ERCP对胆囊切除术后综合征的病因诊断价值

为探讨ＥＲＣＰ对胆囊切除术后综合征的病因诊断价值，对１０８例胆囊切除术后综合征进行ＥＲＣＰ检查，插管成功率９６．３％，有效诊断率８７．０％，结果表明胆总管和（或）肝内、外胆管残余结石占３６．１％，胆总管炎性扩张或狭窄占１７．６％，胆囊管残留过长占６．５％，胆管损伤占１．８％。认为ＥＲＣＰ检查对胆囊切除术后综合征不仅能明确其病因，而且对选择治疗方法也有重要意义。     

腹腔镜胆囊切除术严重手术并发症的预防

目的评价腹腔镜胆囊切除术（ＬＣ）的安全性和有效性，对２８８０例ＬＣ及其并发症的预防加以总结．方法对２８８０例良性胆囊疾病患者行ＬＣ，术前选择性地行ＥＲＣＰ等影像学检查．结果ＬＣ时中转开腹胆囊切除术１２３例（４３％），中转原因多为Ｃａｌｏｔ三角粘连严重，解剖结构不清楚．共发生各种并发症２１例（０７２％），其中胆漏４例，出血３例，膈下积液５例，十二指肠穿孔１例，胆总管残留结石８例，均治愈．无手术死亡病例，也无胆道损伤等严重并发症发生．结论手术者的胆道外科素质，选择性术前ＥＲＣＰ检查，慎重细致的手术操作，是预防胆道损伤等严重手术并发症发生的重要因素．     

腹腔镜超声检查在腹腔镜胆囊切除术中的应用

在腹腔镜胆囊切除术（ＬＣ）中，术者常需要了解胆总管有无结石，肝外胆管及胆囊管的解剖变异及相互关系如何；手术是否已造成严重的胆道损伤等。以往人们为了解这些信息，一般都借助腹腔镜术中胆道造影（ＩＯＣＧ）。近年来一些作者采用了腹腔镜术中超声检查（ＬＵＳ）来...     

经腹腔镜胆囊切除术1650例的经验

本文报告我院为各种类型的胆囊良性疾病患者行腹腔镜胆囊切除术（ＬＣ）１６５０例，中转手术３２例，发生各种并发症３１例，其中肝外胆管损伤４例，术后需剖腹止血３例，胆囊管残端瘘１例。治愈１６４９例，死亡１例。重点讨论ＬＣ手术的并发症与学习曲线，中转开腹手术指征，强调ＬＣ术中正确辩论胆囊壶腹与胆囊管交界部在预防肝外胆管损伤中的作用和地位。     

腹腔镜胆囊切除术并发症的防治

为了提高腹腔镜胆囊切除术（ＬＣ）的安全性，作者对６００例ＬＣ的并发症加以回顾性总结。结果全组共发生并发症２９例（术中１４例，术后１５例），占４．８３％，包括胆管损伤２例，出血９例，皮下气肿２例及胃窦穿孔１例。中转剖腹１４例，其中因术中出现并发症中转４例，因术后并发症再手术２例，全组均治愈出院。因此，及时中转剖腹是避免严重并发症的重要措施，为了积极稳妥地开展ＬＣ手术，手术并发症的防治值得重视。     

腹腔镜与开腹胆囊切除术对机体免疫功能影响的临床研究

目的　研究腹腔镜胆囊切除术（ＬＣ）和开腹胆囊切除术（ＯＣ）对机体免疫功能的影响。方法　监测７０ 例（ＬＣ及ＯＣ各３５ 例）胆囊结石患者术前、术后第一天、术后第三天的外周血淋巴细胞（ＰＢＬ）亚群、补体Ｃ３ 及白细胞介素－６（ＩＬ－６）和肿瘤坏死因子（ＴＮＦ）的变化并行对比研究。结果　ＯＣ组术后第三天成熟的Ｔ淋巴细胞（ＣＤ３）、辅助性Ｔ细胞（ＣＤ４）、ＣＤ４／抑制性Ｔ淋巴细胞（ＣＤ８）比值较术前明显下降（Ｐ＜ ０．０５ 或Ｐ＜ ０．０１）,且两组相比较,ＯＣ组明显低于ＬＣ组（Ｐ＜ ０．０１）,ＯＣ组术后第一天或／和第三天Ｃ３、ＩＬ－６、ＴＮＦ较术前明显升高（ Ｐ＜ ０．０１）。且两组比较ＯＣ组明显高于ＬＣ组（Ｐ＜ ０．０１）。结论　ＬＣ对机体免疫及细胞因子水平影响较小,这构成了ＬＣ术后恢复较快的病理生理基础。     

