腹腔镜、胆道镜联合液电碎石在胆总管结石中的应用

目的 探讨腹腔镜、胆道镜联合液电碎石在胆总管结石中的应用.方法 2009年1月至2013年12月应用腹腔镜、胆道镜联合液电碎石治疗173例胆道结石,其中男性102例,女性71例.年龄24～73岁,平均47.2岁.胆道结石合并胆囊结石者先行腹腔镜胆囊切除术,再通过胆道镜工作通道,应用液电碎石机治疗电极,在直视下接触结石,将胆总管及肝胆管结石击碎后用取石篮套出.结果 173例病人中,147例结石均一次性完全清除,余下病人留置T管后按疗程3～9周内清除结石.无胆管损伤、胆漏.162例术后随访3～30个月,平均15个月,腹部B超或磁共振胰胆管成像（magnetic resonance cholangiopancreatography,MRCP）检查未发现结石复发及残留,无胆道狭窄.结论 腹腔镜、胆道镜联合液电碎石机治疗胆道结石具有直观、准确、方便、疗效确切的特点,是治疗胆道结石的一种安全、有效的新手段.     

胆道镜在肝内胆道手术中的应用

目的：探讨胆道镜在肝内胆管手术中的应用价值。方法：应用0lympus CHF—P20型纤维胆道镜及FUJINON EO-270F电子胆道镜在581例胆总管探查手术中处理肝内胆管病变。结果：明显减少了胆道术后残留结石的发生率，同时对胆道良、恶性狭窄配合手术治疗达到良好的效果。结论：术中胆道镜检查具有诊断治疗双重作用，可及时发现病变部位、程度，结合活检可对病变做出正确处理；配合器械取石可显著降低残石率的发生。     

Percutaneous transhepatic cholangioscopic lithotripsy

Since 1983, 14 patients with intrahepatic and common bile duct stones have undergone percutaneous transhepatic cholangioscopic lithotripsy because the stones were too large to be removed using ordinary percutaneous transhepatic cholangioscopy. Stones were completely fragmented in seven cases (six with intrahepatic stones and one with common bile duct stone) and partially disrupted in five cases with intrahepatic stones. Intrahepatic duct angulation and stricture was the factor most often responsible for failure. All the disintegrated stones were removed by subsequent transhepatic cholangioscopy. Amongst the seven patients with complete stone fragmentation, six stones were found with electrohydraulic shock-wave lithotripsy and one with NdYAG laser lithotripsy. Complications of percutaneous transhepatic cholangioscopic lithotripsy using electrohydraulic shock waves were found in three cases, two had transient haemobilia and one had fever and chills after the procedures. They all recovered by conservative treatment. NdYAG laser treatment was expensive, time consuming and inconvenient to use. Percutaneous transhepatic cholangioscopic lithotripsy by using electrohydraulic shock wave is an effective and safe method to fragment biliary stones and to facilitate their removal.     

Choledochoscopic lithotripsy is a useful adjunct to laparoscopic common bile duct exploration for hepatolithiasis: a cohort study

Background

This study aims to investigate the role of combining choledochoscopic lithotripsy with laparoscopic common bile duct exploration for hepatolithiasis in patients who are not suitable for hepatectomy.

Methods

From March 2009 to March 2013, 86 patients with hepatolithiasis irrespective of whether they underwent a choledochoscopic plasma shock wave lithotripsy or not were analyzed.

Results

Sixty-two patients underwent lithotripsy and 24 patients underwent basket lithoextraction intraoperatively. Plasma shock wave lithotripsy did not lengthen the operating time, but decreased the postoperative residual stone rate and reduced the frequency of postoperative choledochoscopic lithotomy for patients with remnant stones. The overall final stone clearance rate was 98.8%. During a mean follow-up of 26.2 months, recurrent stones and cholangiocarcinoma developed in 1 patient, respectively.

Conclusion

Laparoscopic common bile duct exploration combined with choledochoscopic lithotripsy is a definitive procedure for hepatolithiasis in patients who are not candidates for hepatectomy.     

Is Hepatectomy Necessary in Dealing with Left Hepatolithiasis with Intrahepatic Duct Stricture?

