小胆囊大隐患-Mirizzi综合征的诊断与治疗

目的 探讨Mirizzi( Mirizzi syndrome,MS)综合征的诊断及治疗策略.方法 回顾性分析我院2007年1月至2011年4月收治的33例经手术证实为Mirizzi综合征患者的临床资料.结果 33例Mirizzi综合症病人中仅3例(9.09％)术前确诊.15例Ⅰ型患者行单纯胆囊切除术;12例Ⅱ型和3例Ⅲ型,其中,14例行胆囊切除+胆道修补+T管引流术,1例行胆囊切除+ Roux-en-Y胆肠吻合术;3例Ⅳ型患者均行胆囊切除+Roux-en-Y胆肠吻合术.33例患者中行腹腔镜治疗4例,其中3例中转开腹手术,1例成功实施腹腔镜胆囊切除术.结论 Mirizzi综合征术前确诊困难,术前诊断不明确或者术中处理不当可能会严重影响患者生活质量.结合临床特点、B超、ERCP或MRCP检查可以提高Mirizzi综合征的术前确诊率,手术方式应据根据胆管缺损的类型及局部炎症反应状况决定.对于术前怀疑为Mirizzi综合征的患者,开腹手术为治疗首选.     

腹腔镜治疗Mirizzi综合征35例临床分析

目的探讨Mirizzi综合征的诊断方法选择及腹腔镜治疗的可行性。方法回顾同济大学附属上海市同济医院2010年1月至2015年12月收治的共35例Mirizzi综合征的临床资料,对其诊断方法、手术方式以及治疗结果进行分析。结果实施腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)4 352例,其中确诊为Mirizzi综合征共35例,占0.8%。术前诊断率为60.0%。根据Csendes’s分型:Ⅰ型21例,LC共17例,腹腔镜胆囊大部切除术(laparoscopic subtotal cholecystectomy,LSC)+胆总管切开术+T管支撑引流术4例;Ⅱ型10例,LSC+瘘口直接修补术+胆总管切开术+T管支撑引流术4例,LSC+胆囊壁组织修补瘘口术+胆总管切开术+T管支撑引流术3例,中转开腹行胆囊大部切除术+胆总管空肠Roux-en-Y吻合术3例;Ⅲ型4例,LSC+胆囊壁组织修补瘘口术+胆总管切开术+T管支撑引流术1例,中转开腹行胆囊大部切除术+部分胆管切除术+胆管端端吻合术+胆总管切开术+T管支撑引流术1例,中转开腹行胆囊大部切除术+胆总管空肠Roux-en-Y吻合术2例。结论 Mirizzi综合征术前诊断困难,磁共振胆胰管成像(MRCP)能够作为提高诊断准确率的一种无创手段;腹腔镜可以安全处理大部分Ⅰ型、Ⅱ型及小部分Ⅲ型Mirizzi综合征,对大部分Ⅲ型Mirizzi综合征腹腔镜处理困难,应及时开腹处理。     

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。     

98例Mirizzi综合征的诊治体会

目的 总结Mriizzi综合征的诊断和治疗经验及教训,探讨其临床特点,讨论Mirizzi综合征的诊断和治疗方法。方法对经手术证实的98例Mirizzi综合征的临床资料进行回顾性分析,分析其临床特点及手术方法。结果 Ⅰ型50例,行单纯胆囊切除;Ⅱ型30例和Ⅲ型12例,39例行胆囊切除胆管修补T管引流,3例行胆总管一空肠Roux-Y吻合术;Ⅳ型6例,行肝总管．空肠Roux-Y吻合术。98例中13例行腹腔镜手术,8例术中解剖困难、出血,中转开腹,3例术中损伤胆总管,术后发现再次手术,行Roux—Y吻合术;随访时间平均5年。结论 Mirizzi综合征术前诊断困难,治疗应根据不同类型选择适当的手术方式,行腹腔镜术中诊断此病应及时改为开腹手术。     

Mirizzi综合征的诊断及腹腔镜治疗的临床分析(附37例报告)

