腹腔镜联合十二指肠镜在急性胆源性胰腺炎治疗中的应用

目的探讨胆囊结石继发细径胆总管结石和轻型急性胆源性胰腺炎的手术治疗方法和适应证。方法完成腹腔镜胆囊切除后,经胆囊管残端插入输尿管导管至十二指肠肠腔,经口插入十二指肠镜至十二指肠乳头,针式刀在输尿管导管指引下施行乳头切开术,用十二指肠镜取石网或球囊取石,胆总管腔内留置输尿管导管行胆管引流。结果发病1～7d内急诊或早期手术治疗轻型胆源性急性胰腺炎53例,乳头切开取石39例,乳头切开经胆囊管残端输尿管导管胆管引流5例,经胆囊管残端输尿管导管胆管引流7例,中转为其他术式2例。术后胆管无残留结石,轻型胰腺炎无加重。无胃肠穿孔、胆管穿孔、胆漏、大出血、重症胰腺炎等手术并发症,无死亡。术后其他多种并发症和合并症均经非手术综合疗法治愈。结论只要选择合适的轻型胆源性急性胰腺炎病例,于发病1～7d内急诊或早期行腹腔镜术中联合十二指肠镜手术,是可行、有效和安全的。     

十二指肠镜联合腹腔镜治疗急性胆源性胰腺炎

目的 探讨急性胆源性胰腺炎十二指肠镜联合腹腔镜治疗的可行性、安全性和时机.方法 运用腹腔镜及十二指肠镜对41例急性胆源性胰腺炎首先行十二指肠镜下乳头括约肌切开取石(EST),同时置入鼻胆管引流(ENBD);合并胆囊结石者实施腹腔镜胆囊切除术(LC).结果 全组41例,其中2例为胆总管泥沙样结石,38例胆管结石经EST取出,除1例因十二指肠球部明显畸形检查失败,其余所有病例均行ENBD.合并胆囊结石32例,急诊或择期施行LC,31例成功,1例中转开腹.术后住院时间(16±5)d,随访12~24个月,无严重手术并发症,无一例死亡.结论 两镜联合治疗急性胆源性胰腺炎创伤小,腹腔干扰轻,安全有效,术后恢复快,充分体现了微创手术的可行性,只要掌握好手术时机是目前比较理想的治疗手段.     

两镜法治疗胆囊合并胆总管结石36例疗效分析

目的探讨十二指肠镜乳头括约肌切开术(endoscopic sphincterotomy, EST)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy, LC)治疗胆囊合并总胆管结石的疗效. 方法胆囊合并胆总管结石36例,首先经EST取出胆管结石,然后采用LC切除胆囊. 结果 EST成功34例(94.4%); 失败2例,均因胆管末端狭窄,开腹行胆管空肠吻合术治愈.腹腔镜手术34例,成功32例(94.1%),2例中转开腹. 结论 EST联合LC是治疗胆囊合并胆管结石的优选术式,EST失败者主要原因为胆管狭窄,应首选胆管空肠吻合术.     

十二指肠镜联合腹腔镜治疗胆囊结石合并胆总管结石

目的:探讨内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)或内镜十二指肠乳头球囊扩张术(endoscopic papillary balloon dilatation,EPBD)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)同期治疗胆囊结石合并胆总管结石的可行性。方法:2014年1月至2015年12月为75例胆总管结石合并胆囊结石患者行EST或EPBD取石成功后改全麻下行三孔法LC。结果:71例成功施行EST或EPBD联合LC同期手术,成功率94.7%。2例患者EST成功后因胆囊与周围组织形成致密粘连中转开腹行胆囊切除术;2例患者EST取石未成功改LC+胆总管切开胆道镜取石T管引流术。术后2例患者出现急性胰腺炎,2例患者出现十二指肠乳头出血,均经保守治疗后痊愈;2例患者术后鼻胆管造影发现残余结石,经二次取石后痊愈出院。术后平均随访(13.25±3.45)个月,行腹部彩超及肝功能检查未见明显异常。结论:在严格把握手术指征的基础上,EST或EPBD联合LC同期治疗胆囊结石合并胆总管结石可显著减少患者住院次数、缩短住院时间、降低住院费用,是安全、可行的。     

