腹腔镜胆囊切除术后支气管-胆管瘘

目的提高对腹腔镜胆囊切除术（LC）后支气管-胆管瘘的认识.方法对1例肝硬化伴支气管-胆管瘘患者的临床资料进行分析,并结合文献复习.结果LC可致胆囊破裂,胆汁、胆石漏入腹腔,引起腹腔感染、肝脓肿等,并可致膈肌穿孔、支气管-胆管瘘形成而持续由肺排出新鲜胆汁.结论支气管-胆管瘘实属罕见,痰液中含有高浓度胆红素为其主要临床表现.对LC术后腹腔内残留结石者应想尽一切办法取净结石.再次腹腔镜手术或开腹手术取出“丢失”于腹腔内的结石是治疗腹腔脓肿等并发症的有效方法.     

New strategies for the treatment of gallstone disease

BACKGROUND: Symptomatic gallstones are generally accepted as being the indication for cholecystectomy. Generally, severe abdominal pain in epigastrium and in the right upper abdominal quadrant, and lasting for more than 15 min, is thought to be caused by gallstones. However, many patients with other abdominal complaints undergo cholecystectomy and are satisfied with the outcome of surgery. Possible ways to improve the results of cholecystectomy are discussed. METHODS: Review of previous work by the authors. RESULTS: The introduction of laparoscopic cholecystectomy has even led to an increase in cholecystectomies; in a higher complication rate; and in increased costs of the treatment of gallstone disease. Because of faster recovery, 70% of symptomatic gallstone patients are able and willing to undergo laparoscopic cholecystectomy in day care. Cholecystectomy after sphincterotomy and stone extraction in patients who have stones in the gallbladder was demonstrated to prevent gallstone-related symptoms in at least 40% of patients. If the gallbladder had to be removed later for symptomatic disease, however, this did not result in a higher rate of conversions and complications. Because of shortage in operation capacity in The Netherlands, there is a considerable delay between the diagnosis of symptomatic stones and cholecystectomy. Better selection of patients for cholecystectomy will not only improve the results of cholecystectomy, it will also reduce the number of cholecystectomies and patients on waiting lists. Delay of cholecystectomy is associated with more complications, longer operative times, higher conversion rates to open cholecystectomy and prolonged hospitalization. The efficacy of the bile salt ursodeoxycholic acid in preventing gallstone-related pain attacks and complications in patients with contraindications for operation or waiting to undergo cholecystectomy should be investigated further, since two retrospective studies have demonstrated favourable outcomes for this strategy. CONCLUSION: The results of cholecystectomy are likely to be improved by better selection of patients, prevention of delay of the procedure and possibly treatment with ursodeoxycholic acid.     

Reduction of the risk of unretrieved stones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy entails the risk of gallbladder rupture and consequent loss of stones within the abdominal cavity, which is not an uncommon complication. The development of intraperitoneal abscesses due to the spilled gallstones is one of its major complications. When gallbladder was injured during laparoscopic cholecystectomy, gallbladder was dissected on the medial and lateral side, or from the fundus of the gallbladder in the original position to reduce the spillage of stones. After putting the removed gallbladder into the endoscopic bags, hepatorenal fossa and right subphrenic space was thoroughly examined using retractor and oblique view scope. We performed these procedures in 30 consecutive patients with gallbladder ruptured during operation. Dropped stones were noted in 5 patients and were retrieved successfully. Reduction of stone spillage and the retrieval of spilled stones were essential. It is advisable to retrieve as many gallstones as possible after gallbladder perforation during laparoscopic cholecystectomy.     

“高危”胆囊结石患者腹腔镜胆囊切除术的要点分析--附115例报告

目的：探讨“高危”胆囊结石的疾病特点,总结其行腹腔镜胆囊切除术的诊治经验。方法对我院自2008年10月至2012年3月收治的115例“高危”胆囊结石患者行腹腔镜胆囊切除术的临床资料进行回顾性分析。结果本组115例患者,其中胆囊充满性型结石并胆囊萎缩、瓷化47例,急性化脓性及坏疽性胆囊炎42例,胆囊颈部结石嵌顿20例,胆囊管结石3例,胆囊十二指肠瘘2例,Mirizzi综合征1例。其中急诊腹腔镜胆囊切除术51例,其余均行择期手术,均康复出院。结论“高危”胆囊结石患者,经积极术前准备,加强围手术期的处理,术中精准、规范及娴熟的手术操作,行腹腔镜胆囊切除术是可行的。     

Silent gallstones: a therapeutic dilemma.

