ERCP和EST在腹腔镜胆囊切除术中的作用

目的 总结腹腔镜胆囊切除术(Laparoscopic cholecystectomy，LC)中联合应用内镜技术治疗伴有胆总管结石的胆囊结石病人的疗效。方法 对210例(同济医院124例，武汉市第四医院86例)LC术前、术后可疑合并胆总管结石行内镜逆行胰胆管造影术(Endoscopic retrograde cholangiopancreatogrophy，ERCP)和内镜括约肌切开术(Endoscopic sphincterotorny，EST)。结果 LC术前ERCP发现胆总管结石69例，EST清除63例，清除率91．3％(63／69)；LC术后ERCP发现胆总管残留结石9例，EST清除8例，清除率88．9％(8／9)。结论 LC联合ERCP、EST治疗胆囊结石合并胆总管结石是一种安全有效的方法，使病人避免开腹手术。     

ERCP in association with laparoscopic cholecystectomy

Background With the evolution of laparoscopic cholecystectomy (LC) as the standard operation for benign gallbladder disease, the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones has to be defined. Methods From November 1990 to April 1994 we attempted LC in 1,788 patients. Eighty-nine patients underwent ERCP preoperatively under the following indications: jaundice or a history of jaundice, cholangitis, gallstone pancreatitis, abnormal liver function tests, and a sonogram showing either CBD stones or a dilated CBD. With intent to minimize the number of unnecessary ERCPs only patients with jaundice, cholangitis, and high abnormalities on the liver function tests (LFTs) were directly referred for ERCP. All other patients with suspected choledocholithiasis were initially investigated with intravenous cholangiography (IVC) and tomography; only patients with positive findings on IVC subsequently underwent ERCP. Eighteen patients underwent ERCP postoperatively and the indications included jaundice, bile leak, and abnormal intraoperative cholangiogram. Results Of the 89 patients having ERCP preoperatively 54 patients (60.7%) were found to have CBD stones which were removed endoscopically in all cases except in one patient where a large CBD stone was removed during laparoscopic exploration of the CBD. Eight patients of the 18 patients having ERCP postoperatively were found to have CBD stones and all of them had their CBD cleared endoscopically. There were no mortalities, while four patients developed a mild pancreatitis. Conclusions Although there is an increasing tendency to clear the bile duct with a laparoscopic approach, ERCP and sphincterotomy has a certain role in conjunction with LC in the management of patients with a high suspicion of CBD stones, particularly in institutions where there is easy access to expert interventional endoscopic techniques.     

ERCP联合LC治疗胆囊结石合并胆总管结石的临床分析

目的探讨经内镜逆行胰胆管造影术(ERCP)、内镜十二指肠乳头括约肌切开术(EST)联合腹腔镜胆囊切除术(LC)治疗胆囊结石合并胆总管结石的临床疗效。方法回顾性分析采用ERCP/EST联合LC方法治疗的40例胆囊结石合并胆总管结石的患者的临床资料。结果 ERCP/EST手术成功率97.5%(39/40),1例插管失败,LC手术成功率97.4%(38/39),1例中转开腹手术,8例(20.5%)患者ERCP/EST术后出现高淀粉酶血症,无出血、胆瘘、十二指肠瘘、胆管损伤及胆道结石残留等并发症发生。61.5%(24/39)患者ERCP/EST术后2~5天行LC术,38.5%(15/39)患者ERCP/EST术后6~14天行LC术,前者在住院时间及住院费用上明显低于后者。结论 ERCP/EST联合LC治疗胆囊结石合并胆总管结石安全可行,具有患者创伤小、康复快、并发症少等优点,ERCP术后尽早施行LC可减少患者住院天数及住院费用。     

The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy

Summary The purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphincterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.     

Endoscopic retrograde cholangiopancreatography in the treatment of intraoperatively demonstrated choledocholithiasis

INTRODUCTION

The aim of this study was to determine the efficacy and complications of postoperative endoscopic retrograde cholangiopancreatography (ERCP) in confirming and treating choledocholithiasis found at intraoperative cholangiography during laparoscopic cholecystectomy.

