胆道造影在手术中的应用及其价值

本文报告５６８例胆道疾患病人在手术中根据不同情况采取三种不同的方法行胆道造影，均获得成功。造影发现阳性结石病人１７３例，占３０．４５％。同时讨论了术中胆道造影在了解胆道系统解剖及预防术后残余结石，避免胆道损失，降低术后并发症，提高手术质量，使病人及早康复方面的临床价值。     

胆道手术后近期黄疸的鉴别诊断与处理原则

本文报道我院收治的１３例手术后近期出现黄疸的病人，分析认为，当黄疸发生在胆道手术之后时，应鉴别黄疸是非梗阻性还是梗阻性，非梗阻性黄疸，一般只需内科治疗，梗阻性黄疸，属医源性胆道损伤者需要手术治疗，而由术后胆道残余结石所引起的梗阻性黄疸，可以采取手术治疗，也可采取非手术治疗。     

经胆囊管术中胆道造影的价值与指征探讨

作者分析近十余年来３７９例胆石症手术病人５３例术中经胆囊管胆道造影与３２６例非造影资料，发现该造影使胆管阴性探查率从７５．９－８８．９％降低至１１％，胆道隐匿结石率从５．８％降至０％。造影假阳性率为７．５％。分组分析发现，胆管结石发生率在具有单纯胆囊在结石组为０％，具有一项相对探查指征组为１２．８％，同一病人具有二项以上相对胆管探查征组为７３％。作者认为此造影不宜常规应用所有胆石症手术，主张常规应     

腹腔镜胆囊切除术中胆道造影的价值

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）术中胆道造影的临床价值及适应证。方法2003年1月-2006年1月我院对165例行LC术中经胆囊管胆道造影（intraoperative cholangiography，IOC），根据造影结果指导LC术中操作，调整手术方案。结果165例LC术中经胆囊管胆道造影发现胆囊管变异22例，胆囊管结石12例，合并胆总管结石8例。本组无胆道损伤，避免胆总管阴性探查7例。结论LC术中经胆囊管胆道造影对于预防术中胆道损伤、减少胆总管阴性探查具有重要价值。     

选择性术中胆道造影在腹腔镜胆囊切除术中的应用

目的 探讨术中胆道造影在腹腔镜胆囊切除术（LC）中的应用价值。方法 对105例LC术中经胆囊管胆道造影患者临床资料进行分析。结果 105例中均插管成功，并完成术中胆道造影。其中发现胆总管结石15例，胆总管下段乳头部狭窄5例，假阳性l例。结论 LC术中胆道造影操作简便安全，胆道结构显影清晰，成功率高，能有效发现胆道结石，降低胆管损伤发生率。     

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目的：分析胰源性黄疸术前行直接胆道造影过程中发生并发症的原因，探讨其处理方法。方法：对1997～2002年收治的110例因胰腺疾病导致梗阻性黄疸病人术前行直接胆道造影发生急性胆道并发症的临床资料进行回顾性分析。结果：行PTCD检查42例，ERCP 59例，行两种检查者9例。总急性胆道并发症10例(9．09％)，PTCD组急性胆道并发症7例(13．73％)，急性胆管炎4例，胆道出血2例，胆汁性腹膜炎1例，死亡1例。ERCP组急性胆道并发症3例。结论：胰源性黄疸行直接胆道造影检查虽有一定的并发症发生，但合理的选择适应证，严格操作规范，对术后病人严密观察，积极的保守治疗可避免和治愈并发症。直接胆道造影和胆道引流应是胰源性黄疸术前安全有效的诊断和治疗方法。     

肝胆管结石术后胆道镜检查与经T管胆道造影176例对比分析

目的评估术后经T管胆道造影和胆道镜检查在肝胆管结石术后的意义。方法对176例肝胆管结石行胆总管探查T管引流术后病人,在T管胆道造影基础上常规辅以胆道镜检查。结果176例病人中,造影检查明确或怀疑有残留结石者共39例,其中胆道镜证实者31例,另外8例胆道镜检查未见结石;造影检查未发现结石的137例病人中,胆道镜检查发现有残留结石者13例。结论经T管胆道造影存在一定的假阴性,联合术后胆道造影和胆道镜检查可进一步降低残余结石的发生率。     

术中胆道造影在腹腔镜胆囊切除术中的应用

目的 :探讨术中胆道造影在腹腔镜胆囊切除术 (LC)中应用的临床价值。方法 :回顾总结 6 7例LC术中行胆道造影的技术要点。结果 :LC术中行胆道造影 6 7例 ,发现胆管结石 19例 ,近端胆囊管小结石 1例 ,乳头部狭窄 1例 ,胆道畸形 2例 ,假阳性 3例 ,准确率 95 5 %。结论 :有选择的在LC中胆道造影可以避免胆管残留结石及胆囊管残株结石 ,减少不必要的胆管阴性探查 ,发现乳头部狭窄 ,辨明胆道解剖 ,避免胆道损伤。     