腹腔镜胆囊切除术1475例胆囊动脉胆囊管的解剖与处理

目的:报告腹腔镜胆囊切除术中胆囊动脉及胆囊管的解剖观察。方法:1991—1993年行腹腔镜胆囊切除术1475例,手术认真解剖了胆囊动脉和并用钛夹分别进行钳闭处理。结果:84.9％为主干型胆囊动脉,15.1％为多支型胆囊动脉、胆囊动脉缺如或细小,肝迷走胆囊动脉等变异。90.9％的胆囊管直径0.3—0.4cm,长1—3.5cm。因胆囊炎症的严重程度导致胆囊管纤维化闭锁或增粗多见。短胆囊管76例。因误认致肝外胆管横断伤3例,胆囊动脉后支出血止血钳闭部分肝总管1例,胆囊管残端瘘1例,变异胆囊动脉术后出血2例。术后并发心律失常、肺部感染,21d死于多器官功能衰竭1例(0.1％)。治愈1474例(99.9％)。结论:腹腔镜胆囊切除术治疗胆石症是-安全的方法,术中仔细解剖胆囊动脉和胆囊管极为重要。     

腹腔镜胆囊切除术并发症的防治

为了提高腹腔镜胆囊切除术（ＬＣ）的安全性，作者对６００例ＬＣ的并发症加以回顾性总结。结果全组共发生并发症２９例（术中１４例，术后１５例），占４．８３％，包括胆管损伤２例，出血９例，皮下气肿２例及胃窦穿孔１例。中转剖腹１４例，其中因术中出现并发症中转４例，因术后并发症再手术２例，全组均治愈出院。因此，及时中转剖腹是避免严重并发症的重要措施，为了积极稳妥地开展ＬＣ手术，手术并发症的防治值得重视。     

腹腔镜胆囊切除术与开腹胆囊切除术患者血清白细胞介素-6和C-反应蛋白水平

为了比较腹腔镜胆囊切除术（ＬＣ）和开腹胆囊切除术（ＯＣ）对组织的损伤程度，选择拟行单纯胆囊切除术的患者４０例，分别行ＬＣ和ＯＣ各２０例，用酶联免疫法测定术前２４小时、术后１２、２４及４８小时血清白细胞介素－６（ＩＬ－６）；用散射比浊法测定术前２４小时、术后１２、２４及４８小时血清Ｃ－反应蛋白（ＣＲＰ）。结果显示：两组患者术前２４小时血清ＩＬ－６和ＣＲＰ水平相近（Ｐ＞０．０５）；术后１２、２４及４８小时ＯＣ组血清ＩＬ－６和ＣＲＰ水平分别高于ＬＣ组（Ｐ＜０．０５）；术后４８小时ＬＣ组血清ＩＬ－６和ＣＲＰ降至术前水平（Ｐ＞０．０５），但ＯＣ组仍高于术前水平（Ｐ＜０．０５）。ＯＣ组平均手术时间、切口长度及术后平均住院日均比ＬＣ组长（Ｐ＜０．０５）。结果表明：ＬＣ组织损伤程度比ＯＣ小，而后者平均手术时间和切口长度较长是血清ＩＬ－６和ＣＲＰ反应水平较高的主要原因。     

腹腔镜胆囊切除术胆管损伤4例报告

胆管损伤是腹腔镜胆囊切除术(ＬＣ)最严重的并发症之一[1],自1993年9月至1998年9月中间,我院共完成ＬＣ1866例,其中发生胆管损伤4例,现报告如下。腹腔引流管引出胆汁样液体,次日晨发现巩膜黄染,生化检查示梗阻性黄疸。急诊剖腹探查发现由于在胆囊管根部上夹入院。本组2例肝外胆管横断伤采用肝门胆管空肠ＲｏｕｘｅｎＹ吻合、Ｔ管支撑引流,效果良好。如果ＲｏｕｘｅｎＹ胆肠吻合术后发生胆漏,那么可导致继发性胆管狭窄,一旦发生,再次手术相当困难。胆管损伤的处理必须采取积极、慎重的态度,如果延误诊治,必然对机体产生严重损害,从而对胆管损…     

