分≤69分定义为中危组,69～152分定义为高危组,> 152分定义为极高危组,模型预测的区分度和校准度较好。结论：分析影响CGS患者LRC后并发症发生的危险因素,有利于临床上早期识别高危人群,对...     

Five-year Prospective Audit of Routine Intravenous Cholangiography and Selective Endoscopic Retrograde Cholangiography with or without Intraoperative Cholangiography in Patients Undergoing Laparoscopic Cholecystectomy

Consensus has never been reached regarding the need or the imaging technique for evaluating the common bile duct (CBD) in patients considered for cholecystectomy. With the advent of laparoscopic cholecystectomy there has been a resurgence of interest in the role of preoperative intravenous cholangiography (IVC) as an alternative for evaluating the CBD. The purpose of this audit was to assess whether a diagnostic workup based on IVC, which permits selective use of intraoperative cholangiography (IOC) and endoscopic treatment of CBD stones before surgery, could be useful in patients undergoing laparoscopic cholecystectomy (LC). In patients without jaundice, gallstone pancreatitis, a prior diagnosis of CBD stones, a prior history of contrast allergy, or a risk of contrast-associated acute renal failure, IVC was performed routinely. Patients suspected to have CBD stones based on IVC results or with inconclusive IVC and patients with a strong clinical suspicion of CBD stones were referred for endoscopic retrograde cholangiography (ERC). IOC was carried out in patients who had a history of contrast allergy or risk of contrast-associated acute renal failure and whenever the surgeon was in doubt as to the biliary anatomy or CBD clearance. IVC was carried out in 1155 patients, ERC in 225, and IOC in 54. IVC was conclusive in 1132 patients, with a diagnostic accuracy of 99%. Our workup permitted the sequential endoscopic-laparoscopic treatment of cholecystocholedocholithiasis in 162 cases. During the follow-up period residual CBD stones were detected in four patients. Our diagnostic workup showed that routine IVC exposes the population to a large radiation burden, and the cost is high for the small number of patients who benefit. Moreover, it does not seem helpful in reducing the incidence of CBD injuries during LC.     

中药保留灌肠在腹腔镜胆囊切除术护理中的应用

目的探讨自制中药“和中饮”保留灌肠、不同保留时间预防腹腔镜胆囊切除术后恶心呕吐及促进肠功能恢复的效果。方法将350例胆囊结石行腹腔镜胆囊切除术的患者随机均分为七组,其中1组为对照组,另6组为观察1～6组。对照组行常规护理;观察1～6组分别于术前晚（18：00～20：00）、术后6h、24h用“和中饮”180ml行保留灌肠,保留时间分别为5min、15min、30min、45min、60min、90min。观察各组术后4～36h恶心呕吐情况、肠鸣音出现及肛门排气时间。结果恶心呕吐发生率、肠鸣音出现及肛门排气时间：观察3～6组显著低于/早于对照组（均P〈0.05）;观察组间比较,差异有显著性意义（均P〈0.05）;观察1、2组比较,差异无显著性意义（均P〉0.05）,观察1、2组分别与3～6组比较,差异有显著性意义（均P〈0.05）,观察3～6组比较,差异无显著性意义（均P〉0.05）。结论“和中饮”保留灌肠可有效预防腹腔镜胆囊切除术后恶心呕吐,促进胃肠功能恢复;“和中饮”灌肠保留30min即达最佳疗效,不必常规保留至1h。     

Outcome of Laparoscopic Resection for Colorectal Cancer in Patients with High Operative Risk

Background  

There is general concern that high-risk patients are more susceptible to the adverse effect of pneumoperitoneum and they are often denied laparoscopic surgery. This study investigated the impact of laparoscopic colorectal cancer resection for patients with high operative risk, which was defined as American Society of Anesthesiologist classes 3 and 4.     

中药保留灌肠在腹腔镜胆囊切除术护理中的应用

目的 探讨自制中药"和中饮"保留灌肠、不同保留时间预防腹腔镜胆囊切除术后恶心呕吐及促进肠功能恢复的效果.方法 将350例胆囊结石行腹腔镜胆囊切除术的患者随机均分为七组,其中1组为对照组,另6组为观察1～6组.对照组行常规护理;观察1～6组分别于术前晚(18:00～20:00)、术后6 h、24 h用"和中饮"180 ml行保留灌肠,保留时间分别为5 min、15 min、30 min、45 min、60 min、90 min.观察各组术后4～36 h恶心呕吐情况、肠鸣音出现及肛门排气时间.结果 恶心呕吐发生率、肠鸣音出现及肛门排气时间:观察3～6组显著低于/早于对照组(均P＜0.05);观察组间比较,差异有显著性意义(均P＜0.05);观察1、2组比较,差异无显著性意义(均P＞0.05),观察1、2组分别与3～6组比较,差异有显著性意义(均P＜0.05),观察3～6组比较,差异无显著性意义(均P＞0.05).结论 "和中饮"保留灌肠可有效预防腹腔镜胆囊切除术后恶心呕吐,促进胃肠功能恢复;"和中饮"灌肠保留30 min即达最佳疗效,不必常规保留至1 h.     

