胆道手术中常规应用胆道镜的临床意义

目的探讨胆道手术中常规应用胆道镜的临床意义。方法对我院2003年10月至2009年7月期间使用术中胆道镜处理的136例胆道疾病患者的临床资料进行分析和总结。结果116例肝内、外胆管结石,经术中纤维胆道镜检查、取石和针对性手术治疗,肝外胆管结石取净率为100%(85/85);肝外胆管和肝内胆管残留结石的发生率(简称残石率)分别为0(0/85)和22.6%(7/31),总残石率为6.0%(7/116)。经胆道镜探查发现良性肝内胆管狭窄13例,恶性肝内、外胆管狭窄8例;通过胆道镜取活检,确诊肝门部胆管癌4例,胆总管癌4例,胆总管下段息肉2例,肝胆管结石合并左肝胆管内胆管癌3例;16例梗阻性黄疸的病因得以证实。全部病例均无胆管撕裂、膈下脓肿、急性胆管炎等严重并发症发生。结论胆道镜可大大降低胆管残石率,提高胆道疾病的确诊率,对其治疗方案起到合理的指导作用,术中胆道镜对明确黄疸病因有其独特的优势,胆道镜在胆道疾病诊治中作用显著,值得推广应用。     

胆道镜治疗胆管结石常见结石残留原因分析及对策

目的：探讨胆道镜治疗胆管结石，常见结石残留的原因及对策。方法：回顾性分析219例胆管结石患者术中应用胆道镜探查取石的临床资料。结果：219例患者中，21例术后有胆管结石残留（9．59％），其中术中已知结石残留8例，术后经T管造影和胆道镜证实有结石残留13例。21例中包括急性化脓性梗阻性胆管炎伴感染性休克5例，肝内胆管结石伴胆管开口狭窄5例，肝内胆管结石伴胆管变异4例，十二指肠乳头括约肌内结石2例，胆总管下段节段性狭窄伴结石2例，术后胆道镜探查明显胆总管远段结石3例。结论：胆道镜治疗胆管结石时要仔细操作，逐一探查，术中B超和造影对降低结石漏诊率有帮助。     

纤维胆道镜在肝内胆管结石治疗中的应用

纤维胆道镜是肝内胆管结石诊断和治疗的重要手段。我院自1993年1月～1996年6月间，利用OlympusCHFP—20型纤维胆道镜，在术中术后共检查治疗肝内胆管结石病人37例，收到良好效果，现将治疗体会报告如下：1临床资料1．1一般资料本组37例，男9例，女28例，年龄20岁～62岁。术中应用15例，术后应用22例。1．2临床应用术中应用15例病人，肝内胆管结石合并胆总管结石11例，单纯肝内胆管结石4例，其中13例手术中取净，2例肝内正～巫级胆管残留少量结石，残石率为13．3％，残余结石均于术后一次取净。术后应用22例病人，肝内胆管结石18例，合并胆…     

经纤维胆道镜液电碎石术治疗胆道结石

本文采用经纤维胆道镜液电碎石术,治疗213例各种术后胆道残留结石的病人,其中胆总管结石19例,左肝管结石28例,右肝管结石22例,左右肝管结石124例,左右肝管、胆总管结石20例。全部病人均被取净结石,未发生明显并发症,无死亡。其中一次胆道镜取净结石151例,二次胆道镜取净结石48例,三次胆道镜取净结石14例。经纤维胆道镜液电碎石术为胆道结石的治疗,尤其是肝内胆管结石的治疗提供了一种新的有效的治疗方法。     

术中胆道镜在肝胆管结石手术中的应用

目的探讨术中使用纤维胆道镜在肝内胆管结石外科手术治疗中的临床应用方法及价值。方法回顾分析我院1991年2月至2011年2月外科手术治疗肝内胆管结石病人352例,根据结石部位的不同采取不同的手术方式,包括胆总管探查术、肝左外叶切除、肝左外叶切除+胆总管探查术、肝左叶切除术、肝左叶切除术+胆总管探查术、肝右后叶切除术、右肝叶切除+胆总管探查术、联合肝叶切除+胆总管探查术,分析术中应用胆道镜取石后不同部位的手术后残石率及术后胆道镜再取石后残石率。结果不伴有肝内胆管狭窄的单纯性左肝外和/或左肝内叶结石行胆总管切开取石78例,术后胆道镜取石后无结石残留;孤立性肝内胆管结石行肝左外叶切除、肝左叶切除或肝右后叶切除术119例,可获治愈性效果,无结石残留;肝左外叶切除+胆总管探查术、肝左叶切除术+胆总管探查术、右肝叶切除+胆总管探查术、联合肝叶切除+胆总管探查术,手术后残石率及术后胆道镜再取石后残石率分别为9.5%、2.3%、14.6%、20.9%及4.8%、0%、6.3%、13.9%,总计352例病人术中应用胆道镜取石后残石率及术后胆道镜再取石后残石率分别为5.7%(20/352)、2.8%(10/352)。结论孤立性肝内胆管结石行肝叶切除,可手术治愈结石病,不同部位的肝内胆管结石病外科手术治疗术中应用纤维胆道镜取石,可减少残石率,结合手术后的胆道镜取石,能更加显著降低残石率。     

