内镜、腹腔镜联合治疗高龄急性重症胆管炎系列性方案研究

选择急性重症胆管炎（ACST）患者113例,首先急诊行内镜鼻胆管引流术（ENBD）,待患者平稳渡过急性期后,根据病情特点和结石情况分别行网篮取石、三镜联合胆总管探查术或经十二指肠镜胆肠内引流术（ERBD）。结果：113例ACST患者中,急诊内镜成功106例,无严重并发症及死亡病例。首次急诊内镜取净结石29例,二次内镜取净结石31例。10例行ERBD术,7例急诊腹腔镜胆总管探查、T管引流术。认为内镜、腹腔镜联合及分阶段治疗实现了ACST的全程微创化治疗,手术耐受性好,风险低,提高了存活率和治愈率。     

十二指肠镜、腹腔镜、胆道镜联合治疗胆结石(附20例报告)

目的 探讨十二指肠镜、腹腔镜、胆道镜联合治疗胆囊结石并胆总管结石的可行性与优越性.方法 选择20例胆囊结石并胆总管结石患者,先经十二指肠镜放置鼻胆管引流(ENBD)以便胆道减压,然后完成腹腔镜胆囊切除术,最后完成腹腔镜胆总管切开、胆道镜探查取石术,并一期缝合胆管.统计分析治疗结果,并发症和患者住院天数.结果 20例均痊愈,无并发症发生,住院时间缩短.结论 十二指肠镜、腹腔镜、胆道镜联合治疗胆囊结石并胆总管结石是一种创伤小、有效、安全且可靠的治疗模式.对掌握了腹腔镜下缝扎技术的普外科医师,可作为一种首选手术方法.     

经内镜鼻胆管引流术在腹腔镜胆管探查中的作用

目的：应用经内镜鼻胆管引流术(ENBD)作为腹腔镜胆管探查术(LCBDE)胆管引流方式，探讨其应用价值。方法：对拟行腹腔镜下胆管探查的患者术前进行ENBD，后经胆总管探查切口应用液电碎石、胆道镜取石，将肝内外胆管结石取净，保留鼻胆管于胆管内，将胆总管探查切口一期缝合，常规放置腹腔引流管。术后经鼻胆管造影，肝内外胆管无残余结石，无胆漏，择期拔除腹腔引流管及鼻胆管。结果：共43例患者术前行ENBD，平均6．1d后行LCBDE。36例(83.7％)患者成功进行LCBDE，胆管探查切口一期缝合。术后经鼻胆管造影，发现1例(2．6％)术中胆道镜漏诊--小结石，经内镜取石后痊愈；无胆管狭窄及胆漏等并发症发生。另有7例患者(18．6％)中转开腹手术，其中2例保留鼻胆管，胆管切口行一期缝合，术后顺利拔除鼻胆管。38例患者(88．4％)均成功应用：ENBD进行胆管引流，平均3．2d拔除腹腔引流管，6.7d拔除鼻胆管，无相关并发症发生。结论：ENBD作为LCBDE胆管引流，是安全有效的方式，且术后引流时间短，并发症少，可充分发挥出腹腔镜治疗胆管结石微创的优势。     

腹腔镜联合胆道镜实施保胆手术446例

目的 观察腹腔镜联合胆道镜实施保胆手术的临床疗效.方法 对446例胆囊结石（息肉）患者采用腹腔镜联合胆道镜保胆治疗.胆囊结石患者术后常规口服利胆药物3个月,再间断口服3个月.结果 446例患者均顺利完成腹腔镜联合胆道镜保胆取石（息肉）术,其中68例采用三孔法腹腔镜联合胆道镜保胆取石（息肉）术.手术时间25 ～132（52±6）min.结石数量1～136枚,结石取净率100％.无胆道损伤、胆漏、肠管损伤、出血、气胸等手术相关并发症发生.随访3 ～ 88个月,确认结石复发7例,复发率2.02％,但无1例需要再次手术;保胆摘除息肉的患者无1例复发.结论 腹腔镜联合胆道镜行保胆术治疗胆结石（息肉）有很高的结石取净率和较低的复发率.     

