序贯式双通道胆囊穿刺造瘘联合胆道镜微创保胆取石

目的:探讨超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石术治疗高龄高危急性结石性胆囊炎患者的疗效.方法:回顾性分析2012年1月-2013年4月接受双通道胆囊穿刺造瘘联合胆道镜保胆取石术治疗的30例高龄高危急性结石性胆囊炎患者的临床资料.结果:30例患者均穿刺置管成功,1例发生出血,向腔内注入立止血,夹闭弓引流管后出血停止,带管时间为14d至2个月,平均时间为30 d.4～8周后,28例患者成功行胆道镜取石,1例患者因窦道未形成行开腹胆囊切除术,1例患者因16F猪尾型外导管滑脱行腹腔镜胆囊切除术.28例患者获随访3～19个月,B超检查1例(3.6％)复发.结论:超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石是治疗高龄高危胆囊结石患者可靠、有效的方法.     

双通道植管联合胆道镜保胆取石治疗高龄结石性胆囊炎

目的：评价B超引导下胆囊穿刺双通道植管联合胆道镜保胆取石治疗高龄高危急性结石性胆囊炎患者的疗效。 方法：回顾性分析2012年1月—2013年12月收治的35例80岁以上急性结石性胆囊炎患者的临床资料。 结果：35例患者均行超声引导下胆囊穿刺双通道植管胆囊冲洗、减压、持续引流,6~8周后,行胆道镜经窦道保胆取石。所有患者超声引导穿刺植管均一次性成功,1例发生穿刺后出血,经对症处理止血成功;1例因植管窦道形成不佳改行胆囊切除术,余34例均成功保胆取石（34/35）;随访4~24个月,结石复发1例（1/34）。 结论：双通道胆囊穿刺植管联合胆道镜保胆取石治疗高龄高危胆囊结石方法简单、疗效可靠,具有推广价值。

     

PTGD联合小切口胆道镜取石治疗高龄、高危急性梗阻性结石性胆囊炎

目的探讨B超引导下经皮经肝胆囊穿刺引流(PTGD)联合二期小切口胆道镜取石术治疗高龄、高危急性梗阻性结石性胆囊炎患者的疗效。方法回顾性分析2009年1月至2013年12月期间接受PTGD联合小切口胆道镜取石治疗的124例高龄、高危急性梗阻性结石性胆囊炎患者的临床资料。结果 124例均穿刺置管成功,置管引流后3~5 d出院。除2例引流管脱出;其余122例6~8周后行右上腹小切口胆囊切开胆道镜取石术,其中91例取净结石后一期缝合胆本+更换PTGD管,31例行胆囊切除。继发胆总管结石6例,其中4行经胆囊管胆道镜取石,2例行经胆囊管残端胆道镜取石。手术顺利,未发生胆管损伤、胆漏等重大并发症或死亡。结论 PTGD联合二期小切口胆道镜取石治疗高龄、高危急性梗阻性结石性胆囊炎,符合损伤控制理念,是一项有效、简便、微创的方法。     

超声引导下双通道置管联合胆道镜保胆取石术治疗高龄急性结石性胆囊炎

目的 探讨超声引导下双通道置管联合胆道镜保胆取石术治疗高龄急性结石性胆囊炎患者的疗效.方法 回顾性分析2012年1月至2013年12月成都军区总医院收治的35例高龄(≥80岁)胆囊结石患者的临床资料,先在B超引导下行经皮胆囊双通道穿刺置管引流,后期联合胆道镜保胆取石术.术后长期口服消炎利胆药物,降低结石复发.采用电话和门诊随访,随访时间截至2014年6月30日.结果 35例患者B超引导下胆囊穿刺置管均一次性成功,1例发生穿刺后出血,经对症治疗止血成功;因置管窦道形成不佳改行胆囊切除术1例;余34例均成功取石;随访4～24个月,结石复发1例.结论 双通道胆囊穿刺置管联合胆道镜保胆取石治疗高龄急性结石性胆囊炎,该手术方式方法简单、疗效可靠,具有推广价值.     