胆道镜下球囊扩张术治疗肝内胆管残留结石合并狭窄

目的 探讨胆道镜下球囊扩张术治疗肝内胆管残留结石合并狭窄的临床经验。方法 回顾性分析我院2011年2月至2013年2月经胆道镜下球囊扩张术治疗的15例肝内胆管残留结石合并狭窄的患者临床资料。结果 15例中男6例,女9例。本院手术4例,外院转诊11例。除1例因胆管角度太大,未能取净结石,带管出院后引流管脱落,未及时来院处理;其余病例经胆道造影及胆道镜检查均未见结石残留。结石取净率达93.3%。无胆道感染、大出血、窦道撕裂等严重并发症发生。结论 胆道镜下球囊扩张术治疗肝内胆管残留结石合并狭窄,可有效解除胆管的局限性狭窄,提高结石的取净率,具有创伤小、治愈率高、并发症 少、疗效确切的优点,可作为胆管术后残留结石并狭窄的防治措施之一。     

胆道探查术中及术后纤维胆道镜应用的评价

目的探讨纤维胆道镜在胆道探查术中及术后的应用价值。方法对113例在胆道探查术中及术后应用纤维胆道镜治疗患者的疗效进行回顾性分析。结果 23例胆总管扩张合并黄疸且术前未见结石的患者,其中19例术中胆道镜发现结石并于术中取净结石,2例炎性狭窄,1例胆管癌,1例未见异常。58例胆总管结石患者术中胆道镜取净结石。32例肝内、外胆管结石患者术中胆道镜取净结石21例;2例胆道镜发现结石集中于肝左外叶合并肝内胆管狭窄,行肝左外叶切除;其余9例患者的结石术中未取净,于术后6～8周再经胆道镜T管窦道取净结石。113例患者术后均无严重并发症发生。术后获随访98例（86.7%）,随访时间6～24个月,平均14个月,2例复发,其余96例未见结石复发。结论术中应用纤维胆道镜可明确胆管内病变,降低胆管残余结石的发生率;术后经T管窦道取石是治疗胆管残余结石的有效方法,可避免再次手术的痛苦。     

腹腔镜肝左外叶切除联合胆道镜治疗肝左外叶为主的结石23例

目的探讨腹腔镜肝左外叶切除联合术中应用胆道镜在治疗肝左外叶肝内胆管结石中的可行性及安全性。方法 2014年11月至2016年10月对23例肝左外叶为主的肝内胆管结石病人行腹腔镜肝左外叶切除联合胆道镜检查及取石,其中9例病人合并胆总管结石,合并胆囊结石11例,同时合并胆总管结石及胆囊结石7例,合并肝左内叶结石3例。结果 23例病人均成功行腹腔镜下肝左外叶切除,并通过肝断面胆管经胆道镜对肝内胆管及胆总管检查、取石,9例病人通过胆道镜取出胆总管内结石,11例病人联合胆囊切除,3例病人通过胆道镜取出肝左内叶结石。所有病人手术顺利,手术时间为142~188 min,平均(157±27)min;术中出血量为150~550 ml,平均(240±52)ml;胃肠功能恢复时间为1~3 d,平均(1.7±0.6)d;术后住院时间为7~13 d,平均(9.0±2.2)d。术后1例病人发生肝断面渗血,2例病人发生胆漏,均经保守治疗治愈。术后随访病人3~24个月,均未见结石残留及复发。结论腹腔镜肝左外叶切除联合术中应用胆道镜治疗肝左外叶肝内胆管结石具有疼痛轻、恢复快、残石率低的优势,是一种安全、可行的手术方式,可在临床中广泛应用。     