Background: Hepatolithiasis with intrahepatic biliary strictures, more common in Southeast Asia than elsewhere, remains a difficult problem to manage. Hepatic resection has recently been advocated as one of the treatment modalities for hepatolithiasis; however, this procedure is not without risk. This study was designed to achieve complete clearance of the stones, eliminate bile stasis, and avoid the potential risks of hepatic resection in the patient with hepatolithiasis and intrahepatic biliary stricture.Methods: In this prospective clinical trial 13 patients with retained left hepatolithiasis and intrahepatic biliary strictures were included. All the patients met the following criteria: (1) initial surgical procedure for hepatolithiasis, (2) normal gross findings of the left liver, and (3) no obvious clinical evidence of an associated intrahepatic cholangiocarcinoma. After the operation they underwent matured T-tube tract ductal dilatation with percutaneous transhepatic cholangioscopy tube stenting. Choledoschoscopic electrohydraulic lithotripsy was used in five patients after dilatation when impacted or large stones were encountered.Results: Complete clearance of the stones was achieved in these 13 patients. One patient had fevers develop after ductal dilatation, and another patient had mild hemobilia after electrohydraulic lithotripsy. Both recovered uneventfully with conservative treatment. These successfully treated patients remain well, with a mean follow-up period of 20 months.Conclusions: Postoperative matured T-tube tract ductal dilatation and stenting, combined with endoscopic electrohydraulic lithotripsy when indicated, is an effective and safe alternative to hepatic resection for selected left hepatolithiasis with intrahepatic biliary stricture.     

经皮肝穿刺一期硬镜碎石术在治疗肝胆管结石的应用

目的：探讨经皮肝穿刺一期硬质胆镜碎石术对肝胆管结石的治疗效果。 方法：对65例肝胆管结石患者的肝胆管通过B超定位进行直接穿刺建立窦道，扩张窦道直径至16~18 F后，采用硬质胆道镜取出肝胆管结石。 结果：一次性扩张取尽结石患者达60例；2例由于右肝胆管与胆总管之间的角度<90°而放弃；术后因胆管出血行介入栓塞治疗3例；39例存在胆管狭窄（60.0%），均根据具体情况同时行相应处理。对所有治疗的患者进行26个月随访，肝胆管结石的复发率为7.7%（5/65）。 结论：经皮肝穿刺一期硬质胆镜碎石术治疗肝胆管结石安全、有效，其清除率结石的同时处理胆管狭窄可利于结石复发率降低，是一种避免传统手术治疗的可取方法。

     

Treatment of hepatolithiasis: improvement of result by a systematic approach

In previous decades the result of treatment of hepatolithiasis has been unsatisfactory. The incidence of residual stones after surgery might reach 77%. In the past 6 years we adopted a systematic approach comprised of accurate delineation of disease in the liver and biliary tract by direct cholangiography, ultrasonography, and computed tomography; tailored surgical treatment according to the extent of involvement of the liver and biliary tract; access to the intrahepatic ducts through the left duct or round ligament approach when there was difficulty with common bile duct exposure; routine use of flexible choledochoscopy; and application of electrohydraulic lithotripsy for large and impacted stones. Complete stone clearance was achieved in 114 of 127 patients (89.8%). Of those patients who had incomplete stone clearance, only six cases (4.7%) were related to technical failure of postoperative choledochoscopy. The incidence of stone recurrence was 15.8%, the lowest rate so far reported. It was the same regardless of whether a biliary drainage procedure had been performed, but the treatment for recurrent stones was facilitated by previous hepaticocutaneous jejunostomy. Overall the surgical treatment required for stone recurrence was of a lesser magnitude than that in the past.     

Mechanical lithotripsy of large common bile duct stones using a basket.

Experience with the Olympus basket mechanical lithotriptor (BML-1Q) in crushing large common bile duct stones before their endoscopic removal is reported. From January 1988 to January 1990, 68 patients with common duct stones too large to be extracted by Dormia baskets or balloon catheters after sphincterotomy were treated with the BML system. The largest stones in each patient ranged from 1.0 to 4.9 cm in diameter. Fifty-seven patients required one session of lithotripsy, ten patients two sessions and one patient three sessions; 26 patients required further endoscopic extraction of stone fragments after successful lithotripsy. The stones were successfully crushed by the BML system and the ducts cleared in 55 patients (81 per cent). In 13 patients mechanical lithotripsy failed because the stones could not be engaged in the lithotriptor basket. In one patient the stone was crushed with the Soehendra lithotriptor, six patients were successfully managed by electrohydraulic lithotripsy through a 'mother and baby' endoscope, indwelling stents were inserted in four patients and two patients underwent surgery.     

