继发性胆管结石漏诊原因的分析

我院1990年4月～1996年12月治疗胆囊结石行胆囊切除术后继发性胆管结石23例。均经手术治疗及ERCP镜下取名治愈。漏诊的主要原因为临床表现不典型、肝胆B超检查未发现、术中探查不仔细等、高度怀疑继发性明管结石患者术前行ERCP或行术中经胆囊管胆道造影可有效预防胆管结石的漏诊。     

腹腔镜胆囊切除胆道损伤后再手术时机和选择

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）致胆管损伤（bileduct injury,BDI）的手术时机、手术方式及技巧。方法回顾性分析我院收治的21例接受手术治疗的LC后胆管损伤病例,胆管损伤Ⅰ型2例、Ⅱ型11例、Ⅲ型仅2例、Ⅳ型6例。结果本组1例术中Ⅱ型胆总管损伤,经中转开腹行胆总管修补和T管引流而治愈,术后2例出现胆漏,经充分引流后自愈。术后随访1.5～5年,无胆道狭窄及胆管炎发作。其余20例均接受了毁损的胆管切除、肝总管或左右肝管的胆肠吻合术,并获得治愈。结论LC致BDI手术仍是BDI的首选治疗。把握手术时机,避免盲目手术,及早选择有经验的专科肝胆外科医生恰当处理是提高治愈率的关键。     

Common bile duct stones after laparoscopic cholecystectomy and its treatment

In the present work we recount our experience in handling common bile duct stones (CBDS) in our first 100 cases of laparoscopic cholecystectomy. In the first 50 cases our diagnostic procedures involved the use of ultrasound exploration and intravenous cholangiotomography 48 h before laparoscopic surgery. We found three cases of residual CBDS. One of the cases was treated by means of ERCP. The other two cases were resolved by carrying out a transparietohepatic cholangiography after the ERCP procedure failed. After this experience, we changed our strategy, introducing the intraoperative cholangiography in the cases with an unclear diagnosis. With this new approach, no residual CBDS occurred in the following 50 cases. These findings demonstrate the following: (1) In our hands, intravenous cholangiography is not more effective than ultrasound exploration in resolving dubious cases. (2) These dubious cases are more effectively diagnosed by means of selective intraoperative cholangiography. (3) When CBDS is treated by transparietohepatic cholangiography it proves to be less uncomfortable for the patient than ERCP and, as we found, even more efficient in removing the stones, although our experience is based on only two cases.     

腹腔镜胆囊切除术高位胆管损伤的预防及处理

目的探讨腹腔镜胆囊切除术中高位胆管损伤的原因、预防及处理方法。方法对2009年1月至2014年1月我科收治外院转入的16例腹腔镜胆囊切除术后胆管损伤的病例和同期我科腹腔镜胆囊切除术2200例无胆管损伤的临床资料进行分析。结果16例胆管损伤的部位均为肝总管横断及毁损伤,其中11例行肝总管-空肠Roux-en-Y吻合术,5例行左右肝管整形-空肠Roux-en-Y吻合术,16例病人术后恢复良好,无死亡病例。同期2200例LC术中采用“肝总管显露”确认后再行胆囊切除无一例发生胆管损伤。结论腹腔镜胆囊切除术高位胆管损伤最多见,术中“肝总管显露”是预防高位胆管损伤的可靠方法。肝总管（或左右肝管整形）-空肠Roux-en-Y吻合术是治疗高位胆管损伤最有效的手术方式。     

腹腔镜胆囊切除术中胆管损伤的预防

目的总结腹腔镜胆囊切除术中胆管损伤的原因及其防治方法. 方法回顾分析1 000例腹腔镜胆囊切除术临床资料. 结果中转开腹手术15例(1.5%);并发症6例(0.6%),其中胆总管损伤3例,胃穿刺损伤1例,腹壁刺口出血1例,胆漏1例.无远期并发症. 结论胆道牵拉成角是胆管损伤最常见原因.     

