术中胆道镜87例应用体会

胆道镜手术是近几年发展起来的一项技术,我院自１９８８年至１９９８年应用胆道镜行术中胆道检查及取石术共８７例,取得良好效果,现报告如下。１．临床资料：本组８７例中男性２１例,女性６６例;年龄１６～７８岁,平均４４岁。术前腹部Ｂ超检查胆总管结石５８例,胆总管结石合并肝内胆管结石２１例,单纯肝内胆管结石２例,另外有６例患者术前Ｂ超检查中未发现胆道内有结石,而是在手术中发现有胆总管探查指征并进行了胆总管探查,其中４例于胆总管内取出结石,２例为阴性探查。８７例患者均进行了胆总管探查术,术中均应用胆道镜进行…     

胆道镜在胆道手术中的应用

目的探讨胆道镜在胆道手术中的应用价值.方法对经CT、B超、ERCP或MR证实为胆石症的32例胆道手术患者术中进行胆道镜探查,常规开腹切除胆囊或切开胆管将结石取出后,胆道镜经胆囊管残端或胆管切开处插入胆道依次探查左右肝管,肝总管、胆总管.结果32例患者中发现肝管残留结石1例,胆总管残留结石2例,胆总管末端狭窄2例,胆管癌1例.3例残留结石中2例以取石器将结石取出,1例结石嵌顿在乳头开口处,以胆道镜推送至十二指肠内.2例胆总管末端狭窄,给予胆道镜下扩张治疗,减轻了术后因胆总管末端狭窄而导致的不良后果.1例在探查中发现胆总管下端不光滑,有小结节状隆起,取组织病理检查证实为胆管癌而改变术式,避免了再次开腹手术.结论胆道手术时行胆道镜探查,可减少残留结石的发生,并能及时发现其他病理情况,给予相应治疗,减少漏误诊的发生.     

电子十二指肠镜在胆总管探查术中的临床应用

目的探讨电子十二指肠镜在胆总管探查术中的应用价值和方法。方法回顾性分析33例术中电子十二指肠镜在胆总管探查术中的临床应用。结果3例通过电子十二指肠镜,将乳头切开刀成功插入胆总管,在术中对胆总管进行定位和标志;18例用于腹腔镜胆总管探查胆总管1期缝合,行术中鼻胆引流术;12例用于开腹胆总管探查胆总管1期缝合,行术中鼻胆引流术,均达到1期缝合的治疗效果,避免了传统胆道探查术后T管的放置。结论电子十二指肠镜应用于胆总管探查术中,可避免术中盲目探查,减少手术创伤,提高手术质量,并探索了胆总管探查的一种新的术式,用术中放置鼻胆引流管替代传统术中放置T管。     

老年胆石症患者腹腔镜胆总管切开取石一期缝合35例分析

目的探讨腹腔镜胆总管切开取石一期缝合治疗老年胆总管结石可行性及安全性。方法选取2009年12月至2012年8月行腹腔镜、纤维胆道镜联合治疗胆囊结石、胆总管结石,一期胆总管缝合≥65岁老年病人35例。完全腹腔镜下胆囊切除,联合胆总管切开通过胆道镜置入取石网篮取石,术毕一期缝合胆总管。结果本组腹腔镜胆道镜联合行胆总管探查取石术成功率为100%,手术时间57~170 min,出血量10~100 ml,术后住院时间5~10 d,发生胆漏2例,再次手术1例。术后随访4月至2年,残余胆总管结石1例。结论在严格把握手术指征,认真评价术前影像学,术中熟练胆道镜操作,精准缝合的前提下,老年病人腹腔镜胆总管切开取石一期缝合治疗胆总管结石是安全可行的。     

胆道镜在胆道术中应用的体会

自1987年至1998年8月间,我院应用纤维胆道镜(下称胆道镜)在胆道手术中诊治胆道疾病98例,取得较好效果。现总结如下。临床资料一、一般资料:本组经临床和影像学诊断胆道疾病98例,其中梗阻性黄疸疑诊胆道肿瘤5例,肝内外胆管结石93例。男41例,女57例;年龄16～78岁。急诊手术应用19例,择期手术应用79例。二、胆道镜检查和治疗方法:我们使用ＯｌｙｍｐｕｓＣＨＦＢ3Ｒ,4Ｂ,Ｐ10型纤维胆道镜,按常规行胆总管切开后,先用传统器械探查,如为胆道结石先用传统器械尽量取石,然后行术中胆道镜检查,先肝内胆管,最后检查胆总管远端。遇结石逐一采用取石网…     