Mirizzi综合征的内镜诊断与治疗

目的探讨微创治疗在Mirizzi综合征诊治中的临床价值。方法回顾性分析2001年6月至2006年5月，采用微创方法（十二指肠镜、胆道镜和腹腔镜联合）治疗Mirizzi综合征患者38例的情况。结果Mirizzi综合征患者均经B超、ERCP等影像学检查，其ERCP典型表现为肝总管可见边缘完整的充盈缺损，充盈缺损以上的肝总管及肝内胆管轻至重度扩张，合并胆囊萎缩及胆囊结石。术前放置ENBD导管，38例中35例通过三镜联合（腹腔镜、胆道镜和十二指肠镜）手术获得成功，无胆漏、胆道出血、胆管狭窄等严重并发症的发生。结论ERCP检查是一种可靠、直接的检查手段可以显著提高Mirizzi综合征患者的术前诊断率，微创手术治疗是安全可行的。     

十二指肠镜、电子胆道和腹腔镜序贯治疗胆总管结石合并胆囊结石834例临床观察

目的：探讨十二指肠镜、电子胆道镜和腹腔镜序贯治疗胆总管合并胆囊结石的临床疗效。方法回顾性分析1999年6月至2010年6月间本院采用十二指肠镜、腹腔镜和电子胆道镜序贯治疗的834例胆总管结石并胆囊结石患者。结果834例接受“二镜”（即腹腔镜、十二指肠镜）治疗,成功793例（95．08％）。41例“二镜”治疗困难转入选择“三镜”（即腹腔镜、十二指肠镜、电子胆道镜）治疗,成功39例（95.12％）,“三镜”治疗未取得成功的2例患者因肝门部及小网膜口严重黏连,无法显露胆总管,遂转为开腹手术治疗。834例患者共出现并发症28例。结论序贯性多镜联合技术治疗胆总管结石合并胆囊结石切实可行,并发症率低,安全可靠,值得临床推广。     

腹腔镜术中联合胆道镜或十二指肠镜治疗胆总管结石

目的总结腹腔镜术中联合胆管镜或十二指肠镜治疗胆囊疾病合并细径胆总管（≤0．8cm）结石的治疗经验。方法首先完成腹腔镜下胆囊切除术。胆管镜法：经胆囊管残端扩张、经胆囊管胆总管汇合部切开或经胆总管前壁切口入路,采用胆管镜取石网取石和液电碎石取净结石,经胆囊管残端输尿管导管胆管引流、T管引流或行胆总管切口即时缝合术。十二指肠镜法：经胆囊管残端插入输尿管导管或斑马导丝至十二指肠腔,经口插入十二指肠镜至十二指肠乳头,针式刀或弓式刀在输尿管导管或斑马导丝指引下对乳头施行切开术,用十二指肠镜取石网或球囊取石。结果191例患者进行了联合治疗。联合胆管镜法治疗117例,术中胆管镜下均取净结石,平均手术时间114min;术后胆漏7例,均经术中常规放置的胆管引流和腹腔引流管引流治愈;术后影像学复查,胆总管切口即时缝合区呈现轻度狭窄影像2例。联合十二指肠镜法治疗74例,68例乳头切开和取石成功,5例乳头切开成功,1例中转为其他术式,平均手术时间97min;术后轻症胰腺炎6例。两组均无肠穿孔、胆管穿孔、大出血、重症胰腺炎等严重并发症,无死亡。结论只要选择病例合适,腹腔镜术中联合胆管镜或十二指肠镜治疗细径胆总管结石是安全、有效且可行的。     

三镜联合治疗肝内外胆管结石的临床应用

[目的]探讨腹腔镜、十二指肠镜和胆道镜联合治疗肝内外胆管结石中的治疗效果。[方法]回顾分析2009年1月~2012年12月150例肝内外胆管结石患者行三镜联合手术的临床资料,并对患者进行随访。[结果]150例胆石症患者三镜联合治疗后,均恢复良好,术后随访1~2年,其中4例复发胆道结石,无胆道狭窄等并发症。[结论]三镜联合治疗复杂性肝内外胆管结石具有创伤少,康复快,及并发症少的特点,技术较成熟,安全、有效,值得临床推广应用。     

