胆管扩张症术后胆道感染的相关因素分析

目的:探讨胆管扩张症患者在术后近期和远期发生胆道感染的相关因素。方法:回顾性分析2012年5月至2020年10月北京协和医院收治并获得随访的121例胆管扩张症患者的临床资料。男性21例（17.4%）,女性100例（82.6%）,年龄（40.5±15.3）岁（范围：18~80岁）。将术后30 d内发生的胆道感染定义为近期...     

肝内胆管引流治疗恶性胆道梗阻

我们自 1993年 6月至 1998年 9月对 2 2例恶性胆管梗阻 ,经肝正中裂入路行肝内胆管内或外引流术。减黄效果较好 ,病人生命延长。现报道如下。临床资料1.本组 2 2例 ,男 14例 ,女 8例。年龄 30～ 79岁 ,平均 5 6 .5岁。2 .全组病人均有胆道梗阻黄疸表现。经术中探查无法根治切除 ,其中高位胆管癌 7例 ,晚期胆囊癌6例 ,胃癌肝门部转移 4例 ,结肠癌、胰腺癌肝门部转移各 2例 ,十二指肠癌肝门部浸润 1例。术前Ｂ超及ＣＴ均提示肝门肿块 ,肝内胆管扩张 ,术前血清胆红素平均 (2 0 2± 2 1)ｍｇ/ｄｌ。3.手术方式 :切断肝周韧带 ,游离肝脏 ,采…     

胆管空肠搭桥内引流治疗恶性胆道梗阻

目的：探索恶性胆道梗阻更安全简便的手术方法。方法：我院设计采用胆管空肠搭桥术治疗不能行根治术的恶性胆道梗阻病人25例,并与同期外引流组12例和传统内流20例比较。结果：搭桥组及外引流组比内引流组术后黄疸消退快,搭桥组术后不带引流管,生存期生活质量较高,优于外引流组。结论：认为胆管空肠塔桥术是一种简单,创伤小,安全性大的术式。     

胆道低位梗阻的MRCP影像分析

目的：探讨胆道低位梗阻性疾病的MRCP影像特征,分析MRCP在胆道低位梗阻诊断中的价值。方法：260例胆道低位梗阻病人,以FSE序列行MRCP扫描,以MIP法行3D重建,对影像诊断与手术发现及病理诊断结果进行对比分析。结果：237例手术治疗,MRCP对胆总管结石、胆总管蛔虫均能明确诊断,对胆管炎性狭窄、胰腺炎可以进行诊断,但有一部分病例可误诊为胆总管占位,胰腺占位,对胰上段胆总管癌诊断较可靠,壶腹癌的MRCP表现为双管扩张征,MRCP对梗阻部位的诊断率可达100％。结论：MRCP不仅能判断胆道低位梗阻的具体部位,而且还可以根据影像特征分析病变性质。     

胆总管十二指肠吻合术治疗良性胆道梗阻的远期疗效观察

为了探讨胆总管十二指肠吻合术的疗效，对随访时间１０年以上，应用胆总管十二指肠吻合术（ＣＤＤ）治疗胆道良性梗阻的４６例随访结果进行了分析。结果显示：疗效优２６例（５６．５％），良１３例（２８．３％），差７例（１５．２％）。优良率８４．８％，与同期胆总管空肠Ｒｏｕｘ－ｅｎ－ｙ吻合１７１例的优良率８６．５％相比，无显著差异（Ｐ＞０．０５）。提示：对于胆道良性梗阻，特别是高危老年病人，ＣＤＤ仍是一种安全有效的术式；胆总管扩张达１．５ｃｍ以上，吻合口达２．５ｃｍ以上，吻合口上方各级胆道无残留病变是取得远期良好效果的基本条件。     

腹腔镜联合胆道镜胆总管探查术治疗胆管结石

胆石症在我国是常见病和多发病,收治率约占普外科住院患者的11.5%,且发病率呈上升趋势[1]。对于肝外胆管的结石,传统方法是行开腹胆总管切开取石、T管引流治疗为主。目前,随着微创设备的高速发展,腹腔镜、胆道镜的普及,腹腔镜联合胆道镜治疗模式因其创伤小、康复快、住院时间短、切口感染率低、并发症少等诸多优点已逐渐取代传统开腹手术,必将成为今后治疗胆管系统结石的主流模式。现就腹腔镜联合胆道镜胆总管探查术在治疗胆管结石中的应用情况做简要叙述。     

