输尿管镜气压弹道碎石取石术治疗胆道结石的疗效及安全性探讨

目的探讨输尿管镜气压弹道碎石取石术治疗胆道结石的疗效及安全性。方法利用输尿管镜气压弹道碎石取石技术治疗肝内外胆管结石151例(输尿管镜组),与以往采用胆道镜取石的100例患者(胆道镜组)进行回顾性病例对照研究。结果与胆道镜组相比,输尿管镜组在手术时间、取石时间上具有明显优势(P<0.05),而在术后住院时间、术中出血量及术后胃肠道恢复功能时间上无明显差异(P>0.05)。两组患者治疗后6～8周复查B超及胆道造影,输尿管镜组100例病例肝外胆道内发现残留结石2例,残石率1.3%;无一例出现胆道出血、胆漏、肝功能损害及并发胰腺炎。输尿管镜组90例病例肝外胆道内未发现残留结石,残石率10%;并发胆道出血1例、胆漏2例、胰腺炎1例,均经保守治疗治愈。输尿管镜组术后残石率明显低于胆道镜组(P<0.01);而两组患者并发症发生率比较无统计学差异(P>0.05)。结论输尿管镜气压弹道碎石取石术治疗肝内外管结石有效、安全。     

胆道镜联合输尿管镜气压弹道碎石治疗难取胆管结石的临床应用

【摘要】〓目的〓探讨胆道镜联合输尿管镜气压弹道碎石治疗难取胆管结石的临床效果。方法〓回顾性分析采用胆道镜联合输尿管镜气压弹道碎石65例患者的临床资料。结果〓全组手术均成功,取石时间25~70分钟,平均40分钟,结石取尽63例,结石残留2例,术中无胆管出血和胆管壁穿孔等并发症。随访一年,胆管不扩张,未发现肝外胆管残余结石,肝功能检查均正常,所有患者未再出现腹痛、发热、黄疸等症状。结论〓胆道镜联合输尿管镜气压弹道碎石治疗难取性胆管结石有效、可行。     

超声气压弹道碎石治疗肝内胆管结石19例分析

目的探讨胆道镜联合EMS超声气压弹道碎石术治疗肝内胆管结石的疗效及安全性。方法采用胆道镜联合EMS超声气压弹道碎石治疗肝内胆管结石19例。结果 19例均一次碎石成功,无结石残留,无胆道出血、胆漏等并发症,黄疸消退,肝功恢复。结论超声气压弹道碎石治疗肝内胆管结石具有安全、高效、并发症少、损伤小等优点。     

胆道镜联合钬激光碎石治疗肝内外胆管难取性残留结石

目的探讨经胆道镜钬激光碎石治疗肝内、外胆管难取性残留结石的实用性及安全性。方法观察18例胆道术后肝内、外胆管难取性残留结石患者接受胆道镜下钬激光碎石治疗的临床效果，并进行随访。结果经1～4次胆道镜下钬激光碎石治疗，18例患者残石全部取尽，未出现近期并发症。16例获得随访，随访时间6个月-1年，无结石复发和钬激光碎石相关的胆管狭窄出现。结论经胆道镜钬激光碎石是治疗肝内、外胆管难取性残留结石的一种安全、有效的方法。     

输尿管镜在肝内胆管结石术中的临床应用

目的探讨输尿管镜在肝内胆管结石术中的应用价值。方法采用输尿管镜术治疗肝内胆管多发性结石26例。结果 22例结石一次清除干净,左肝外叶结石残留4例,留置T管,3例术后6周经T管窦道再次用输尿管镜取尽结石,1例因经济原因放弃治疗。本组均未发生胆道出血、胆管损伤及十二指肠破裂等并发症。结论输尿管镜术治疗肝内胆管结石效果良好,且有碎石快捷、清石彻底、残石率低、创伤小等优点,临床实际应用价值较大。     

肝内外胆管难取性残留结石经胆道镜钬激光碎石治疗

目的 探讨经胆道镜钬激光碎石治疗肝内、外胆管难取性残留结石的实用性及安全性。方法 观察18例胆道术后肝内、外胆管难取性残留结石患者接受胆道镜下钬激光碎石治疗的临床效果，并进行随访。结果 经1～4次胆道镜下钬激光碎石治疗，18例患者残石全部取尽，未出现近期并发症。16例获得随访，随访时间6月到1年，无结石复发和钬激光碎石相关的胆管狭窄出现。结论 经胆道镜钬激光碎石是治疗肝内、外胆管难取性残留结石的一种安全、有效的方法。     