选择性术中胆道造影的临床应用价值

目的 探讨选择性术中胆道造影在胆石症病人中的临床应用价值。方法 通过对75例术中胆道造影的胆石症病人和62例胆道但未行术中胆道造影的胆石症病人的对比研究。比较两组术后胆道残石的发生率。结果 发现在有胆道相对探查指征的病人经胆囊管造影的阴性率为64.7%，曾行术中造影的胆石症病人的术后残石率为2.0%，而未行术中造影的胆石症病人的残石率为15.5%。结论 选择性术中胆道造影可降低胆道阴性探查率，避免不必要的胆道探查，还可降低胆道残石发生率。     

术中经胆囊管胆道造影的体会

术中胆道造影对降低术后胆道残余结石和胆道损伤的发生率有重要价值。我院 2 0 0 2年 8月～2 0 0 3年 3月共行无黄疸病史的单纯胆囊结石病人术中胆道造影 5 7例。报告如下。临床资料本组共 5 7例 ,其中 ,男性 2 1例 ,女性 36例 ;年龄 2 3～ 79岁。病史 2～ 1 0年。术前B型超声检查均无胆管异常、无黄疸史、无胆管炎表现。术中先用手法探查胆囊、胆总管、胰腺等 ,顺逆行结合切除胆囊后 ,用细硅胶导管 (直径 2mm)插入残存胆囊管内1～ 1 .5cm ,以 4号丝线结扎 ,松紧适宜 ,尽量抽尽造影管内气体 ,缓慢推注 2 5 %～ 38%的泛影葡胺 1 5～2 0ml,然…     

17O例胆道术后T管造影的动态观察

目的 为获取胆道手术后胆管内的准确影像变化信息。方法 对170例胆道术后T管引流患者，采用不同角度、不同体位及较长时间的动态观察，明确胆道内影像变化后将其存人磁盘、点片或打印成像。结果 170例患者中有120例胆管内无异常发现，拔除T管引流后治愈；余50例中有30例为胆管残余结石，9例为胆管炎性狭窄，4例为胆管下端肿瘤，7例假阳性影像变化中，3例为假结石影像，4例为假阳性信息。全部结果均经BUS、CT、纤维胆道镜检查、手术或延长观察时间所证实。结论 应用动态观察，行胆道T管造影，方法简便、实用，无痛苦，不增加患者经济负担，可作为临床获取胆道术后肝内外胆管影像学变化的一种常用方法。     

术中胆道造影在腹腔镜胆囊切除术中应用价值

目的探讨术中胆道造影在腹腔镜胆囊切除术中的应用价值。方法腹腔镜胆囊切除术中在切除胆囊前,常规在C型臂X线下行胆道造影,并及时采集、保存图像,以了解肝外胆管内有无结石存在。若发现结石,继而行中转开腹胆总管探查取石术。结果施行的76例术中胆道造影中,发现胆总管结石5例,其中胆总管下段多发结石2例,胆总管内单发结石2例,胆总管内一长柱状结石1例。5例胆总管结石取出术后均放置T型管,随访T管造影复查,未见结石残留。结论腹腔镜胆囊切除术常规行术中胆道造影可有效地防止胆道结石残留,避免了不必要的胆管探查,减少了胆管损伤和术后并发症的发生,减少了患者的住院费用和住院时间,且术中胆道造影操作简单、迅速、安全,除有禁忌证外,应常规应用术中胆道造影。     

Intraoperative cholangiography. A review of indications and analysis of age-sex groups

A retrospective review was performed of patients who had biliary tract stone formation as the primary diagnosis for hospitalization and indication for surgery. Five hundred and eighty-nine consecutive charts were reviewed of patients admitted between 1975 and 1979. Intraoperative cholangiography was performed in 166 patients of whom 22 had common duct exploration. Choledochotomy in this series was performed in 63 cases without utilizing pre-exploratory cholangiography. A normal intraoperative cholangiogram was found to be 100% accurate; however, an abnormal cholangiogram was associated with a 16% false positive rate of exploration of the common duct. The incidence of unsuspected common duct stones detected only by intraoperative cholangiography was 2.3%. Age-sex analysis confirms a 10-year mean age difference between men and women within the population of this study (p less than 0.001). This age-sex difference is maintained in patients without common duct pathology as well as in patients with sterile bile. However, the mean age difference between male and female patients with either demonstrable common duct obstruction by stones or infected bile as determined by routine intraoperative culture is not statistically significant. A review of the role of intraoperative cholangiography, and the experience at Northeastern Hospital is discussed.     

Common bile duct injuries during videolaparocholecystectomy

In the years an increase of last biliary injuries during laparoscopic cholecystectomy was observed. At present this occurrence rate is 0.1-3.4% of laparoscopic procedures. Probably this is to be related to less contraindications to cholecystectomy by laparoscopic procedures, with increase of more difficult operations. The intraoperative biliary injuries are due to anatomical anomalies of the local structures, mistakes of technique, flogosis of the cholecisto-choledocal region. Factors preventing iatrogenic injuries are accurate and standardized operative technique, adoption of modern instruments, intraoperative cholangiography. The Authors have reviewed their experience based on 1236 laparoscopic cholecysectomies performed in six years (1992-1998) in their own structure. Four lesions of the biliary tract (0.3%) have occurred: three Bismuth I-II and one Bismuth IV. They have always performed intraoperative cholangiography, without false negative, in contrast with present literature. They conclude underlining the need of the routine contrastrographic study of the biliary tract in all cholecysectomies as well as of an adequate training in radiological imagines interpretation.     