术中胆管镜的应用在胆道梗阻性疾病治疗中的价值评价

目的降低结石性胆道疾病术后结石残余及非结石性胆道疾病术中直观了解病情，避免二次手术率。方法总结我院62例应用胆道镜胆囊切除术患者术后残余结石率，非结石性患者术中镜下治疗或取活组织检查，及时正确诊断，采取相应治疗措施。结果术后残石率明显降低，手术并发症减少，非结石性病变术中得到及时诊断。结论术中胆道镜的应用在胆道梗阻性疾病中发挥了较理想的作用。     

胆道术后急性胰腺炎的特点及诊治

我科于1995.1～1997．11月胆道探查术后并发急性胰腺炎病人12例．男4例，女8例，年龄42～63岁。平均52岁。原发疾病中3例为肝内外胆管结石并梗阻性黄疽，4例为胆囊结石，胆总管结石。5例合并重症胆管炎。手术方式：胆囊切除，胆总管探查．“T”管引流6例，二次胆道手术行胆总管切开取石及胆肠吻合术3例。肝左外叶切除及不规则肝叶切除 胆总管探查取石3例，其中胆道泥抄样结石8例。     

急性胆道梗阻和胆道感染与血小板激活因子的关系

急性胆道梗阻和胆道感染与血小板激活因子的关系董晓强，陈易人，胡振雄，仲明根，汪良，丁晓林采用急性胆道梗阻和胆道感染动物模型，研究血小板激活因子（ｐｌａｔｅｌｅｔ－ａｅｔｉｖａｔｉｎｇｆａｃｔｏｒＰＡＦ）与胆道感染、梗阻所致的脓毒血症和多器官衰竭的关系...     

胆道梗阻时胆囊及胆管胆汁流动特性比较

采用犬胆总管梗阻模型，观察阻道梗阻后不同时期胆囊胆汁及胆管胆汁流动特性的变化。结果：正常犬胆囊胆汁及胆管胆汁的流动符合Ｃａｓｓｏｎ流动；胆道梗阻后，随胆道梗阻时间延长，胆囊及胆管胆汁均保持Ｃａｓｓｏｎ流动，胆管胆汁的屈服值及高、低切变率下表观粘度变化均类似于胆囊胆汁。     

Resected cystadenoma of the common bile duct

Biliary cystadenoma in the extrahepatic bile ducts is a very rare tumor. A 62-year-old woman with jaundice was admitted to our hospital. Imaging studies revealed a 4-cm cystic lesion around the hepatic hilum, compressing the common bile duct (CBD). When laparotomy was performed, a cystic tumor was detected in the hepatic hilum, filling the lumen of the CBD. Bile duct resection that included the tumor was performed, followed by biliary reconstruction. Microscopically, the cyst wall was lined by a single layer of cuboidal epithelial cells, covering an ovarian-like stroma. The degree of atypia was low and warranted the diagnosis of cystadenoma.     

胆总管取石术后发生下端梗阻的原因分析及处理

目的分析胆总管探查取石术后发生下端梗阻的原因及采取的对策效果,为临床治疗胆总管结石及解决梗阻提供参考,减少胆总管探查取石术后发生下端梗阻。方法收集2013年1月至2015年12月间在深圳市第六人民医院行胆总管探查取石术后发生下端梗阻19例病人的一般资料及术前、术中和术后的临床资料,分析胆总管探查取石术后发生下端梗阻的原因,之后对病人采取的医疗对策并随访效果。结果 1胆总管下端良性狭窄引起的下端梗阻5例,行内镜下十二指肠乳头括约肌切开术(EST)治疗,术后随访6个月行腹部彩超、生化检查复查,结果显示均无异常。2胆总管下端嵌顿性结石引起的下端梗阻9例,行内镜逆行胰胆管造影(ERCP)+EST术治疗,术后随访6个月均无异常。3胰头部病变引起的下端梗阻5例,其中胰头慢性胰腺炎2例,行胆肠Roux-en-Y吻合术治疗,术后随访6个月无异常,复查腹部CT胰头无明显炎性改变;肝胰壶腹癌1例,胰头癌2例,均行胰十二指肠切除术治疗,术后随访1年均无复发转移。结论对于不具有典型胆总管结石临床表现的病人,或者胆总管结石直径明显小于胆总管内径,而胆总管却有明显扩张的病人,应该引起重视。术前、术中均应该进行严格排查,术中应"重探查、轻取石",找到胆总管梗阻的真正原因。     

