经胆囊管术中胆道造影52例分析

目的　探讨经胆囊管术中胆道造影对胆总管的探查价值。方法　回顾性分析术前B型超声检查和术中检查有胆总管探查相对指征的 5 2例患者术中胆道造影的情况。结果　 5 2例中 ,阳性 6例 ,假阳性 2例 ,假阴性 1例 ,准确率 96 %。结论　经胆囊管术中胆道造影可避免不必要的胆总管探查 ,提高胆道结石诊断率 ,避免遗漏胆管结石 ,能防止或了解胆道损伤 ,是一种安全、简便的方法     

术中胆道造影的临床应用和评价

目的：评价术中胆道造影在胆道手术中的临床价值。方法：1995年1月～1998年12月,行胆道手术中选择性胆道造影365例,其中经胆囊营造影263例;T营造影87例;肝门部胆管穿刺造影5例。结果：假阳性11例,假阴性5例,准确率95．62％。结论：术中胆道造影在降低胆道残石率,避免胆总管阴性探查,指导制定合理的术式,以及避免胆管损伤等方面具有较大临床价值。建设在下列情况下积极行术中胆道造影：（1）胆总管切开探查取石后;（2）胆囊结石伴有胆总管探查相对指征者;（3）肝内结石拟行胆肠内引流、复杂的胆道手术及胆囊切除术中发现胆道有可疑变异者。     

术中造影在胆道手术中的应用分析

目的比较术中胆道造影与术前影像检查的差异,分析其对胆道疾病的诊断及术式选择的指导价值。方法 118例胆囊结石和胆道疾病患者,术前24例行B超检查,发现正常胆管22例,胆总管结石1例,胆管扩张1例;69例行CT检查,发现正常胆管49例,泥沙样胆管结石16例,胆管扩张4例;25例行MRCP检查,发现正常胆管17例,胆总管结石6例,胆管扩张2例。术中行胆道造影,根据造影结果确定相应术式。结果术前行B超检查的24例中造影发现正常胆管15例,胆总管结石6例,胆管癌1例,胆囊管变异1例,Caroli氏病1例;术前行CT检查的69例术中造影发现正常胆管51例,胆总管结石10例,胆管癌1例,胆囊扩张2例,胆囊管变异1例,Mirizzi综合征2例,胆管损伤2例;术前行MRCP检查的25例,术中造影发现正常胆管14例,结石5例,胆管扩张4例,胆囊管变异1例,M irizzi综合征1例。术中胆道造影对正常胆管的识别能力优于术前B超(P0.05)。结论术中胆道造影具有操作简单、创伤小、结果可靠等优点,对胆道早期肿瘤、解剖畸形、术中胆道损伤的诊断及术式选择具有指导意义。     

纤维胆管镜的应用

目的:总结256例胆道病人应用纤维胆管镜治疗残余结石的经验.方法:对196例剖腹胆道手术时施行了纤维胆管镜检查和治疗,对60例行手术后的胆道镜检查,分析其临床表现并予以随访.结果:术中胆管镜检查发现4例的壶腹部有肿瘤,2例有胆总管癌,假阳性结石8例,胆管畸形2例.16例术前B超检查胆道内未发现结石,而术中胆管镜检查发现了结石.60例术后经“T”管引流窦道行胆管镜检查,发现8例的胆管造影所示的“结石”实属假阳性,2例胆管造影示“无结石”实属假阴性,胆总管下端狭窄2例.结论:纤维胆管的使用提高了诊断准确率,降低了残余结石的发生率,防止了盲目取石引起的胆管损伤,避免了不必要的胆总管切开探查.     

超声内镜诊断胆总管小结石的临床研究

目的:探讨超声内镜检查术(EUS)对于胆总管小结石的诊断率及临床价值。方法:回顾性分析行EUS检查患者159例,所有病人结合病史及临床体征考虑为胆总管结石,但影像学检查未发现结石。EUS发现胆总管结石者随即行ERCP取石术;ERCP失败者行手术取石。EUS未发现胆总管结石者,则不行ERCP,但随访至少三个月。结果 :159例患者中EUS发现结石者96例;89例ERCP取石成功,1例ERCP失败者手术取出结石,1例排石,5例为假阳性。63例EUS未发现结石者随访三个月未发现结石。无操作相关并发症发生。超声内镜诊断胆总管小结石的准确性、敏感性、特异性、阳性和阴性预测值分别为96.8%、100%、92.6%、94.8%和100%。结论:超声内镜诊断胆总管小结石安全、可靠。     