腹腔镜胆囊切除术并发胆管损伤26例临床分析

目的 探讨腹腔镜胆囊切除术中并发胆管损伤的类型。原因及其预防。方法 回顾分析26例胆管损伤的原因。修复方法与结果。结果 本组术中胆管解剖关系不清所致胆管损伤15例。其中经胆囊管造影显示胆管识别错误电动致胆管切开10例，钛夹夹闭胆管3例；胆管电凝热传导伤4例。胆管撕裂，4例。结论 胆管解剖不清所致的胆管损伤是LC胆管损伤最常见类型。占58%，准确掌握术中造影能及时发现胆管识别错误所致的胆管损伤，仔细分清肝总管远端，胆总管近端，胆囊管近端及其汇合处，胆囊三角区内正确分离与安全止血是预防腹腔镜胆囊切除术胆管损伤的关键。     

Handling of biliary complications following laparoscopic cholecystectomy in the setting of Tripoli Central Hospital

BackgroundLaparoscopic cholecystectomy (LC) has an increased incidence of bile duct injury and bile leak when compared with open cholecystectomy. This study reviews management of these complications in a general hospital setting. Data collected from patients diagnosed and treated in one surgical unit for biliary complications after LC between 1992 and 1996 were analysed.MethodA total of 14 patients were examined. Diagnosis was defined mainly by Endoscopic retrograde cholangiopancreatography (ERCP) and undetected choledocholitiasis was discovered in association with two of these complications. 43% of patients presented after LC with early postoperative bile leak or jaundice due to partial or complete bile duct excision or slippage of clips from the cystic duct. 57% presented with late biliary strictures. Thirteen patients were treated surgically, with biliary reconstruction (11 patients), direct repair (one) and cystic duct ligation in combination with clearance of bile duct from large multiple stones (one). One patient,who had clip displacement from cystic duct in combination with misplaced clip on right hepatic duct, was treated elsewhere. Postoperatively, one patient developed anastomotic leak and another died from sequellaie of bile duct transection requiring staged operations.ConclusionsIt is concluded that, in an environment similar to that where the authors had to work, LC should be performed in hospitals with facility to perform ERCP or when access for this technique is available in a nearby institution. Early recognition and immediate management of biliary injuries is dependent on individual resources and circumstances but, if required, consultation with colleagues or referral of patients with suspected or established biliary complications should not be delayed.     

Analysis of bile duct injuries (Stewart-Way classification) during laparoscopic cholecystectomy

In order to investigate mechanisms underlying the occurrence of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC), we analyzed results for 34 patients (0.59%; 17 men, 17 women; average age, 57 years) with BDI out of 5750 LCs, based on questionnaire responses from surgical operators, records of direct interviews with these operators, operative reports, and videotapes of the operations. The indications for LC in the 34 patients were chronic cholecystitis in 32 patients and acute cholecystitis in 2. The BDIs in these patients were divided into four classes using the Stewart-Way classification: class I, incision (incomplete transection) of the common bile duct (CBD), n = 6 (17.6%); class II, lateral damage to the common hepatic duct (CHD), n = 9 (26.5%); class III, transection of the CBD or CHD, n = 15 (44.1%); and class IV, right hepatic duct or right segmental hepatic duct injuries, n = 4 (11.8%). In all class III and 3 class I cases (18 in total; incidence 53%), the mistake involved misidentifying the CBD as the cystic duct. Of all types (classes) of injuries, class III injuries showed the mildest gallbladder inflammation, and there was a significant (P = 0.0005) difference in the severity of inflammation between class II and III injuries. We conclude that complete transection of the CBD, which is rare in laparotomy, was the most common BDI pattern occurring during LC and that the underlying factor in the operator making this error was mistaking the CBD for the cystic duct.     

