Ultrasound study in the diagnosis of extrahepatic bile duct diseases]

Ultrasonic examination (USE) conducted in 7,000 persons, among whom 3,000 had gastroenterological diseases, gave evidence for suspected diseases of the biliary tract in 1,471. Analysis of the results of the examination showed the method to be effective in 99% of patients with cholelithiasis and chronic recurring cholecystitis; the preoperative diagnosis of acute cholecystitis was confirmed in 98% of cases. The possibilities of USE in identifying the nature of jaundice were high, but the true topical diagnosis was established before the operation by the method only in 53% of 226 patients with obstructive jaundice. Stones in the common bile duct were discovered in 58 cases in a group of 100 patients, tumors in the extrahepatic biliary tract in 28 among 35 patients, and carcinoma of the pancreas in 33 among 35 patients.     

Imminent changes in the preoperative diagnosis of bile duct diseases

The author's views on the expedient sequence of using different diagnostic examinations in patients with bile duct diseases are presented. The author recommends instrumental methods to be predominantly used as more reliable ones.     

Three-dimensional virtual cholangioscopy: a reliable tool for the diagnosis of common bile duct stones

OBJECTIVE: Our goal was to evaluate the clinical reliability of a new software system employing 3-dimensional (3D) virtual anatomic reconstruction and intraluminal virtual exploration for detection of choledocholithiasis and preoperative visualization of the biliary anatomy. SUMMARY BACKGROUND DATA: Virtual reality systems have been proposed for gastroscopy, bronchoscopy, and colonoscopy, as well as for the 3D reconstruction of liver anatomy and hepatic lesions. The impact of these systems in preoperative diagnostics has not been established due to the lack of large clinical series evaluating their reliability. METHODS: From November 2000 to July 2002, all patients presenting to our Institute with suspected choledocholithiasis were prospectively included in the study. All patients underwent conventional magnetic resonance cholangiopancreatography (MRCP) and either intraoperative cholangiogram (IOC) or endoscopic retrograde cholangiopancreatography (ERCP). The digital data from MRCP were incorporated into an original virtual reality software system to generate a 3D reconstruction. All 3D reconstructions were evaluated by a surgeon and a computer software engineer who were blind to the results of the IOC or ERCP. Sensitivity and specificity were then calculated based on the results of either the IOC or ERCP. RESULTS: Sixty-five patients were enrolled in the study. The average time required to reconstruct the images into navigable virtual reality was 7.5 minutes (range, 4-13.5). The 3D virtual cholangioscopy had sensitivity and specificity rates of 71% and 91%, respectively, compared with 61% and 86% of the standard MRCP. CONCLUSION:: The 3D virtual cholangioscopy provides detailed preoperative reconstruction of biliary anatomy and reliable identification of choledocholithiasis with acceptable sensitivity and specificity in a clinical setting. Newer software developments may further enhance its accuracy, so that virtual cholangioscopy might challenge or replace more invasive diagnostic measures in the near future.     

Bacteriological studies in gallbladder and bile duct diseases]

In 373 hospitalized patients with bacteriologically positive bile samples, the aetiology was clarified by laboratory methods in 80% of clinically verified gallbladder and biliary duct infections and in 15.5% of diseases related to the biliary duct. The relationship between anacidity and biliary duct infection and the high incidence of biliary duct infections at advanced age are pointed out. About 90% of the cultures yielded intestinal bacteria and in more than 50% of the bile samples, E. coli was present.     

