ERCP在腹腔镜胆囊切除术中的作用15例分析

本文对15例内镜逆行胰胆管造影(ERCP)结果与腹腔镜胆囊切除术术中所见进行了对比分析,认为ERCP可以预测手术难度、显示胆囊管与胆总管的关系,预防手术并发症,能代替术中胆道造影。     

急性胆囊炎腹腔镜胆囊切除术93例体会

目的总结腹腔镜下处理急性胆囊炎的临床经验。方法回顾性分析2003年5月-2005年5月93例急性胆囊炎行腹腔镜手术治疗的临床资料，其中15例术前确诊胆总管结石而先行内镜逆行胰胆管造影（endoscopic retrograde cholangiopancreatography，ERCP）联合内镜括约肌切开（endoscopic sphincterotomy，EST）取石，6例疑似胆道结石者行术中胆道造影。均于48h内完成LC。结果91例（97．8％）手术成功，2例（2．2％）中转开腹。手术时间35—160min，平均65min。术后胆囊管残端漏3例（3．2％），胆道残余结石3例（3．2％），经开腹手术结合ERCP、EST、鼻胆管引流（endoscopic nasobiliary drainage，ENBD）治愈，全组无医源性损伤。结论选择性应用ERCP和EST，腹腔镜胆囊切除术治疗急性胆囊炎是安全可行的，但中转开腹及并发症的发生率高。     

肝硬变时腹腔镜胆囊切除术治疗30例胆囊疾病的体会

目的总结肝硬变状态下腹腔镜胆囊切除术（LC）治疗胆囊疾病的经验。方法回顾性分析30例肝硬变合并胆囊疾病患者行LC的临床资料。结果30例患者中肝功能Child-PughA级8例,B级11例,C级11例。LC术后6例（20.0%）发生并发症,其中Child-PughB级2例,C级4例。治愈29例（96.7%）;死亡1例（3.3%）,死亡者为Child-PughC级。结论存在肝硬变时,肝功能Child-PughA及B级者行LC比较安全,C级风险较大,应列为手术禁忌。     

Mirizzi综合征Ⅰ型的腹腔镜胆囊切除术

Mirizzi综合征（mirizzi syndrome，MS）是指胆囊结石在胆囊颈或胆囊管嵌顿及其炎症所引起的胆总管梗阻。Csendes将其分为4型：Ⅰ型，胆囊颈或胆囊管结石压迫胆总管；Ⅱ、Ⅲ、Ⅳ型都存在胆囊胆管瘘，只是程度不同。Ms因其病变造成的特殊解剖关系，手术中易损伤胆管，被视为腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）的禁忌。但随着LC技术的不断发展，过去的许多禁忌被打破。本文回顾性分析我院1999年12月～2004年12月1750例LC，其中16例符合MSI型诊断，旨在讨论LC治疗MSI型的疗效。     

腹腔镜胆囊切除术后胆汁性腹膜炎的原因及处理

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）术后发生胆汁性腹膜炎的原因及治疗措施。方法对我院1993年3月到2009年3月腹腔镜下胆囊切除术后发生的25例胆汁性腹膜炎的处理进行回顾性分析。结果8例经再次手术,10例行B超介入置管引流（猪尾巴管）,7例行B超介入置管引流联合内镜逆行胰胆管造影（ERCP）放置鼻胆管或内支架引流,均治愈出院。结论B超介入的腹腔引流联合ERCP放置鼻胆管或内支架引流是Lc术后发生的胆汁性腹膜炎的一种安全而有效的方法。     