Treatment of Complicated Hepatolithiasis with Intrahepatic Biliary Stricture by Ductal Dilatation and Stenting: Long-term Results

A group of 190 cases of hepatolithiasis with postoperative residual stones located proximal to the stricture sites were managed with the aim of complete clearance of stones and relief of bile stasis to decrease the potential risk of recurrence. All procedures were performed through a T-tube track with gradual dilatation and stent placement through the stricture sites, creating a channel that allows cholangioscopy and electrohydraulic lithotripsy. Complete clearance of intrahepatic duct (IHD) stones was achieved in 88.4% of cases. Multiple sharply angulated IHD strictures in right-sided hepatolithiasis constituted a major cause of failure. Recurrent stone formation and repeated cholangitis, subsequent drainage, and liver resection are associated with high mortality rates particularly if there is late development of a cholangiocarcinoma. We concluded that postoperative ductal dilatation and stenting through the T-tube track combined with endoscopic electrohydraulic lithotripsy is effective and safe for managing complicated hepatolithiasis. Persistent irreversible aneurysmal dilatation of IHD and atrophic change of the affected hepatic lobe at follow-up were ominous signs of recurrence and cholangiocarcinoma development. Early drainage with stone extraction combined with surgical intervention can prevent subsequent morbidity and mortality.     

输尿管镜气压弹道碎石技术在肝胆管结石中的应用体会

目的探讨一种新技术即用输尿管镜气压弹道碎石技术治疗肝胆管结石的疗效。方法回顾性分析2010年1月-2014年10月36例术中采用输尿管镜气压弹道碎石治疗肝胆管结石病患者的资料。结果胆总管结石肝总管结石一次性取净结石率100%（12/12）。二级以上肝胆管结石一次性取净结石率66.7%（24/36）。结石残余术后采用经T管瘘道输尿管镜＋气压弹道碎石取石12例,33.3%（12/36）。肝内结石碎石后结石下移,阻塞肝外胆管2例5.56%（2/36）,术中配合胆道镜网篮取石3例8.33%（3/36）,切口感染4例11.1%（4/36）,胆瘘、腹腔局限性腹膜炎2例5.56%（2/36）,无胆道狭窄、穿孔、出血。结论采用输尿管镜气压弹道碎石治疗肝胆管结石具有操作简单、取石快、残石率低、并发症少、费用低等优点,为临床提供了一种治疗肝胆结石的新方法,有推广应用价值。     

胆道镜下液电碎石术联合B超治疗肝内胆管残留结石的体会

目的探讨胆道镜下液电碎石术联合B超治疗胆道术后残留结石临床价值和疗效。方法将82例术后肝内胆管残留结石患者分为两组,胆道镜辅以术中B超经T管窦道液电碎石取石治疗肝内胆管术后残石42例为治疗组。以胆道镜取石40例患者为对照组。结果治疗组结石取净率显著高于对照组（P〈0．05）,平均手术时间、手术次数、住院时间和平均住院费用等明显优于对照组（P均〈0．05）。两组患者手术后均无严重并发症。结论胆道镜下液电碎石术联合术中B超治疗术后肝内胆管残留结石,具有定位准确、创伤小、安全有效、可重复操作等优点,值得临床推广使用。     

腹腔镜在再次胆道手术中的应用

目的探讨腹腔镜下再次胆道手术的可行性及临床疗效。方法2002年3月至2007年11月对48例胆总管结石复发者行腹腔镜下再次胆总管切开取石、术中行胆道镜取石、T管引流术或安装内置管胆总管一期缝合术。结果手术成功46例;中转开腹2例:1例为胆总管下段狭窄、胆道镜无法进入十二指肠,另1例为术中胆道镜活检证实为胆总管下段癌伴结石嵌顿。术后胆漏1例,无出血、腹腔感染等并发症。46例随访6～34个月,平均21个月,无结石复发、胆管狭窄及胆管炎发生。结论腹腔镜下再次胆道手术治疗胆总管结石复发是一种安全、可行、有效的方法。     

Biliary lithotripsy as an adjunct to laparoscopic common bile duct stone extraction