Asymptomatic gall stones are defined as stones that have not caused biliary colic or other biliary symptoms. Nearly two-third of patients with gall stones are asymptomatic. Studies of the natural history of asymptomatic gall stones suggest that the cumulative probability of developing biliary colic after 10 years ranges from 15% to 25%. The incidence of other complications is much less. The operative mortality of elective cholecystectomy is <0.5% but increased mortality is seen in elderly persons (>60 year of age), particularly in those with complications such as acute cholecystitis. Most decision analysis studies do not favour prophylactic cholecystectomy for asymptomatic cholelithiasis. Nonetheless, many studies have listed certain criteria for carrying out elective cholecystectomy in asymptomatic patients. The authors, from their own experience and after reviewing the literature, propose the following criteria for cholecystectomy: life expectancy >20 years, calculi >3 cm in diameter, particularly in individuals in geographical regions with a high prevalence of gall bladder cancer or calculi <3 mm, chronically obliterated cystic duct, non-functioning gallbladder and calcified (porcelain) gallbladder. The widespread use of diagnostic abdominal ultrasonography has led to the increasing detection of clinically unsuspected gall stones. This, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic or 'silent' gall stones. While cholecystectomy is the undisputed gold standard treatment for symptomatic gall stones, the natural history of silent gall stones is not known well enough to recommend a definitive therapeutic strategy for such patients. The treatment options for asymptomatic or silent gall stones range from no treatment to selective cholecystectomy in at-risk group to elective cholecystectomy in all patients. There are a large number of proponents for each of these options so that each merits careful consideration. In this article, the authors examine the evidence for and against treating silent gall stones with the aim of providing more specific guidelines for the management of patients found to have asymptomatic gall stones.     

Single port laparoscopic cholecystectomy: a new evolving technique

Although multiple groups have reported initial success with single port laparoscopy, no consensus exists concerning the technical aspect of this surgery. In this report, we describe in detail our technique to perform single port laparoscopic cholecystectomy. Twelve cases of single port laparoscopic cholecystectomy for gallbladder stones were performed in our surgical unit. There was only one conversion during the first operation of the series to standard laparoscopy, and never to open operation. No intraoperative adverse events or major perioperative complications were reported. All the patients have been discharged within 48 hours, with uneventful postoperative course, nearly painless, without any discomfort and no visible scar. Single port laparoscopic surgery is a promising option for the treatment of gallbladder stones providing that technical and oncological surgical principles are respected.     

Combination of Preoperative EST,Laparoscopic Cholecystectomy with Choledochotomy,and Postoperative Cholangioscopy in the Treatment of Common Bile Duct Stones

A case of common duct stones, successfully managed with a combination of preoperative EST, laparoscopic choledochotomy and postoperative choledochoscopic stone extraction, is reported. A 32-year-old man was admitted to our hospital because of jaundice and right hypochon-dralgia of several-days' duration. CT, US and ERCP revealed stones in the gallbladder and common bile duct. EST was performed to remove the stones in the common bile duct prior to laparoscopic cholecystectomy. However, the patient developed pancreatitis as a complication of EST, which was successfully managed by conservative therapy. Though some stones remained in the common duct following the first trial of EST, the patient rejected a second round of EST. Laparoscopic cholecystectomy and choledochotomy were performed to remove the gallbladder and the stones remaining in the common bile duct. A T tube was placed in the incised common bile duct for management of possible retained stones. Twenty days after the surgery, successful postoperative cholangioscopy was performed, and the stones remaining in the common duct were removed. Hyperamylasemia and pancreatitis are relatively common complications of EST occurring in about 7% of cases, but only 3% of these patients experience severe pancreatitis, requiring hospitalization. Conservative therapy is always the treatment of choice. In our particular patient, pancreatitis caused by EST was successfully managed by decompression with ENBD and administration of ulinastatin. Residual stones in the CBD were completely removed by laparoscopic common bile duct exploration following EST and postoperative cholangioscopy through the T tube fistula.     