腹腔镜胆囊切除术中Mirizzi综合征的诊治经验

目的探讨腹腔镜胆囊切除术中Mirizzi综合征的诊治方法及疗效。方法回顾2005年1月至2013年12月收治Mirizzi综合征患者的临床资料,对其诊断方法、手术方式及近远期治疗效果进行分析。结果 10 200例腹腔镜胆囊切除术中共诊断Mirizzi综合征62例（0.608%）。术前诊断30例,占48.4%。按Csendes分型,Ⅰ型41例,Ⅱ型16例,Ⅲ型3例,Ⅳ型2例。腹腔镜下处理48例,中转开腹手术14例。手术方式有胆囊切除、胆总管缺损胆囊壁修补（伴或不伴T管引流）、肝总管空肠Roux-en-Y吻合。术中胆管损伤4例,术后并发胆漏3例,随访59例患者6个月~9年,胆肠吻合口狭窄1例。结论 Mirizzi综合征术前诊断困难,应予以重视。不强求术前明确诊断,关键在于提高术中认识,遵循正确的胆道处理原则,提高腹腔镜技术,选择合适的胆道缺损重建方式。部分Mirizzi患者可腹腔镜下完成手术,同样可获得良好的治疗效果。     

Mirizzi综合征腹腔镜治疗的安全性分析

目的:探讨Mirizzi综合征行腹腔镜手术治疗的安全性。方法:回顾分析2013年1月至2018年7月31例经腹腔镜探查证实为Mirizzi综合征患者的临床资料,并对其影像特点及手术方式进行总结。结果:术前31例均行腹部B超,28例行MRCP检查。按照Csendes及Beltran分型,术中确诊Ⅰ型24例,21例行腹腔镜胆囊切除术(LC),1例LC中转开腹行胆囊切除,2例行LC+腹腔镜肝总管修补+胆总管探查T管引流;Ⅱ型3例,2例行LC+腹腔镜胆总管修补+T管引流,1例中转开腹行胆囊切除+胆总管修补+T管引流术;Ⅲ型2例,均中转开腹行胆囊切除+胆囊瓣修补肝总管+T管引流术;Ⅳ型1例,中转开腹行胆囊切除+肝总管空肠Roux-en-Y吻合;Ⅴ_a型1例,行LC+腹腔镜横结肠修补术。结论:影像学检查可提高Mirizzi综合征的术前诊断,大部分Ⅰ型及部分Ⅱ、Ⅴ_a型可在腹腔镜下顺利完成手术,而Ⅲ型、Ⅳ型局部解剖复杂,及时中转开腹可保障手术的安全性。     

内窥镜逆行性胰胆管造影联合腹腔镜及胆道镜治疗Mirizzi综合征

目的 探讨内窥镜逆行性胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)联合腹腔镜及胆道镜对不同类型Mirizzi综合征的相应治疗方法.方法 自2005年7月至2009年6月期间收治经手术证实为Mirizzi综合征的患者12例.应用ERCP联合腹腔镜及胆道镜对12例患者采取相应的治疗方法.结果 12例Mirizzi综合征患者合并胆总管结石7例.根据Csendes分型:Ⅰ型8例;Ⅱ型3例;Ⅲ型1例.12例患者均行ERCP+腹腔镜胆囊切除术(laporoscopic cholecystectomy,LC)+术中胆道镜探查及取石术.11例患者顺利完成三镜联合手术,于腹腔镜下行胆总管一期缝合4例,所有患者均经手术治愈,Ⅲ型患者拔除T管后,复查胆道造影,无胆道狭窄.结论 ERCP联合腹腔镜、胆道镜治疗Mirizzi综合征具有微创、安全、住院时间短、恢复快等优点.     

Mirizzi综合征与腹腔镜胆囊切除术中的胆管损伤

Mirizzi综合征是一种较少见的慢性胆囊炎、胆石症的并发症。此病于1948年由Mirizzi所命名。由于此种综合征在术前不易确诊，故此在腹腔镜胆囊切除术(LC)已广泛开展的今天，它是导致胆管损伤的主要原因之一。我们总结我院1992年1月至2002年7月期间收治的Mirizzi综合征病人14例，分析引起胆管损伤的情况，以期达到吸取教     

Mirizzi Syndrome Type II: Is Laparoscopic Cholecystectomy Justified?