Summary We investigated various energy sources and delivery systems suitable for fragmentation of common duct calculi by a laparoscopic technique. We evaluated electrohydraulic lithotripsy (EHL) using 1.9-Fr probe delivering 80 W and laser lithotripsy using a 200-m fiber delivering 30–70 mJ/pulse at 5–20 Hz. In vitro biliary stone fragmentation analysis suggested that the laser lithotripsy produced a more controllable fragmentation than EHL. Initial attempts to employ EHL techniques in animal models resulted in common bile duct injury or inadequate fragmentation of stones. In contrast, biliary lithotripsy was accomplished in pigs using the pulsed-dye laser at 10 Hz and 60 mJ/pulse. Histologic evaluation revealed no evidence of ductal injury related to laser stone fragmentation. Subsequently, laser common duct lithotripsy was used in two human subjects. One patient had a 1.8-cm impacted ampullary stone and one patient had a 3-cm intrahepatic stone. In both cases, the stones were removed laparoscopically after laser fragmentation. Our experience suggests that the laser lithotripsy may facilitate laparoscopic common duct stone extraction procedures.     

Percutaneous transhepatic small-caliber choledochoscopic lithotomy: a safe and effective technique for percutaneous transhepatic common bile duct exploration in high-risk elderly patients

Abstract. Purpose: Endoscopic bile duct clearance is now the treatment of first choice for bile duct stones, particularly in elderly or high-risk patients. The purpose of this study was to objectively assess the safety, efficiency, and ease of use of percutaneous transhepatic choledochoscopy, using a small-caliber choledochoscope with a facilitated insertion technique, in high-risk elderly patients with choledocholithiasis. Methods: Sixty-five consecutive patients with common bile duct stones scheduled for percutaneous transhepatic choledochoscopic lithotomy were studied prospectively. Choledochoscopy was carried out with a simplified introducer system, using a 2.8-mm choledochoscope with electrohydraulic lithotripsy. Results: The common bile duct was successfully accessed and the stones removed in all 65 patients. The average time for the entire procedure was 45 min. There were no serious procedure-related complications. Conclusions: Percutaneous transhepatic choledochoscopic lithotomy, using electrohydraulic lithotripsy, is an attractive alternative for patients with common bile duct stones when surgery or retrograde methods are not suitable. Received: February 27, 2001 / Accepted: May 11, 2001     

内镜下钬激光碎石治疗胆管结石的应用

目的探讨内镜下钬激光碎石治疗胆总管结石的方法与近期疗效,总结其技术要点。方法回顾性分析我院施行内镜下钬激光碎石治疗胆总管结石23例的治疗经过及近期随访结果,其中腹腔镜结合胆道镜手术8例,开腹胆总管切开取石12例,经T管窦道硬质输尿管镜下钬激光碎石治疗胆道残余结石3例。结果 23例均获成功,无胆道损伤、胆漏;其中1例腹腔镜结合胆道镜行胆总管探查术者因胆总管下段结石嵌顿、胆管粘膜水肿严重致视野不清仅行T管引流,二期经T管窦道钬激光碎石,余病例均获得一次性结石清除,2例术后胆道少量出血未行特殊处理自愈,随访3～6月无残留结石。结论钬激光碎石治疗胆管结石是一种安全、有效的方法。     

腹腔镜下胆道镜液电碎石术治疗肝内外胆管结石

目的:总结腹腔镜下胆道镜液电碎石术治疗肝内外胆管结石的手术方法、效果及安全性。方法:回顾分析2005年1月至2012年1月采用腹腔镜下胆道镜液电碎石术治疗23例难取性肝内外胆管结石患者的临床资料,观察结石取净率及并发症发生率。结果:23例术中均碎石成功,其中22例一次性取净结石,结石取净率95.7%;1例因结石数量较多,术后6周经T管窦道行胆道镜取石术。无胆道穿孔、大出血、胆漏、切口感染等并发症发生。术后3～4 d拔除腹腔引流管,5～7 d出院。术后4周常规行T管造影,夹管3 d后拔除T管。结论:腹腔镜下结合胆道镜液电碎石术可显著提高肝内外胆管结石的疗效,手术安全、可靠。     

胆道镜下钬激光联合液电碎石治疗肝内外胆道难治性结石

目的 探讨经胆道镜用钬激光联合液电碎石治疗肝内外胆道结石的安全性及疗效.方法 对67例胆道术后肝内外胆管结石患者接受胆道镜下钬激光联合液电碎石治疗患者的临床资料进行回顾性分析.结果 经1～7次胆道镜下钬激光联合液电碎石治疗,65例患者残石全部取尽,碎石取石成功率达97.1%,未出现并发症.结论 通过钬激光联合液电碎石后再行胆道镜取石,可大大提高肝内外胆管残留结石的清除效果,是一种安全而有效的治疗方法 .     