目的:探讨Mirizzi综合征的诊断及腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗Mirizzi综合征的价值及术中处理方法。方法:回顾分析1996年5月至2006年10月3651例LC术中37例Mirizzi综合征患者的临床资料。结果:37例中Ⅰ型30例,28例成功施行了LC或大部切除术,2例中转开腹;Ⅱ型5例,3例施行了腹腔镜胆囊大部切除,瘘口修补,胆总管切开胆道镜探查T管支撑引流术,2例中转开腹;Ⅲ型2例均中转开腹。术后发生胆漏3例均经引流痊愈。结论:B超是首选的检查方法,ERCP、MRCP能提高术前诊断率。腹腔镜及腹腔镜胆道镜联合应用能安全处理大部分Ⅰ型和Ⅱ型的Mirizzi综合征病例。     

35例Mirizzi综合征的诊治分析

目的:探讨Mirizzi综合征的病例特点及治疗经验。方法:回顾性分析35例Mirizzi综合征患者的临床资料,总结病例的临床症状、影像学特点及诊治经验。结果:35例患者术前腹部超声、MRCP、CT、ERCP的临床符合率分别为51.4%、74.1%、25.0%、100%。Ⅰ型患者19例(54.3%),其中14例行腹腔镜胆囊切除术,3例行开腹胆囊切除术,2例行开腹胆囊部分切除术。Ⅱ型患者7例(20.0%),其中2例行腹腔镜胆囊切除术、胆总管探查、T管引流术,3例行鼻胆管引流、腹腔镜胆囊切除、胆总管探查一期缝合,1例行开腹胆囊部分切除+胆囊壁修补瘘口,1例行开腹胆囊切除术、胆总管探查一期缝合;Ⅲ型患者5例(14.3%)和Ⅳ型患者4例(11.4%),全部行胆管空肠Roux-en-Y吻合术。结论:Mirizzi综合征的术前诊断困难,MRCP、ERCP的诊断灵敏度高。腹腔镜手术仅适用于I型和部分Ⅱ型Mirizzi综合征患者。     

腹腔镜下切除急性坏疽性胆囊致胆管损伤的临床分析

目的探讨腹腔镜下切除急性坏疽性胆囊术中避免损伤胆管的可行性分析及手术技巧。方法回顾性分析湖北省中西医结合医院普通外科收治的168例急性坏疽性胆囊炎病人的临床资料。结果156例病人行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),10例病人行腹腔镜下胆囊大部分切除术。1例Mirizzi综合征病人术中出现胆总管损伤中转开腹行胆肠吻合术。1例病人术中误扎胆总管,再次手术行胆肠吻合术。结论急性坏疽性胆囊炎病人术前给予充分评估,术中掌握操作要点可有效避免胆管损伤等并发症。     

Mirizzi综合症诊治体会

目的 总结Mirizzi综合症的诊断和洽疗经验及教训,探讨其临床特点,讨论Mirizzi综合症的诊断和治疗方法。方法 对经手术证实的32例Mirizzi综合症的临床资料进行回顾性分析,分析其临床特点及手术方法。结果 Ⅰ型15例,行单纯胆囊切除;Ⅱ型9例和Ⅲ型4例,10例行胆囊切除胆管修补T管引流,3例行胆总管-空肠吻合术;Ⅳ型4例,2例行胆囊切除术,2例行胆囊切除,肝总管-空肠Roux-Y吻合术。32例中12例行腹腔镜手术,9例术中解剖困难、出血,中转开腹,3例术中损伤胆总管,术后发现再次手术,行Roux-Y吻合术;择期手术26例,6例行急诊手术。随访时间平均6.1Y。结论 Mirizzi综合症术前诊断困难,治疗应根据不同类型选择适当的手术方式,行腹腔镜术中发现此病应及时改为开腹手术,腹腔镜不是Mirizzi综合症的适应症。     