腹腔镜十二指肠镜联合治疗胆囊结石合并胆总管结石

目的探讨腹腔镜十二指肠镜联合治疗胆囊结石合并胆总管结石的效果和安全性。方法1998年5月～2008年7月,应用内镜下十二指肠乳头切开术（endoscopic sphincterotomy,EST）与腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）联合成功治疗胆囊结石合并胆总管结石459例。首先行ERCP,证实胆总管结石后行EST,网篮或气囊导管取石,必要时放置鼻胆管引流,血、尿淀粉酶正常,无发热、腹痛后l～5天内在全麻下行LC。结果成功完成内镜胆管取石及LC共438例,成功率95.4%;19例内镜取石未成功而行开腹手术;2例因无法耐受改为保守治疗。术后并发高淀粉酶血症73例,轻型胰腺炎32例,上消化道出血4例。252例术后随访3～6个月,无逆行胆管炎、EST后乳头狭窄等并发症,无胆管结石残留。结论腹腔镜十二指肠镜联合治疗胆囊结石合并胆总管结石安全可行,创伤小。     

三镜联合治疗胆囊结石合并胆总管结石临床疗效及预后分析

目的:比较腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)联合胆总管探查术(腹腔镜、胆管镜和十二指肠镜三镜联合治疗)与内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)联合LC治疗胆囊结石合并胆总管结石老年病人(≥65岁)的临床疗效.方法:回顾性...     

十二指肠镜、腹腔镜同期治疗胆囊结石合并胆管结石

目的 探讨十二指肠镜、腹腔镜同期治疗胆囊结石合并胆管结石的疗效. 方法 对58例胆囊结石合并胆管结石先行十二指肠镜乳头切开(endoscopic sphincterotomy,EST)取石,取石成功后同期完成腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC). 结果 58例中成功56例(96.6%),另2例1例结石不能完全取净、1例插管失败均改为LC联合术中电子胆道镜取石成功.56例成功者中EST出血1例,急性水肿性胰腺炎2例,腹腔穿刺孔感染1例,总的并发症发生率为7.1%(4/56).1例胆总管结石残余经十二指肠镜再次取石成功. 结论 十二指肠镜、腹腔镜同期治疗胆囊结石合并胆管结石是一种安全可靠、疗效确切的微创治疗方法.     

急性胆源性胰腺炎的内镜治疗体会(附112例报告)

目的 探讨应用十二指肠镜及腹腔镜治疗急性胆源性胰腺炎（acute gallstone pancreatitis,AGP）的可行性、有效性和安全性。方法 对我院1996年5月－2002年5月收治的112例急性胆源性胰腺炎首先内镜下乳头括约肌切开取石（EST），同时置入鼻胆管引流（ENBD）；合并胆囊结石者，待胰腺炎恢复后，施行腹腔胆囊切除术（LC）。结果 全组112例中，78例胆管结石行EST取出，所有病人均行ENBD；胰腺炎顺利治愈107例，治愈率95.5%；合并胆囊结石85例，恢复期行LC，82例顺利切除胆囊，3例中转开腹全部治愈，25例经过非手术治愈，占22.3%，87例行腹腔镜探查或开腹探查手术，占77.7%。结论 EST＋ENBD能有效治疗急性胆源性胰腺炎，伴胆囊结石者联合应用LC，使微创手术的优点在该病整个疗程中得以体现，不失为目前理想的治疗方法。     