Electrohydraulic shock wave lithotripsy (ESWL) fragmentation of retained common duct stones

Retained or recurrent stones in the common bile duct remain a clinical problem in 2% to 5% of patients undergoing cholecystectomy. Nonoperative extraction via the T tube tract or endoscopic sphincterotomy is successful in 85% to 95% of patients; however, the remainder require reoperation. This study evaluates the efficacy of electrohydraulic shock wave lithotripsy therapy of common duct stones too large to be extracted endoscopically or by T tube. Six patients were entered into the study. Ages ranged from 62 to 93 years. All patients either had severe preexisting systemic disorders or were of an advanced age. Stones ranged in size from 10 to 41 mm, with a mean largest dimension of 22 mm. In all patients either extraction by traditional nonoperative means failed or there was a stone that was considered to be too large to be extracted successfully. Patients were treated with 1200 to 2400 shocks at 16 to 20 kV. Five of six patients were treated with local anesthesia and sedation. Stones were successfully fragmented in all but one patient. Five patients required extraction of the remaining fragments either through the T tube tract (one patient) or via endoscopic sphincterotomy. All patients were free of stones at discharge, with the exception of one patient with severe cirrhosis who had an intrahepatic stone behind a right hepatic duct stricture. This stone had been successfully fragmented but an endoscopic retrograde cholangio-pancreatogram revealed some residual fragments despite normal alkaline phosphatase and bilirubin values. There were no hospital deaths, although the patient with the intrahepatic stone died of bleeding varices several months later. Electrohydraulic shock wave lithotripsy seems to be an effective adjuvant treatment in clearing the bile duct of stones that would otherwise require reoperation.     

经口胆道子母镜碎石治疗胆管巨大嵌顿性结石21例

目的探讨经口胆道子母镜液电联合机械碎石治疗胆管巨大嵌顿性结石的可行性。方法常规经内镜逆行胰胆管取石（ERCP）治疗困难的胆管巨大嵌顿性结石患者21例,用子母镜液电先将结石击散,再用机械碎石网篮碎清除结石。结果21例患者子母镜取石治疗均获成功。18例肝外胆管结石中14例一次性取净结石,4例两次取净结石。3例左右肝管嵌顿结石病例,2例取净结石;1例合并右肝内胆管多发嵌顿结石,未能取净结石。术中短暂出血3例,术后胆管炎1例,术后胰腺炎2例,无穿孔、死亡等严重并发症。结论对常规ERCP治疗困难的胆管巨大嵌顿性结石,子母镜液电联合机械碎石是一种安全和有效的办法。     

Electrohydraulic lithotripsy (EHL) for the treatment of large retained common duct stones

Retained biliary stones may be too large for extraction through the existing T-tube tract. It may be necessary to dilate the tract, crush the stones or use endoscopic papillotomy. There are reports of stones and the extracting basket becoming stuck in the T-tube tract and tract ruptures caused by extracting large stones. In this study electrohydraulic lithotripsy (EHL) is used in combination with T-tube tract choledochoscopy for the fragmentation of large stones prior to basket extraction. T-tube choledochoscopy was performed under IV sedation and sterile conditions no sooner than one month following common bile duct exploration. The Olympus 4.9-mm choledochoscope was passed through the T-tube tract to visualize the stone. A #5 Fr EHL probe was passed through the endoscope and advanced to within 1 mm of the surface of the stone. EHL discharge was started at a low energy level being increased until the spark discharges caused stone fragmentation. The resultant stone fragments were basket extracted under direct vision. The procedure was used in twelve patients with removal of all stones in eleven patients. Eight patients were treated with one endoscopic session. Because of multiple stones, two patients required two sessions and one patient four sessions. In one patient stone position prevented adequate fragmentation and endoscopic papillotomy also failed. Repeat choledochoscopy and EHL were successful. There were no complications of EHL or choledochoscopy in any of the patients. EHL was both effective and safe for fragmentation of large common duct stones when performed under direct vision using a choledochoscope.