胆囊颈管结石嵌顿患者行腹腔镜胆囊切除术的体会

目的:探讨胆囊颈管结石嵌顿合并急、慢性胆囊炎的患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的特点及注意事项。方法:回顾分析78例胆囊颈管结石嵌顿伴急、慢性胆囊炎、胆囊积液患者行LC的临床资料。结果:76例顺利完成LC,其中3例为Mirizzi综合征Ⅰ型;1例因合并胆囊结肠漏、胆囊右肝管漏中转开腹,另1例为Mirizzi综合征Ⅱ型,术中胆总管损伤中转手术行胆总管对端吻合"T"管支撑引流术。结论:腹腔镜手术治疗胆囊颈管结石嵌顿患者(包括Mirizzi综合征Ⅰ型)是安全可行的,术中对解剖困难或合并胆囊与邻近脏器内瘘的形成以及Mirizzi综合征Ⅱ型以上等应及时采取开腹手术。     

腹腔镜下复杂胆囊三角的处理体会(附668例报告)

目的:探讨腹腔镜下复杂胆囊三角的处理技巧。方法:回顾分析2000年2月至2011年10月为668例复杂胆囊患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的临床资料,对萎缩性胆囊炎、胆囊管结石、急性胆囊炎等复杂情况采取相应的手术技巧,细致解剖胆囊三角。结果:644例顺利完成LC;24例中转开腹,其中Mirizzi综合征Ⅱ～Ⅳ型5例,胆囊三角致密粘连15例,胆囊十二指肠内瘘2例,胆管损伤行胆管修复及T管引流2例,分别于术后6个月、12个月拔除T管。16例术后发生胆漏,均保守治愈。术后随访,无严重并发症发生。结论:腹腔镜复杂胆囊切除术中细致解剖胆囊三角是手术成功的关键,胆囊三角致密粘连、Mirizzi综合征Ⅱ型～Ⅳ型或内瘘形成等是中转手术的指征。     

Mirizzi综合征的腹腔镜诊治体会

目的:探讨Mirizzi综合征患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的特点及处理措施。方法:回顾分析7例Mirizzi综合征患者行LC的临床资料。结果:5例中转开腹置T管引流,2例顺利完成腹腔镜手术,无严重并发症发生。结论:Mirizzi综合征I型行LC、II型行胆总管T管引流+保留部分胆囊壁缝合瘘口的手术安全可行。     

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。     

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.     

Mirizzi syndrome: noteworthy aspects of a retrospective study in one centre

BACKGROUND: Mirizzi syndrome is uncommon. It is, however, clinically important, as it is associated with an increased incidence of bile duct injury and demands more complex surgical techniques. METHODS: A retrospective review of 24 consecutive cases of Mirizzi syndrome that arose between January 1997 and July 2002 was performed. A total of 1881 cholecystectomies were performed during that period. RESULTS: Of the 24 patients, 19 (79.2%) had Mirizzi type I, four (16.7%) had type II, while one (4.2%) had type III disease. Only 54.2% of patients were symptomatic prior to presentation. One-third of patients had normal liver function tests. Ultrasonography and computed tomography were not helpful in diagnosing this entity. Endoscopic retrograde cholangiopancreatography (ERCP) was useful to identify cholecystocholedochal fistulas and to allow therapeutic endoscopic stenting but failed to pick up the syndrome in half of the patients. Inadvertent bile duct injury occurred in four patients (16.7%), all occurred in patients without a preoperative diagnosis. Three of the four injuries occurred during operations by a senior registrar rather than a consultant. Mirizzi type I was managed with either total or subtotal cholecystectomy, while types II and III cases were managed with either T-tube insertion or biliary bypass procedures. Bile duct injury was managed with T-tube successfully in one patient while the rest went on to biliary bypass operations. All except one patient had good functional outcomes on follow up. CONCLUSION: The preoperative diagnosis of Mirizzi syndrome is a challenge. Only constant vigilance during intraoperative dissection of the Calot's triangle will reduce the incidence of bile duct injury in Mirizzi syndrome that can occur in both open and laparoscopic surgery.     

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。