A Rare Case of Biliobiliary Fistula

Abstract: Biliobiliary fistula is a rare clinical entity. The case of a 72 year old female, who presented with epigastric pain and jaundice, is detailed herein. Endoscopic retrograde cholangiopancreatography (ERCP) revealed two stones, one each in the common bile duct and the gallbladder. Continuous endoscopic nasobiliary drainage (ENBD) was performed to relieve obstructive jaundice. Further study with contrast medium administered via the ENBD tube revealed a fistula between the neck of the gallbladder and the common bile duct. The cystic duct was intact. A stone was considered to have migrated into the common bile duct through the fistula. A diagnosis of biliobiliary fistula, Corlette type I was made. However, in this particular case, a biliobiliary fistula was noted at a site below the junction of the cystic duct and common bile duct. Removal of the gallbladder stones was followed by cholecystectomy. The common bile duct was then repaired by utilizing a T-tube. No evidence of malignancy was recognized in the resected gallbladder specimen. In the one year to date since surgery, the patient has been asymptomatic and without signs of biliary disease.     

哑铃样金属支架置入后内镜下胆囊 取石术的动物实验（含视频）

目的通过动物活体实验探索内镜超声引导下哑铃样金属支架(LAMS)置入后胆囊取石的安全性与可行性。方法选择体重30~35 kg小型猪6头,静脉麻醉下经腹部开放手术于胆囊内分别置入直径0.8~2.0 cm无菌人结石2~4枚,缝合胆囊及腹腔。造模成功后内镜超声引导下置入LAMS。超细内镜经胃越过支架进入胆囊后寻找结石并取出。经内镜乳头括约肌切开术(EST)及经内镜胆道内支架引流术(ERBD)预防胆漏。再以普通内镜拔出LAMS,金属夹封闭胃壁创面。观察技术成功率、操作时间及并发症发生情况。结果5头猪在内镜超声引导下成功置入LAMS,超细内镜顺利进入胆囊,取石网篮取出直径小于1 cm结石,大结石经激光碎石后完全取出。操作总时间为87~128 min。术后观察无出血、穿孔、感染、胆瘘等并发症发生。另1头猪置入LAMS失败,由于先行EST加ERBD,造成胆囊体积缩小并远离胃腔,穿刺困难。结论内镜超声引导下经胃-胆囊置入LAMS后超细内镜取出胆囊结石技术安全可行,可为行胆囊切除术困难者提供一种新的治疗途径。     

Cancer risk in different types of gallstones (author's transl)

Among 22,868 autopsied adults were 7,411 cases with cholelithiasis or cholecystectomy. In the cancerous gallbladders pigment-stones, pure crystalline cholesterol stones and lobulates stones were seldom found but multiple faceted stones and solitary combined stones are more frequent. If the partial volume of gallstones increased, there were more cases with cholecystitis or later carcinoma. Nevertheless in males with all forms of gallstones, carcinoma of the lung, the stomach, the colon and rectum and the prostatic gland were more frequent then carcinoma of the gallbladder. Only in female with multiple faceted stones and solitary combined stones, carcinoma of the gallbladder was the most frequent cancer. The "St?rfeld" of the gallbladder with stones is more important for the localisation of a later carcinoma in female then for men. If the gallbladder with stones should be resected in good time, the patient is protected of the risk of cancer of gallbladder, but the percentage of all cancers among inoperated cases with gallstones is not higher than among cases with previons cholecystectomy. Instead of carcinoma of the gallbladder other cancers develop after cholecystectomy.     