急性胆源性胰腺炎189例分析

目的探讨腹腔镜、十二指肠镜联合治疗急性胆源性胰腺炎（acute biliary pancreatitis,ABP）的治疗时机及治疗方法,推荐ABP的合理治疗方案。方法回顾性分析ABP患者189例,其中轻型胰腺炎163例,在综合治疗的基础上,采用单纯腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）68例,单纯内镜逆行胰胆管造影（endoscopic retrograde cholangiopancreatography,ERCP）下内镜乳头括约肌切开术（endoscopic sphincterotomy,EST）取石治疗39例,十二指肠镜、腹腔镜联合微创治疗56例。重症胰腺炎26例,行ERCP＋内镜鼻胆管引流（endoscopic nasobiliary drainage,ENBD）14例,单纯保守治疗12例。结果 163例轻型ABP患者6,8例LC除中转开腹3例外均获成功;单纯ERCP＋EST治疗39例取石成功;十二指肠镜、腹腔镜联合微创治疗56例,中转开腹2例,无围手术期死亡,无术后出血及胆漏并发症。26例重症胰腺炎中,行ERCP＋ENBD 14例均获成功;12例保守治疗患者中1例死亡,余治愈。结论对于ABP患者,做好充足的围手术准备,早期实施LC或ERCP＋LC是首选治疗方式。重型胰腺炎患者早期提倡实施个体化治疗方案。     

同期三镜、鼻胆管引流选择性治疗急性胆源性胰腺炎92例

目的探讨同期三镜(腹腔镜、胆管镜、十二指肠镜)、鼻胆管引流术(LCDND)选择性治疗胆囊结石、胆总管结石合并急性胆源性胰腺炎的应用体会。方法回顾性分析2010年4月至2016年9月期间,符合入选标准的92例胆囊结石继发胆总管结石合并急性胆源性胰腺炎患者的临床资料。先游离胆囊至胆总管汇合部,经胆囊管汇合部切开或胆总管前壁切开,采用胆管镜取石网取石或液电碎石术;经胆管切口插入引导管进入肠腔,引导十二指肠镜行乳头切开术和鼻胆管引流术;结石取净后,行胆管切口的一期缝合术,切除胆囊。结果腹腔镜下切除胆囊、胆管镜探查、内镜乳头切开92例。胆管镜取石后留置鼻胆管82.6%(76/92),胆管镜联合十二指肠镜取石后留置鼻胆管9.8%(9/92),因胆总管残石而腹腔镜下留置T形管2.2%(2/92),因乳头狭窄未解除留置鼻胆管失败而腹腔镜下留置输尿管导管3.3%(3/92),因腹腔镜下取石失败而中转为开腹胆总管探查取石术并留置鼻胆管2.2%(2/92)。术后发现残石1例(1.1%),胆汁漏3例(3.3%),应激性溃疡出血3例(3.3%)。无肠穿孔、胆管穿孔、重症胰腺炎等并发症,无死亡。术后总并发症发生率为7.6%(7/92)。结论初步研究发现,只要病例选择合适,同期三镜、鼻胆管引流术治疗胆囊结石、胆总管结石合并急性胆源性胰腺炎是可行、有效和安全的。     

急性胆源性胰腺炎的微创治疗

目的探讨应用十二指肠镜及腹腔镜治疗急性胆源性胰腺炎(ABP)的有效性。方法回顾性分析5年间对94例ABP患者进行微创治疗的临床资料。ABP合并胆囊结石的59例行行单纯腹腔镜胆囊切除术(LC);胆总管结石14例内镜下乳头括约肌切开取石术(EST),同时置入鼻胆管引流(ENBD),其中3例联合LC;对胆囊结石合并胆总管结石21例行ERCP EST,联合LC治疗。结果全组术后再次发作胰腺炎1例,胆道出血1例,均为ERCP EST患者;另肺部感染2例,切口感染1例,5例均经非手术治疗痊愈。全组有效率100%。结论十二指肠镜及腹腔镜联合应用于治疗ABP效果好。微创技术是目前ABP理想的治疗方法。     