腹腔镜胆总管探查一期缝合术后胆瘘及胆总管狭窄的危险因素分析

目的 探讨腹腔镜胆总管探查（LCBDE）及一期缝合术后发生胆瘘及胆总管狭窄的临床危险因素。方法 收集自2017年1月至2019年6月湖州市中心医院收治的92例行LCBDE胆总管一期缝合术患者的临床资料,行回顾性对列研究及多因素回归分析。结果 全组患者术后胆瘘及胆总管狭窄发生率分别为11.9%（11/92）和18.5%（17/92）。合并糖尿病、胆总管直径＜1 cm、由胆总管一期缝合手术操作例数＜30例的主刀医师行手术治疗的患者术后胆瘘及胆总管狭窄的发生率明显升高（P＜0.05）。多因素回归分析发现,上述三个因素是LCBDE胆总管一期缝合术后胆瘘发生的独立危险因素[合并糖尿病：OR（95%CI）4.782（1.176～19.439）,P=0.029;胆总管直径＜1 cm：OR（95%CI）5.743（1.535～21.481）,P=0.009;胆总管一期缝合手术操作例数＜30例：OR（95%CI）4.693（1.251～17.612）,P=0.022],同时上述三个因素也是术后胆总管狭窄发生的独立危险因素[合并糖尿病：OR（95%CI）3.455（1.147～10.406）,P=0.028;胆总管直径＜1 cm：OR（95%CI）4.667（1.500～14.518）,P=0.008;胆总管一期缝合手术操作例数＜30：OR（95%CI）3.094（1.049～9.121）,P=0.041]。结论 合并糖尿病、胆总管直径＜1 cm、主刀医师经验不足（操作例数＜30例）是LCBDE胆总管一期缝合术后发生胆瘘及胆总管狭窄的独立危险因素。对存在糖尿病或胆总管直径＜1 cm的患者应避免行胆总管一期缝合术;在学习曲线内的主刀医师应采取合理的胆总管一期缝合方式以避免术后胆瘘及胆总管狭窄的发生。     

输尿管导管胆道引流在胆总管探查及胆管Ⅰ期缝合术中的应用

目的 :评价经胆囊管残端输尿管导管胆道引流在胆总管探查、胆管Ⅰ期缝合术中的应用价值。方法 :回顾分析经胆囊管残端输尿管导管胆道引流应用于完成开腹胆总管探查、胆管Ⅰ期缝合术 1 86例病例。结果 :全组 1 86例均手术成功 ,术后无胆漏、胆管狭窄等并发症。术后 5～ 7d拔管 1 83例 ,术后 1 0d拔管 3例 ,无拔管并发症发生。术中结石取净率为 99.5 % (1 85 / 1 86 )。术后住院时间为 (6 .5± 3)d。随访 1 86例 ,时间 1～ 5年 ,平均 3年 ,B超检查无胆管狭窄。结论 :经胆囊管残端输尿管导管胆道引流在开腹胆总管探查、胆道Ⅰ期缝合术中的应用 ,对预防术后胆漏、胆总管狭窄以及对术后遗留病变的诊断和治疗有广泛的应用价值。该方法安全、可靠、有效     

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

Background : The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Methods : Over the three‐year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio‐pancreatography. Results : Transcystic stenting was the ‘intention‐to‐treat’ basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1–15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio‐pancreatography, was 98%. A second endoscopic retrograde cholangio‐pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. Conclusion : A treatment option open to all surgeons for non‐jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.     