Mirizzi syndrome type II is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in Hartmann''s pouch or the cystic duct with a resultant cholecystocholedochal fistula. Two cases of Mirizzi syndrome type II are presented. Clinically only one patient had jaundice and endoscopic retrograde cholangiopancreatogram (ERCP) established a preoperative diagnosis of Mirizzi syndrome. The other patient''s diagnosis of Mirizzi syndrome was made intraoperatively.It is important to properly identify the anatomy at the time of surgery to avoid compromising the common bile duct. Operative treatment of Mirizzi syndrome type II includes laparoscopic or open subtotal cholecystectomy; placement of a T-tube with either laparoscopic or open cholecystectomy; or creation of a hepaticojejunostomy with cholecystectomy. Although there is a report of laparoscopic treatment of this syndrome without long term follow-up, we believe that once there is any question of injury to the common bile duct, safety demands that the laparoscopic procedure be converted to an open one with implementation of appropriate therapy.     

Acute Mirizzi Syndrome

Background:

Mirizzi syndrome is a rare complication of cholecystolithiasis characterized by jaundice due to compression of the common hepatic duct. The diagnosis may not be immediately apparent, and management is controversial with open surgery still recommended by some authors.

Method:

A case is detailed herein of a 67-year-old man who presented with abdominal pain, fever, and jaundice. A dilated bile duct was found on ultrasound, but the gallbladder could not be seen. The diagnosis of Mirizzi syndrome was made at ERCP, and a stent was placed through the papilla. Laparoscopic retrograde (fundus first) cholecystectomy was carried out utilizing a laparoscopic liver retractor.

Results:

In this particular case, it was not possible at ERCP to get a guidewire and stent past the obstruction. A stent was left through the papilla, below the obstruction and this allowed primary duct closure during surgery.

Conclusion:

Acute Mirizzi syndrome should be suspected when a patient presents with acute cholecystitis and jaundice with dilated intrahepatic ducts on ultrasound. ERCP is useful to confirm the diagnosis and allows stenting to alleviate the jaundice and facilitate the subsequent operation. Laparoscopic ultrasound is useful to locate the impacted stone and to partially replicate the touch of the surgeon''s hand, which is not available in laparoscopic surgery.     

Laparoscopic subtotal cholecystectomy for Mirizzi syndrome: A report of a case

IntroductionMirizzi syndrome is a rare complication of gallstone disease. The purpose of this report is to describe the utility of laparoscopic subtotal cholecystectomy for Mirizzi syndrome.Presentation of caseA 53-year-old female presented with dark urine and right upper quadrant pain. Blood tests revealed elevated liver and biliary enzyme levels. Magnetic resonance cholangiopancreatography showed a narrowed common hepatic duct compressed by a large gallstone, consistent with Mirizzi syndrome. Semi-urgent laparoscopic cholecystectomy was planned. At operation, circumferential dissection of the gallbladder neck was difficult. The fundus of the gallbladder was opened and a 2 cm stone extracted. The gallbladder neck was sutured and a drain placed. The postoperative clinical course was uneventful.DiscussionAfter laparoscopic cholecystectomy in patients with Mirizzi syndrome, complication rates, including bile duct injuries, is high. In patients with Mirizzi syndrome, removal of the responsible stone is the main purpose of treatment.ConclusionLaparoscopic subtotal cholecystectomy is a useful technique for patients with Mirizzi syndrome to avoid bile duct injury.     

