How can cholangioscopy improve the management of intrahepatic stones?

Summary Experience with endoscopic treatment of intrahepatic stones in 93 cases encountered over 13 years starting in 1974 was analyzed and the usefulness of the procedure is discussed in this paper. Postoperative cholangioscopy are percutaneous transhepatic cholangioscopy are easy, safe and reliable procedures because they can be carried out under both fluoroscopic and direct visual control. They can be safely and repeatedly carried out if the sinus tract is kept open. Preoperative percutaneous transhepatic cholangioscopy is an important tool in the diagnosis and treatment of intrahepatic stones, because it provides the important information necessary for selection of an appropriate therapeutic procedure. Different stone extraction techniques can be accurately carried out with endoscopic guidance, and stones that are visible are readily removable. A good prognosis can be expected when stones are completely extracted. With this approach, the author believes that the results of treatment for intrahepatic stones will be significantly improved. Presented at the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

内镜乳头球囊扩张术治疗非扩张性肝外胆管结石的疗效分析

目的 分析内镜乳头球囊扩张术(EPBD)和EST治疗非扩张性肝外胆管结石的疗效.方法 回顾性分析1999年1月至2008年4月太钢总医院收治的317例非扩张性肝外胆管结石患者的临床资料.其中119例行EPBD治疗,198例行EST治疗.各选取62例进行对照研究,分别设为EPBD组和EST组.EPBD组的患者在经ERCP检查确诊后,沿导丝置入柱状球囊,使其中部位于十二指肠乳头开口处.完成扩张后,用网篮或拖石气囊取石,术后常规行ENBD.EST组的患者在经ERCP检查确诊后,采用退刀切开法切开十二指肠乳头,在数字减影血管造影X线监视下,用网篮或拖石气囊取石.两组疗效分析采用χ2检验.结果 EPBD组和EST组的一次取石成功率分别为92%(57/62)和94%(58/62),两组比较,差异无统计学意义(χ2=0.222,P>0.05).EPBD组患者发生高淀粉酶血症、胰腺炎的例数略多于EST组,而发生十二指肠穿孔的例数略少于EST组,两组比较,差异均无统计学意义(χ 2=0.286,1.000,2.000,P>0.05).EPBD组患者发生乳头出血和胆道感染的例数明显少于EST组(χ2=4.000,7.000,P<0.05).两组患者均随访24个月.在术后的第6、12、24个月的随访统计中,EPBD组出现胆管结石复发及胆道逆行感染的例数明显少于EST组(χ2=4.000、5.000、6.000,6.000、8.000、11.000,P<0.05).结论 EPBD后取石+ENBD是治疗非扩张性肝外胆管结石的首选.该方法具有保护十二指肠乳头的功能、创伤小、恢复快等优点.     

肝内胆管细胞癌的外科治疗及预后因素分析

目的探讨肝内胆管细胞癌（ICC）患者的外科治疗方法和影响手术预后的因素。方法回顾性分析80例经手术治疗的ICC患者的临床病理资料,对其中71例肿瘤切除的患者行术后生存预后的单因素和多因素分析。结果本组80例手术患者术后中位生存时间为21．5月。1、3、5年生存率为68．6％、40-3％、25．4％。根治性手术切除组和姑息性手术切除组的中位生存时间分别为40个月及15个月,两组间比较差异有统计学意义（X^2=13．62,P〈0．001）。本组总的肿瘤切除率为88．8％（71／80）,对可能影响患者肿瘤切除术后生存的15个因素分别进行单因素分析,结果表明肿瘤大小、肿瘤数目、淋巴结转移、术前血清CAl9-9水平、手术切缘及邻近组织器官侵犯对预后有影响（P〈0．05）。COX模型多因素分析结果表明手术切缘和肿瘤数目是两个独立预后因素。结论手术切除是ICC的首选治疗方法,R0切除和单个肿瘤是评估ICC患者肿瘤切除术后取得良好预后的独立指标。     

Experience with percutaneous transhepatic fiberoptic choledochoscopy for retained stones in the biliary tract