术中胆道造影736例临床分析

本院自 1 990年 1月～ 1 999年 8月共作胆道手术 4998例 ,其中对 73 6例行术中胆道造影 ,现对其临床价值、胆道造影方法进行探讨分析如下。1　临床资料1 .1　胆总管探查置 T型管进行术中造影 40 8例 ,阳性结石发现 70例 ,占 1 7.7% ,其中肝内胆管结石残留 2 2例 ,胆总管结石残留 48例 ,行 T型管术中造影还发现单纯性胆总管下端良性狭窄 4例 ,壶腹部癌 2例 ,假阳性 2例 ,胆总管十二指肠假道 2例 ,左右肝管不慎完全断离 4例 ,右肝细胞癌 2例。本组40 8例术中造影前已从胆总管取出结石 1 46例。同时有合并部分肝萎缩者 1 2例 ,有 6例结石残留 …     

磁共振胰胆管成像对胆总管结石的假阴性诊断

目的 总结磁共振胰胆管成像（MRCP）检查对胆总管结石的假阴性诊断经过及临床应对经 验。方法 回顾性分析2012年1月至2017年6月苏州市吴江区第一人民医院肝胆外科8例胆总管结石患 者MRCP假阴性诊断的临床资料、MRCP影像资料及诊断结果、临床手术情况及应对方法。结果 8例 MRCP假阴性诊断胆总管结石患者中,2例MRCP仅提示胆囊结石伴胆囊炎,胆总管不扩张; 6例MRCP仅 提示胆总管轻度扩张或扩张。其中6例经腹部CT确诊胆总管结石,2例经ERCP明确胆总管下段结石。2例 行ERCP治疗胆总管结石,1例经松弛Oddi括约肌药物治疗后胆总管结石排出,5例行腹腔镜下胆囊切除+ 胆总管探查术。本组8例患者恢复良好,均未出现明显急性胆管炎、急性胰腺炎等严重并发症。术后随访 3～6个月,复查B超均未见残留结石、结石复发及胆管狭窄。结论 MRCP检查虽然对胆总管结石的诊断 敏感性较高,但是对胆总管下段结石有一定的假阴性诊断率。临床医师不能仅依靠MRCP诊断排除胆总 管结石,应综合分析患者的症状和体征等临床资料,完善相关生化和腹部CT等辅助检查;同时结合术中 探查情况,尽量减少胆总管结石的漏诊。     

术中胆道造影在腹腔镜胆囊切除术中的应用价值

目的: 探讨降低腹腔镜胆囊切除术后胆总管残留结石发生率的方法.方法: 回顾性分析83例患者的病史、术前B超、生化检查、MRCP及术中胆管造影结果的临床资料.结果:83例中1例术中胆道造影失败;造影成功的82例中,发现合并胆总管结石12例,阳性率为14.6%(12/82).结论: 对于术前怀疑有胆总管结石的患者,应适当放宽术中胆道造影指征,可降低术后胆总管残留结石的发生率.     

腹腔镜超声检查在胆囊切除胆道探查术中的应用

目的：探讨腹腔镜超声检查在胆囊切除胆道探查术中的应用价值。方法：腹腔镜下对126例腹腔镜胆囊切除胆道探查术患者常规行腹腔镜超声检查,并选择其中30例行术中胆管造影。与腹腔镜超声检查行对比研究。结果：腹腔镜超声检查平均时间17min,对胆道系统和血管系统扫描结果显示：胆囊和门静脉100％显像,肝胆管,胆总管97％显像,胆总管未端85％显像,腹腔镜超声检查和术中胆管造影对比结果显未腹腔镜超声检查的胆总管检查成功率及胆管结石的敏感性,特异性及总诊断成功率均优于术中胆管造(影（分别为97％,82％,97％,98％和80％,75％,95％,95％）。结论：腹腔镜超声检查的应用有助于判断胆道系统的解剖结构,防止发生胆管损伤,有助于发现或排除肝内外胆管结石,为胆管造影及胆道探查术提供重要指标。降低了胆道残石和阴性胆道探查术的发生率。     

