Choledochoduodenostomy in choledocholithiasis and benign strictures of the common bile duct

The methods of external and of internal drainages of the bile ducts are alternatives in choledocholithiasis and benign strictures of the choledochus. In the Central Research Institute of Gastroenterology, 349 operations were performed on the common bile duct, stones were found in the choledochus in 259 (74.2%) cases and benign strictures of the terminal part of the choledochus and the major duodenal papilla in 103 (29.5%) cases. Ninety-five operations were secondary or reconstructive in character. A precise diagnosis of affection of the biliary tract can be established only during an operation or by retrograde cholangiopancreatography. External drainage of the common bile duct was conducted in 229 (65.6%) cases. Choledochoduodenostomy was undertaken in 105 patients (55 were operated on for the first time and 50 underwent operation on the biliary tract for a second time). Endoscopic papillosphincterotomy was successful in 28 cases with short strictures of the choledochus and choledocholithiasis. The stones were removed from the ducts with instruments or were expelled spontaneously at days 2 to 5.     

胆道自脱落支架在老年胆总管结石患者胆管一期缝合中的应用体会

目的总结老年患者胆总管切开取石胆道自脱落支架置入的临床体会。方法分析27例胆结石老年患者行胆总管切开取石术的术式及病例资料特点。结果 13例在腹腔镜下全部完成胆总管切开取石胆道自脱落支架置入术,14例开腹胆总管切开取石胆道自脱落支架置入术,并发症少,无死亡病例。结论胆总管切开探查取石、胆道自脱落支架置入术具有安全可靠、患者损伤小、康复快、住院时间短等优点,是治疗老年胆总管结石的有效术式。     

Choledochotomy in emergency surgery on the extrahepatic biliary tracts]

Choledochotomy in urgent operations for acute cholecystitis has been carried out upon 255 patients. Indications for the dissection of the common bile duct in acute cholecystitis are considered. Methods of completion of choledochotomy are discussed. According to the authors' data in the most of the patients the external drainage of the common bile duct was done. Immediate and late results of this operation happened to be worse than those following choledochal blind suture or biliodigestive anastomosis (choledochoduodenostomy). On this basis it is recommended to restrict the use of the external drainage.     

Laparoscopic cholecystectomy in choledocholithiasis and stricture of the terminal part of the common bile duct

The authors offer the treatment and diagnostic algorithm in choledocholithiasis, stricture of a terminal portion of the common hepatic duct and papilla stenosis revealed in laparoscopic cholecystectomy (LCE). With the purpose of intraoperative assessment of bile ducts states during LCE, the diagnostic system including laparoscopic and ultrasonic examinations, cholangiography and choledochoscopy was developed and applied. In intraoperative revealing of choledocholithiasis without bile outflow disorders and wide cystic duct the authors prefer to remove the concrements during choledochoscopy through cystic duct without intervention on Vater's papilla (VP). In combination of choledocholithiasis with bile outflow disorders and also in isolated papilla stenosis and stricture of a terminal portion of the common hepatic duct, one-stage laparoscopic cholecystectomy, intraoperative antegrade papillosphincterotomy and retrograde calculus extraction is optimal. In cases when complete endoscopic calculus extraction is impossible, the drainage of the common hepatic duct by Cholsted's with subsequent delayed endoscopic papillosphincterotomy (EPST) is acceptable. During intraoperative examination in 49 patients (57.6%) the concrements in choledochus, not diagnosed earlier, were revealed, in 21--stricture of terminal choledochus portion and in 19 patients--papilla stenosis. In 12 cases the concrements were removed during choledochoscopy through the cystic duct stump, 4 patients with big concrements required laparoscopic choledocholithotomy. In 16 cases LCE with various variants of choledochus drainage was performed as the first stage, as the second stage--EPST and lithoextraction. Antegrade papillosphincterotomy was performed in 15 patients during LCE. In 12 cases intraoperatively revealed choledocholithiasis combined with papilla stenosis (7) and choledochus stricture (5) was the indications to intraoperative papillosphincterotomy. Papilla stenosis was the indication to antegrade papillosphincterotomy in 3 patients.     