胆道镜检查

胆道镜检是用胆总管镜(Choledochoscope)在术中或术后窥视胆管的较新诊断治疗方法。多年来,许多学者为降低胆道残余结石作了不懈的努力,但发生率仍为4～28%。为减少胆道残余结石,最重要的是在胆石症初次手术时彻底探查胆道,除净结石。术中胆道造影也有4～14%假阴性。常规器械探查胆总管已是胆道手术的重要步骤,但这是仅凭感觉的盲目探查,易遗漏结石、损伤胆道内粘膜,并有一定并发症。胆道镜检已使胆道残余结石率降至0～2%。有人譬喻不用胆道镜而“盲目”找结     

腹腔镜与内镜联合应用治疗胆总管结石

我院自 1992年 1月至 1999年 1月共行腹腔镜胆囊切除术 (LC)3 125例,术后发生胆总管残留结石 12例,占 0.38％。在 LC后行内镜乳头括约肌切开术 (EST)及 EST后取石,成功 9例,失败 3例。另有 4例 LC术中发现胆总管结石者,行腹腔镜下胆总管切开探查、纤维胆道镜取石全部成功,现报告如下。 临床资料： 12例患者中男 4例,女 8例,年龄 48～ 54岁。术前均无黄疸, B超胆总管亦无异常,肝功能正常。术后胆道造影发现有胆总管继发结石。 2例患者术中见胆囊多发结石,胆道造影提示胆总管下端分别有直径 0.5cm、 0.7cm大小结石, LC后一…     

胆总管探查致胆道下段损伤的预防及处理

胆道探查手术是胆道外科的常见手术,由于术者对胆道下段解剖结构特点不熟悉,或者探查胆道的方法不正确,使用胆道探子的时候探子的方向、使用的力度不恰当,就可能导致胆总管下段的医源性损伤,甚至合并胰腺或者十二指肠损伤。我院2000～2007年行胆总管探查时发生胆道下段损伤6例,现报告如下。     

腹腔镜联合内镜胆总管探查术

目的 探讨运用多种微创治疗手段,治疗经内镜取石失败的胆总管结石患者。方法 运用三窥联合的手术方式（术前内镜下经鼻胆管引流、腹腔镜胆总管探查术及术中胆道镜（对３９例胆总管结石患者进行微创治疗。结果 ３９例手术均获成功,无中转开腹,无残留结石及严重并发症。术后住院时间明显缩短,而手术时间与开腹手术相似。部分病例随边半以上未见远期并发症。结论 三镜联合行胆囊切除、胆总管探查术对于有较高内镜、腹腔镜技术水     

胆总管探查术中应用纤维胆道镜的护理体会

1998～ 2 0 0 0年我院应用纤维胆道镜行胆总管探查术 182例 ,现将护理体会总结如下。临床资料 :本组 182例中 ,男 78例 ,女 10 4例 ;年龄 2 2～79岁 ;初次手术 12 7例 ,二次手术 5 5例。术前诊断 :胆总管结石 72例 ,肝内胆管结石 5 8例 ,胆总管囊肿 2 9例 ,胆管及相邻组织的恶性肿瘤 2 3例。护理体会 :1物品准备 :应用配有监视系统的Olym pu CHP2 0型纤维胆道镜。术前应将胆道镜、取石网、活检钳、碎石钳等置于密闭薰箱内 ,用福尔马林薰蒸 4 h消毒备用 ,另备胆道镜冷光源、电视目镜接头、术中冲洗用的输液器、生理盐水、吸引器及各种型号…     

Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

BACKGROUND: Endoscopic papillotomy is successful in more than 95% of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. AIM: To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. METHODS: Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful extracorporeal shock-wave lithotripsy and electrohydraulic were also performed before laser in 35% and 26% of the cases, respectively. RESULTS: Laser was effective in 79.2% of 72 patients guided by cholangioscopy and in 82.4% of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,335 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7% vs. 31.9%). When the stones were in the distal bile duct, fluoroscopic control was more successful. CONCLUSION: In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated proximal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.     