超声引导下经皮胆囊穿刺双管引流联合胆道镜治疗急性结石性胆囊炎高危患者

目的探讨超声引导下经皮胆囊穿刺双管引流联合胆道镜治疗急性结石性胆囊炎高危患者的可行性及应用价值。方法回顾性分析2012年6月~2013年12月急性结石性胆囊炎高危患者24例的临床资料。合并高血压6例,心绞痛4例,心力衰竭2例,急性心肌梗死介入术后1例,慢性阻塞性肺病5例,糖尿病5例,慢性肾功能衰竭1例。美国麻醉师协会(American Society of Anesthesiologists,ASA)分级,Ⅲ级11例,Ⅳ级13例。行超声引导下经皮经肝胆囊穿刺引流,抽尽胆汁,注入生理盐水使胆囊充盈,再于右侧肋缘下穿刺胆囊,双管引流,1周后扩张窦道,行胆道镜取石。结果所有患者穿刺引流后症状及体征缓解,均胆道镜取净胆囊结石,无胆漏、肠漏、出血等严重并发症发生。21例随访6~24个月,(11.1±6.1)月。1例胆囊结石复发。结论该方法治疗高危急性结石性胆囊炎患者安全有效,具有临床应用价值。     

超声引导经皮经肝穿刺一期窦道扩张引流后二期胆道镜多次取石治疗复杂肝内胆管结石(附42例报道)

目的探讨超声引导经皮经肝穿刺一期窦道扩张引流后二期胆道镜多次取石治疗复杂肝内胆管结石的可行性及疗效。方法回顾性分析2012年6月至2017年6月期间西安交通大学第一附属医院肝胆外科胆道病区采用超声引导经皮经肝胆道镜检查术治疗的42例复杂肝内胆管结石患者的临床资料,治疗均采用超声引导经皮经肝穿刺一期窦道扩张引流后二期胆道镜多次碎石取石术。结果 42例患者手术均成功,无中转手术。穿刺右侧肝内胆管10例、左侧肝内胆管25例及双侧肝内胆管7例。31例患者通过二期胆道镜探查取净结石,其中1次取净结石者4例、2次取净结石者6例、3次及以上取净结石者21例;11例有结石残留。一期窦道扩张引流后出现胆管出血4例、胆管炎8例及胸部并发症2例,术后引流管脱落2例;二期胆道镜取石后出现胆管炎3例,引流管脱落3例。术后随访(18.6±7.8)个月,31例取净结石患者中10例(32.2%)结石复发;11例结石残留患者中9例获得随访,病情基本稳定。结论超声引导下经皮经肝穿刺一期窦道扩张引流后二期胆道镜多次取石治疗复杂肝内胆管结石安全、有效,可对传统手术有效补充。     

经皮经肝穿刺同期胆道镜取石治疗复发性肝胆管结石

目的总结应用经皮经肝穿刺同期胆道镜治疗复发性肝胆管结石的治疗经验。方法回顾性分析我院2014年10月~2016年6月22例复发性肝胆管结石患者,在同一次麻醉下,B超引导下经皮经肝胆道穿刺成功后,同期行胆道镜碎石取石的手术疗效。结果 21例患者穿刺后。取石成功,仅1例穿刺失败后中转开腹;1次取尽结石成功17例(81.0%),2次取尽结石者3例,3次取尽结石者1例,无严重并发症及死亡。随访至今无发现结石复发。结论对于复发性肝胆管结石患者,严格把握适应证,经皮经肝穿刺胆道镜同期治疗是可行、有效和安全的。     

胆囊穿刺造瘘后双通道胆道镜保胆取石与腹腔镜胆囊切除术治疗老年患者结石性胆囊炎疗效的比较

目的比较超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石与胆囊穿刺造瘘后行腹腔镜胆囊切除术（1aparoscopiccholecystectomy,LC）治疗老年患者急性结石性胆囊炎的临床疗效。方法回顾性分析2012年1～9月接受双通道胆囊穿刺造瘘联合胆道镜保胆取石治疗的30例老年结石性胆囊炎（保胆取石组）和胆囊穿刺造瘘后行Lc治疗的30例老年结石性胆囊炎（Lc组）的临床资料,比较2组手术操作时间、术中出血量、住院时间、消化不良症状发生率等。结果60例均穿刺置管成功,带管时间14d-2个月,平均30d。4～8周后,保胆取石组30例成功行胆道镜取石,结石取净率100％,取石过程中无出血、漏胆、继发胆总管结石、切口感染等手术并发症。LC组28例三孔法完成LC,2例因粘连组织难以分离中转开腹手术,术中、术后均无严重并发症。保胆取石组术中出血量（8．8±1．7）ml,显著少于LC组（18．9±1．2）ml（t=-25．968,P=0．000）;保胆取石组住院时间（4．4±0．6）d,显著短于LC组（5．6±0．5）d（t=-8．243,P=0．000）。保胆取石组术后随访3、6、12个月,B超检查1例复发,5例有上腹部不适、腹泻、食欲不佳等消化不良症状,发生率16．7％（5／30）,LC组术后21例有消化不良症状,发生率70．o％（21／30）,2组比较有显著性差异（x2=17．376,P=0．000）。结论超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石操作简便,在术中出血量、住院时间、远期生活质量等方面均优于胆囊造瘘后行LC。     