Intraoperative biliary exploration through the left hepatic duct orifice during left hepatectomy in patients with left-sided hepatolithiasis

Background and aims Left-sided hepatolithiasis often requires left hepatectomy and exploration of the common bile duct and right hepatic duct. The aim of this study was to assess the feasibility of alternative method of bile duct exploration other than choledochotomy. Materials and methods A prospective study involving 50 cases of left hepatectomy for left or bilateral intrahepatic stone was performed. Left hepatic duct (LHD) orifice was used as primary access route for biliary exploration. Choledochotomy was performed only for large common bile duct stones, variant bile duct anatomy, or intentional T-tube insertion for later removal of residual stones. Results In 44 patients with left-sided hepatolithiasis, biliary exploration through LHD orifice was performed in 40 (90.9%); T-tube choledochotomy was required in three (9.1%). There was neither residual stone nor major surgical complication except infection, and recurrence occurred in one patient during mean follow-up of 32 months. On the other hand, T-tube choledochotomy was performed in three of six patients with bilateral hepatolithiasis (50%). Three patients had residual stones, and two of them were treated by cholangioscopy through the T-tube tract. Recurrence occurred in two patients. Conclusion We think that intraoperative biliary exploration through LHD orifice in left-sided hepatolithiasis patients is an effective approach simplifying the operation procedure by avoiding choledochotomy and subsequent T-tube insertion.     

"三镜"联合一次麻醉序贯治疗肝外胆管结石

目的同顾性评估腹腔镜、胆道镜、十二指肠镜(三镜)联合,一次麻醉序贯治疗肝外胆管结石和胆源性急性胰腺炎(ABP)的可行性.方法总结112例肝外胆管结石(其中23例ABP)治疗经验,对术式选择、操作要点、胆漏防治、注意事项等做分析.结果102例成功,10例中转开腹手术.其中16例内镜胰胆管造影(ERCP)+腹腔镜胆囊切除(LC)、胆总管切开、胆道镜取石、T管引流(LCTD),18例ERCP+LC、胆道镜经胆囊管胆总管取石;22例内镜乳头括约肌切开(EST)取石未完成或禁忌,继续LC、胆总管切开、胆道镜取石、一期缝合;46例鼻胆管引流(ENBD)+LC、胆总管切开、胆道镜取石、一期缝合.内镜治疗时间平均35 min,腹腔镜手术时间平均110 min,术后住院平均6.5 d.无手术死亡,ERCP和EST并发症9例,其中6例急性胰腺炎,2例十二指肠乳头部出血,1例十二指肠穿孔.胆总管一期缝合术后胆漏11例,腹腔引流治愈.拔T管后胆漏2例,再次腹腔镜下置管引流治愈.随访1～3年,B超或MRCP检查无胆管狭窄;胆总管残石和再发结石各3例,EST取石治愈.结论一次麻醉"三镜"序贯治疗肝外胆管结石和ABP,手术环节衔接更为合理,无内镜治疗的恐惧感,能从严掌握EST适应证和减少并发症,提高微创手术成功率等.一旦遇有解剖不清、出血、结石未取净或胆管狭窄等,及时改变术式.     

Treatment of recurrent or residual calculosis of the choledochus. A comparison of the technics

The results of treating residual or recurrent calculosis of the choledochus for the purpose of obtaining elements for deciding whether or not to carry out a given operation in a particular group of patients are reported. Although they do not offer elements of certainty, the results still make it possible to arrive at an indication for endoscopic papillotomy in elderly patients in poor general condition with one or a few calculi and non-dilated choledochus, for choledochotomy in patients with choledochus of normal diameter and with multiple calculi, or for an intervention of biliodigestive drainage (particularly choledochojejunostomy) in patients with multiple calculosis and with dilated choledochus. In cases in which the apparatus of Oddi is the site of an irreversible inflammatory process and has lost its function, transduodenal papillosphincterotomy is justified.     

Late results of endoscopic papillosphincterotomy treatment in patients with acute cholecystitis

The authors examined 81 patients who were subjected to endoscopic papillosphincterotomy (EPST) in the management of acute cholecystitis attended by total or partial obstruction of the choledochus. Cholestomy was carried out before or after EPST in 68 patients but not in 13 patients. The duration of the follow-up period after treatment ranges from 12 months to 6 years. All patients who were examined felt well and had no complaints caused by cholelithiasis. It was found that destruction of the sphincter apparatus of the major duodenal papilla and terminal choledochus led to the development of reflux from the duodenum into the choledochus in 25% of cases. In 18 patients ultrasonic examination revealed signs of chronic pancreatitis which was not manifested clinically. Among 13 patients with a preserved gallbladder containing concrements only 3 were operated on during the follow-up period. Residual choledocholithiasis was found in 5 patients in whom during good bile drainage after EPST it was not manifested clinically. The authors come to the conclusion that EPST shows a high clinical efficacy in the treatment of acute cholecystitis complicated by obstruction of the terminal choledochus.     

