胆管缺损和损伤的处理

胆道手术中遇到胆管壁缺损并非少见 ,不外乎病理性和医源性损伤两大类。前者多见于Ｍｉｒｉｚｚｉ综合征[1 ] 和胆管穿孔 ,后者则是手术损伤。现将 1 992年 2月～ 2 0 0 0年 2月治疗的 2 2例报告如下。临床资料　　 1 .一般资料　　男 1 3例 ,女 9例 ,年龄 35～ 66岁。Ｍｉｒｉｚｚｉ综合征 1 1例 ,其中Ⅱ型 6例 ,Ⅲ型 4例 ,Ⅳ型 1例 ;胆管结石发生急性梗阻性胆管炎致肝外胆管穿孔 5例 ,穿孔直径均小于胆管周径的 1 / 3 ;腹腔镜胆囊切除 (ＬＣ)胆管损伤 4例 ,均横断胆管且缺损 >1 .0ｃｍ ,其中胆囊管汇合处 3例 ,左、右肝管汇合处 1例 ;开腹…     

Penetrating Bile Duct Injury

European Journal of Trauma and Emergency Surgery - Cases of extrahepatic biliary tree trauma are not as common as other intraabdominal injuries and may pose a diagnostic and therapeutic challenge....     

胆总管探查时胰腺段损伤的处理

肝外胆管损伤的部位以贴近肝门的肝总管和胆总管十二指肠上段最为多见 ,而发生于胆总管探查时的胆总管胰腺段损伤较为少见 ,且处理较为困难。现将 1993年至 2 0 0 1年本院收治的 5例病人作一总结报道于下。临床资料　　 1.一般资料　　男 2例 ,女 3例。年龄 2 9～ 74岁 ,平均 5 7岁。急诊手术 3例 ,病因分别为重症胆石性胰腺炎伴黄疸 1例 ,胆囊结石伴慢性胆囊炎急性发作合并胆总管扩张 2例 ;择期手术 2例 ,病因均为胆总管结石合并胆总管扩张。胆总管胰段损伤原因均为采用硬质探条探查所致。住院 14～ 96ｄ。除 1例入院第 13天时因发生近全胰…     

Reconstruction of Bile Duct Injury and Defect with the Round Ligament

Journal of Gastrointestinal Surgery - Lateral injury of the bile duct can occur after cholecystectomy, bile duct dissection, or exploration. If direct repair is not possible, conversion to...     

Laparoscopic Common Bile Duct Exploration

Since the introduction of laparoscopic cholecystectomy, the management of common bile duct (CBD) stones has undergone significant change. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is now routinely done in cases where the diagnosis of choledocholithiasis is suspected preoperatively, with clearance of the bile ducts before laparoscopic cholecystectomy. Intraoperative discovery of CBD stones by cholangiography represents a challenge to the surgeon, who must make a decision about when to perform laparoscopic CBD exploration, convert to open surgery, or send the patient for ERCP during the postoperative period. Because ERCP has a definite failure rate, laparoscopic CBD exploration can be a treatment option. Among 2500 laparoscopic cholecystectomies done by our group from January 1991 to June 1997, 50 patients (2%) underwent laparoscopic CBD exploration, 13 by the transcystic technique and 37 by choledocotomy, with a conversion rate of 8% and a hospital stay of 4.3 days. One patient died from complicated pancreatitis following ERCP and unsuccessful extraction of a CBD stone. We obtained our goal of a CBD free of stones in 92% of the cases. We conclude that laparoscopic CBD exploration is an effective method for treating choledocolithiasis that allows management of this pathology in one stage, although it requires advanced laparoscopic skills and adequate equipment.     

Laparoscopic Common Bile Duct Exploration

Laparoscopic cholecystectomy has become the procedure of choice for laparoscopically skilled surgeons when dealing with both chronic and acute cholecystitis. When choledocholithiasis is encountered in the treatment of these patients the skilled laparoscopist has several treatment options available to treat the patient in one stage and avoid the morbidity of endoscopic sphincterotomy. Although still controversial, laparoscopic common bile duct exploration has been shown to be safe, applicable, and cost-effective in the treatment of choledocholithiasis. This report details several laparoscopic treatment alternatives for choledocholithiasis.     