腹腔镜联合胆道镜、十二指肠镜治疗胆囊结石合并肝内外胆管结石的效果观察

目的总结应用腹腔镜联合十二指肠镜、胆道镜对胆囊结石合并肝内外胆管结石患者的治疗经验及疗效。方法收集2010年3月-2015年3月于梅州市人民医院肝胆外科就诊的胆囊结石合并肝内外胆管结石患者413例,根据患者个体情况分别进行腹腔镜、胆道镜、十二指肠镜"二镜"或"三镜"联合治疗。结果腹腔镜胆囊切除术(LC)+胆道镜经胆囊管胆总管探查取石术(LTCBDE)31例,成功率29.0%(9/31);LC+LCBDE+胆道镜取石术+T管引流术101例,成功率93.1%(94/101);LC+胆总管探查术(LCBDE)+胆道镜取石术+Ⅰ期缝合术96例,成功率97.9%(94/96);LC+LCBDE+肝部分切除术61例,成功率91.8%(56/61);十二指肠乳头括约肌切开术(EST)+LC或LC+EST 155例,成功率93.5%(145/155);腹腔镜+十二指肠镜+胆道镜(同时)10例,成功率90%(9/10)。19例患者中转开腹,治疗总成功率95.4%(394/413),各组病例均治愈,无严重并发症,无死亡病例。结论腹腔镜联合胆道镜、十二指肠镜治疗胆囊结石合并肝内外胆管结石是切实可行和安全可靠的。     

经皮肝Ⅰ期胆道造瘘联合胆道镜治疗胰十二指肠切除术后继发胆管结石

目的探讨经皮肝I期胆道造瘘(PTOBF)联合胆道镜治疗胰十二指肠切除术后继发胆管结石的安全性和有效性,探讨胰十二指肠切除术后胆肠吻合口狭窄的原因及处理对策。方法回顾性分析2017年10月至2021年5月于山东省第二人民医院接受PTOBF联合术中硬质胆道镜、术后电子胆道镜治疗的12例胰十二指肠切除术后继发胆管结石患者的临床资料。结果所有患者均成功行PTOBF,经胆道镜取净肝胆管结石,术中发现胆肠吻合口狭窄8例(线结性狭窄3例),经胆道气囊扩张及胆肠吻合口线结拆除,7例近期缓解(87.5%),1例再次胆肠吻合手术。结论PTOBF联合胆道镜治疗胰十二指肠切除术后继发胆管结石安全有效,取净率高,可缓解胆肠吻合口狭窄。     

腹腔镜下胆肠内瘘的诊治探讨

目的探讨腹腔镜下胆肠内瘘的诊断及治疗措施。方法对5年间术中发现14例胆肠内瘘患者的临床资料作回顾性分析，评价术中诊断、处理方法以及临床疗效。结果全部病例均在腹腔镜手术中确诊，11例胆囊十二指肠瘘，3例胆囊结肠瘘，均在腹腔镜下完成手术，平均手术时间约100min；术后1周左右治愈出院，无手术并发症发生。结论对于胆肠内瘘，腹腔镜手术在诊断和治疗上是一种安全有效的方法。     

Laparoscopy for pre-operative staging and assessment of operability in gastric carcinoma.

Laparoscopy was performed in 40 patients with gastric carcinoma, whose lesions were otherwise considered amenable to operation, in order to more accurately stage the disease and ascertain the prospect of resectability. Laparoscopy disclosed hitherto unrecognized distant metastases in 5 cases (12.5%) and locally advanced, unresectable neoplasia in 11 cases (27.5%). Thus, laparoscopy served as a basis for avoiding the burden of futile laparotomy in 16 patients (40%). Laparoscopy confirmed the feasibility of resection in 24 patients, and this finding was borne out in 20 of 23 patients surgically explored (87%). The overall diagnostic accuracy of laparoscopy was 91.6%. Laparoscopy was performed in these patients with no mortality or morbidity. We conclude that laparoscopy is an effective means of evaluating resectability of gastric carcinomas and can provide valuable help in planning surgical approach.     