Intraoperative Real-Time Cholangiography and C-tube Drainage in Donor Hepatectomy Reduce Biliary Tract Complications

Background

In living-donor liver transplantation, biliary tract complications are a serious problem for recipients and donors.

Methods

We applied intraoperative real-time cholangiography using a C-arm and/or C-tube drainage to reduce biliary tract complications in donor hepatectomy. From 2003 to 2010, intraoperative real-time cholangiography and C-tube drainage was applied to 39 and 19 donor cases, respectively. Fifteen donor cases had both procedures.

Results

We confirmed the division line of the hepatic duct by visualizing a stricture on the monitor of the C-arm by pulling a thread and dissecting the proper site of the bile duct. The number of hepatic ducts of the graft to be anastomosed was 1 in 11 cases and 2 or 3 in 8 of the 19 cases without intraoperative real-time cholangiography, and it was 1 in 32 cases and 2 in 7 of the 39 cases with intraoperative real-time cholangiography. Bile leakage from the resection occurred in seven donors without, and in none of those with, C-tube drainage.

Conclusion

In living-donor liver transplantation, intraoperative real-time cholangiography enables effective determination of the precise division line of the hepatic duct. Moreover, C-tube drainage is effective for reducing bile leakage from the resected surface of the liver of donors.     

C型臂X线机下动态术中胆道造影在胆囊切除术中的应用

目的 探讨C型臂X线机下动态术中胆道造影在胆囊切除术中的应用价值.方法 对2006-2010年我科利用C型臂X线机对126例开腹胆囊切除术病例行动态术中胆道造影的资料进行回顾性分析.结果 造影成功122例,成功率96.8%.造影发现结石11例,其中胆总管结石8例,左肝管结石1例,右肝管结石2例,均行胆总管切开,胆道镜下取石,T管引流术.胆管损伤1例,行胆管修补.副肝管1例,Mirizzi综合征1例.均采取相应方法予以正确处理,一期愈合出院.全组无假阳性发生.平均耗时6.25min.结论 C型臂X线机下动态术中胆道造影法在胆囊切除术中是一种有效方法,省时,省力,显影清楚,值得推广.     

复杂高位胆管狭窄的手术治疗

目的:研究探讨各种原因引起的高位胆管狭窄的手术方式、疗效和术中B超及造影的应用价值。方法:应用术中B超和造影等特殊方法,确定病变部位并采取各自不同的手术方式治疗复杂高位胆管狭窄。结果:采用各种不同手术方式治疗高位胆管狭窄32例,其中良性狭窄25例,除1例因肝功能衰竭死亡外其余均痊愈。7例高位胆管癌患者只1例生存4年以上,其余6例均于术后8个月至2年内因肿瘤复发死亡。结论:应用术中B超和造影可准确定位狭窄或肿瘤的部位、大小、范围以及与门静脉、肝动脉的关系,即可控制术中大出血,减少医源性损伤,并可大大提高切除率,取得良好治疗效果。     

Asymptomatic lithiasis of the common bile duct: diagnostic difficulty and essentiality of intraoperative cholangiography]

Biliary lithiasis is a widespread pathology the diagnosis of which, following the introduction of ultrasonography, is increasingly easy. The frequent possibility of association between gallstones and choledocholithiasis, demands pre- or intraoperative recognition. The inadequacy of ultrasonography in excluding lithiasis of the common biliary tract with certainty, notwithstanding its other unquestionable advantages, and the disproportionate costs and risks of other investigations (cholangiography, ERCP, ecc.) which are such as to discourage routine use, confirm the role of operative cholangiography in the diagnosis of asymptomatic choledocholithiasis, so permetting its treatment. Personal experience of 100 consecutive cases of gallstones which showed fully 10 of them to be negative to preoperative investigation were found to have lithiasis of the common biliary tract.     

腹腔镜技术在难治性婴儿肝炎综合征诊治中的应用体会

目的:探讨腹腔镜胆道探查、胆道造影在难治性婴儿肝炎综合征诊治中的应用价值。方法:回顾分析2011年2月至2012年11月为71例符合标准的难治性婴儿肝炎综合征患儿行腹腔镜下胆道探查、胆道造影的临床资料,术中根据情况行胆囊造瘘、胆道冲洗、Kasai术。结果:71例均经腹腔镜胆道探查、胆道造影明确诊断,其中胆道闭锁32例,23例行腹腔镜Kasai术;胆汁淤积症36例,胆管发育不良3例,均予以胆囊造瘘、胆道冲洗。结论:腹腔镜胆道探查、胆道造影用于难治性婴儿肝炎综合征的鉴别诊断与治疗具有较高的临床应用价值,值得推广应用。