METHODS

Patients who had undergone ERCP following a cholecystectomy between 2008 and 2011 with an indication of intraoperative cholangiography findings consistent with choledocholithiasis were identified from a prospectively collected database of a single endoscopist. Deep biliary access rate, confirmation of choledocholithiasis, clearance rate of bile duct stones, delay between cholecystectomy and postoperative ERCP, and the complication rates following the procedure were analysed.

RESULTS

The median age of the 41 patients (16 male, 25 female) was 42 years (range: 18–82 years). Sixteen surgeons performed the operations with a median delay of 6 days (range: 1–103 days) between cholecystectomy and postoperative ERCP. Common bile duct access was achieved in 100% of the patients, with ERCP taking a median time of 16 minutes (range: 6–40 minutes). Initial ERCP confirmed the presence of a stone in 30 patients (73%) and successful stone removal occurred in 28 of these 30 patients (93%) during the first ERCP and in the remaining 2 on a subsequent ERCP. Following ERCP, two patients (4.9%) experienced extended hospital stays for four and eight days owing to complications, including one patient (2.4%) with mild acute pancreatitis.

CONCLUSIONS

This study demonstrates that postoperative ERCP is highly effective in both confirming and treating choledocholithiasis. However, there is a significant risk of short-term complications that must be taken into consideration when deciding management.     

The endoscopic management of persistent bile leakage after laparoscopic cholecystectomy

Background: Bile leakage after laparoscopic biliary surgery is a surgical challenge in which endoscopy can play an important role. Methods: A total of 26 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) in our department. Patients with evidence of major ductal injury were treated surgically. In all other cases, endoscopic sphincterotomy was performed, any retained bile duct stones were removed, and a biliary endoprosthesis or a nasobiliary catheter was inserted on a selective basis. Results: ERCP was successful in 24 patients. Seven patients were treated surgically after cholangiography revealed major ductal injury. Two more patients were eventually operated on due to bile peritonitis. Of the other 15 patients, 11 had leakage from the cystic duct and four had leakage from the gallbladder bed. Bile duct stones were removed from eight patients, an endoprosthesis were inserted in five patients, and a nasobiliary catheter was inserted in two patients. Bile leakage was treated successfully in all 15 patients with no further complications. Conclusion: ERCP is a means of safe diagnosing the cause of a bile leakage and offers a definitive treatment in most cases.     

Sequential intraluminal endoscopic and laparoscopic treatment for bile duct stones associated with gallstones

Background: On the basis of a flowchart including prior or current jaundice or pancreatitis, abnormal liver function, ultrasound or IV cholangiography, bile duct (BD) stones were suspected in 71/593 patients referred for gallstones. Methods: When endoscopic retrograde cholangiography detected BD stones, endoscopic sphincterotomy (ES) and endoscopic BD clearance were attempted, followed by laparoscopic cholecystectomy (LC). BD stones were found in 44/71 patients. The sensitivity values of preoperative conditions were: 92% for IV cholangiography, 88% for abnormal liver function, 50% for ultrasound, and 37% for jaundice at admission. Results: Endoscopic clearance succeeded in 37 patients and LC was completed in 33 patients. Conversion to open surgery (9%) was comparable with the rate in patients without BD stones. The median hospital stay for the sequential endoscopic and laparoscopic treatments was 13 days (range 4–54) or 22 days if open surgery was used. Conclusions: In conclusion, BD stones can be endoscopically cleared preoperatively in most patients without interfering with LC.     

Endoscopic retrograde cholangiographic demonstration of a double gallbladder following laparoscopic cholecystectomy

We report a case of a doubled gallbladder missed in preoperative ultrasound and laparoscopic cholecystectomy but demonstrated by endoscopic retrograde cholangiography (ERC) postoperatively.     

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis

Summary Six hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.     