三镜联合治疗Mirizzi综合征106例

目的探讨三镜联合治疗Mirizzi综合征的手术方法及疗效。方法回顾分析2001年2月至2011年6月106例Mirizzi综合征患者的临床资料,联合腹腔镜、胆道镜、十二指肠镜实行腹腔镜下胆囊切除、胆总管切开,胆道镜探查取石术,乳头括约肌切开术,总结各种手术方式。结果按Csendes分型,Ⅰ型58例,Ⅱ型32例,Ⅲ型11例,Ⅳ型5例。根据患者不同情况在腹腔镜下分别行胆囊切除、瘘口修补或胆囊大部切除、胆管修复、胆道探查术、乳头括约肌切开取石术、T管引流术。术后发生胆漏2例,轻症胰腺炎1例。结论三镜联合治疗Mirizzi综合征是切实可行和安全可靠的。     

Early versus delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis

Background

The recommended treatment for patients presenting with mild acute biliary pancreatitis is early cholecystectomy performed during the index admission. However, the data are less clear in regards to patients who undergo endoscopic sphincterotomy prior to surgery. While it has been shown that these patients still benefit from cholecystectomy, the optimal timing of this intervention is not well defined. We hypothesized that delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis is associated with significant preventable morbidity.

Methods

A retrospective chart review was performed at two academic hospitals for patients diagnosed with biliary pancreatitis who underwent endoscopic sphincterotomy followed by cholecystectomy. Patients aged 18 and over admitted from 2006 to 2011 were included, while those with severe pancreatitis were excluded. The primary outcome was biliary complications experienced during the waiting period for cholecystectomy. Secondary outcomes included length of stay, operative complications, and conversion rate. Student t test was used to compare continuous data and Fischer’s exact test was used for categorical data.

Results

80 patient charts were reviewed. Time to cholecystectomy was 3.3 days (range 0.5–10) in the early group and 141.6 (range 18–757) in the delayed group. The groups were comparable in terms of age and American Society of Anesthesiologists (ASA) classification. 21 of 35 patients (60 %) in the delayed group experienced biliary complications compared with 1 of 45 (2 %) in the early group (p < 0.001). 14 patients in the delayed group required re-admission (40 %) and 5 (14 %) required additional procedures. Secondary outcomes were not statistically significant.

Conclusions

The data demonstrate a significantly increased biliary complication rate associated with delayed cholecystectomy in this patient population. Early cholecystectomy should be strongly considered for patients with mild biliary pancreatitis even when endoscopic sphincterotomy has been performed pre-operatively.     

Acute biliary pancreatitis. Therapeutic trends

BACKGROUND: Treatment of biliary pancreatitis includes suppression of the biliary cause by cholecystectomy and common bile duct clearance. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy for eradication of biliary stones and laparoscopic cholecystectomy (L.C.) for residual gallbladder stones would be ideal but were once considered to be contraindicated by most surgeons. The timing of definitive biliary tract surgery and the role of ERCP have been the focus of discussion in recent years. METHODS: During a two-year study period 51 patients with acute biliary pancreatitis were studied. Seven patients (14%) underwent emergency laparotomy, necrosectomy, cholecystectomy, exploration of the common bile duct and T-tube insertion, because unstable clinical conditions, with evidence of pancreatic and peripancreatic necrosis on CT-scan. Elective open cholecystectomy and CBD exploration were performed in 7 patients after the resolution of acute pancreatitis during the same hospital admission. RESULTS: Early ERCP and L.C. were associated with favourable outcomes. 33 patients underwent ERCP preoperatively: 17 within 72 hours of admission and 16 after signs of clinical improvement. Laparoscopic cholecystectomy performed 3-25 days after admission was successful in 27 of 29 patients. Postsphincterectomy bleeding occurred in one patient and was treated successfully by endoscopic epinephrine injection. For median hospital stay and recurrence there were statistical differences between early and delayed ERCP. CONCLUSIONS: ERCP and sphincterectomy have a certain role in conjunction with laparoscopic cholecystectomy in the management of patients with acute biliary pancreatitis, particularly in institutions where there is easy access to expert interventional endoscopic techniques. This policy should reduce the risk of cholangitis and recurrent pancreatitis.     