Biliary navigation surgery using endoscopic nasobiliary drainage tube for the prevention of bile duct injury in laparoscopic cholecystectomy

Bile duct injury is the most troublesome complication in laparoscopic cholecystectomy (LC). The identification of the anatomical relationship between the cystic duct and common bile duct is one of the most important points for the safe LC. Therefore, we introduced a biliary navigation surgery using endoscopic nasobiliary drainage (ENBD) tube to avoid bile duct injury during LC. The benefit of intraoperative cholangiography using an ENBD tube is that the identification of the anatomical relationship between the cystic duct and common bile duct can be confirmed by using intraoperative cholangiography through the ENBD tube. We consider that ENBD tube is useful for identifying the biliary tract by repeated intraoperative cholangiography and, thus, for preventing injury to the bile duct in LC.     

Extrahepatic bile duct injury due to abdominal trauma

The diagnosis of bile duct injury due to abdominal trauma is usually not feasible preoperatively, but it must be suspected interoperatively with the presence of bile staining fluid in the subhepatic area. Four patients with bile duct injuries were encountered; these were the results of blunt injury in three and penetrating injury in one. The injury sites were in the common bile duct in two patients, and in the right hepatic duct just proximate to the bifurcation in two patients. One patient was diagnosed on the finding of bile stain discharged from the drainage tube after the first abdominal exploration. The other three patients were diagnosed by the amount of bile stained fluid collected in the subhepatic area during the primary laparotomy. The injuries of the common bile duct were treated by primary repairs and T-tube choledochostomy in two patients. The other two patients with right hepatic duct injuries were treated by right lobectomy because of extensive liver parenchyma injury. The postoperative courses were smooth and there were no deaths. We reviewed 27 reports (1984–1994) from around the world. The total operative mortality of the 75 patients in these reports was 18.67% (14/75) for the primary operation, and 7.14% (1/14) for re-operation in patients in whom reoperation was performed due to overlooked injuries or biliary complications.     

Laparascopic cholecystectomy: cystic duct occlusion with titanium clips or ligature? A prospective randomized study.

During laparoscopic cholecystectomy (LC), cystic duct occlusion can be done with titanium clips or laparoscopically tied knots. However, till date, there is no randomized, controlled study reported in the literature that has prospectively compared the outcome using either of these methods. In the present study, 105 patients who were to undergo LC were randomly assigned to two groups. Group I comprised patients undergoing cystic duct occlusion with clips while group II comprised those undergoing cystic duct occlusion with knots. Our aim was to compare the postoperative outcome in both the cases. The incidence of overall bile leak following LC was 4 out of 105 (3.8%) while the leak rate following cystic duct occlusion with clips was 2 out 52 (3.9%), and that following ligature was 2 out of 53 (3.8%). The procedure using ligature took slightly longer time than that using clips. There was no significant difference in the postoperative outcome in either group. The use of ligature is a feasible, safe and cost-effective alternative to the use of titanium clips for cystic duct occlusion during LC.     

Pseudoaneurysm following laparoscopic cholecystectomy

BACKGROUND:Laparoscopic cholecystectomy(LC)is the operation of choice for removal of the gallbladder. Unrecognized bile duct injuries present with biliary peritonitis and systemic sepsis.Bile has been shown to cause damage to the vascular wall and therefore delay the healing of injured arteries leading to pseudoaneurysm formation.Failure to deal with bile leak and secondary infection may result in pseudoaneurysm formation. This study was to report the incidence and outcomes of pseudoaneurysm in patients with bile leak following LC referred to our hospital. METHODS:A retrospective analysis of our prospectively maintained liver database using pseudoaneurysm, bile leak and bile duct injury following laparoscopic cholecystectomy from January 2000 to December 2005 was performed. RESULTS:A total of 86 cases were referred with bile duct injury and bile leak following LC and of these,4 patients (4.5%)developed hepatic artery pseudoaneurysm(HAP) presenting with haemobilia in 3 and massive intra- abdominal bleed in 1.Selective visceral angiography confirmed pseudoaneurysm of the right hepatic artery in 2 cases,cystic artery stump in one and an intact but ectatic hepatic artery with surgical clips closely applied to the right hepatic artery at the origin of the cystic artery in the fourth case.Effective hemostasis was achieved in 3 patients with coil embolization and the fourth patient required emergency laparotomy for severe bleeding and hemodynamic instability due to a ruptured right hepatic artery.Of the 3 patients treated with coil embolization, 2 developed late strictures of the common hepatic duct. . (CHD)requiring hepatico-jejunostomy and one developed a stricture of left hepatic duct.All the 4 patients are alive at a median follow up of 17 months(range 1 to 65)with normal liver function tests. CONCLUSIONS:HAP is a rare and potentially life- threatening complication of LC.Biloma and subsequent infection are reported to be associated with pseudoaneurysm formation.Late duct stricture is common either due to unrecognized injury at LC or secondary to ischemia after embolization.     