三镜联合治疗胆囊结石合并胆总管结石的临床优势

【摘要】 目的 探讨三镜联合治疗胆囊结石并胆总管结石的临床优势。方法〓将汕尾市第二人民医院普外科2010年2月至2015年10月期间共处理胆囊结石伴难处理的胆总管下端结石44例患者作为研究对象(改进组),采用三镜(即腹腔镜、十二指肠镜、胆道镜)联合治疗。另选择同期采用常规腹腔镜和胆道镜(双镜)治疗患者44例为对照组。比较两组患者临床治疗效果。结果〓手术中转开腹率、结石残留率、术后并发症发生率两组比较差异无统计学意义(P>0.05);改进组的手术时间、术中失血量、术后住院时间均低于对照组,差异有统计学意义(P<0.05)。结论 三镜联合治疗胆囊结石并胆总管结石,较传统的双镜联合方式具有明显优势。     

腹腔镜胆囊切除术胆管损伤的防治

目的 :探讨腹腔镜胆囊切除术 (LC)致胆管损伤的原因及预防。方法 :回顾分析腹腔镜胆囊切除术 192 0例的临床资料。发生胆管损伤 6例 ,发生率为 0 31%。分析损伤的部位、类型、发生时间、原因、手术方法及采取的预防措施体会。结果 :本组 6例全部治愈 ,随访 1～ 6年 ,除 1例胆管狭窄及胆管炎外 ,余 5例健康状况良好。结论 :预防胆管损伤是关键 ,加强对LC操作训练及规范LC操作的重视。应根据发现胆管损伤的时间、部位、类型等选择不同的处理方法     

Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study

Background

Endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration are safe and efficient methods that have recently been used for the treatment of bile duct stones. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+LC).

Methods

One hundred twenty patients were prospectively randomized into 2 groups: LCBDE with LC in a single intervention and LC after ERCP.

Results

The success rate of the LCBDE+LC group (96.5%) was found to be higher than for the ERCP+LC group (94.4%). Complication rates of the LCBDE+LC and ERCP+LC group were 7% and 11.1%, respectively. Complications requiring ERCP in the postoperative period after LCBDE+LC have been noted in 3.5% of cases.

Conclusions

Laparoscopic CBD exploration provides an alternative therapeutic approach that has less morbidity, is cost-effective, and allows earlier recovery with a reduced period of short-term disability.     

An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction

Background Endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones. Stone recurrence can, however, occur in up to 25% of cases. Risk factors have been poorly defined, but are believed to be related to bile stasis. This study investigated whether an angulated common bile duct (CBD) that may predispose to bile stasis influences symptomatic stone recurrence after successful endoscopic therapy. Methods This study included 232 consecutive patients (mean age, 64.1 years; 86 men) who had undergone therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones. Data from the follow-up period (36 ± 17 months) were obtained from medical records and patient questioning. Common bile duct angulation and diameter were measured from the cholangiogram after stone removal. Results Symptomatic bile duct stones recurred in 16% of the patients (36/232). Three independent risk factors were identified by multivariate analysis: an angulated CBD (angle, ≤145°; relative risk [RR], 5.2; 95% confidence interval [CI], 2.2–12.5; p = 0.0002), a dilated CBD (diameter, ≥13 mm; RR, 2.6; 95% CI, 1.2–5.7; p = 0.017), and a previous open cholecystectomy (RR, 2.7; 95% CI, 1.3–5.9; p = 0.0117). Gender, age, urgency of procedure, or a periampullary diverticulum did not influence the recurrence rate. Conclusions Angulation of the CBD (≤145°) on endoscopic cholangiography, a dilated CBD, and a previous open cholecystectomy are independent risk factors for symptomatic recurrence of bile duct stones. The findings support the role of bile stasis in stone recurrence. Further studies using these data prospectively to identify high-risk patients are warranted. Part of this work was presented at the Digestive Disease Week in New Orleans, 16–20 May 2004, and published in abstract form in Gastrointestinal Endoscopy 2004;59: AB197     

