肝管空肠吻合术治疗医源性胆管损伤伴狭窄

医源性胆管损伤是胆囊切除术严重的并发症之一.在LC迅速发展的今天,LC导致医源性胆管损伤的发生率较开腹胆囊切除术更高.2006年10月至2011年8月我中心采用肝管空肠吻合术治疗14例医源性胆管损伤患者,取得了良好的疗效,现报道如下. 1 资料与方法 1.1 一般资料 本组医源性胆管损伤患者14例,男6例,女8例;年龄28～62岁,平均年龄46岁.5例胆管损伤发生于开腹胆囊切除术,9例发生于LC.14例患者中,修复手术距胆囊切除术时间4个月至6年.4例患者带有T管.所有患者有急、慢性胆管炎表现,包括腹痛,伴或不伴发热,症状发作时均伴有黄疸.     

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.     

球囊扩张法治疗损伤性胆管狭窄的前瞻性研究

目的 探讨球囊扩张法治疗损伤性胆管狭窄(TBS)修复术后再狭窄的效果.方法 将1997年2月至2007年2月成都军区总医院收治的81例TBS患者按随机数字表法分成2组:对照组40例,采用传统胆肠吻合术,术后T管支撑6个月;球囊组41例,方法同对照组,同时在吻合口置人球囊,并逐渐扩张肝门部胆管空肠吻合口及上方胆管.两组疗效比较采用x2检验.结果 对照组7例失败(18%),其中6例改用球囊扩张治疗后5例获得成功.球囊组2个月内吻合口径达到12 mill,再维持1个月后将T管和球囊拔出,仅1例失败(2%).两组比较差异有统计学意义(x2=5.10,P＜0.05).结论 球囊扩张法能大大提高TBS修复术的疗效.     

胆管损伤修复术后胆管狭窄的处理

目的　探讨胆管损伤修复术后胆管狭窄的治疗方法。　方法　回顾分析 3 2例胆管损伤修复术后 16例胆管再次狭窄的临床资料 ,12例再次行胆管空肠Roux -en -Y吻合术、4例原Roux -en -Y吻合口扩大再行盆式吻合术。　结果　全部病例获随访 ,2例术后出现肝脏转氨酶ALT升高 ,给予保肝治疗 ,1月后均恢复正常。余 1例随访 0 5年 ,4例 1年～ 3年 ,3例 3年～ 5年 ,6例 >5年 ,无黄疸、无胆管炎症状发作。 12例术后 1年B超检查扩张的胆管减小 0cm～ 0 5cm 5例 ,0 5cm～1cm 7例。　结论　胆管损伤修复术后胆管狭窄再次行手术治疗可获满意效果     

肝外胆管梗阻性疾病的MRCP诊断价值

目的探讨磁共振胆胰管成像技术对肝外胆管梗阻性疾病的诊断价值。方法对52例经病理或随访证实的肝外胆管梗阻性疾病患者的MRCP资料进行回顾性分析,总结良恶性肝外胆管梗阻的不同MRCP表现。结果52例中,MRCP均能够准确测定胆管扩张程度和梗阻的水平,其中良性梗阻27例,MRCP主要表现为胆管均匀扩张及逐渐狭窄,肝外胆管较肝内胆管扩张明显,肝内胆管呈“枯树枝状”;恶性梗阻25例,MRCP主要表现为胆管截断,胆胰管扩张,出现“双管征”,肝内外胆管扩张一致。恶性梗阻患者的肝内外胆管扩张程度明显大于良性梗阻者。结论MRCP作为一种无创的影像检查方法,对肝外胆管梗阻性疾病的诊断具有较高准确性,     

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     

胆道再手术原因和对策

目的探讨胆道再手术原因及对策。方法回顾分析我院1999年1月至2002年12月间共行了胆道手术2881例，其中因各种原因行胆道再手术260例；并对其首次手术方式，再次手术方式和再次手术原因进行了详细分析。结果109例行胆总管切开取石，其中33例同时行肝叶切除；32例行胆总管空肠Roux-Y吻合术；94例行胆道镜取石术；2例行胰十二指肠切除术；残余胆囊再切除1例；22例分别行引流、止血或修补术。再手术原因早期主要以胆漏（7．3％）、腹腔内出血（1．2％）为主。晚期主要以结石残留或复发（76．9％），胆管良性狭窄（11．5％）为主。结论胆道再手术主要原因是处理胆道手术并发症。为降低胆道再手术率应强调术前全面分析诊断、术中审慎操作，并结合胆道镜、B超及胆道造影等检查行根治性手术，术后加强抗感染预防炎性狭窄。     