超声引导经皮肝穿刺一期硬质胆道镜碎石术治疗肝胆管结石

目的探讨超声引导经皮肝穿刺一期硬质胆道镜碎石术治疗肝胆管结石的可行性及疗效。方法 2013年1月至2016年1月期间,南方医科大学附属何贤纪念医院的21例肝胆管结石患者,均采用超声引导经皮肝穿刺一期硬质胆道镜碎石术。结果 21例患者手术均成功,无中转手术。18例(85.7%)患者最终取净结石,其中1次结石取净者14例(66.7%)。手术时间(95.7±21.0)min,术中出血量(15.1±7.6)ml,住院时间(11.6±4.3)d。术后发生并发症4例,其中1例出现胆瘘并局部胆汁性腹膜炎,经超声定位穿刺置管引流后痊愈;2例出现右侧少量胸腔积液,1例出现右下肺盘状不张,均经过保守治疗后痊愈。无术后胆道感染或胆道出血,无死亡病例。所有患者均获得随访,随访8~44个月,4例(19.0%)出现结石复发。结论超声引导下经皮肝穿刺一期硬质胆道镜碎石术治疗肝胆管结石安全有效、创伤小,提高了碎石取石效率,缩短患者住院时间。     

经皮经肝胆囊穿刺引流术治疗高龄急性梗阻性胆囊炎治疗体会

目的评估经皮经肝胆囊穿刺引流术于治疗高龄高危急性梗阻性胆囊炎患者中的应用。方法对2008年1月-2013年12月之间53例接受经皮经肝胆囊引流术治疗的高龄高危急性梗阻性胆囊炎患者临床资料进行回顾性分析。结果所有的53个病人成功地接受经皮穿刺及胆囊引流,并取得有效的引流。所有患者的腹痛症状于操作后2~3小时得以减轻,体温于操作后24-48 h下降到正常水平。引流的平均时间是15.5天。所有患者在经皮经肝胆囊引流术后6-48天内出院。没有术后出血和胆漏。没有患者在PTGD后有严重并发症或死亡除了1例气胸。结论 PTGD治疗高龄高危急性梗阻性胆囊炎是一项安全、有效、简便的方法。     

经窦道取石技术治疗高龄复杂胆结石的现状与进展

高龄患者手术风险大、结石易残留易复发、胆系凶险感染等困难仍然是治疗胆结石面临的重要挑战。近年来,经窦道取石技术不断发展,为胆结石的微创治疗提供了新的选择。经皮经肝胆囊穿刺建立窦道,为高龄、高危、急性结石性胆囊炎患者保胆取石提供了安全有效治疗手段。经皮经肝胆管穿刺建立窦道,有助于治疗弥漫性肝胆管结石合并胆系化脓性感染;经T管窦道、胆囊管导管窦道、U管窦道以及经皮下盲襻穿刺建立窦道,是治疗胆管残留结石或再生结石的重要措施。     

Surgical treatment of acute cholecystitis in elderly and senile patients]

There were analyzed the results of treatment of 69 elderly and senile patients, operated on for an acute calculous cholecystitis, in 19 of whom cholecystectomy, using miniapproach was performed. The performance of an assisting manipulating channel, application of oblique-changing puncture of gall bladder and of special instruments were proposed to improve technical condition of cholecystectomy performance while usage of miniapproach, its rational exploitation and reduction of intra- and postoperative complications occurrence.     

Significance of preoperative ultrasound measurement of gallbladder wall thickness

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (> or =3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.     

Surgical treatment of biliary tract infections

Despite major advances in surgical and nonsurgical therapy, biliary tract infections remain a significant cause of morbidity and mortality. The two classic biliary tract infections most commonly encountered are acute cholecystitis (either calculous or acalculous) and acute cholangitis. In addition, bile leakage associated with bile duct injuries during laparoscopic cholecystectomy has become a problem not infrequently encountered by surgeons. Acute calculous cholecystitis results from a combination of mechanical, biochemical, and infectious mechanisms, initiated by stone impaction in the cystic duct. After instituting empiric antibiotics, early laparoscopic cholecystectomy should be performed. Although conversion to open cholecystectomy is more common than in chronic cholecystitis, there appears to be no increased morbidity or mortality in that setting. Acute acalculous cholecystitis usually occurs in critically ill patients and may present both a diagnostic and therapeutic dilemma. Aggressive management, however, is warranted, both because of the critical nature of illness in these patients and the high incidence of perforation. Percutaneous cholecystostomy is indicated, particularly in high-risk patients both for diagnosis and treatment. Acute cholangitis results from a combination of bactibilia and biliary obstruction. The majority of patients can be successfully managed with intravenous antibiotics and fluid resuscitation. In those patients in whom initial management is not successful, biliary drainage, which is best accomplished nonoperatively, should be instituted. There is a very limited role for early surgical intervention in acute suppurative cholangitis. Biliary leaks resulting in bile "peritonitis" or bilomas are common sequelae of laparoscopic bile duct injury. Although surgeons may feel it is necessary to operate urgently, delineation of the proximal biliary anatomy via percutaneous transhepatic cholangiography and biliary stent placement is the appropriate first step in management. This procedure will usually control the bile leak and allow delineation of the anatomy and opportune timing of definitive reconstruction.     