Summary Residual choledochal stones in 11 patients and stones in the intrahepatic bile ducts in 5 patients were successfully removed by the use of the fiberoptic choledochoscope (FCH-6T), introduced percutaneously into the intrahepatic biliary tract. The reasons for the use of percutaneous transhepatic extraction were: (1) unsuccessful endoscopic papillotomy; (2) unsuccessful choledochoscopic removal via the T-tube tract; (3) high surgical risk; (4) the presence of percutaneous transhepatic biliary drainage for acute cholangitis and acute pancreatitis. All stones were extracted through the liver or the papilla of Vater after crushing them. All minor complications such as pain, vomiting, or fever resolved without further therapy. Percutaneous transhepatic choledochoscopy proved safe and effective for the removal of retained choledochal stones and was essential for the treatment of stones in the intrahepatic bile ducts.     

复杂肝内胆管结石的取石策略

目的探讨复杂肝内胆管结石取石技巧,尽量降低残石率。方法回顾性分析近四年来我院收治的复杂肝内胆管结石病例225例,术中首先用取石钳钳取胆总管、肝门部胆管结石,其次胆道镜检查胆道系统,确定取石策略。然后应用取石钳钳取、胆道镜取石网篮套取、活检钳咬碎、冲击波碎石、脉冲式冲洗等多种方法联合取石,部分病人结合肝叶切除、胆肠吻合等术式。结果行胆道引流术者(含肝叶切除术)201例行T管造影结石取尽133例,结石取尽率66.2%(133/201)。行胆肠吻合术者4例术后残余结石伴胆管炎。无死亡病例。结论肝内胆管复杂结石治疗棘手,术前应准备充分、准确评估、术中遵循基本手术原则、联合多种方法取石,争取获得最佳手术效果。     

A new endoscopic technique for the buried bumper syndrome

Background The Buried Bumper Syndrome is a well-recognized long-term complication of percutaneous endoscopic gastrostomy (PEG). Overgrowth of gastric mucosa over the inner bumper of the tube will cause mechanical failure of feed delivery, rendering the tube useless. Endoscopic removal is usually attempted but fails in most cases. Therefore, most of the buried inner bumpers are removed by making an external incision over the PEG site under local anaesthesia or at laparotomy. These approaches can be associated with pain, wound infection, or a gastrocutaneous fistula. Technique A new method to facilitate the removal of a PEG tube, where the inner bumper is buried in the gastric mucosa, is described. A length of ureteric catheter, or similar tube, is passed through the shortened external PEG tube into the gastric cavity and is then tied to the tube above the skin. The intragastric part of that tube helps to identify the site of the buried bumper and is then trapped within an endoscopic snare. Traction is then applied to the snare, inverting the tube and dislodging the bumper with minimum disruption to the stomach wall. This avoids the need for repair and allows for immediate reinsertion of a fresh PEG tube. Conclusions A PEG tube in a patient with buried bumper syndrome can be safely removed endoscopically, without a skin incision or gastric wall disruption. A novel, simple, and safe endoscopic removal technique is described. Presented as a poster at the 13th meeting of the EAES, Venice, Italy, June 2005     

Peroral tunable-dye laser lithotripsy of intrahepatic stones in Oriental cholangitis

Summary This case report details the use of a pulsed tunable-dye laser lithotripter in the endoscopic management of recurrent intrahepatic stones in a patient with Oriental cholangitis. A 42-year-old Chinese man had a cholecystectomy and choledochoduodenostomy in 1980. Subsequently he had three episodes of recurrent cholangitis which responded to medical treatment. The patient presented in April 1989 with a fourth attack of cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) and ultrasound demonstrated a large mass of stones in the right intrahepatic ductal system. A flexible upper gastrointestinal endoscope was passed into the right hepatic duct via the choledochoduodenostomy. The stones were fragmented with a tunable-dye laser and the residual fragments were removed endoscopically.     