胆道镜治疗术后胆道难取性残余结石

目的 探讨X线引导胆道镜经T管隧道超选择胆道造影方法及其对胆道残留结石介入治疗技术的临床价值.方法 在术后保留T管隧道的条件下,在X线机透视下精确引导胆道镜、导丝、导管、取石网篮等对疑难性胆道改变进行超选择性造影,并对胆道术后残留结石及胆道狭窄进行治疗的45患者进行分析.结果 7例胆管粘连性狭窄胆道反复行局部冲洗及扩张治疗后胆道通畅,2例疤痕性胆道狭窄行扩张效果不佳;7例胆总管结石并左右肝Ⅱ或Ⅲ级胆管多发结石1.5 h内顺利取出;6例左右肝胆管狭窄并多发结石1.0 h内顺利取出;6例肝左右Ⅱ或Ⅲ级胆管多发巨大结石使用液电碎石机碎石后取出,耗时2.0 h以上;6例左右肝Ⅱ～Ⅳ级胆管结石1.5 h内顺利取出;6例单纯胆总管结石30 min内顺利取出.3例左右肝胆管狭窄并多发结石因胆道狭窄未能取出;2例左右肝Ⅱ或Ⅲ级胆管结石因T管隧道出血未能取出.结论 X线引导胆道镜治疗术后胆道残余结石的方法具有易行性、科学性,能提高治疗胆道残余结石的工作效率和成功率.     

Laparoscopy in primary carcinoma of the gallbladder.

Fifty-three patients with suspected gallbladder carcinoma underwent ultrasonography and laparoscopy. Laparoscopy correctly excluded malignancy in five patients when ultrasonography had suggested gallbladder neoplasia. Of 48 patients with gallbladder carcinoma, laparoscopy identified 46 (95.8%) as compared with 30 (62.5%) by ultrasonography (p less than 0.001). Distant metastases in the liver, parietal peritoneum, or omentum were present in 41 patients (85.4%) and were detected by laparoscopy in 39 (sensitivity 95%) and by ultrasonography in 21 (sensitivity 51.2%) (p less than 0.001). Combination of ultrasonography and laparoscopy improved the overall diagnostic accuracy to 100%. Laparoscopy provided histological diagnosis of the disease in 36 patients (75%) and circumvented unnecessary laparotomy in 40 (83.3%) patients by revealing advanced or associated disease. When laparoscopy suggested that the disease was localized, the diagnosis was correct in 83.3% (5 of 6) patients. Laparoscopy under local anesthesia is useful in the diagnosis and staging of gallbladder carcinoma, and therefore helpful in planning management.     

三镜(腹腔镜、十二指肠镜、胆道镜)联合治疗胰胆疾病

目的探讨内镜联合、微创治疗在胰胆疾病中的应用。方法病例筛查,一镜应用(ERCP)、二镜联合、三镜联合应用的指征,术中应注意事项,术后观察并发症等。一镜26例即十二指肠镜(ERCP);二镜方案I:腹腔镜及十二指肠镜7例;二镜方案Ⅱ:腹腔镜+胆道镜17例;三镜方案10例:十二指肠镜、腹腔镜、胆道镜三者联合应用。结果 ERCP 26例,其中2例插管未成功,成功率92.6%。1例2次取石。并发症:2例乳头切开处少量渗血,2例并发高淀粉酶血症。二镜方案I,二镜方案Ⅱ,三镜均操作成功,未出现并发症。结论内镜联合微创治疗取长补短,成功率高,降低了并发症,疗效确切,安全性高,经济实用,体现了微创治疗的优越性。     