术中经胆道镜液电式碎石在肝内胆管结石中的应用

目的　探讨胆道探查术中胆道镜网篮取石加碎石病例的疗效 ,分析其技术要点。方法　回顾性分析我院 2 0 0 2年 6月至 2 0 0 3年 6月施行胆道探查术中胆道镜网篮取石加碎石术 1 5例的治疗经过 ,并与同期采用单纯胆道镜网篮取石的 35例胆道结石病例进行比较。结果　 1 5例胆道镜碎石病例均获得了胆道结石的一次性完全清除 ;而对照组中有 31例获得一次性完全清除 ,2例术后多次胆道镜取石后清除 ,2例未能完全清除。结论　术中胆道镜碎石技术可明显提高胆道结石的完全清除率 ,减少残余结石的发生率     

19 胆管上皮细胞的生理及其与胆管疾病的相关性

胆管上皮细胞衬复着从赫令（Hering）管到胆总管的十二指肠开口的所有胆管。胆管上皮细胞具有从形态到功能上的复杂性和多态性。胆管上皮细胞不仅在水、电解质运输过程中起着重要的作用，同时也能分泌和表达与炎症有关的细胞因子和黏附分子等。另外胆管上皮细胞在一些与免疫调节有关的胆管疾病的发展过程中发挥着重要的作用。笔者仅就胆管上皮细胞的生理及其与胆管疾病的关系作一综述。     

经腹腔镜胆总管探查一期缝合术

目的探讨经腹腔镜电视胆道镜胆总管探查一期缝合的合理性。方法自2002年4月至2005年4月间行经腹腔镜电视纤维胆道镜胆总管探查一期缝合术65例(腹腔镜组),行开腹电视纤维胆道镜胆总管探查一期缝合术132例(开腹组),比较这两种手术方式的治疗效果。结果腹腔镜组平均手术后住院时间为4d,开腹组术后平均住院时间为8d,两组比较有显著性差异(P<0.01)。腹腔镜组2例(2/65)出现胆漏,开腹组3例(3/132)出现胆漏,两组比较无显著性差异(P>0.05)。结论经腹腔镜胆电视胆道镜探查后对选择性病例行胆总管一期缝合是安全和有效的,值得推广应用。     

腹腔镜下胆道镜液电碎石术治疗肝内外胆管结石

目的:总结腹腔镜下胆道镜液电碎石术治疗肝内外胆管结石的手术方法、效果及安全性。方法:回顾分析2005年1月至2012年1月采用腹腔镜下胆道镜液电碎石术治疗23例难取性肝内外胆管结石患者的临床资料,观察结石取净率及并发症发生率。结果:23例术中均碎石成功,其中22例一次性取净结石,结石取净率95.7%;1例因结石数量较多,术后6周经T管窦道行胆道镜取石术。无胆道穿孔、大出血、胆漏、切口感染等并发症发生。术后3～4 d拔除腹腔引流管,5～7 d出院。术后4周常规行T管造影,夹管3 d后拔除T管。结论:腹腔镜下结合胆道镜液电碎石术可显著提高肝内外胆管结石的疗效,手术安全、可靠。     

术中胆道镜对胆管下端疾病的诊治

笔者在1 250例胆管手术中应用胆道镜检查,检出胆道下端疾病102例,并取石取活检获明确诊断及治疗。102例中,胆道下端癌24例,良性狭窄33例,下端结石嵌顿33例，下端囊状扩张例5例,胰头癌致下端狭窄7例。提示术中胆道镜可明确诊断胆道下端疾病,同时可协助术者取出难以取出的结石及选择手术方式。     

Endoscopic retrograde cholangioscopy. An adjunct to endoscopic exploration of the common bile duct

Choledochoscopy is an accepted technique in the operative exploration of the common bile duct, and is complimentary to operative cholangiography. Retrograde cholangiography can be achieved perorally in up to 97 per cent of patients and it is reasonable to assume that the use of complimentary cholangioscopy in such patients would help to improve the accuracy of bile duct examination just as it does when applied in the operative setting. We have had the opportunity to use a new technology in the endoscopic evaluation of the common bile duct. An endoscopic retrograde cholangioscopy (ERCP) is first performed and ductal anatomy outlined. When indicated, an endoscopic sphincterotomy is performed. If large stones are present they are removed with a balloon or basket. The standard side-viewing endoscope is then removed and replaced with the large channel, side-viewing scope. A "baby" scope is introduced through the "mother" scope and canulation of the common duct with the "baby" scope is performed. Biopsies and brushings of lesions may be obtained and numerous instruments are available for manipulation through the biopsy channel of the "baby" scope. The use of retrograde cholangioscopy as an adjunct to retrograde cholangiography should provide the same advantages that have been demonstrated with the use of operative choledochoscopy. Use of this instrument will allow the endoscopist to accurately identify questionable lesions seen on the cholangiogram, selectively canulate particular biliary radicals, biopsy lesions of the common duct, and perhaps intervene therapeutically in selected biliary tract lesions.     