早期微创胆囊切除治疗合并急性轻型胆源性胰腺炎的胆囊结石疗效探讨

目的：探讨急性轻型胆源性胰腺炎患者实施早期腹腔镜微创胆囊切除治疗的疗效。方法：本次研究对象为 2010年 1 月—2018 年 3 月期间收治的 82 例急性轻型胆源性胰腺炎患者，分别为观察组和对照组，各 41 例。给予观察组患者行早期（首次住院时间内，一般为住院 3 至 5 天后）腹腔镜微创胆囊切除术，给予对照组患者行延期（炎症控制后 2 至 3 月， 无胆囊炎或胰腺炎复发）腹腔镜微创胆囊切除术，比较观察两组患者手术时间、术后肛门排气时间、术后并发症的发生率、住院时间和费用以及术后病情复发情况。结果：两组患者在术后均无病情复发的情况发生；观察组患者手术中使用的时间、术后肝门排气时间、术后并发症的发生率较对照组无明显差异，无统计学意义（P>0.05）；观察组患者的住院时间与住院费用显著较对照组低，数据差异具有统计学意义（P<0.05）。结论：合并急性轻型胆源性胰腺炎的胆囊结石患者实施早期腹腔镜微创胆囊切除术治疗能有效减少住院时间和费用，并减少患者在等待手术过程中所带来的胰腺炎复发隐患，具有临床治 疗意义。     

Treatment of Common Bile Duct Stones in Sweden 1989–2006: An Observational Nationwide Study of a Paradigm Shift

Background

The preferred strategies for treatment of common bile duct stones have changed from choledochotomy with cholecystectomy to sphincterotomy with or without cholecystectomy. The aim of the present study was to compare the effectiveness of these treatment strategies on a nationwide level in Sweden.

Methods

All patients with hospital care for benign biliary diagnoses 1988–2006 were identified in Swedish registers. Patients with common bile duct stones and a first admission with choledochotomy and or endoscopic sphincterotomy from 1989 through 2006 comprised the study group. These patients were analyzed with respect to readmission for biliary diagnoses and acute pancreatitis.

Results

Incidence of open and laparoscopic choledochotomy decreased from 19.4 to 5.2, whereas endoscopic sphincterotomy increased from 5.1 to 26.1 per 100,000 inhabitants per year, respectively. Among patients treated for common bile duct stones (n?=?26,815), 60.0?% underwent cholecystectomy during the first hospital admission in 1989–1994, compared to 30.1?% in 2001–2006. The treatment strategy that included endoscopic sphincterotomy was associated with more readmissions for biliary diagnoses and increased risk for acute pancreatitis than the treatment strategy with choledochotomy. However, patients treated with endoscopic sphincterotomy and concurrent cholecystectomy at the index admission had the lowest risk of readmission.

Conclusions

Cholecystectomy has been increasingly separated from treatment of bile duct stones, and endoscopic sphincterotomy has superseded choledochotomy as a first alternative for bile duct clearance in Sweden. In patients fit for surgery, clearance of the common bile duct can be combined with cholecystectomy, as it probably reduces the need for biliary related readmissions.     