小儿经脐单孔腹腔镜胆囊切除术(附41例报道)

目的探讨经脐单孔腹腔镜胆囊切除(LC)治疗小儿胆囊良性疾病的可行性、手术方法及临床应用价值。方法回顾性分析2009年6月至2011年6月期间我院收治的64例小儿LC患者的临床资料,其中行经脐单孔LC手术41例(经脐单孔LC组),行常规三孔LC手术23例(三孔LC组)。记录2组患者的手术时间、术中失血量、中转情况、并发症及住院时间;运用视觉模拟评分法(VAS)对2组患者术后3 h、6 h、12 h、24 h、48 h及72 h的疼痛进行评分;采用Kiyak满意度问卷对2组患者术后1周、2周、1个月、3个月、6个月及12个月的满意度进行评分,并做统计学分析。术后随访12个月。结果 64例患者均顺利完成手术,无中转开腹病例,仅经脐单孔LC组有2例增加了戳孔。2组均无胆管损伤、胆汁漏及切口疝发生。三孔LC组有1例发生切口感染〔4.35%(1/23)〕,经脐单孔LC组发生1例切口感染和1例皮下血肿〔4.88%(2/41)〕,2组总的并发症发生率比较差异无统计学意义(P>0.05)。经脐单孔LC组和三孔LC组在手术时间〔(47.54±18.71)min比(45.33±10.58)min〕、术中失血量〔(18.56±13.34)ml比(17.28±12.53)ml〕及住院时间〔(1.67±0.36)d比(1.81±0.38)d〕方面比较差异均无统计学意义(P>0.05)。2组VAS疼痛评分在术后24 h内比较差异均无统计学意义(P>0.05),术后24 h后经脐单孔LC组VAS疼痛评分较三孔LC组明显降低(P<0.05)。2组术后随访12个月,经脐单孔LC组不同随访时间点满意度评分均明显高于三孔LC组(P<0.05)。结论经脐单孔LC手术能有效缓解术后疼痛,美容效果明显,患者满意度高,治疗小儿胆囊良性疾病安全、可行。     

Postoperative Complications of Laparoscopic Cholecystectomy for Acute Cholecystitis: A Comparison to the ACS-NSQIP Risk Calculator and the Tokyo Guidelines

Background

We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS.

Methods

A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed.

Results

ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes.

Conclusion

ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.

     

Diagnostic Value of Ultrasonographic Examination for Nonalcoholic Steatohepatitis in Morbidly Obese Patients Undergoing Laparoscopic Bariatric Surgery

Background There are few data relating to the role of fatty score (FS) and modified fatty score (MFS) in ultrasonographic (US) examination on the diagnosis of nonalcoholic steatohepatitis (NASH) in patients undergoing bariatric surgery. Methods We investigated consecutive patients undergoing laparoscopic bariatric surgery with biopsy-proven nonalcoholic fatty liver disease. Patients with other liver diseases and significant alcohol consumption were excluded. Clinico-demographic and anthropometric data were collected before surgery. Each biopsy specimen was assessed by the same pathologist. Liver US examinations were performed by an independent and experienced sonographer before surgery. FS and MFS, determined by the US scoring system based on degrees of parenchymal echogenicity, far gain attenuation, gallbladder wall blurring, portal vein wall blurring and hepatic vein blurring, were used to assess the severity of fatty liver. US findings were correlated with histologic results. Results Totally 101 patients were enrolled. The mean BMI of the patients was 44.6 ± 5.4 kg/m². 29 patients (29%) were categorized with simple steatosis and 72 (71%) with NASH. FS and MFS were significantly correlated with the histological steatosis, fibrosis and the presence of NASH (P < 0.001). A receiver operating characteristic curve identified the MFS of 2 as the best cut-off point for the prediction of NASH, yielding measures of sensitivity, specificity, positive predictive value, and accuracy for 72%, 86%, 93% and 76%, respectively. The positive likelihood ratio of 5.24 for MFS approximately doubled the post-test probability of NASH from 30% to 70%. Conclusion FS and MFS on US examination exhibit acceptable sensitivity and high specificity for the detection of the presence of NASH in morbidly obese patients and may aid in the selection of patients for closer follow-up or liver biopsy.