The role of endoscopic biliary sphincterotomy for the treatment of type 1 biliary dysfunction (papillary stenosis) with or without biliary stones

BackgroundThis study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones.MethodsThe records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES.ResultsAll patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval.ConclusionsES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.     

Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones

In the Far East, hepatic resection is the definitive treatment for complicated intrahepatic stones (IHS). However, many investigators have reported that the associated intrahepatic biliary stricture is the main cause of treatment failure. A retrospective comparative study was undertaken to clarify the long-term efficacy of hepatic resection for treatment of IHS and to investigate the clinical significance of intrahepatic biliary stricture in treatment failure after hepatic resection performed in 44 patients with symptomatic IHS. The patients were divided into two study groups: group A, with intrahepatic biliary stricture (n = 28) and group B, without stricture (n = 16). Residual or recurrent stones, recurrence of intrahepatic biliary stricture, late cholangitis, and final outcomes were analyzed and compared statistically between the two groups. The patients were followed up for a median duration of 65 months after hepatectomy. The overall incidence of residual or recurrent stones was 36% and 11%, respectively, in groups A and B. The initial treatment failure rate was 50% in group A and 31% in group B. Intrahepatic biliary stricture recurred in 46% of patients in group A, while none of the group B patients had biliary stricture recurrence (P = 0.001). More than two-thirds of the restrictures in group A were identified at the primary site. The incidence of late cholangitis was higher in group A (54%) than in group B (6%) (P = 0.002). Three-quarters of the patients with cholangitis in group A had severe cholangitis, that was recurrent, and related to stones and strictures (n = 11). They and 2 asymptomatic patients in group B required secondary procedures done at a median of 12 months after hepatectomy. Final outcomes after hepatectomy with or without secondary management were good in 80%, fair in 16%, and poor in 4% of our 44 patients. Most recurrent cholangitis after hepatectomy in patients with IHS was related to recurrent intrahepatic ductal strictures. Therefore, to be effective, hepatic resection should include the strictured duct. However, with hepatectomy alone it is difficult to clear the IHS or relieve the ductal strictures completely, particularly in patients with bilateral IHS, so perioperative team approaches that include both radiologic and cholangioscopic interventions should be combined for the effective management of IHS. Received for publication on Oct. 15, 1997; accepted on Feb. 2, 1998     

肝内外胆管结石腹腔镜、内镜联合微创手术方案研究

目的:研究肝内外胆管结石腹腔镜、十二指肠镜、胆道镜联合微创治疗方案。方法:回顾分析2000年10月至2009年10月为671例患者微创治疗肝内外胆管结石的临床资料。采用一镜Ⅰ方案治疗321例,一镜Ⅱ方案治疗12例;二镜Ⅰ方案治疗216例,二镜Ⅱ方案治疗67例,二镜Ⅲ方案治疗5例;三镜Ⅰ方案治疗46例,三镜Ⅱ方案治疗31例。结果:用内镜、腹腔镜联合微创治疗方案治疗肝内外胆管结石成功657例,总成功率97.9%(657/671),术后无严重并发症发生及死亡病例。结论:肝内外胆管结石临床表现多样,采用相应的内镜、腹腔镜联合微创治疗方案,拓宽了微创治疗范围,疗效满意。     

经皮胆肠吻合口胆道镜治疗肝内胆管复发结石

目的探讨经皮胆肠吻合口胆道镜治疗胆管空肠Roux-en-Y吻合术后肝内胆管复发结石的方法及疗效。方法20．0．0年1月～2005年2月，对8例胆肠吻合术后肝内胆管再发结石，采用经皮经空肠输胆襻造口术建立通道，胆道镜经胆肠吻合口进入肝内胆管取石，纠正吻合口和肝内胆管狭窄。结果8例肝内胆管结石均取净，4例胆管狭窄和2例吻合口狭窄解除。8例随访1～3年，肝内胆管无复发结石和再狭窄。结论经皮胆肠吻合口胆道镜治疗肝内胆管复发结石创伤小、安全、可行，效果满意。     

Biliary access loops for intrahepatic stones: results of jejunoduodenal anastomosis