腹腔镜胆囊切除术中经胆囊管胆道造影的临床意义

目的 探讨腹腔镜胆囊切除术中行经胆囊管胆道造影对隐匿性胆总管结石及医源性胆管损伤诊断的临床意义.方法 回顾性分析341例腹腔镜胆囊切除术患者的临床资料,其中137例术中行经胆囊管胆道造影,207例未行造影.结果 137例行术中胆道造影者,术中发现胆总管结石11例（8.03％）,胆管损伤1例（0.72％）;术后随访3～6个月发现胆总管残余结石4例（2.92％）,未发现胆管损伤.204例未行术中胆道造影者,术中发现胆总管结石5例（2.45％）,术中未发现胆管损伤;术后随访3～6个月发现胆总管残余结石18例（8.82％）,胆管损伤2例（0.98％）.结论 腹腔镜胆囊切除术中经胆囊管胆道造影操作安全、快速、无创,可提高胆总管结石诊断的敏感度,及时发现胆管损伤,降低胆总管残余结石发生率,避免不必要的胆道探查.     

Selective use of magnetic resonance cholangiopancreatography in clinical practice may miss choledocholithiasis in gallstone pancreatitis

Background

Gallstone pancreatitis is a consequence of ampullary obstruction by common bile duct (CBD) calculi. Magnetic resonance cholangiopancreatography (MRCP) has been advocated for routine use to diagnose choledocholithiasis. However, the selective use of MRCP in clinically equivocal situations has not been explored until now. This study examines the diagnostic value of selective MRCP in gallstone pancreatitis.

Methods

We conducted a retrospective audit of all presentations of gallstone pancreatitis between January 2001 and December 2007 at Middlemore Hospital, Auckland, New Zealand. Demographic data, clinical presentation, biochemical and radiological findings and outcomes were reviewed.

Results

There were 339 cases of gallstone pancreatitis during the study period; 236 patients were women and the mean age was 52 years. Overall, choledocholithiasis was diagnosed in 95 patients. A total of 117 patients underwent MRCP within a median of 4 days of admission, with 15 (13.7%) showing choledocholithiasis. There was no significant difference in time to MRCP between positive and negative groups. Endoscopic retrograde cholangiopancreatography (ERCP)/intraoperative cholangiography (IOC) confirmed 13 of 15 stones within a median of 2.5 days. However, MRCP missed 8 cases of choledocholithiasis subsequently demonstrated on ERCP/IOC, where clinical suspicion remained after a negative MRCP. Its sensitivity was 62% and specificity 98%. The positive likelihood ratio was 6.5 and the negative likelihood ratio was 0.1. In all, 222 patients followed different clinical pathways with 82 CBD stones diagnosed by ERCP/IOC.

Conclusion

Selective MRCP is highly specific in gallstone pancreatitis but may not be sensitive enough to exclude choledocholithiasis in this context.     

Limitations of fluoroscopic intraoperative cholangiography in cases suggestive of choledocholithiasis

BACKGROUND: Fluoroscopic intraoperative cholangiography (IOC) has been proposed as a safe and accurate screening method for choledocholithiasis, with a sensitivity and specificity of nearly 100% in selected cases. In the present study we retrospectively reviewed the diagnostic accuracy of IOC in cases highly suggestive of choledocholithiasis. MATERIALS AND METHODS: Between January 1999 and December 2002, 103 patients underwent IOC as an imaging method for common bile duct (CBD) stone detection. We did not routinely perform IOC in all patients who were submitted to laparoscopic cholecystectomy, reserving the method for patients with a high probability of choledocholithiasis, namely patients with a history or the presence of painful obstructive jaundice at the time of referral, patients with a history of mild acute pancreatitis of biliary origin, and patients with abnormalities in their liver biochemistry profile as measured by liver function tests (LFT). RESULTS: The mean rates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for IOC were 98%, 94%, 94.5%, and 98% for the whole series, respectively. The diagnostic accuracy was 100% in patients with a history of obstructive jaundice or liver biochemical derangement, but was less in patients with a history of biliary pancreatitis. There were 3 false positive cases and 1 case of false negative results, all of which occurred in the subgroup of patients with a history of pancreatitis. CONCLUSION: Selective fluoroscopic IOC is generally feasible and safe, as well as highly accurate (100%) for CBD stone detection in patients with obstructive jaundice or abnormal LFT. The PPV of the method decreases in patients with a history of pancreatitis (75%), while a negative result is highly suggestive of the absence of CBD stones (NPV = 98%). The present study concluded in a higher incidence of false results in patients with a normal size CBD, suggesting that the diagnostic accuracy of IOC is probably related to the size of the CBD rather than the indication for its performance.     