LONG‐TERM PROGNOSIS OF BILE DUCT STONES: ENDOSCOPIC PAPILLARY BALLOON DILATATION VERSUS ENDOSCOPIC SPHINCTEROTOMY

Aim: Endoscopic papillary balloon dilatation (EPBD), which allows preservation of papillary functions, is used as the first‐line therapy in our hospital for common bile duct (CBD) stones to reduce biliary complications. In the present study, we investigated causal factors for CBD stones and compared long‐term prognosis between EPBD and endoscopic sphincterotomy (EST). Methods: A total of 453 EPBD and 233 EST cases treated between April 1996 and May 2007 were examined. They were categorized into four groups: group 1, gallbladder (GB) with stones was resected after CBD stones were extracted (cholecystectomy for GB with stones); group 2, GB with stones was not resected after CBD stones were extracted (no cholecystectomy for GB with stones); group 3, only CBD stones were extracted while the GB without stones was not resected (GB without stones); and group 4, CBD stones with a history of cholecystectomy (absence of GB). Then, postoperative recurrence of CBD stones was compared. To examine changes in papillary functions by EPBD, Oddi's sphincter pressure was measured before and after EPBD. Results: Recurrence was observed in 31 EPBD and 40 EST cases. When recurrence rates by EPBD/EST were compared among the four treatment groups, they were lower with EPBD than with EST in all groups. Oddi's sphincter functions were preserved by 70% after EPBD. Conclusion: Low‐pressure EPBD in combination with isosorbide dinitrate enabled preservation of papillary functions by 70%, which would improve a long‐term prognosis.     

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.     

Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique

BACKGROUND: The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. METHODS: This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. RESULTS: Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). CONCLUSIONS: The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones.     

Wait-and-see policy versus cholecystectomy after endoscopic sphincterotomy for bile-duct stones in high-risk patients with co-existing gallbladder stones: A prospective randomised trial

Background and study aimsEndoscopic sphincterotomy (ES) is one of the most important advances in the treatment of common bile duct (CBD) stones. However, the use of ES to remove CBD stones in high-risk patients without cholecystectomy is still debatable. The aim of this study was to compare the efficacy of a wait-and-see policy versus cholecystectomy after ES for CBD stones in high-risk patients with co-existing cholelithiasis.Patients and methodsA total of 162 patients after undergoing ES with the clearance of CBD stones were randomised after informed consent to cholecystectomy or conservative management of their gallbladder stones.ResultsThe results indicated that cholecystectomy after ES for CBD stones significantly reduced the biliary complications in high-risk patients.ConclusionEvery patient who has both CBD stones and gallstones with significant co-morbid illnesses, after clearance of CBD stones by ES, should undergo early cholecystectomy.     

Gallensteine

In Germany, 15–20% of individuals develop gallstones, and more than 190,000 cholecystectomies are performed for symptomatic stones annually. Overall, 90% of gallstones are cholesterol stones, which are due to increased hepatic cholesterol secretion and gallbladder hypomotility. Cholesterol hypersecretion is attributed to exogenous risk factors, such as a hypercaloric carbohydrate-rich diet and physical inactivity, as well as to lithogenic genes, such as common gene variants of the hepatic cholesterol transporter ABCG5/G8. Of stone carriers, 1–3% per year develop symptoms (biliary colic), and the rate of complications (cholecystitis, cholangitis, pancreatitis) ranges from 0.1% to 0.3% per year. Today laparoscopic cholecystectomy represents the standard of care for most symptomatic stones with and without complications because it leads to shorter hospital stays and recovery times than open cholecystectomy but has similar complication rates. The recently updated German S3 guidelines for diagnosis and treatment of gallstones recommends preoperative endoscopic retrograde cholangiography and stone extraction in cases of simultaneous bile duct and gallbladder stones; if the probability of bile duct stones is moderate, endoscopic ultrasound – or magnetic resonance cholangiography – should precede cholecystectomy.     

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES: Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy. METHODS: Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations. RESULTS: Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (相似文献   

Management of gallstone pancreatitis: cholecystectomy or ERCP and endoscopic sphincterotomy