Background: Patients with intrahepatic calculi require multiple interventions following successful surgical stone clearance for recurrent stones and cholangitis. The present paper describes the results of a technique of in‐continuity side‐to‐side jejunoduodenal anastomosis (JDA) that provides endoscopic access to the hepaticojejunostomy and intrahepatic ducts. This operation is compared to other techniques in a critical appraisal of various biliary access procedures described for long‐term management of intrahepatic ­calculi. Methods: A retrospective analysis of clinical data of 13 patients who underwent biliary drainage procedures with access loops for intrahepatic calculi during the period March 1990 to December 2000 was performed. The postoperative course of patients and the feasibility of postoperative endoscopic access to the hepaticojejunostomy and intrahepatic ductal system in treatment of recurrent cholangitis were assessed. Nine patients underwent JDA, two underwent permanent‐access hepaticojejunostomy (PAH) and two others underwent an interposition hepaticojejunoduodenostomy (IHJ). Results: The analysis revealed no major procedure‐related complications or mortality. Endoscopic access (using forward‐viewing gastroscope) was possible in 100% of cases following JDA, and with difficulty in both cases after PAH. Endoscopic access in the two patients with IHJ failed because of technical reasons. Recurrent cholangitis was seen in seven patients (54%) ? two out of two patients in the PAH group, one out of two in the IHJ group and four out of nine in the JDA group. This required 12 endotherapy sessions (mean: 1.5 procedures per patient). Conclusion: In‐continuity side‐to‐side JDA allows easy access of conventional gastroduodenoscopes to the biliary tree for removal of recurrent/residual intrahepatic stones. The technique has advantages over other access loop procedures in the long term management of recurrent intrahepatic stones.     

Long-term symptoms following endoscopic sphincterotomy for common bile duct stones

Background: Endoscopic sphincterotomy (ES) has an important role in the management of biliary stones. However, the long-term effects of free duodenobiliary reflux are not established, and it may lead to low-grade morbidity. Methods: We used a questionnaire survey to assess the prevalence of symptoms of biliary disorder in patients who had undergone endoscopic retrograde cholangio pancreatography (ERCP) and ES under the care of a single surgeon (R.J.R.G) between November 1993 and May 1998. Results: ES was carried out on 136 patients during this period. Current addresses were available for 94 patients, and 54 of them (57%) responded. Patients were surveyed a mean of 43 months after ES. Only 42.1% of patients denied having any symptoms. Nausea and pale stools were reported by 28% and 26% of patients, respectively, and nearly one-fifth of patients had symptoms suggestive of cholangitis. In addition, 18.5% of patients experienced one or more symptoms frequently. Conclusion: Severe long-term symptoms are uncommon following ES; however, a significant minority of patients do suffer occasional symptoms that suggest biliary dysfunction.     

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目的 探讨内镜治疗肝内外胆管残余结石的效果。方法 对1990年1月至2000年1月间的306例胆道残余结石的治疗效果进行回顾性分析,采用十二指肠镜127例,胆道镜116例,经皮经肝胆道镜（PTCS）63例。结果 306例中有286例成功（93.46%）。十二指肠镜治疗127例,成功125例;胆道镜经T管窦道治疗116例,成功109例;PTCS治疗肝内结石63例,成功52例。结论 内镜治疗肝内外胆道结石效果显著,可使绝大多数病人避免再次手术。     

胰管结石的手术治疗

目的 探讨胰管结石的手术治疗方式.方法 对1997-2007年间24例胰管结石患者的手术治疗方式进行回顾性分析.结果 24例胰管结石中行胰管纵行切开取石、胰管空肠Roux-en-Y吻合17例,其中附加主胰管外引流2例,附加胆管空肠吻合3例,附加胰腺囊肿空肠吻合1例,1例术后并发胰肠吻合口出血,1例术后早期出现应激性溃疡,均经保守治疗治愈;胰十二指肠切除3例,1例并发吻合口出血,经保守治疗治愈;胰体尾切除2例,保留十二指肠胰头切除1例,胰管切开取石、Ⅰ期缝合1例,术后均无并发症.全组21例得到随访,17例效果优良.结论 胰管纵行切开取石、胰管空肠Roux-en-Y吻合是治疗胰管结石的合理术式,保留十二指肠的胰头切除和胰管切开取石、Ⅰ期缝合用于治疗胰管结石是可行的.     