Timing of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in the treatment of choledocholithiasis

Although experience with laparoscopic approaches to common duct stones is increasing, endoscopic retrograde cholangiopancreatography (ERCP) performed either before or after laparoscopic cholecystectomy (LC) remains the most common approach. Debate remains as to the best timing for ERCP in patients with suspected choledocholithiasis. Because clinical, laboratory, and radiological data are poor predictors of choledocholithiasis, many ERCPs done before LC give negative results. ERCP performed after LC with a positive intraoperative cholangiogram (i.o.p.) would eliminate many unnecessary preoperative endoscopic studies. This is a retrospective analysis of the treatment of choledocholithiasis with the combination of LC and ERCP. All patients included could have had ERCP preoperatively or postoperatively; therefore, those with cholangitis requiring emergent preoperative ERCP were excluded. Two groups of patients were compared: those who underwent ERCP followed by LC and those who underwent LC and IOC followed by ERCP. No significant differences were found with respect to age, gender, health status, clinical presentation, laboratory values (most liver functions, white blood cell count, hemoglobin, and serum amylase), surgery time, blood loss, ERCP time, time between treatment modalities, and days to regular diet. However, the preoperative ERCP group was found to have a longer hospital stay (6.7 days vs. 3.5 days, p = 0.003) and higher hospital cost ($9,406.39 vs. $12,816.23, p = 0.05). The preoperative ERCP group had two patients requiring two ERCPs to clear the common duct, one patient requiring conversion to open procedure because of failed LC, and four minor complications. The postoperative ERCP group had no failed LC, IOC, or postoperative ERCPs and one minor complication. The rate of false positive IOC was 6.7% and of negative preoperative ERCP, 43%. We conclude that in the absence of cholangitis requiring emergent endoscopic decompression, suspected choledocholithiasis can be successfully managed first with LC, ERCP being reserved for patients with a positive IOC. This eliminates many negative preoperative ERCPs.     

Results of cholecystectomy without intraoperative cholangiography.

BACKGROUND: To determine if cholecystectomy can be performed satisfactorily without the use of adjunctive intraoperative cholangiography (IOC), we planned a retrospective analysis at a Canadian university teaching hospital. METHODS: General operative morbidity and mortality (in particular, occurrences and complications of missed choledocholithiasis and reoperations for same, and occurrences of bile duct injuries and bile leaks) were noted and analyzed for a consecutive series of cholecystectomies from a single practice, carried out without IOC. MAIN RESULTS: In general, choledocholithiasis could be identified and treated before the operation; missed cases were infrequent and were treatable without reoperation. No major injuries to the bile duct were encountered. CONCLUSIONS: IOC appears to be optional with cholecystectomy; cholecystectomy can be performed without IOC safely in the defined setting, without related major complications from missed choledocholithiasis or excess occurrence of bile-duct injury.     

腹腔镜联合术中胆管造影、括约肌切开术序贯诊治胆结石病106例

目的 探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy，LC)联合术中胆管造影(intraoperative cholangiography，IOC)、术中括约肌切开术(intraoperative endoscopic sphincterotomy，IOEST)序贯诊治胆结石病的价值。方法回顾分析序贯诊治106例胆结石病的临床效果。结果64例(60．4％，64／106)术前诊断胆囊结石，经IOC发现有胆总管结石；序贯治疗手术成功率为93．4％(99／106)，98例胆总管结石被取净。术后并发症：水肿型急性胰腺炎6例(6．1％)、十二指肠穿孔1例(0．9％，1／106)、胆漏1例(0．9％，1／106)、气胸1例(0．9％，1／106)、漏诊十二指肠乳头癌1例(0．9％，1／106)、胃潴留2例(1．8％，2／106)。术后平均住院时间3．7d。结论LC联合IOC、IOEST能一次性微创诊治胆囊结石合并胆总管结石。     

腹腔镜胆管造影在胆总管结石误探与漏探中的应用价值

目的 为避免胆总管结石误探和漏探,分析腹腔镜胆管造影在胆管探查中的应用价值.方法 回顾性分析2015年1月至2019年12月完成的230例腹腔镜胆囊切除(LC)、胆总管探查术(LCBDE)患者的临床资料,选取腹腔镜术中胆管造影(intraoperative cholangiography,IOC)的患者41例作为观察组...     