超声引导下经皮经肝胆囊造瘘治疗老年急性重症胆囊炎

目的探讨超声引导下经皮经肝胆囊穿刺置管引流（percutaneous transhepatic gallb ladder catheterizing drainage,PTGCD）治疗老年急性重症胆囊炎的临床疗效。方法18例有急诊胆囊切除禁忌的老年急性重症胆囊炎患者,在超声引导下行PTGCD。其中,结石性胆囊炎14例,非结石性胆囊炎4例。结果均一次性置管成功,未出现并发症;14例结石性胆囊炎患者中,11例择期行胆囊切除术,3例不能耐受手术患者无症状长期置管。4例非结石性胆囊炎患者于引流后3~4周行胆道造影示无梗阻后拔管康复。结论超声引导下PTGCD治疗老年急性重症胆囊炎是一种简单、安全而有效的方法。     

经皮胆囊微造瘘联合肾镜治疗老年急性结石性胆囊炎研究(附62报告)

目的探讨经皮胆囊微造瘘联合肾镜治疗高危老年急性结石性胆囊炎的临床体会。方法回顾分析62例高危老年急性结石性胆囊炎患者临床资料,评估经皮胆囊微造瘘联合肾镜治疗结石性胆囊炎的技术价值。结果 62例高危老年急性胆囊炎患者行"经皮胆囊造瘘联合经皮肾镜治疗",72 h内症状有明显缓解。并发症:3例切口感染,2例因胆囊活检显示癌变再次入院治疗,余60例全部带管出院,或转内科治疗原发内科疾患。术后3、6、12个月随访未发生胆囊炎再发。结论经皮胆囊微造瘘联合肾镜治疗高危老年急性结石性胆囊炎是一种安全、有效的方法,具有重要临床应用价值。     

急性结石性胆囊炎经腹腔镜胆囊切除术68例临床分析

目的探讨急性结石性胆囊炎行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)患者的临床疗效。方法回顾性分析2007-12—2011-12通过LC治疗68例急性结石性胆囊炎患者的临床资料。结果 68例患者中,67例顺利完成LC,其中1例中转剖腹,术后病理证实为肝门部胆管癌,合并结石性、化脓性胆囊炎,2例患者发病72 h后出现胆汁渗漏,经治疗痊愈。2例术后第2天腹腔引流管引流出胆汁样液体,量为200～300 mL,经治疗2周后无液体引出拔出引流管,顺利出院。结论急性结石性胆囊炎明确诊断后,患者应尽早施行腹腔镜胆囊切除术,术中操作困难者应及时中转开腹。尽量减少或避免急性结石性胆囊炎LC手术并发症的发生,显著减轻患者痛苦。     

不同手术方案在急性结石性胆囊炎患者中的应用效果对比

目的探讨不同手术方案在急性结石性胆囊炎患者中的应用效果。 方法回顾性分析2013年1月至2016年6月收治的221例急性结石性胆囊炎患者资料,根据治疗方案分为腹腔镜下胆囊切除术(LC)组(行急诊LC术,n＝152)、经皮肝胆囊穿刺引流术(PTGD)＋LC组(n＝46)、开腹胆囊切除术(OC)组(n＝23)。采用SPSS19.0统计学软件进行分析,术中术后指标以均数±标准差表示,两组比较用t检验,多组比较采用方差分析;术后并发症发生率采用χ²检验;P<0.05差异有统计学意义。 结果⑴PTGD＋LC组的年龄、胆囊炎严重程度明显高于另外两组(P<0.05);三组的其他基线资料比较,差异均无统计学意义(P>0.05)。⑵PTGD＋LC组的手术时间显著高于LC组,总住院时间、总住院费用均显著高于另外两组(P<0.05)。OC组的术中出血量显著高于另外两组(P<0.05)。LC组和PTGD＋LC组中转开腹率比较,差异无统计学意义(P>0.05)。三组的术后并发症发生率比较,差异无统计学意义(P>0.05)。 结论对于无明显手术禁忌症的急性结石性胆囊炎患者而言,急诊LC是首选治疗方法,对于暂时不直接实施手术者可先行PTGD术,之后再考虑下一步治疗。