Large-bile-duct stones — extracorporeal piezoelectric lithotripsy as adjuvant measure for endoscopic basket extraction

Summary Extracorporeal piezoelectric lithotripsy (EPL) was performed in 12 patients with large-bile-duct stones and intrahepatic stones. The Piezolith 2300 lithotripter (Wolf, Knittlingen, FRG) was used in all patients in whom routine endoscopic approaches for removal of the calculi had failed or were considered inappropriate because of large stone size or difficult localization. In 9 of the 12 patients the stones were fragmented. Complete stone clearance from the bile ducts was obtained in 8 of 10 patients by EPL alone or combined with one of the following: endoscopic extraction, mechanical lithotripsy or installation of solvents. Adjuvant EPL in conjunction with endoscopic therapy increased the success rate of nonsurgical treatment for bile duct stones from 73% to 95%. No clinically significant side effects or complications were noted.     

侵犯第一肝门肝内胆管癌手术的临床价值

背景与目的:侵犯第一肝门肝内胆管癌(HICC)侵袭性强,病理生理复杂 外科手术是首选的治疗方法,但R0切除率低,预后差.本文通过分析接受手术治疗的HICC患者预后情况,探讨其手术治疗的临床价值.方法:回顾性分析2010年11月-2016年6月在东方肝胆外科医院手术治疗98例HICC患者的临床及病理资料.根治手术67例,...     

胰管结石诊治的体会（附15例报告）

目的探讨胰管结石的诊断及外科处理方法。方法对2000年1月～2008年1月收治的15例胰管结石的临床资料进行回顾性分析。结果全组均采用影像学检查方法（B超,腹部X线平片。CT,内镜逆行胰胆管造影,磁共振胰胆管造影）确诊。9例行胰管切开取石、胰管空肠侧侧Roux-en-Y吻合术,3例胰体尾切除、胰断端套入空肠端Roux-en-Y吻合术,3例胰十二指肠切除术。术后随访1至5年。15例术前有上腹痛症状者,术后10例腹痛消失,3例缓解。5例合并糖尿病者,3例血糖恢复正常。3例合并脂肪泻者,2例脂肪泻消失,1例减轻。结论影像学检查是确诊胰管结石的主要方法。胰管切开取石、胰管空肠侧侧Roux—en—Y吻合术为治疗胰管结石的主要术式。     

Choledochoscopy during biliary surgery for reducing the risk of overlooked stones

Summary Although cholangiography is routinely performed during biliary surgery to ensure the removal of all stones, it is not always successful. Some investigators have claimed that intraoperative choledochoscopy is more effective in detecting all stones, although reports on the efficacy of this method have been contradictory. Furthermore, no study has systematically examined either of these procedures in terms of the actual incidence of overlooked stones. Thus, to evaluate the merits of intraoperative cholangiography as opposed to choledochoscopy, we studied the incidence of overlooked bile duct stones after surgery. We investigated 126 patients who had undergone surgery during which choledocholithotomy was performed within the past 10 years; 117 of these cases involved common bile duct stones and 22, intrahepatic stones. After the exclusion of 13 subjects whose stones were deliberately left for postoperative treatment due to severe complications, 126 patients were finally analyzed. Overlooked stones were found postoperatively in 13 (10%) of these 126 subjects, including 11 (14%) of 63 patients who had been inspected by intraoperative cholangiography alone and 2 (3%) of 63 who had undergone both choledochoscopy and cholangiography during surgery. Therefore, the incidence of overlooked stones proved to be significantly lower in those who had undergone choledochoscopy combined with cholangiography (P <0.01). Our results suggest the value of combining choledochoscopy with cholangiography during surgery for reducing the risk of overlooked bile duct stones.