Role of computed tomographic arterial portography and intraoperative ultrasound in the evaluation of patients for resectability of hepatic lesions

Computed tomographic arterial portography (CTAP) has been shown to be the most sensitive preoperative test for determining resectability of hepatic lesions but we have shown it to have low specificity. Intraoperative ultrasound (IOUS) evaluation of the liver has also been proposed as an accurate means of assessing resectability. We sought to compare the effectiveness of the two modalities. Fifty-six patients who had been deemed candidates for liver resection based on CTAP findings underwent systematic exploration, liver mobilization, and IOUS findings were in complete agreement with those of CTAP. In 10 patients CTAP lesions could not be verified by IOUS and these patients did not undergo resection. Follow-up of these 10 patients revealed eight who did not have progression of malignancy at the CTAP-predicted site (CTAP false positive). Two patients did have progression at a CTAP-positive IOUS-negative site (IOUS false negative). Sensitivity for CTAP and IOUS was 100% and 96%, respectively. Specificity for IOUS ficity of IOUS. CTAP may “overcall” hepatic lesions but IOUS can correctly identify these false positives ploration, we conclude that the two modalities are complementary for the assessment of resectability of hepatic lesions. The false positive rate for CTAP implies that caution must be used when declining to operate on patients on the basis of this test. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Intraoperative ultrasonography and surgical strategy in hepatic resection: What difference does it make?

Background

With modern advancements in preoperative imaging for liver surgery, intraoperative ultrasonography (IOUS) may be perceived as superfluous. Our aim was to determine if IOUS provides new information that changes surgical strategy in hepatic resection.

Methods

We retrospectively analyzed 121 consecutive liver resections performed at a single institution. Preoperative computed tomography and/or magnetic resonance imaging determined the initial surgical strategy. The size, location and number of lesions were compared between IOUS and preoperative imaging. Reviewing the operative report helped determine if new IOUS findings led to changes in surgical strategy. Pathology reports were analyzed for margins.

Results

Of 121 procedures analyzed, IOUS was used in 88. It changed the surgical plan in 15 (17%) cases. Additional tumours were detected in 10 (11%) patients. A change in tumour size and location were detected in 2 (2%) and 3 (4%) patients, respectively. Surgical plans were altered in 7 (8%) cases for reasons not related to IOUS. There was no significant difference (p = 0.74) in average margin length between the IOUS and non-IOUS groups (1.09 ± 1.18 cm v. 1.18 ± 1.05 cm).

Conclusion

Surgical strategy was altered owing to IOUS results in a substantial number of cases, and IOUS-guided resection planes resulted in R0 resections in nearly all procedures. The best operative plan in hepatic resection includes IOUS.     

Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP

Introduction  The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population. Methods  All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p < 0.05. Results  A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p > 0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis. Conclusions  The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.     

Intraoperative ultrasonography (IOUS) during laparoscopic cholecystectomy

Background: The purpose of this study was to evaluate the usefulness of intraoperative ultrasonography (IOUS), a new method of imaging the biliary tree and related structures, during laparoscopic cholecystectomy. Method: An IOUS probe (Aloka, Tokyo, Japan) with a 7.5-MHz linear-array transducer was used during cholecystectomy in 124 patients with symptomatic cholelithiasis (45 men, 79 women; mean age, 48±14 years). Results: The examination of the common bile duct (CBD) was excellent in 117 patients but unsatisfactory in 7 cases (5.6%) at the level of the head of the pancreas. In 5 patients, IOUS showed unsuspected choledocholithiasis: a subsequent intraoperational cholangiogram confirmed this. In five cases IOUS was able to help the surgeon to localize a Calot area obscured by inflammation. Postoperatively, one patient had an injury of the cystic duct stump: a nasobiliary tube resolved the bile leakage after 7 days. Another patient was submitted to postoperative endoscopic retrograde cholangiopancreatography (ERCP) for a choledocholithiasis recognized by a trans-cystic-tube cholangiography: the stone was suspected but not demonstrated either by laparoscopic IOUS or by intraoperative cholangiography. During the follow-up period, one patient had an episode of acute pancreatitis. ERCP showed a small stone wedged in the sphincter of Oddi. Conclusions: IOUS may be a real alternative to cholangiography during laparoscopic cholecystectomy since it is safer and offers a complete examination of the biliary tree. It has some disadvantages which can solved by additional experience.