胆管扩张声像特征在梗阻性胆管疾病鉴别诊断中的意义

目的探讨胆管扩张声像特征在梗阻性胆管疾病（DBDO）鉴别诊断中的意义。方法164例DBDO患者分为4组：胆管结石组（n=52）、胆管癌组（n=56）、胆管囊状扩张症组（n=32）和胆管乳头状瘤组（n=24）。将胆管扩张声像表现分为规则型、不规则型、囊状扩张型和胆汁湖型,比较各组胆管扩张最大内径平均值以及各组胆管扩张类型所占的比例。结果164例DBDO患者超声诊断准确率为98.17%（161/164）。胆管结石组和胆管癌组胆管扩张内径分别与胆管囊状扩张症组与胆管乳头状瘤组比较差异均有统计学意义（P均〈0.01）;胆管囊状扩张症组胆管扩张内径与胆管乳头状瘤组比较差异亦有统计学意义（P〈0.01）。胆管结石组胆管扩张规则型（34/52,65.38%）、胆管癌组胆管扩张不规则型（47/56,83.93%）、胆管囊状扩张症组胆管囊状扩张型（26/32,81.25%）以及胆管乳头状瘤组胆管扩张呈胆汁湖型（20/24,83.33%）所占比率分别与其他各组比较差异均有统计学意义（P均〈0.01）。结论胆管扩张的不同声像特征在DBDO的鉴别诊断中具有重要的临床意义。     

经皮经肝胆道镜治疗医源性胆管损伤后再狭窄

目的探讨医源性胆管损伤后肝外胆管再狭窄的原因和治疗方法。方法对我院1998年1月～2005年1月12例（开腹胆囊切除术5例，腹腔镜胆囊切除术7例）医源性胆管损伤后肝外胆管再狭窄，建立经皮经肝通道，采用胆道镜取石、球囊扩张、支架管置入支撑扩张狭窄段胆管。结果8例用F20 Gruntzig型球囊导管扩张狭窄段胆管，2次即可放入6～8mm塑料支架引流管；4例球囊扩张3次后置入。塑料支架引流管置管6～12个月。12例随访2～3年，平均2．6年，无腹痛、发热、黄疸再次发作，B超、MRCP检查胆管无狭窄及再发结石。结论胆道镜取石、球囊扩张支架管置入治疗医源性胆管损伤后肝外胆管再狭窄创伤小，安全可行，效果良好。     

Peroral cholangioscopy for the diagnosis and treatment of biliary diseases

Peroral cholangioscopy with duodenoscopic assistance can allow direct visualization of the bile duct. Several clinical studies suggest the utility of peroral cholangioscopy for the management of various bile duct lesions. Although direct visual observation may be a useful adjunct to endoscopic retro-grade cholangiopancreatography (ERCP) for distinguishing malignant from benign bile duct lesions, the assessment of diagnostic accuracy needs further controlled clinical studies. Intracorporeal lithotripsy with the use of a peroral cholangioscope may be a safe and effective method for difficult-to-treat bile duct stones, including intrahepatic stones. At present, however, the fragility of the fiberscope equipment and technical difficulties hold back its popularity. Preliminary data obtained by using a new videoscope, which provides excellent quality images, are encouraging. Furthermore, it is expected that this videoscope will have longer durability of optical images and better manipulation than previous fiberscopes.