Mirizzi综合征的诊断与治疗

为探讨Ｍｉｒｉｚｚｉ综合征的诊断和治疗特点，对３４例经手术证实的Ｍｉｒｉｚｚｉ综合征进行回顾性分析。结果显示：术前确诊仅７例（２０．６％），其中ＥＲＣＰ确诊５例。３４例中行胆囊大部分切除术１２例，胆囊切除术７例，胆囊切除及胆管瘘口缝合修补术６例，胆囊大部分切除及胆囊瓣瘘口修补术４例，胆囊切除及肝总管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术５例。２５例获随访，随访时间为１～１４年，其中疗效优１８例（７２％），良５例（２０％），欠佳２例（８％）。提示：Ｂ超结合ＥＲＣＰ检查可以提高Ｍｉｒｉｚｚｉ综合征的术前确诊率，手术方式应根据病理损伤程度决定。     

Outcomes of Laparoscopic Cholecystectomy in Octogenarians

Background and Objectives:

Extremely elderly patients usually present with complicated gallstone disease and are less likely to undergo definitive treatment. The purpose of this study was to evaluate the results of laparoscopic cholecystectomy in octogenarians, with an interest in patients presenting initially with complicated gallstone disease and pancreatitis who underwent laparoscopic cholecystectomy during the same hospitalization.

Methods:

Data for 42 patients ≥80 years who underwent an elective laparoscopic cholecystectomy between January 2007 and August 2011 were retrospectively reviewed. Indications for the procedure were stratified into 2 groups: Outpatients, who were admitted electively to undergo cholecystectomy, and Inpatients, who came to our Emergency Room due to complicated biliary diseases. Data analysis included age, sex, ASA score, conversion to open surgery, time spent under general anesthesia, and length of hospital stay.

Results:

Mean age was 83.9 years; 19 (45.2%) were men. Thirteen patients (30.9%) were in the outpatient group, and 13 (30.9%) had a preoperative ASA of 3. Fourteen patients (33.3%) needed ICU. Two patients (4.8%) had their surgery converted. There were 7 (16.7%) postoperative complications, all of them classified as Dindo-Clavien I or II. No differences were noted between groups regarding conversion rates or complications. We had no mortalities in this series. There was no difference in hospital length of stay between the groups.

Conclusion:

Laparoscopic cholecystectomy in the extremely elderly is safe, with acceptable morbidity. Patients with complicated gallstone disease seem not to have worse postoperative outcomes once the initial diagnosis is properly treated and would benefit from definitive therapy during the same hospitalization.     

Laparoscopic treatment for Mirizzi syndrome

Background: Mirizzi syndrome is an uncommon complication of longstanding gallstone disease resulting in obstructive jaundice and remains surgically challenging. Mirizzi syndrome is generally considered a contraindication to laparoscopic surgery. We present the surgical experience of 11 consecutive patients with Mirizzi syndrome who were diagnosed correctly preoperatively and treated laparoscopically. Methods: From January 1991 to December 2001, 4,560 patients underwent laparoscopic cholecystectomy for gallbladder lesions, 11 (0.24%) of whom were diagnosed with Mirizzi syndrome. Results: The 11 patients diagnosed with Mirizzi syndrome included four men and seven women, with ages ranging from 21 to 72 years (median, 54). There were 10 patients with Mirizzi syndrome type I (one was caused by gallbladder cancer in the neck), and 1 patient with type II, according to McSherrys classification. Right upper quadrant abdominal pain was the most common symptom, occurring in all 11 patients. All 11 patients were diagnosed correctly preoperatively by endoscopic retrograde cholangiography (ERCP) with 100% sensitivity. Four of the 11 patients (36.4%) were converted to open procedure. The postoperative course was uneventful, except for one patient complicated with a residual common bile duct stone. Hospital stay ranged from 4 to 33 days (median, 7). Conclusions: Mirizzi syndrome is an uncommon disorder. Preoperative suspicion is crucial for correct preoperative diagnosis. ERCP is the most useful tool for correct preoperative diagnosis and consequent prevention of common bile duct injury during operation. Should Mirizzi syndrome be diagnosed, laparoscopic treatment is a feasible and safe procedure, especially for type I Mirizzi syndrome.     