基层医院腹腔镜胆囊切除术防治胆管损伤的体会

目的：总结基层医院腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）预防和治疗胆管损伤的体会。方法：回顾分析1994年10月至2008年12月为12 759例患者行LC的临床资料。结果：胆道损伤16例,胆道损伤率0.13%。结论：熟练的操作技巧可减少或避免胆管损伤的发生,早期诊断和及时处理胆管损伤是重要举措。     

腹腔镜胆囊切除术预防胆道损伤的体会

目的　探讨腹腔镜胆囊切除术胆道损伤的防治方法。方法　回顾性总结 32 0例腹腔镜胆囊切除术的经验。结合文献复习分析胆道损伤可能发生的原因以及其预防和处理。结果　 32 0例腹腔镜胆囊切除术无 1例胆道损伤。结论　腹腔镜胆囊切除术胆道损伤的预防是关键。损伤的处理应根据发生的时间、部位及程度等选择不同的方法     

腹腔镜胆囊切除术胆管损伤的因素及对策

目的:通过对腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)胆管损伤因素的探讨,找准其预防对策,减少胆管损伤率。方法:回顾性分析我院1992年10月~2004年8月实施的35 000例LC术中29例胆管损伤的因素。结果:胆总管损伤11例;汇合部分离性损伤6例;穿孔性胆管损伤9例;右侧副肝管损伤3例。29例全部治愈,27例随访1.5~11年,无严重并发症。结论:LC术中要警惕胆管损伤因素,仔细操作每一步,胆管损伤率可减少。     

腹腔镜胆囊切除术后胆管损伤围手术期处理

目的探讨腹腔镜胆囊切除术后胆管损伤围手术期的处理方法。方法分析我院1989年1月至2005年6月收治的38例腹腔镜胆囊切除术后胆管损伤的临床资料，结合随访结果总结有关围手术期处理方面的经验。结果38例胆道重建包括胆肠吻合术29例和对端吻合及胆管修补术9例，术后均放置胆道支撑管；术后发生胆瘘5例（13．15％），切口感染4例（10．52％），腹腔积液3例（7．89％）。胆道引流管3～4周内拔除31例；5～6周拔除7例。随诊6个月～15年，平均93个月，33例（86．84％）手术效果良好，5例（13．16％）术后吻合口狭窄，其中3例再次手术治愈，2例经十二指肠镜介入球囊扩张好转。结论胆管损伤宜术中及时发现和合理的处理；胆管损伤导致严重腹腔感染应尽早探查引流择期再行胆道重建术；胆道重建术后吻合口再狭窄处理前须获得满意的影像学检查结果；是否胆管重建术后常规放置支撑管和通过介入方法行胆管扩张治疗胆道狭窄的疗效有待进一步研究。     

单中心腹腔镜胆囊切除术预防胆管损伤的体会

目的:探讨如何预防腹腔镜胆囊切除术(LC)胆管损伤。方法:回顾分析37 781例LC的临床资料。结果:胆管损伤25例(0.066%),其中术中发现8例,术后发现17例。胆管横断伤12例,其中离断+缺损8例(1例是中转开腹损伤),钛夹夹闭无胆管缺损4例;胆总管部分剪切伤4例;肝总管电损伤2例,分离损伤2例;右肝管损伤3例;副肝管损伤2例。胆管修补(端端吻合)+T管支撑引流5例、胆肠Roux-en-Y吻合16例,腹腔穿刺+鼻胆管引流1例(ENBD)、损伤胆管修复,置管引流3例。无死亡病例。结论:熟悉肝门解剖,仔细处理Calot三角,适时中转开腹,避免盲目自信可以有效的降低胆管损伤的发生率。     

腹腔镜胆囊切除术胆管并发症的防治

目的 :探讨腹腔镜胆囊切除术中避免胆道损伤的有效方法。方法 :回顾性分析 1 996～ 2 0 0 2年行腹腔镜胆囊切除的临床资料。其中胆道损伤 9例 ,包括胆总管横断 2例 ,胆总管电灼伤 1例 ,胆总管夹闭 2例 ,胆囊管残端漏 1例 ,胆囊床损伤或胆囊迷走胆管损伤 3例。胆总管损伤患者均行一期手术 ;胆囊床损伤或胆囊迷走胆管损伤的患者行穿刺抽液或置管引流治愈。结果 :本组患者 1例因发生胆肠吻合口狭窄而再次手术 ,其它患者恢复顺利。结论 :严格规范的操作 ,胆囊三角良好的显露 ,辨清肝总管、胆总管和胆囊管之间的关系 ,正确处理胆囊床和胆囊管是避免肝外胆管损伤和预防胆漏的关键。     