肝内胆管结石不同术式对结石残留及复发的影响

目的 前瞻性研究肝内胆管结石不同术式对术后结石残留复发率的影响.方法 选择167例肝内胆管结石病人,按肝内外胆管结石分布、胆管狭窄和并发症情况将病人分组,比较各组病人不同术式(胆总管切开取石术、胆肠内引流术、胆总管切开取石加纤维胆道镜取石术、肝叶/段切除术)下术后结石残留和二年内复发情况.结果 初次手术选择胆总管切开加纤维胆道镜取石术或肝叶/段切除术,其术后残石率及结石复发率低于初次手术单纯行胆总管切开取石术者(P＜0.05);肝叶/段切除术的术后残石率及结石复发率较胆总管切开加纤维胆道镜取石术有降低趋势;合并胆总管结石的病人行肝叶/段切除术或胆总管切开加纤维胆道镜取石术后,其残石率与无胆总管结石者无显著性差异(P＞0.05).结论 肝内胆管结石较好的治疗方法为肝切除术或胆总管切开加纤维胆道镜取石术.     

规则性肝脏切除联合胆道镜治疗肝内胆管结石的疗效评价

目的探讨规则性肝脏切除联合胆道镜治疗肝内胆管结石的安全性和有效性。方法回顾性分析我院2012年1月至2017年12月间采用肝脏切除联合胆道镜治疗的65例肝内胆管结石患者的临床资料,评价其疗效。结果所有患者均顺利完成手术,手术时间170～330分钟,平均237.1±46.2分钟,术中常规切开胆总管行胆道镜探查取石,53例术中取净结石,术中结石清除率81.5%,术后12例结石残留,残留结石患者术后经1～4次胆道镜取石,11例成功取出,围手术期死亡术1例,术后随访6例结石复发。结论规则性肝脏切除联合胆道镜取石治疗肝内胆管结石安全有效疗,联合胆道镜有助于选择正确的肝脏切除范围,减少术后结石的残留和复发。     

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??A one-stage percutaneous tract dilation technique in percutaneous transhepatic cholangioscopy (PTCS) for patients with bile duct stones: A report of 35 cases LOU Jian-ying, CHEN Wei, WANG Ji, et al. Department of Hepato-Pancreato-Biliary Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
Corresponding author: LIANG Ting-bo, E-mail: liangtingbo@zju.edu.cn
Abstract Objective To evaluate the safety, efficiency, indications and procedure of percutaneous transhepatic cholangioscopy (PTCS), using a one-stage percutaneous tract dilation technique, in patients with intrahepatic and/or common bile duct stones. Methods The medical records of 35 cases of intrahepatic and/or common bile duct stones treated by PTCS, using a one-stage tract dilation technique, from January, 2015 to April, 2017 in the Second Affiliated Hospital of Zhejiang University School of Medicine were studied retrospectively. All the patients were treated with lithotripsy and basket stone removal through PTCS using one-stage percutaneous tract dilation technique after percutaneous transhepatic cholangial drainage (PTCD). The perioperative morbitity, stone clearance rate, and stone recurrence rate were analyzed. Results The intrahepatic biliary duct and common bile duct were successfully accessed in all 35 cases using ultrasound-guided one-stage percutaneous tract dilation PTCS technique. The stones were completely removed (level A) in 65.7% (23/35) of the cases including 18 cases of intrahepatic stones and 5 cases of common bile duct stones. The stones were almost cleared (level B) in 22.9% (8/35) of intrahepatic stones cases. Stone clearance was achieved in 31 (88.6%) cases (level A and B). One case suffered PTCD site bleeding and one case had percutaneous transhepatic tract rupture during the secondary stone removal procedure. There were no other serious procedure-related complications such as life-threatened bleeding, bile leak and conversion to laparotomy. With follow-up of 1-28 months, 6 (26.1%) of 23 cases of level-A stones clearance had recurrent intrahepatic stones and cholangitis. Conclusion PTCS using one-stage dilation of the tract, is an effective, safe and alternative minimal invasive method forintrahepatic and/or common bile duct stones when surgery or peroral approach is not indicated.     

术中经胆道镜液电式碎石在肝内胆管结石中的应用

目的　探讨胆道探查术中胆道镜网篮取石加碎石病例的疗效 ,分析其技术要点。方法　回顾性分析我院 2 0 0 2年 6月至 2 0 0 3年 6月施行胆道探查术中胆道镜网篮取石加碎石术 1 5例的治疗经过 ,并与同期采用单纯胆道镜网篮取石的 35例胆道结石病例进行比较。结果　 1 5例胆道镜碎石病例均获得了胆道结石的一次性完全清除 ;而对照组中有 31例获得一次性完全清除 ,2例术后多次胆道镜取石后清除 ,2例未能完全清除。结论　术中胆道镜碎石技术可明显提高胆道结石的完全清除率 ,减少残余结石的发生率     