腹腔镜胆总管探查术与内窥镜下括约肌切开术治疗胆总管结石的临床应用比较

目的 比较腹腔镜胆总管探查术(LCBDE)和内镜下括约肌切开术(EST)治疗不同胆总管结石的疗效及并发症,探讨其适应证的差异,指导临床合理应用.方法 202例胆总管结石患者,按手术方式分为腹腔镜胆总管探查术组(LCBDE组,45例)和内镜下括约肌切开术组(EST组,157例);评价两组操作成功率、一期手术治愈率、残余结石和(或)病变率、并发症率、平均住院时间和费用.结果 LCBDE组和EST组操作成功率分别为97.8％(44/45)和98.7％(155/157)(P> 0.05).一期手术治愈率分别为84.4％(38/45)和45.2％(71/157) (P<0.01).LCBDE组术后残余病变主要为残石,残石率为15.6％(7/45); EST组主要为术后遗留未处理的胆囊病变和肝内外胆管结石,残留率为54.8％(86/157)(P<0.01).LCBDE组并发术后胆漏4例、残余感染1例,并发癌率为11.1％;EST组并发术后胆漏3例、出血4例、高淀粉酶血症32例(其中急性胰腺炎14例)、急性胆管炎15例,并发症率34.4％ (P< 0.05).平均住院时间为(10.0±2.8)和(9.4±4.1)d (P>0.05);住院费用为(17504±4128)和(16453±3541)元(P>0.05).结论 LCBDE和EST均有操作成功率高、住院时间短等优点;但LCBDE并发症率、残余病变率均低于EST; LCBDE主要适于胆囊合并胆总管结石的患者,尤其是Oddi括约肌功能完好者;EST主要适于单纯胆总管结石或胆管炎患者,特别是年老体弱、Oddi括约肌无功能或既往有胆道手术史且不愿再次手术者.     

Technical aspects in the laparoscopic management of complicated common bile duct stones

The management of common bile duct (CBD) stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of last century, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) has become the mainstream treatment for CBD stones and gallstones in most medical centers around the world. However, in certain situations, ERCP cannot be feasible because of difficult cannulation and extraction. ERCP can also be associated with potential serious complications, in particular for complicated stones requiring repeated sessions and additional maneuvers. Since our first laparoscopic exploration of the CBD (LECBD) in 1995, we now adopt the routine practice of the laparoscopic approach in dealing with endoscopically irretrievable CBD stones. The aim of this article is to describe the technical details of this approach and to review the results from our series.     

LC+LCBDE术后胆管一期缝合治疗胆囊结石合并正常直径胆总管结石的临床研究

目的 探讨腹腔镜胆总管探查术(laparoscopic common bile duct exploration,LCBDE)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆囊结石合并正常直径胆总管结石术后胆管一期缝合的可行性和安全性.方法 回顾性分析东南大学医学院附属江阴医...     

Laparoscopic common bile duct exploration

Background: Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). Methods: From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). Results: The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients (n = 2530)—that is, those not undergoing LCBDE or any other additional procedure—was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. Conclusions: Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.     

Laparoscopic exploration of common bile duct: A solution to difficult choledocholithiasis

Objective: To evaluate the role of laparoscopic exploration of common bile duct (LECBD) in the management of common bile duct stone, particularly for patients with failed endoscopic extraction and patients younger than 60 years old. Method: Prospective data of laparoscopic exploration of common bile duct during 1995–1999 were analysed. Results: During 1995–1999, 27 laparoscopic exploration of common bile duct (LECBD) were performed in patients with concomitant gallstone and common bile duct stone, in which half of these LECBD were performed after unsuccessful endoscopic retrieval (13 patients). LECBD was also indicated in patients younger than 60 years old (14 patients) because there was a concern about the potential long‐term complications of papillotomy‐like papillary stenosis and ascending cholangitis. One transcystic duct exploration and 26 choledochotomies were performed. Mean operating time was 138.7 min (70–300 min) and additional procedures included 19 laparoscopic ultrasounds (LUS), three laparoscopic intraoperative cholangiograms (LIOC) and two laparoscopic choledochoduodenostomies. Stone clearance rate was 96% with only one exception. Complications were encountered in nine patients (33%) and one patient died of sepsis subsequent to major bile leak (3.7%). Complications included bile leak/stent migration/collection (4), wound infection (3), minor wound bleeding (1) and self‐limiting postoperative intestinal obstruction (1). Conclusion: LECBD has a high success rate of ductal clearance in patients with ‘difficult common bile duct stones’ despite unsuccessful attempts at endoscopic extraction.