腹腔镜胆囊切除术胆管损伤的防治

目的:探讨腹腔镜胆囊切除术(LC)中避免胆道损伤的有效方法。方法:回顾分析1 220例LC患者的临床资料,总结LC术中发生胆管损伤的常见原因及处理方法。结果:1 220例LC中发生胆管损伤10例,占0.8%(10/1 220),经中转开腹手术,均治愈出院。结论:胆管损伤是LC中最严重、最常见的并发症,经过及时有效的处理,可避免严重后果。     

腹腔镜胆囊切除术胆管损伤的原因与处理

目的 :探讨腹腔镜胆囊切除术 (LC)胆管损伤的原因及处理方法。方法 :回顾分析 10 80例LC的临床资料 ,总结LC术中发生胆管损伤的常见原因及处理方法。结果 :10 80例LC中发生胆管损伤 4例 ,占0 37% (4 /10 80 ) ,经中转开腹手术 ,均治愈出院。跟踪随访 3年 ,效果良好。结论 :胆管损伤是LC术中最严重且最常见的并发症 ,经过及时有效的处理 ,可避免严重后果。     

腹腔镜下处理腹腔镜胆囊切除术胆道和胃肠道损伤

目的评价腹腔镜下处理腹腔镜胆囊切除术后胆道和胃肠道损伤. 方法 1991年10月～2002年12月,完成连续无选择腹腔镜胆囊切除术和腹腔镜胆囊切除联合胆道探查9 016例,其中发生胆道损伤14例(0.15%),胃肠道损伤3例(0.03%).其中1例胆管横断伤、10例胆管部分损伤、1例胃损伤、2例十二指肠损伤均在腹腔镜下修补. 结果 1例胆道损伤腹腔镜下修补术后胆漏,1年后发生胆道狭窄,其余均痊愈出院. 结论胆道部分损伤及胃肠道损伤可在腹腔镜下处理,对于胆道横断伤的腹腔镜处理,需进一步探讨.     

腹腔镜胆总管探查术的临床应用

目的:总结腹腔镜胆总管切开探查取石术(laparoscopic common bile duct exploration,LCBDE)的临床价值及手术方法。方法:回顾分析2007年3月至2010年8月为85例胆管结石患者行LCBDE的临床资料。术中联合应用胆道镜、输尿管硬镜及气压弹道碎石设备、L形腹腔镜胆道取石钳取石。结果:85例手术均获成功。78例经胆总管探查取石;7例经胆囊管胆总管探查取石。73例使用L形腹腔镜胆道取石钳取结石;12例使用输尿管硬镜气压弹道碎石设备碎石;6例为肝内胆管结石。62例放置T管引流,23例一期缝合胆总管。结论:腹腔镜胆总管探查取石术微创、安全、有效。联合应用胆道镜、输尿管硬镜及气压弹道碎石设备、L形腹腔镜胆道取石钳操作简捷、有效。     

腹腔镜胆囊切除术胆管损伤术后胆漏的处理

目的:总结腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)胆管损伤术后胆漏的预防与处理。方法:回顾分析2000年1月至2008年6月我院9例LC胆管损伤术后胆漏患者的临床资料,总结胆漏的原因、预防措施及处理。结果:9例全部痊愈出院。随访3~60个月无黄疸、发热等胆管炎症状。结论:LC胆管损伤后胆漏重在预防。肝内胆管分支损伤及肝外胆管侧壁损伤可采取保守治疗,腹腔引流联合内镜治疗明显缩短病程。肝外胆管横断伤需腹腔引流4周,周围炎症基本消退再行肝门胆管盆式空肠内引流术。