Intraductal papillary neoplasm of the bile duct

Intraductal papillary neoplasm of the bile duct(IPNB)is a variant of bile duct carcinoma that is characterized by intraductal growth and better outcomes compared with common cholangiocarcinoma.IPNBs are mainly found in patients from Far Eastern areas,where hepatolithiasis and clonorchiasis are endemic.According to the immunohistochemical profiles of the mucin core proteins,IPNBs are classified into four types:pancreaticobiliary,intestinal,gastric,and oncocytic.Approximately 40%-80%of IPNBs contain a component of invasive carcinoma or tubular or mucinous adenocarcinoma,suggesting that IPNB is a disease with high potential for malignancy.It is difficult to make an accurate preoperative diagnosis because of IPNB’s low incidence and the lack of specificity in its clinical manifestation.The most common abnormal preoperative imaging findings of IPNB are intraductal masses and the involvement of bile duct dilation.Simultaneous proximal and distal bile duct dilation can be detected in some cases,which has diagnostic significance.Cholangiography and cholangioscopy are needed to confirm the pathology and demonstrate the extent of the lesions.However,pathologic diagnosis by biopsy cannot reflect the actual stage in many cases because different foci may be of different stages and because mixed pathologic findings may exist in the same lesion.Surgical resection is the major treatment.Systematic cholangioscopy with staged biopsies and frozen sections is recommended during resection to ensure that no minor tumors are left and that curative resection is achieved.Staging,histologic subtype,curative resection and lymph node metastasis are factors affecting long-term survival.     

Biliary interventions using single‐operator cholangioscopy

Cholangioscopy provides an opportunity to directly visualize the bile duct for diagnosing biliary lesions and for therapeutic interventions. Although there are different cholangioscopy techniques available, single‐operator cholangioscopy has gained widespread acceptance as the standard technique for interventions in the biliary system because of its ease of use and widespread availability. Single‐operator cholangioscopy can be used for both diagnostic and therapeutic indications in the biliary tract. Diagnostic cholangioscopy is used for direct evaluation of indeterminate bile duct strictures with biopsies, diagnosing filling defects in the bile ducts observed during endoscopic retrograde cholangiography (ERC) imaging, preoperative mapping of the precise location and extension of tumors of the biliary tract, and diagnosis of intraductal neoplasms. Therapeutic cholangioscopy is used for visually guided treatment of biliary stones that have failed extraction with conventional ERC techniques, residual or impacted stones by using intraductal lithotripsy, ablation of biliary tumors and for facilitation of guidewire advancement into selective intrahepatic ducts for adequate biliary drainage. In this review, we will focus on advances in the single‐operator cholangioscopy techniques in the diagnosis and management of biliary disorders.     

Large Gallstones Stacked Together in the Common Bile Duct after Choledochojejunostomy

A 65-year-old man had a history of cholecystectomy and treatment for cholelithiasis with a common bile duct incision. Owing to frequent cholangitis, he underwent choledochojejunostomy. Twenty years after the surgery, he was hospitalized for cholangitis and was suspected of having hilar cholangiocarcinoma based on imaging findings. Percutaneous transhepatic cholangioscopy using a SpyGlass™ DS (Boston Scientific, Marlborough, USA) showed gallstones and bile sludge in the bile ducts, but no tumors were noted. Electrohydraulic shockwave lithotripsy with double-balloon enteroscopy enabled complete stone removal; a direct visual biopsy with peroral cholangioscopy showed no malignancy in the bile duct.     

Cholangioscopic findings in bile duct tumors

BACKGROUND: Cholangioscopy has been used in the treatment of bile duct stones and the diagnosis of various bile duct tumors. However, the cholangioscopic characteristics of the various types of bile duct tumors have not been clearly described. We analyzed the results of cholangioscopic examinations and classified the findings according to tumor histology. METHODS: Cholangioscopic findings from 111 patients with benign or malignant bile duct tumors were reviewed. The mucosal changes, the presence of neovascularization, and the patterns of luminal narrowing were analyzed and compared with the histologic diagnosis. RESULTS: Bile duct adenocarcinoma can be classified into 3 different types according to the cholangioscopic findings: nodular, papillary, and infiltrative. Bile duct adenoma, hepatocellular carcinoma and other types of bile duct cancer such as mucin-hypersecreting cholangiocarcinoma, biliary cystadenocarcinoma, and squamous cell carcinoma also presented unique cholangioscopic characteristics. CONCLUSIONS: Bile duct tumors exhibit characteristic cholangioscopic findings and cholangioscopy seems to be useful for differential diagnosis.     

Cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct.

A case of cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct is reported. The main tumor in the caudate lobe was detected by computed tomography and angiography, and two intraluminal tumors at the hepatic hilus and at the root of the right posterior segmental duct were well demonstrated by cholangiography and percutaneous transhepatic cholangioscopy. Independent total caudate lobectomy with bile duct resection was performed. Cholangiocellular carcinoma of the liver with intraluminal growth in the extrahepatic bile duct is very rare and has not been reported in the literature. Independent caudate lobe resection requires a rather complicated technique. However, this method has the advantage of reducing to a minimum the hepatic volume to be resected, and is useful for poor-risk patients or for cases with localized carcinoma at the hepatic hilus.     

Calcification in mucinous cholangiocellular carcinoma

Calcification is rarely seen in cholangiocellular carcinoma. We herein report the case of a 53 year-old man with calcification in a cholangiocellular carcinoma. Because imaging studies had revealed coarse calcified foci, hepatolithiasis was suspected pre-operatively. The patient underwent a laparotomy in which intra-operative cholangioscopy revealed no gallstones but did reveal an unsuspected tumor with abundant mucin. A left hepatic lobectomy with resection of the extrahepatic bile duct was performed. The tumor histology was mucinous adenocarcinoma with calcification. In the English language literature, we found 9 cases of cholangiocellular carcinoma with macroscopic calcification. Six of these cases were mucinous adenocarcinomas. Roentgenologic examination revealed coarse calcification in 7 cases and fine calcification in 2 cases. Clinicians should note that cholangiocellular carcinoma, especially the mucinous variant, may be accompanied by coarse calcification.     

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.     

Mucin ball-producing extrahepatic bile duct carcinoma

The characteristic features of surgically curable mucin-producing extrahepatic bile duct carcinoma (MPEBC) have not previously been elucidated. Three (6.5%) of 46 patients who underwent surgery in our department for bile duct carcinoma between 1986 and 1997 had MPEBC. Clinicopathological features, diagnostic procedures and operative methods for patients with MPEBC were investigated. Tumors in the bile duct were identified by cholangioscopy combined with cholangiography after removal of mucin balls. Tumors were located close to the hepatic confluence in these patients. Two patients underwent hepatic lobectomy together with caudate lobectomy while the other underwent resection of the hepatic confluence. Absence of residual tumors was confirmed histologically in these patients. All three patients remain alive without evidence of recurrence, 22-54 months after surgery. MPEBC is a curable disease. Accurate localization in the biliary tree is essential and can only be obtained after, i) removal of mucin balls, and ii) extensive diagnostic work-up including cholangiography, cholangioscopy and intraoperative pathological examination.     

Mucin Ball-producing Extrahepatic Bile Duct Carcinoma

The characteristic features of surgically curable mucin-producing extrahepatic bile duct carcinoma (MPEBC) have not previously been elucidated. Three (6.5%) of 46 patients who underwent surgery in our department for bile duct carcinoma between 1986 and 1997 had MPEBC. Clinicopathological features, diagnostic procedures and operative methods for patients with MPEBC were investigated. Tumors in the bile duct were identified by cholangioscopy combined with cholangiography after removal of mucin balls. Tumors were located close to the hepatic confluence in these patients. Two patients underwent hepatic lobectomy together with caudate lobectomy while the other underwent resection of the hepatic confluence. Absence of residual tumors was confirmed histologically in these patients. All three patients remain alive without evidence of recurrence, 22?54 months after surgery. MPEBC is a curable disease. Accurate localization in the biliary tree is essential and can only be obtained after, i) removal of mucin balls, and ii) extensive diagnostic work-up including cholangiography, cholangioscopy and intraoperative pathological examination.