术中经鼻胆管胆道造影在两镜联合治疗胆囊合并胆总管结石中的应用

目的探讨内镜下十二指肠乳头括约肌切开术（endoscopic sphineterotomy，EST）联合腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）治疗胆囊合并胆总管结石术中经鼻胆引流管（endoscopic nasobiliary drainage，ENBD）胆道造影的价值。方法EST处理胆总管结石并放置ENBD管，在LC术中经ENBD管行胆道造影。结果46例术中经ENBD胆道造影均成功，造影时间5—15min，平均8．2min。术中经ENBD管胆道造影发现胆囊脱落至胆总管形成胆总管继发结石4例，其中2例术中再次内镜取出结石，2例结石直径〈3mm术中未处理，术后随访未见胆管结石及胆管炎发生。43例随访6—36个月，平均22个月，未发现胆总管再发结石及胆道逆行感染。结论两镜联合治疗胆囊结石合并胆总管结石，术中经ENBD胆道造影可及时发现并通过术中内镜及时处理继发性胆总管结石，减少术后胆管残余结石的发生。     

Combination therapy of laparoscopic cholecystectomy and endoscopic transpapillary lithotripsy for both cholecystolithiasis and choledocholithiasis

Summary This report describes five patients with cholecystolithiasis and choledocholithiasis who were treated by combination endoscopic extraction of common bile-duct stones with sphincterotomy (EST) and laparoscopic cholecystectomy (LC). Following this combination procedure the patients were relieved completely of obstructive jaundice and right upper quadrant pain, leaving only small trocar insertion scars made during the short course of hospitalization. The combination therapy of EST and LC will be recommended for this kind of patient as a minimally invasive procedure.     

Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy

BACKGROUND: To provide optimal selection of patients for preoperative endoscopic retrograde cholangiopancreatography or intraoperative cholangiography, we evaluated simple, noninvasive biochemical parameters as screening tests to predict the absence of common bile duct stones prior to laparoscopic cholecystectomy. METHODS: A total of 1002 patients underwent laparoscopic cholecystectomy. Five biochemical parameters were measured preoperatively: gamma glutamyl transferase (GGT), alkaline phosphatase, total bilirubin, alanine aminotransferase, and aspartate aminotransferase. Conventional diagnostic tests, including ultrasound imaging, computed tomography, magnetic resonance imaging, common bile duct diameter, endoscopic retrograde cholangiopancreatography, and serum amylase were performed. Along with the five biochemical tests above, these diagnostic tests were scrutinized and compared as potential predictors for common bile duct stones. RESULTS: Eighty-eight (8.8%) patients with gallstone disease who underwent laparoscopic cholecystectomy had concurrent common bile duct stones. Among all diagnostic tests, endoscopic retrograde cholangiopancreatography had the highest sensitivity (96.0%), specificity (99.1%), probability ratio (107.3), accuracy (98.0%), and positive predictive value (98.8%) in detecting common bile duct stones. At least one abnormal elevation among the five biochemical parameters had the highest sensitivity (87.5%). Total bilirubin had the highest specificity (87.5%), highest probability ratio (3.9), highest accuracy (84.1%), and highest positive predictive value (27.4%). All five biochemical predictors had high negative predictive values; gamma glutamyl transferase was highest (97.9%), while the lowest was total bilirubin (94.7%). Multivariate analysis showed only gamma glutamyl transferase, alkaline phosphatase, and total bilirubin to be independent predictors; gamma glutamyl transferase appeared to be the most powerful predictor (odds ratio 3.20). CONCLUSION: Biochemical tests, especially gamma glutamyl transferase with 97.9% negative predictive value, are ideal noninvasive predictors for the absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. We suggest that unnecessary, costly, or risky procedures such as endoscopic retrograde cholangiopancreatography can be omitted prior to laparoscopic cholecystectomy in patients without abnormal elevation of these biochemical values.     