腹腔镜检查在疑难性腹部疾病病因诊断中的应用

目的　探讨腹腔镜检查在疑难性腹部疾病病因诊断中的价值。方法　应用电视腹腔镜对１４ 例临床诊断不明的腹水和腹块患者进行腹腔镜检查及活检。结果　全部病例检查成功并获确诊,同时发现罕见的腹部疾病７ 例,无１例并发症发生。本组临床和影像学诊断与腹腔镜病理诊断符合率分别为３５．７１％ （５／１４）和２８．５７％ （４／１４）;腹腔镜肉眼诊断与病理诊断符合率为４２．８６％ （６／１４）。结论　腹腔镜检查是疑难性腹部疾病病因诊断中的一种具有确诊价值和比较安全可靠的方法;腹腔镜直视下对病灶（结节或肿块）进行多部位、多点和大块组织活检可使病理诊断阳性率提高达１００％ 。     

Diagnostic laparoscopy: a prospective review of 100 cases

The perceived role of laparoscopy in the management of liver disease has changed because of the widespread use of image-guided biopsy. Laparoscopy, however, permits direct inspection of the liver surface and the abdominal cavity, as well as tissue sampling. In order to assess the utility of laparoscopy, and specifically, the diagnostic value of direct visualization of the liver surface, we prospectively collected information on 100 consecutive patients undergoing laparoscopy. The contribution of the laparoscopic findings to patient management and the predictive value of the laparoscopic diagnosis compared to histology were assessed. Laparoscopy had a 95% diagnostic yield. Liver surface characteristic consistent with malignancy, cirrhosis, or fibrosis were sensitive and specific predictors of histologic findings. We conclude that laparoscopy continues to be a valuable diagnostic procedure, especially in cases where accurate assessment of the liver architecture is required.     

增大型甲亢^131I治疗给药系数与疗效分析

目的 对^131I治疗甲亢常规公式增设给药系数，以提高增大型甲亢的一次治愈率，降低甲低率。方法 对比分析增加系数组116例和常规对照组143例的治愈率、甲低率、好转率、二次服药率。结果 增加系数组较对照组一次治愈率明显提高，由75．68％提高到83.62％（P〈0.01）。增加系数后痊愈率由58.04％提高到80.17％（P〈0．01）；二次服药率由14．69％降到6．03％（P〈0．01）；一过性甲低率和甲低率未见显著性差异。结论 增加系数后提高了增大型甲亢的一次治愈率，而甲低率未见明显增高。     

Minilaparoscopy versus conventional laparoscopy in the diagnosis of hepatic diseases

BACKGROUND: Minilaparoscopy (ML) is being used increasingly in the diagnosis of liver disease. This is a prospective study of the accuracy and safety of ML compared with conventional laparoscopy (CL) in the diagnostic workup of liver disease. METHODS: One hundred four patients with suspected liver disease were randomized either to undergo CL (n = 50) or ML (n = 54). CL was performed with a standard Storz laparoscope (? 11 mm, Storz GmbH, Tuttlingen, Germany) according to accepted guidelines. For ML a 1.9-mm small-diameter optical telescope was used (Richard Wolf GmbH, Knittlingen, Germany). In all cases, an attempt was made to obtain a liver biopsy specimen. RESULTS: Laparoscopy could successfully be performed in 100 of 104 (96%) patients with simultaneous procurement of biopsy specimens of the liver. In 4 cases, postoperative adhesions prevented sufficient inspection of the liver and in another patient the technique was switched from CL to ML for the same reason. Minor self-limiting bleeding at the biopsy site was observed in 20% of CL and 15% of ML examinations. One patient in each group required surgery for uncontrollable bleeding from the biopsy site. The patients' subjective perception of the examination was comparable in both groups. Compared with CL, ML could be performed in a significantly shorter time (27 vs. 22 min, p < 0.05). Liver cirrhosis diagnosed during laparoscopy was histologically confirmed in 77%, independent of the method of examination. Cirrhosis was diagnosed by histology in 1 of 14 (7%) and 1 of 21 (5%) patients without macroscopic signs of cirrhosis. CONCLUSIONS: Laparoscopy with a small diameter telescope in the workup of liver disease is comparable in terms of results to CL. Possible advantages of ML are a shorter examination time and a subjective impression of lower degree of invasiveness.