BACKGROUND: Currently, cholecystectomy is recommended for patients with gallstone-induced pancreatitis. ERCP with endoscopic sphincterotomy (ES) within 24 to 48 hours is also suggested for the treatment of acute gallstone pancreatitis. The aim of this study was to determine outcome after cholecystectomy versus ES alone in patients with gallstone pancreatitis. METHODS: One hundred seventeen patients with gallstone pancreatitis were included in this prospective observational study. Inclusion criteria were typical abdominal pain; serum amylase level 3 times or greater than normal; and gallbladder stones and a dilated bile duct, with or without stones, by US, CT, or ERCP. RESULTS: Eighty-three patients (Group A) underwent cholecystectomy after initial evaluation including ERCP in 43 (53%) and ERCP with ES in 38 (47%). The remaining 34 (Group B) underwent successful ERCP with ES alone. Mean follow-up was 33 months for Group A and 34 months for Group B. Recurrent gallstone pancreatitis was noted in 2 patients (2.4%) in Group A (bile duct stone in 2, sludge and papillary stenosis in 1), and in 1 patient (2.9%) in Group B. Ten patients in Group B had follow-up US of the gallbladder that showed disappearance of stones in 3. During follow-up, there was no significant difference in the rates of biliary complications (Group A, 3.6% vs. Group B, 11.6%; p = 0.19) or serious complications (pancreatitis, cholecystitis, cholangitis) (Group A, 3.6% vs. Group B, 5.8%). Also, there was no significant difference in procedure-related complications. CONCLUSIONS: Recurrence of pancreatitis after ERCP with ES alone for gallstone pancreatitis is rare. In patients who have undergone ES alone, cholecystectomy should be considered only if there are overt manifestations of gallbladder disease (e.g., biliary pain, cholecystitis, cystic duct obstruction) and not for prevention of recurrent gallstone pancreatitis. Because treatment by ES alone may be associated with a higher risk of biliary complications during follow-up compared with cholecystectomy, these patients may require close surveillance.     

Tips for single‐port laparoscopic cholecystectomy

Single‐port laparoscopic cholecystectomy (SPLC) is an emerging technique and gaining increased attention by its superiority in cosmesis. A 1.5‐cm vertical transumbilical incision is used for the single port, followed by the glove method. Indications for SPLC are the same as those for standard 4‐port laparoscopic cholecystectomy, including patients with morbid obesity, previous upper abdominal surgery, severe acute cholecystitis, or suspected presence of common bile duct stones. Some randomized controlled trials have shown negative results of SPLC regarding operative time, wound‐related complications, and postoperative pain. However, our retrospective analysis shows equivalent clinical outcomes among the two approaches in terms of postoperative pain and complications. In this context, SPLC can be a good option for gallbladder pathologies.     

经皮经肝胆囊镜治疗胆囊结石价值的探讨

目的：探讨经皮经肝胆囊镜（PTCCS）治疗胆囊结石的价值。方法：1999年9月至2001年11月选择有胆囊结石临床症状但有全身疾病不能耐受手术或不适宜腹腔镜胆囊切除及不愿接受胆囊切除的患者86例，行经肝胆囊镜(PTCCS)治疗，先行经皮经肝胆囊引流术(PTGBD)，l周后用探条扩张此通路至16—22 F，采用PTCCS取石或液电碎石(EHL)。结果：86例中82例(95．3％)PTGBD成功，80例(93．0％)行PTCCS治疗。结石单发28例，多发52例，结石大小5—32 mm，大于15 mm的结石45例。26例网篮取石，54例EHL，结石清除率97．5％(78／80)，残石率2．5％(2／80)。4例合并腹膜炎和2例引流管脱出未同意再次PTGBD者转外科手术。平均随访16．4个月，2例(2．5％)结石复发。30例结石做红外线光谱定量分析，24例(80％)为胆固醇结石。结论：PTCCS治疗胆囊结石对不能耐受手术或不适合腹腔镜胆囊切除以及不接受胆囊摘除者是一种较安全、有效的方法。正确选择适应证可减少并发症，降低结石复发率。     

Endoscopic sphincterotomy for common bile duct calculi in patients without stones in the gallbladder

Endoscopic sphincterotomy (ES) was performed in 25 patients for common bile duct (CBD) calculi in the absence of stones in the gallbladder. Eighteen of these patients were considered unfit for surgery because of age or concomitant disease. All ES procedures were technically successful with complete evacuation of the CBD in all cases. Early complications occurred in only one patient, a 91-year-old female who died from nonbiliary tract disease. Long-term follow up over a period of 42 months was available in 19 of the 24 patients. Late complications occurred in two patients (10%), both of whom developed cholecystitis; they underwent surgery without subsequent morbidity or mortality. This 10% incidence of long-term complications is similar to that of other series that did not differentiate between patients with isolated CBD calculi and those with stones also present in the gallbladder. The observed complication rate does not justify routine prophylactic cholecystectomy after ES for isolated CBD stones.