腹腔镜内窥镜治疗胆囊结石合并胆总管结石两种术式的临床分析

目的 评价腹腔镜胆囊切除、胆总管探查取石术(LC+LCBDE)与内镜下Oddi括约肌切开、腹腔镜胆囊切除术(EST+LC)两种术式治疗胆囊结石合并胆总管结石的临床效果.方法 回顾总结LC联合治疗胆囊结石合并胆总管结石256例,采用LC+LCBDE术132例、EsT+LC术124例治疗的临床资料,对两组病例的手术成功率、并发症发生率、手术总时间、住院费用、住院日进行对比统计分析.结果 两种术式的手术成功率、并发症发生率、平均住院日无显著性差异(P>0.05),手术总时间、手术费用比较有显著性差异(P<0.01).结论 两种术式各有其适应证和优缺点.胆总管直径<1.0 cm、胆总管中下端结石或老年胆石症病人宜采用EST+LC术式;胆总管直径>1.0 cm的多发性较大结石、尤其是中青年病人应首选LC+LCBDE术式.     

ERCP在腹腔镜胆囊切除围手术期的应用

目的 探讨内交易ＥＲＣＰ在腹腔镜胆囊切除围手术期的应用价值。方法 从１９９８年１月至１９９９年４月在１５００例ＬＣ病人中,有选择地进行术前３３例和术后２０例的ＥＲＣＰ及内镜治疗,包括ＥＳＴ,ＥＮＢＤ和网篮取石术。其指征为：近期有为发生或黄我,肝功能异常,碱性磷酸酶升高,Ｂ超或ＣＴ示胆总管扩张或有结石,术中造影有胆管结石,术后有临床症状。结果 在术前３３例ＥＲＣＰ中,除１例失败外,胆囊病变外的阳性发     

Hemolysis caused by G-6PD deficiency after a difficult and prolonged therapeutic endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP), together with its substantial therapeutic capabilities, carries a higher potential for complications than other endoscopic procedures. Common major complications specific to pancreaticobiliary instrumentation include pancreatitis, post–sphincterotomy hemorrhage, perforation, and cholangitis with or without systemic sepsis. Two patients underwent therapeutic ERCP for recurrent episodes of abdominal pain and elevation of hepatobiliary enzymes. Endoscopic sphincterotomy was difficult and prolonged. The calculi were successfully extracted by sweeping the choledochus with a balloon-tipped catheter or basket in both cases. The patients experienced postprocedure diffuse abdominal pain unassociated with nausea or vomiting. Laboratory data showed normal serum amylase and lipase 2, 6, and 18 h after the end of procedure, a fall in hematocrit level, and an increase of indirect bilirubin and lactic dehydrogenase. The abdominal pain subsided in 4 to 6 h. The hematocrit level remained stable during the next 3 days, and the patients were very well when discharged. Examination of glucose-6-phosphate dehydrogenase (G-6PD) enzyme levels in red cells 20 days later showed complete enzyme deficiency. This report highlights the importance of examining G-6PD deficiency in patients with post-ERCP abdominal pain, normal serum amylase and lipase, and laboratory findings of hemolysis.     

Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy

Background : The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP. Methods : All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones. Results : A total of 112 patients had successful preoperative ERCP. Sixty‐one per cent of these were negative for stones and the morbidity was 9%. Univariate analysis revealed the following variables as predictors: cholangitis (P = 0.006), abnormal serum bilirubin ≥ 3 days (P = 0.002), serum alkaline phosphatase ≥ 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001) and CBD diameter ≥ 8 mm (P = 0.009) with positive predictive values of 80%, 68%, 49%, 38% and 52%, respectively. Multivariate analysis revealed the model with the best ability to discriminate for CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for ≥ 3 days and CBD diameter ≥ 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%. Conclusions : The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.     