Endoscopic management of retained bile stones with an indwelling T-tube

Background Endoscopic sphincterotomy (ES) is widely used for the treatment of residual bile duct stones in patients who had common bile duct (CBD) exploration and T-tube insertions. Methods In a 4-year period 45 patients were referred for endoscopic removal of residual bile duct stones. All patients had been operated 7–15 days earlier for choledocholithiasis and had a T-tube in the common bile duct (CBD). Results Four patients were excluded. Three patients had a periampullary carcinoma and the fourth patient had no residual stone seen at cholangiography. All patients had a successful ES, conventional in 34, precut-knife in 3, and with the rendezvous technique in 4 patients. In 24 patients, all having stones distal to the T-tube, complete clearance of the CBD was achieved during one session and the T-tube was removed after 48 h. In the remaining 17 patients (15 having stones proximal to the T-tube), the T-tube had to be removed first and following stone extraction, a plastic stent was inserted in the CBD. Complete bile duct clearance and stent removal was achieved in a second session 3–4 weeks later. There were no serious complications or biliary related symptoms after the procedures and after a mean follow-up period of 18 months. Conclusion The endoscopic technique is safe and efficient for the treatment of residual stones after CBD exploration with a T-tube insertion, offering immediate cure compared to the percutaneous techniques. It is also an ideal method for the diagnosis of periampullary carcinomas. Online publication: 24 August 2004     

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.     

One hundred and twenty-five consecutive choledochotomies for suspected lithiasis without mortality. Current state of complications from common bile duct surgery]

The postoperative courses of 125 consecutive surgical common bile duct explorations performed between 1983 and 1990 were analysed. All cases of common bile duct lithiasis, but three, were operated on. Intraoperative cholangiography was performed in 98 percent and cholangioscopy in 92 percent of patients; common bile duct stones were found in 95 patients (76 percent); the common bile duct was sutured without drainage in 78 patients (58 percent). There were no deaths. Morbidity was 14 percent, of which 10 percent were serious. Four percent of common bile ducts retained stones. The specific morbidity was 4 percent. These results confirm the reliability of surgical management of common bile duct stones and therefore should be considered for the evaluation of new procedures, such as laparoscopic treatment of common duct stones, or combined laparoscopic cholecystectomy and endoscopic sphincterotomy.     

腹腔镜、胆管镜、扩张导管、T管支架治疗肝左外叶及胆总管结石17例

目的探讨腹腔镜、胆管镜、扩张导管(逐级扩张导管、球囊导管)、T管支架(T形管＋塑料胆管支架,LCDTS)治疗肝左外叶及胆总管结石的应用体会。 方法回顾性分析2002年4月至2017年9月间符合入选标准的17例患者的临床资料。 结果腹腔镜下切除肝左外叶和探查胆总管17例,切除胆囊12例。胆管镜取石、逐级导管扩张左肝管和乳头并留置LCDTS 52.9% (9/17),逐级导管扩张左肝管和推挤左肝管结石出总管切口并留置LCDTS 23.5% (4/17),逐级导管联合球囊导管扩张左肝管并留置LCDTS 11.8%(2/17),因肝内胆管残石和狭窄扩张左肝管并留置LCDTS 11.8% (2/17)。术后残石2例(11.8%),胆汁漏1例(5.9%)。无肠穿孔、胆管穿孔、大出血、急性胰腺炎等并发症,无围手术期再手术和死亡患者。术后总并发症发生率为17.6%(3/17)。 结论只要病例选择合适,LCDTS治疗肝左外叶及胆总管结石是可行、有效和安全的。     

腹腔镜胆总管探查一期缝合胆道内支架管的应用经验

目的总结腹腔镜胆总管探查一期缝合胆道内支架管应用治疗胆总管结石的经验。方法回顾性分析我院自2016年1月至2018年1月期间96例胆总管结石病例,其中腹腔镜胆总管探查一期缝合组(一期组)47例,腹腔镜胆总管探查一期缝合胆道内支架置入组(支架组)49例,比较两种术式的手术相关情况(手术时间和术中出血量)、术后恢复情况(首次进食时间、腹腔引流时间及术后住院天数)、术后并发症(胆漏、腹腔出血、结石残留)。结果两组病例均治愈出院,无手术死亡,术后无结石残留。在首次进食时间、腹腔引流时间及术后住院天数,支架组优于一期组(P0.05);在手术时间、术中出血量、术后并发症(出血、胆漏)发生率,两组病例之间的差异无统计学意义(P0.05),4例胆漏病人(一期组3例,支架组1例)经短期引流后治愈,2例出血病人(一期组1例,支架组1例)经输血等保守治疗后治愈。支架组术后2～3周行胃镜检查拔除胆道内支架管,其中有部分病例胆道内支架管已自行排出。术后随访1～6月,无胆道结石复发、胆道狭窄。结论腹腔镜胆总管探查一期缝合胆道内支架管应用具有创伤少、恢复快、住院时间短、护理简单,不增加胆道并发症的发生率,是治疗胆总管结石的一种有效、可行方法。     