中药配合腔镜治疗高龄胆囊合并胆总管结石69例

目的:探讨联合运用腹腔镜、十二指肠镜、胆道镜与中药治疗高龄胆囊及胆总管结石的疗效。方法:69例高龄胆囊及胆总管结石病人,平均年龄72.6岁,平均病程5.8d。先行十二指肠镜逆行胆胰管造影(ERCP),通过十二指肠镜Oddi括约肌气囊扩张(EPBD)或切开(EST)取石,再行腹腔镜胆囊切除(LC)、胆总管探查术(LCBDE),术中配合胆道镜取石、激光碎石,术后运用中药及针灸。结果:69例ERCP全部成功。9例EPBD后取石成功;60例行EST,成功57例;EST后取石成功50例,失败后行鼻胆管引流(ENBD)4例。经ERCP、EST取石后62例均II期行LC,成功60例,中转剖腹手术2例。EST失败和EST取石失败者7例,II期行LC并LCBDE,均获得成功。术中术后无残余结石及严重并发症。均在术后3～7d出院,随访6～9个月均健康生活。结论:三镜联合手术结合中药治疗高龄胆囊合并胆总管结石,切实可行,安全可靠,具有创伤小、痛苦轻、术后恢复快等特点。     

腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石的诊治体会

目的探讨腹腔镜胆囊切除术联合十二指肠镜乳头括约肌切开术治疗胆囊结石合并胆总管结石的手术疗效。方法共收集45例胆囊结石合并胆总管结石患者行不同手术方式的病例资料,其中行十二指肠镜下乳头括约肌切开联合腹腔镜胆囊切除术者(EST+LC组)共20例,行腹腔镜胆囊切除+胆总管切开取石+T管引流术者(OC+OCHTD组)共25例。对两种术式患者的手术成功率、术后并发症发生率以及住院时间等指标进行统计学分析。结果所有患者均获得2~6月随访。EST+LC组中,18例手术完成,2例因局部粘连或技术原因插管困难,转为开放手术;手后并发症包括2例轻度胰腺炎,1例十二指肠乳头出血,均经过保守后痊愈。OC+OCHTD组中,5例出现手术并发症,包括1例胆漏、2例切口感染、2例腹部感染,经保守治疗痊愈。EST+LC组患者住院时间较OC+OCHTD组明显缩短。结论至少在短期内,内镜十二指肠括约肌切开联合腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石是一种安全、有效、可行的微创治疗方法。     

Acute biliary pancreatitis: Diagnosis and management

Acute biliary pancreatitis is a serious complication of biliary calculous disease and is associated with significant morbidity and mortality. The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute biliary pancreatitis has been the focus of discussion in recent years. In addition, the exact role of laparoscopic cholecystectomy (LC) in the management of acute biliary pancreatitis has not yet been fully defined. In this report, we evaluated a protocol of emergency ERCP (within 24 hours) for predicted severe attacks, early ERCP (within 72 hours) for predicted mild attacks, and interval LC for management of acute biliary pancreatitis. Between January 1992 and June 1995 a total of 75 patients with acute biliary pancreatitis were managed according to the protocol. Bedside ultrasonography at admission diagnosed 94% of all 64 patients with gallbladder stones, but the sensitivity of visualizing choledocholithiasis was low (19%). Forty-five (60%) of them were predicted to have a severe attack by either Ranson or glucose/urea criteria. Emergency ERCP and endoscopic sphincterotomy (ES) for identifiable common bile duct (CBD) or ampullary stones were performed on all patients predicted to have a severe attack within 24 hours from presentation. An early endoscopic procedure was performed on all patients predicted to have a mild attack within 72 hours from presentation. ERCP was successful in 95% of all patients, and CBD stones were detected in 52 (69%) of them. ES and stone clearance were successful in all of these 52 patients. The morbidity associated with the endoscopic procedure was 3%, and there were no deaths. All except one patient survived the attack of acute pancreatitis, resulting in an overall mortality of 1%. Interval LC was performed on 46 patients with a conversion rate of 4%. The median postoperative hospital stay after LC was 2 days, and there was no major intraoperative or postoperative morbidity or mortality. Our experience suggests that the policy of emergency ERCP for patients with predicted severe disease, early ERCP for patients with predicted mild disease, and interval LC are associated with favorable outcomes in patients with acute biliary pancreatitis. Acute biliary pancreatitis can be managed safely and effectively by a combined endoscopic and laparoscopic approach.