Biliary stones: treatment by shock-wave lithotripsy

Extracorporeal shock-wave lithotripsy has been introduced as a novel nonsurgical therapy for gallstone disease. To substantiate the initial results, more than 400 patients with biliary calculi have been treated. In selected patients with gallbladder stones, complete clearance of all stone fragments can be expected within 1 year in about 80%. In patients with bile-duct stones not amenable to endoscopic measures, sufficient stone fragmentation by extracorporeal shock waves was achieved in about 80%. Extracorporeal shock-wave lithotripsy is a safe and efficient therapy for selected patients with gallbladder calculi. For patients with bile-duct stones not amenable to endoscopic measures it offers a nonsurgical alternative.     

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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。     

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     

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。     

腹腔镜联合胆道镜治疗胆管结石77例临床体会

目的探讨腹腔镜联合胆道镜治疗胆管结石的可行性及临床体会。方法回顾性分析2011年12月~2013年12月77例在我院腹腔镜联合胆道镜下行胆囊切除、胆总管切开取石+T管引流术的病人术中情况、术后临床恢复情况及疗效,对其手术成功率、手术时间、术中失血量、肠功能恢复时间、住院时间、术后胆漏例数及残石例数等指标进行分析。结果77例患者手术均获成功,无中转开腹,其中63例行T管引流,14例行胆总管一期缝合;手术时间75~170min;术中出血40~150ml;胃肠道功能恢复时间为1~3 d;住院时间4~14 d;术后胆漏1例;经腹腔引流治愈;术后胆道残石3例,术后经T管胆道镜下取尽结石。结论腹腔镜联合胆道镜治疗胆管结石安全有效、可靠,损伤小,恢复快,但术者需要掌握熟练的操作技能。     

经皮肝胆道镜术两种不同路径治疗复杂肝内外胆管结石的临床疗效比较

目的比较经皮肝胆道镜两种不同路径手术治疗复杂肝内外胆结石的临床疗效。方法以本院2014年1月~2016年6月收治的105例复杂肝内外胆管结石患者为研究对象,均行经皮肝胆道镜手术,根据术中不同路径将其分为A组(一步造瘘取石)与B组(二步造瘘取石),比较两组手术成功率、结石取净率、术中出血量、术后并发症等情况,并对两组手术前后细胞免疫功能测定。结果 A组手术成功率、结石取净率、术后并发症总发生率分别为92.00%、80.00%、28.00%,较B组的97.50%、82.50%、20.00%差异无统计学意义(P0.05);A组平均术中出血量、住院时间分别为(53.48±20.34)m L、(19.29±5.48)d,较B组的(39.15±16.87)m L、(22.58±5.56)d差异有统计学意义(P0.05);两组治疗前后CD3+、CD4+水平比较差异无统计学意义(P0.05)。结论经皮肝胆道镜一步造瘘法、二步造瘘法在复杂肝内外胆管结石患者结石取净、并发症方面上效果类似,且对机体免疫功能影响小,但一步造瘘法术中出血量相对明显多,而住院时间显著短。     

Adenomyoma of the Common Hepatic Duct Mimicking Bile Duct Cancer: Report of a Case

We report an unusual case of adenomyoma of the common hepatic duct mimicking bile duct cancer. A 50-year-old woman was referred to our hospital for the investigation of general fatigue. Laboratory data showed abnormal liver test results and computed tomography showed a mass lesion in the hepatic hilum and dilatation of the intrahepatic bile ducts. These findings led to a preoperative diagnosis of hilar bile duct carcinoma, and we performed a left lobectomy with resection of the extrahepatic bile duct. Macroscopically, an elevated lesion was found in the common hepatic duct, which was confirmed histologically to be an adenomyoma. Bile duct strictures are rarely caused by benign tumors of the biliary tract, such as adenomyoma. Surgical resection of the bile duct should be considered for all bile duct strictures because it is often difficult to differentiate malignant from benign lesions in this location preoperatively, and malignant cells may be present in the lesion.     