Treatment of biliary leakages after cholecystectomy and importance of stricture development in the main bile duct injury.

BACKGROUND/AIMS: Endoscopic treatment of biliary leakages after cholecystectomy, though widely accepted, has some restrictions. The efficacy and safety of endoscopic treatments in this patient group are evaluated in this study, and the problem of biliary stricture development in time after biliary ductal injuries is also emphasized. METHODS: Seventy-four patients (20 male, 54 female, mean age 50.9+/-21 years) referred for ERCP between 1992-2002 were included in the study. Minor leakages (cystic duct leaks, accessory bile duct leaks) were managed by nasobiliary drainage +/- endoscopic sphincterotomy; major leakages were managed by nasobiliary drainage +/- endoscopic sphincterotomy +/- stenting. RESULTS: Twenty-seven patients with cystic duct leaks and 6 patients with accessory bile duct leaks were successfully treated with nasobiliary drainage. Endoscopic treatment could not be performed on patients with total bile duct obstruction (7 patients) and aberrant bile duct injury (7 patients). All leakages from main bile ducts were closed (27 patients). Six of 27 patients had strictures at the beginning and they were treated by stenting. Twenty-one patients had no strictures at the beginning. Eight of 21 were treated by stenting and only 1 of them developed biliary stricture. Seven of 13 patients who had been treated by nasobiliary drainage developed biliary strictures. There were no mortalities due to procedure. CONCLUSIONS: ERCP is an effective and safe method for diagnosis and management of bile leakages after cholecystectomy. Stricture development in the main bile duct leakages was an important complication.     

Instrumental detection of cystic duct stones during laparoscopic cholecystectomy

Residual cystic duct stones (CDSs) after cholecystectomy have been recognized as a cause of postcholecystectomy pain. This study was undertaken to determine the incidence of CDSs during laparoscopic cholecystectomy (LC). A cohort of 330 consecutive patients (80 males and 250 females) undergoing LC between November 2006 and May 2010 was studied. Their age ranged between 16 and 88 years (median 50, IQR: 36.62). The data were prospectively collected of preoperative liver function tests, imaging, the presence of intraoperative CDSs, and common bile duct stones at on-table cholangiogram. CDSs were detected intraoperatively in 64 of the 330 patients (19%). Ultrasound failed to detect CDSs in any of these cases. Deranged liver function tests were noted in 73% of the patients with CDSs and in 57% without CDSs. Common bile duct stones were detected in 9% (29) of the 330 patients. CDSs occur commonly at routine cholecystectomy, and preoperative investigations are not helpful in their diagnosis. As CDSs may lead to postoperative morbidity, they should be actively sought out during surgery if present.     

Mirizzi syndrome secondary to an adenoma of the cystic duct

Bile duct adenomas are uncommon lesions that can cause obstructive jaundice. We report the unusual case of a 54-year-old man who developed Mirizzi syndrome secondary to a bile duct papillary adenoma located in the cystic duct remnant. A case report is presented, together with a review of extrahepatic bile duct adenomas published in the English-language literature, with special attention directed toward the clinical manifestations, locations, and prognosis of these tumors. Bile duct adenomas are very rare tumors. Although cholangiography can detect many of these lesions, few cases were correctly diagnosed preoperatively. Most lesions were located in the distal common bile duct or at the ampulla of Vater. Pathologic examination often revealed foci of carcinoma in situ, dysplasia, or atypia. Local resection was performed in most cases. There were no previous case reports of extrinsic common bile duct obstruction caused by tumors within the cystic duct. We describe here a very rare, acalculous variant of Mirizzi syndrome secondary to a solitary papillary adenoma of the cystic duct. In general, bile duct adenomas are uncommon lesions that are difficult to diagnoses preoperatively. These tumors usually present with jaundice secondary to intraluminal biliary obstruction. These lesions are premalignant and should be managed by complete surgical resection.