Endoscopic retrograde cholangiopancreatography management of common bile duct stones in a surgical unit

BACKGROUND: Choledocholithiasis, if left untreated, can lead to significant morbidity and mortality. The management of such a problem has progressed tremendously but controversy still exists as to ideal management, laparoscopic exploration or endoscopic retrograde pancreatography with sphincterotomy. The purpose of this study is to evaluate the results of endoscopic retrograde cholangiopancreatography (ERCP) in a surgical unit. METHODS: We performed a retrospective review on 336 patients who underwent ERCP between 1997-2000. RESULTS: We achieved a successful cannulation rate of 98% and stone clearance rate exceeding 90%. Morbidity has been minimal and there was no mortality in our study. CONCLUSION: We conclude that ERCP is an effective and safe surgical alternative for the management of choledocholithiasis.     

Post–Endoscopic Retrograde Cholangiography Laparoscopic Cholecystectomy: Challenging but Safe

Background and Objectives:

Up to 19% of patients undergoing laparoscopic cholecystectomy (LC) have common bile duct stones and may require endoscopic retrograde cholangiography (ERCP) before LC. The risk of complications of LC after ERCP is higher, and the optimal interval between ERCP and LC is disputed. In our unit, LC is performed approximately 6 weeks after ERCP. This study aims to compare outcomes between subsets of patients undergoing LC with or without prior ERCP.

Methods:

All patients undergoing ERCP and elective laparoscopic cholecystectomy (ELC) over a 1-year period were included. Outcome measures included ERCP outcomes, duration of surgery, intraoperative findings, and postoperative outcomes. Two groups of patients were compared: LC after ERCP and ELC.

Results:

The study included 190 ELC patients and 43 patients with LC after ERCP (ERCP-LC) (December 2008 to December 2009). At ERCP, 25 patients (58%) had ductal stones. The post-ERCP complication rate was 5%. The median time to LC was 42 days, and 6 patients (14%) were readmitted before LC. There were more severe adhesions and longer median operating times in the ERCP-LC group (75 minutes for ELC vs 110 minutes for ERCP-LC, P = .013). We found no significant differences in rates of conversion to open surgery, postoperative complications, lengths of stay, and readmission rates.

Conclusion:

Interval LC after ERCP is a more technically challenging procedure but is associated with a low rate of complications. Although there is emerging evidence that early LC after ERCP is feasible, our study shows that our current practice of delaying LC by approximately 6 weeks is safe.     

Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy after Roux-en-Y gastric bypass

Background The use of Roux-en-Y gastric bypass (RYGB) for morbid obesity has raised concern that subsequent endoscopic evaluation of the gastric remnant and duodenum is difficult. By gaining percutaneous access to the gastric remnant, however, both gastroduodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP) can be performed easily. This report describes the results of a novel technique for performing “transgastrostomy” gastroduodenoscopy and ERCP. Methods Six patients with a RYGB for morbid obesity underwent transgastric remnant endoscopic evaluations. If a gastric remnant tube had not been placed during prior surgery, one was placed percutaneously by an interventional radiologist. The tube tract then was dilated to either 20- or 24-Fr. At the time of endoscopy, the gastrostomy tube was removed and the skin anesthetized. Then either a pediatric duodenoscope (outer diameter, 7.5 mm) or a slim gastroscope (outer diameter, 5.9 mm) was inserted through the gastrostomy tube tract. Results Percutaneous gastroduodenoscopy was successfully performed for all six patients. The findings included two patients with prepyloric ulcers identified and assessed with a biopsy, one patient with intestinal metaplasia and a benign gastric polyp, and three patients with a normal gastric remnant and duodenum. A nonstrictured enteroenterostomy was noted in one of the three patients with a normal endoscopic evaluation. Percutaneous transgastrostomy ERCP was performed for three of the six patients who underwent gastroduodenoscopy. The findings included one patient who had papillary fibrosis treated with a sphincterotomy, a second patient with a normal biliary tree, and a third patient with a normal pancreatic duct. Selective cannulation of the common bile duct was not successful in the third patient. Conclusion The transgastrostomy endoscopic route ensures access to the excluded stomach and proximal small bowel after RYGB. This route is safe and effective, allowing the use of a duodenoscope to improve the cannulation success rate for ERCPs in this patient population.