胆道镜下激光治疗术后肝内残余结石74例体会

目的 探讨胆道镜下U-100双频激光碎石术治疗术后残余肝内结石的临床疗效.方法 对74例胆道术后肝内胆管残余结石患者接受胆道镜下U-100双频激光碎石治疗患者的临床资料进行回顾性分析.结果 63例(85.1％)1次碎石成功,8例(10.8％)碎石2次,3例(4.1％)碎石3次.碎石成功率100％.结论 胆道镜下U- 100双频激光碎石是治疗术后残余肝内结石的一种安全有效手段.     

Peripapillary duodenal diverticulum and biliary tract diseases

The relationship between peripapillary duodenal diverticulum and benign biliary tract disease was studied. Peripapillary duodenal diverticulum could be classified pathophysiologically into three types. Type I represents the disease not directly affecting the biliary tract. Type II shows the elevation of bile duct pressure directly caused by intraduodenal pressure loading. Type III includes patients in whom the diverticulum is small and is prone to cause papillitis or mechanical stimulation. This, then, may lead to organic changes in Oddi's sphincter and possibly to biliary tract disorders. In our patients, many cases of peripapillary duodenal diverticulum were associated with calcium bilirubinate stones, indicating that a peripapillary duodenal diverticulum is likely to lead to bile stagnation and ascending infection of the biliary tract and thus cause formation of calcium bilirubinate stones. Based on findings in this study, we want to emphasize that Type II peripapillary duodenal diverticulum should be surgically treated.     

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目的 了解我国当前对医源性胆管损伤外科治疗概况及胆管损伤治疗效果。方法 通过检索解放军医学图书馆中文生物医学期刊数据库（CMCC）从1995年1月至2000年1月全国各级期刊关于胆管损伤的论文,统计来自165个医疗单位2742例医源性胆管损伤。结果 统计显示胆管损伤的94％来自与胆囊有关的手术,以胆管横断伤为多（47％）,损伤类型时要为胆总管（44％）和肝总管（36％）,有40％为术中及时发现处理,胆管损伤修复手术因狭窄再手术占总数的23％,术中发现和术后发现及胆管修复的方式有明显的差异。结论 胆管损伤后期的修复防止狭窄是较困难的,调查修复方式显示术中发现的作胆管修补＋T管支撑引流,术后发现手术作胆管空肠吻合＋长期支撑的手术方式效果较好。     

肝内胆管囊腺癌临床病理特点及治疗(附12例报告)

目的：探讨肝内胆管囊腺癌临床病理特点及治疗方法。方法：回顾分析了12例肝内胆管囊腺癌的临床病理表现、诊治经验并结合文献资料加以讨论。结果：5例中可见局部癌细胞向囊璧外肝组织内浸润生长，另7例癌组织局限于囊壁内。12肝内胆管囊腺癌中7例行根治性手术切除，其中5例存活了5年，1例存活2年，另1例存活11个月；3例行肿块大部分切除，分别存活16，13，10个月；1例未能手术治疗，存活5个月；1例发现于尸检。5例存活超过5年者，其手术切除标本病理检查显示肿瘤生长均局限于囊壁内。结论：肝内胆管囊腺癌局限于囊肿内者，通过行肝切除完整肿块可获得较满意的临床疗效。     

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目的 分析胆肠吻合术治疗肝内胆管结石并胆道狭窄的选择和疗效。方法 对１９９１年９月至１９９８年１２月６９例行胆肠吻合术的肝内胆管结石并胆道狭窄病例进行总结,包括临床表现、结石部位、狭窄情况、手术方式和治疗效果等。结果 胆管狭窄主要位于１￣２级胆管内。５１例（７３．９％）行肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,１８例（２６．１％）采用胆总管十二指肠吻合术,随访结果表明,肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合