A Hybrid Endo-Laparoscopic Therapy for Common Bile Duct Stenosis of a Choledocho-Duodenostomy After a Roux-en-Y Gastric Bypass

The essential growth of the number of Roux-en-Y gastric bypass procedures will obviously be accompanied by an increase of cases of common bile duct lithiasis. It seems evident that a close cooperation between surgeon and endoscopist will be needed on a routine basis. A laparoscopic-assisted transgastric ERCP is a well-documented approach to investigate the pancreatico-biliary tree in patients where the duodenum has been bypassed as in Roux-en-Y gastric bypass. In this case we present the possibility of assisting the endoscopist not only by providing access to the gastric remnant but also by helping with laparoscopic instruments during duodenoscopy. A formally obese woman who had benefited from a RYGB developed recurrent jaundice despite a precedent common bile duct exploration and choledocho-duodenostomy. A laparoscopic-assisted transgastric endoscopy revealed an obstructed choledocho-duodenostomy caused by accretions around a migrated clip. The obstructing clip could be extracted by laparoscopic instruments under endoscopic control. The authors declare no commercial interest interfered with production of the report. No financial or material support has been obtained.     

Common Bile Duct Obstruction by Free Floating Tumor

Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrsasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. Conclusion: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.     

Management of Common Bile Duct Stone Late after Laparoscopic Roux-en-Y Gastric Bypass for Obesity

Rapid weight loss following Roux-en-Y gastric bypass (RYGBP) for the treatment of obesity can increase the incidence of cholelithiasis formation. Nevertheless, routine simultaneous cholecystectomy at the time of bariatric surgery remains controversial. However, in case of delayed occurrence of common bile duct (CBD) stones, the difficulty to reach endoscopically the biliary tract after RYGBP should be kept in mind.

We here report the case of a patient who presented with CBD stones seven years after gastric banding followed five years later by RYGBP without associated cholecystectomy.

Our approach of transgastric laparoscopic assisted endoscopic retrograde cholangiopancreatography followed by sphincterotomy and balloon stones extraction is illustrated.     

腹腔镜下经胆囊管肝总管汇合部微切开胆总管探查的可行性

目的探讨腹腔镜下经胆囊管肝总管汇合部微切开胆总管探查免置T管的可行性及病例选择。方法回顾性分析我院2009年1月至2011年12月期间52例拟行胆总管探查患者的临床资料,实施了经腹腔镜、胆道镜双镜联合下经胆囊管肝总管汇合部微（3～4mm）切开取石、不放置T管引流,一期缝合。结果本组52例患者术中无阴性探查,术中使用胆道镜及胆道造影检查证实结石完全取出,结石取净率为100％,手术时间为90～200min,平均100min。术中胆道造影时间为3～10min,平均6min。胆道镜协助取石时间为5～15min,平均8min。术后腹腔引流管拔管时间3～5d,平均3．5d。术后腹腔引流液量为20～60mL／d,平均30mL／d。术后无胆汁漏、腹痛、黄疸及切口感染发生。术后住院5～12d,平均6．5d。术后随访时间为3～40个月,平均20个月,无结石再生或胆管狭窄发生。结论若术者腹腔镜、胆道镜技术熟练,手术病例选择适当,术中检查仔细,冲洗干净,经胆囊管肝总管汇合部微切开取石后行胆总管一期缝合是安全、可行的。     

Unusual Segmental Stricture of the Lower Common Bile Duct Mimicking Bile Duct Cancer

In some cases of bile duct stricture, malignancy cannot be diagnosed preoperatively even with the use of various diagnostic imaging modalities and histologic examination. As long as malignancy cannot be ruled out completely, surgery can be undertaken for the purposes of diagnosis and treatment. We report a case of unusual segmental stricture of the lower common bile duct mimicking bile duct cancer and discuss the differential diagnosis.     

Prevalence of Bile Duct Injury Following Cholecystectomy

Introduction: A review of our experience with CAS in a non-academic hospital is presented. Materials and methods: A consecutive series of 18 CAS-interventions between 2003 and 2005 is studied retrospectively. Indication, medical history, preoperative carotid imaging, operative technique and results were studied for each patient.

Results: CAS was used 12 times in men and six (33.3%) times in women between 2003 and 2005. Five (27.8%) symptomatic stenoses, 12 (66.6%) asymptomatic stenoses and one (5.6%) arterio-venous fistula were treated. One permanent postoperative ipsilateral ischaemic neurologic deficit occurred (5.6%). The mean duration of hospital stay was 4.9 days (range: 2–9 days).

Conclusions: Our study shows that CAS is feasible in non-academic hospital settings, with acceptable early results. Participating in larger studies should confirm our results.     

Ectopic Drainage of the Common Bile Duct

Two patients are presented with ectopic drainage of the common bile duct, one entering the stomach and the second entering the first portion of the duodenum. They make the seventh patient with the common bile duct entering into the stomach and the 19 patients with anomalous drainage into the duodenum. The awareness of this and other biliary system anomalies is stressed to prevent damage to vital structures in this area. The theories explaining this anomalies are discussed.