Surgical Outcomes of Laparoscopic Cholecystectomy for Severe Acute Cholecystitis

The aim of this study was to evaluate the surgical outcomes of laparoscopic cholecystectomy (LC) in patients who were diagnosed with severe acute cholecystitis (SAC) and to clarify the useful treatment modalities of SAC. Of 112 patients who presented SAC, we selected 99 patients and divided them into 3 groups: 37 patients who underwent preoperative percutaneous transhepatic gallbladder drainage (PTGBD; group 1), 62 patients with SAC but not indicated for PTGBD (group 2), and 59 patients with acute and chronic cholecystitis (group 3). The conversion rate was 2.7% (1/37) in group 1, 6.5% (4/62) in group 2, and 1.7% (1/59) in group 3. In groups 1 and 2, the postoperative stay and operative time were longer than those in group 3 with significant difference, respectively (P < 0.05). In group 2, there was correlation not only between postoperative stay and age but also between postoperative stay and ASA class (P < 0.05). In group 2, there was no correlation between time to operation and operative time and also between time to operation and postoperative stay, however, there was surprisingly significant correlation between time to operation and conversion rate in SAC (P = 0.018). In conclusion, PTGBD should selectively be performed in patients with severe comorbidities rather than improving surgical outcomes of LC for severe acute cholecystitis. If patients are not indicated for PTGBD, an early laparoscopic cholecystectomy is recommended because it can decrease conversion rate, although it cannot decrease operative time and postoperative stay.     

Laparoscopic Cholecystectomy in Cirrhotics

Background and Objectives:

Due to the concern of risk of intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered a contraindication for laparoscopic cholecystectomy (LC). This article intends to review the literature and underline the various approaches to dealing with this technically challenging procedure.

Methods:

A Medline search of major articles in the English literature on LC in cirrhotic patients over a 16-y period from 1994 to 2011 was reviewed and the findings analyzed. A total of 1310 cases were identified.

Results:

Most the patients who underwent LC were in Child-Pugh class A, followed by Child-Pugh classes B and C, respectively. The overall conversion rate was 4.58%, and morbidity was 17% and mortality 0.45%. Among the patients who died, most were in Child-Pugh class C, with a small number in classes B and A. The cause of death included, postoperative bleeding, liver failure, sepsis, duodenal perforation, and myocardial infarction. A meta-analysis of 400 patients in the literature, comparing outcomes of patients undergoing LC with and without cirrhosis, revealed higher conversion rate, longer operative time, higher bleeding complications, and overall increased morbidity in patients with cirrhosis. Safe LC was facilitated by measures that included the use of ultrasonic shears and other hemostatic measures and using subtotal cholecystectomy in patients with difficult hilum and gallbladder bed.

Conclusions:

Laparoscopic cholecystectomy can be safely performed in cirrhotic patients, within Child-Pugh classes A and B, with acceptable morbidity and conversion rate.     

Laparoscopic Splenectomy Coupled with Laparoscopic Cholecystectomy

Background and Objectives:

The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases.

Methods:

Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients.

Results:

The mean operative time was 100 minutes (range, 80–160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred.

Conclusion:

Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.     

Mirizzi综合征Ⅱ型的外科手术治疗体会

目的探讨胆囊全切、瘘口缝合、T管引流及游离肝圆韧带粘贴(Mirizzi征四联术)治疗Mirizzi综合征Ⅱ型的临床疗效。方法采用病例对照研究,按治疗时间将34例Mirizzi综合征Ⅱ型患者分为两组,A组20例,分别采用胆囊次全切9例、瘘口移植物修补4例、瘘口直接缝合4例、胆肠Roux-en-Y术3例;B组14例,采用上述Mirizzi征四联术治疗。结果 A组术后并发症:胆漏2例,残株胆囊炎5例,反流性胆管炎1例,胆管狭窄2例,胆囊窝积液感染6例,其并发症发生率高达80.0%,而B组Mirizzi征四联术后无上述并发症,效果良好,两组比较差异显著(P0.01)。结论 Mirizzi综合征Ⅱ型外科处理较为复杂,采用胆囊全切、瘘口缝合、T管引流及游离肝圆韧带粘贴(Mirizzi征四联术)可取得较为满意的疗效。