十二指肠镜、腹腔镜序贯治疗胆石症2 248例分析

目的探讨十二指肠镜、腹腔镜序贯性诊治胆石症的价值. 方法回顾性分析2000年1月～2004年12月采用十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症2 248例的临床资料. 结果确诊胆囊结石1 817例,胆囊结石合并胆总管结石431例.B超诊断为胆囊结石2 021例中,行术前ERCP 690例,发现胆总管结石213例;术中胆道造影(IOC)85例,发现胆总管结石10例;腹腔镜胆囊切除(LC)术后胆总管残余结石6例,并经EST治愈.B超诊断胆囊结石合并胆总管结石227例中,ERCP证实胆总管结石202例.行LC 1 817例,EST LC 395例,LBDE 36例(其中胆管一期缝合26例,T管引流10例).全组中转开腹28例(1.2%),并发症52例(2.3%). 结论十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症,体现了内镜、腔镜联合应用的优势,术后残余结石率低,微创治疗成功率高.     

Simultaneous laparoscopic treatment for common bile duct stones associated with acute cholecystitis. Results of a prospective study

Laparoscopy for the management of acute cholecystitis has gained wide acceptance. Although it is well known that acute cholecystitis may be complicated by common bile duct stones in up to 15% of cases, to date there are no published studies addressing the management of common bile duct stones detected during laparoscopy for acute cholecystitis. We postulated that, when found, common bile duct stones associated with acute cholecystitis could be effectively and safety managed during the same laparoscopic procedure. We report on a five-year prospective study (2001-2005) involving 313 unselected patients who presented with a clinical diagnosis of acute cholecystitis (confirmed by specimen examination) and without any contraindication to laparoscopy. At surgery, transcystic cholangiograms were obtained in 289 (92%); the other 24 were excluded from the study. With an established diagnosis of common bile duct stones, attempts were made to clear the common bile duct by transcystic basket retrieval, ERCP or choledochotomy. Prevalence of common bile duct stones in acute cholecystitis, success of laparoscopic common duct clearance, conversion rate, operative time, morbidity, and postoperative hospital stay were the main outcome measures. Common bile duct stones were found in 63 pts (21.7%) presenting with acute cholecystitis. At laparoscopy, 12 patients (19%) required conversion to open surgery, 3 of these being due to failure to achieve common bile duct clearance. Common bile duct stones were cleared entirely laparoscopically in 51 patients (81%) by means of transcystic stone retrieval (38 pts, 75%), ERCP (12 pts, 23%) or choledocotomy (1 pt, 2%). At intention to treat analysis, patients undergoing cholecystectomy plus common bile duct clearance compared to those undergoing cholecystectomy alone, spent significantly more time in the operating theatre (mean 192 min vs 118 min, p < 0.001), needed open conversion more frequently (19% vs 6.1%, p = 0.0045), and had a higher overall morbidity rate (17.4% vs 4.4%, p = 0.015). The simultaneous procedure also adversely affected the postoperative hospital stay (mean 4.8 vs 3.4 days, p = 0.0164). Mortality was nil in both groups. The prevalence of common bile duct stones in patients presenting with acute cholecystitis should not be neglected. When common bile duct stones are found, clearance may be obtained laparoscopically in a substantial number of cases without any need for open surgery. The simultaneous laparoscopic approach for acute cholecystitis and common bile duct stones remains, however, a highly skilled and technically demanding procedure. Although a moderate incidence of drawbacks is observed, the results should be interpreted from the point of view of an all-in-one procedure that allows the patients to be cured without needing any further sequential interventions.     

Percutaneous transhepatic cholangioscopy

Since 1983, percutaneous transhepatic cholangioscopy has been performed in 50 patients for both therapeutic and diagnostic purposes. Percutaneous transhepatic cholangioscopy was used to evaluate the nature of obstructive jaundice in 15 patients and bile duct stones were removed in 35 patients, 27 of whom also had intrahepatic duct stones. The overall success rate for stone removal was 80 per cent. Complications were few with no mortality. Emergency surgery was necessary in two patients, one for subphrenic haematoma, the other for a bile leak. Percutaneous transhepatic cholangioscopy is an effective and safe method for management of biliary stones and is a useful procedure for establishing the diagnosis of obstructive jaundice.