腹腔镜联合输尿管镜肝内外胆管取石术（附34例报告）

目的总结腹腔镜联合输尿管镜治疗肝内外胆管结石的经验。方法34例慢性胆囊炎伴肝内外胆管结石患者,行LC术,术中应用输尿管镜对肝内外胆管结石进行取石、气压弹道碎石、高压冲洗等操作。结果全部患者手术均获成功,结石取尽率100%,术后1例出现拔除T管后胆漏,经T管窦道再放置引流等处理后治愈。结论腹腔镜联合输尿管镜气压弹道碎石术,有助于肝内外胆管结石的取尽并可减轻病人的身心痛苦。     

输尿管镜在肝内外胆管结石术中的应用

目的:探讨输尿管镜在肝内外胆管结石术中的应用优势。方法:分别对术中应用输尿管镜碎石取石及胆道镜取石的156例开放性肝内外胆管结石手术患者临床资料及疗效进行回顾性比较分析。结果:术中输尿管镜碎石取石者(输尿管镜组,80例)手术时间为40~120 min,平均手术时间70 min,住院天数6~12 d,平均住院10 d,手术并发症发生率为3.75%,术后复查结石残留率为1.25%;胆道镜取石者(胆道镜组,76例)手术时间为50~150 min,平均手术时间85 min,住院天数8~16 d,平均住院12 d,手术并发症发生率为7.89%,术后复查结石残留率9.21%;输尿管镜组手术时间、住院天数、手术并发症发生率及术后结石残留率明显低于胆道镜组,两组比较差异均有统计学意义(P0.05)。结论:开放性肝内外胆管结石术中应用输尿管镜碎石取石比胆道镜更快速、有效,并发症更少、住院时间更短、术后结石残留率更低,是术中清除肝内外胆管结石的一种安全可靠的理想方法。     

输尿管镜下气压弹道碎石术治疗ESWL术后残留输尿管结石38例

目的探讨输尿管镜下气压弹道碎石术治疗体外冲击波碎石术（extracorporeal chock wave lithotripsy，ESWL）术后残留输尿管结石的疗效。方法对38例ESWL术后残留输尿管结石患者应用输尿管镜下气压弹道碎石术治疗。结果38例均一次碎石成功，术后1个月复查结石均排尽。结论输尿管镜下气压弹道碎石术治疗ESWL术后残留的输尿管结石安全、有效。     

胆道镜下液电碎石术联合B超治疗肝内胆管残留结石的体会

目的探讨胆道镜下液电碎石术联合B超治疗胆道术后残留结石临床价值和疗效。方法将82例术后肝内胆管残留结石患者分为两组,胆道镜辅以术中B超经T管窦道液电碎石取石治疗肝内胆管术后残石42例为治疗组。以胆道镜取石40例患者为对照组。结果治疗组结石取净率显著高于对照组（P〈0．05）,平均手术时间、手术次数、住院时间和平均住院费用等明显优于对照组（P均〈0．05）。两组患者手术后均无严重并发症。结论胆道镜下液电碎石术联合术中B超治疗术后肝内胆管残留结石,具有定位准确、创伤小、安全有效、可重复操作等优点,值得临床推广使用。     

Laparoscopic transcystic duct common bile duct exploration

The modern era of common bile duct (CBD) surgery started with Mirizzi, who introduced intraoperative cholangiography in 1932. Intraoperative choledoscopy had been developed as an adjunctive to intraoperative cholangiography, which helped to detect CBD stones in an additional 10% to 15% of instances that otherwise would have been missed. Findings have shown choledochoscopy to be an important technique for efficient and effective management of CBD stones. Efforts to treat patients with common duct stones in one session and to avoid the potential complications of endoscopic sphincterotomy resulted in several laparoscopic transcystic CBD (LTCBDE) techniques. The techniques of transcystic stone extraction include lavage, trolling with wire baskets or biliary balloon catheters, cystic duct dilation, biliary endoscopy, and stone retrieval with wire baskets under direct vision and antegrade sphincterotomy, lithotripsy, and catheter techniques. The indications for LTCBDE are filling or equivocal defects at cholangiography, stones smaller than 10 mm, fewer than 9 stones, and possible tumor. The contraindications are stones larger than 1 cm, stones proximal to the cystic duct entrance into the CBD, small friable cystic duct, and 10 or more stones. Experience with LTCBDE shows that the approach is applicable in more than 85% of cases, with a success rate of 85% to 95%. It also is shown to be more cost effective than postoperative endoscopic retrograde cholangiopancreatography. Recent developments in LTCBDE have focused mainly on implementation of robotically assisted surgery and new imaging methods such as magnetic resonance cholangiopancreatography with three-dimensional virtual cholangioscopy and three-dimensional ultrasound. Further technological advances will facilitate the application of laparoscopic approaches to the common duct, which should become the primary strategy for the great majority of patients.     

Patient and duct selection for nipple duct lavage

BACKGROUND: Nipple ductal lavage (NDL) is a new minimally invasive procedure with the potential to help identify women who could benefit from breast cancer risk intervention. NDL is currently encouraged for women with fluid-producing ducts and a 5-year Gail risk > or =1.7%. The purpose of this study was to evaluate the atypia rate by NDL in fluid-producing ducts compared with non-fluid-producing ducts and the atypia rate in high-risk verses low-risk patients to determine if current recommendations are supported. METHODS: Fifty-nine women were studied with NDL. The 226 ducts lavaged included all fluid-producing ducts (n = 136) and any dry ducts we could cannulate (n = 90). Breast cancer risk was calculated using mathematic models. RESULTS: There were 26 (44%) women with a 5-year Gail risk > or =1.7% and 33 (56%) with a 5-year Gail risk <1.7%. Cytologic atypia was diagnosed in 20 of 59 (34%) of patients. The atypia rate was similar for women with a 5-year Gail risk > or =1.7% (9 of 26 or 35%) compared with lower-risk women (11 of 33 or 33%, P = 1.0) and for fluid-producing ducts (26 of 136 or 19%) compared with dry ducts (14 of 90 or 15%, P = 0.61). No significant differences were found when the atypia was categorized as mild versus marked. Of note, the insufficient sample rate was higher for dry ducts (33%) compared with fluid-producing duct (22%, P = 0.07). CONCLUSIONS: If NDL results are found to correlate with breast cancer incidence, it will be important to apply the test in a way that maximizes sensitivity for the detection of atypia in a screened population. We were unable to identify patient or duct characteristics that predict NDL atypia rates.     

Cystic duct directly joining the main pancreatic duct

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.     

肝胆管结石并狭窄的手术治疗

回顾性分析近12年来收治的64例肝胆管结石并胆管狭窄患者的临床资料。64例均手术治疗，肝叶（段）切除术19例，胆管空肠端侧Roux-en-Y吻合术21例，2种方法联合使用24例;其中行T 管和U管引流分别为11 例和8 例，肝门部肝胆管狭窄整形9例。全组无术中及术后死亡;随访0.5 ～12 年，术后残留结石7例，残石率10.9%。术后用胆道镜取石4例，取净3例;体外震波碎石3例，结合冲洗及中药治疗，排净2例，最终残石率3.12%。提示肝段(叶) 切除联合其他手术是治疗肝胆管结石较为有效的手术方式。     

腹腔镜再次胆道探查术治疗胆管结石

目的：探讨腹腔镜再次胆道探查术治疗胆管结石的方法和临床应用价值。方法：回顾分析为31例复发性胆管结石患者施行腹腔镜胆道探查取石术的临床资料。结果：31例中2例因腹腔粘连致密,胆道周围组织充血水肿严重而中转开腹。29例完成腹腔镜手术,其中1例因胆总管结石大,1例胆总管下端结石嵌顿,1例肝内胆管结石较多,胆道镜和取石钳取石困难,剑突下切口延长至3~4 cm,直视下用取石钳联合胆道镜取石。行胆总管一期缝合5例,24例行胆总管T管引流术。手术时间平均170 min。术后均无腹腔出血和肠漏等并发症发生。3例出现少量胆漏,未出现腹膜炎和腹内感染征象,腹腔引流管分别于术后第6,9,10天拔除。2例剑突下切口感染均是切口延长者,通过局部换药愈合。胆总管一期缝合5例,术后5~7 d出院。24例行胆总管T管引流的患者中,10例于术后7 d带T管出院,14例于术后14 d夹闭T管后带管出院。术中19例结石取净,10例胆道残余结石患者于术后2个月经胆道镜取出。结论：腹腔镜再次胆道探查术安全,患者创伤小,康复快。胆管炎症严重及肝内外结石较多、胆总管下端结石嵌顿者需慎重选择腹腔镜手术。     

腹腔镜胆总管切开取石方法探讨

目的 :探讨腹腔镜下胆总管探查胆道取石的方法。方法 :于腹腔镜下对胆总管结石 4 5例按由简单到复杂 ,由损伤轻到损伤重的原则应用冲洗、挤压及分离钳、胆道镜、改良取石钳取石。结果 :用冲吸法取净结石 3例 ,占 6 .6 % ;挤压和分离钳取净结石 13例 ,占 2 8 9% ;胆道镜取净结石 11例 ,占 2 4 % ;取石钳取净结石 18例 ,占 4 0 %。结论 :腹腔镜下胆总管取石应遵循由简到繁的原则 ,用取石钳取石较为可靠