腹腔镜联合纤维胆道镜胆总管探查术22例分析

目的总结腹腔镜联合纤维胆道镜治疗胆总管结石的体会,扩大腹腔镜手术治疗范围。方法回顾性分析22例行腹腔镜胆总管切开探查、胆道镜取石、T管引流术（LCTD）患者的临床资料。结果22例患者,手术成功21例,平均手术时间120min,中转开腹1例,均留置T管。术后第1天可下床活动和进食,术后第2周T管造影拔管,无一例发生胆汁漏、胆道狭窄、胆道出血和残余结石等手术并发症。结论腹腔镜胆总管探查术具有痛苦小、损伤轻、恢复快、腹腔脏器干扰少等优点,同时又能取得与开腹手术相同的治疗效果。     

腹腔镜下经胆囊管取石及胆囊管内置管(C管)在胆道外科中的应用

目的:对比研究腹腔镜下胆总管切开取石术与腹腔镜下经胆囊管取石术,胆囊管置管(C管)在胆道外科中的应用。方法:回顾调查1995年10月至2004年12月术前经影像学证实为胆总管结石的89例患者。结果:腹腔镜下胆总管切开取石T管引流35例,术后残留结石2例,胆漏4例,放置T管(24±5.6)d。经胆囊管取石C管引流39例,术后残留结石2例,无胆漏,C管放置(8±4.5)d,与T管引流组差异有统计学意义(P<0.001)。结论:腹腔镜下经胆囊管取石是值得推荐的方法。经胆囊管路径,不仅可用胆总管取石后的引流,且可在胆道外科诸方面发挥作用。     

经胆囊管腹腔镜胆道探查术治疗胆总管结石的临床研究

目的:比较分析腹腔镜下经胆囊管和经胆总管切开T管引流两种方法胆道镜取石治疗胆囊结石继发胆总管结石的疗效,以评价经胆囊管腹腔镜胆道探查术治疗胆总管结石的临床价值。方法:2001年3月至2003年3月按胆道探查途径不同将28例胆石症患者分为胆囊管组(n=8)和胆总管切开组(n=20)。患者经B超和术中胆道造影或加内窥镜逆行胆管造影(ERC)确诊。观察两组病例的术后肛门排气时间、腹腔引流时间、术后住院日、住院费用及手术并发症的发生情况,术后对患者进行全程跟踪随访。结果:胆总管切开组肛门排气时间、腹腔引流时间、术后住院日、住院费用明显长于或高于胆囊管组(P>0.05)。胆囊管组发生手术并发症1例(12.5%);胆总管切开组5例(25.0%),其中胆道并发症4例(20.0%),需要再次微创处理2例(10.0%),需再次手术治疗的严重并发症2例(10.0%);手术并发症发生率胆总管切开组明显高于胆囊管组(P<0.05)。随访两组患者均无胆管狭窄、急性胆管炎及急性胰腺炎发生和结石复发。结论:经胆囊管途径的腹腔镜胆道探查术充分体现了微创外科技术的优点,适于胆囊结石继发胆总管结石患者,其疗效优于胆总管切开T管引流途径的腹腔镜胆道探查术。     

胆总管切开探查术后一期缝合的临床价值研究(附60例报道)

目的探讨胆总管切开探查术后一期缝合的临床效果。方法选取2011-01—2015-06间收治的60例胆总管结石患者,随机分为观察组和对照组,各30例。观察组采用胆囊切除+胆总管切开探查及胆总管一期缝合术,对照组采用胆囊切除+胆总管切开探查+T管引流术。比较观察2组临床疗效。结果观察组患者手术时间、术后肛门排气时间及术后住院时间明显较对照组短,差异有统计学意义(P0.05)。观察组胆管狭窄及胆瘘发生率与对照组相比,差异无统计学意义(P0.05)。2组患者均无结石残留。结论胆总管切开探查术后一期缝合,创伤小,能有效缩短患者住院时间,恢复更快,安全性好。     

腹腔镜胆总管切开取石术治疗细径胆总管结石

目的总结运用腹腔镜胆总管切开取石术治疗细径胆总管结石的治疗经验。方法1993年10月至2005年3月运用腹腔镜胆总管切开取石术(包括胆总管切开,胆管镜取石,经胆囊管残端输尿管导管胆管引流、T管引流、胆总管切口即时缝合等)有选择地对87例胆总管内径≤0.8 cm的胆总管结石病人进行治疗。结果87例腹腔镜胆总管切开取石均手术成功,无中转开腹及术后残余结石。术后5例出现胆漏,均经术中常规放置的胆管引流和腹腔引流管引流治愈。术后经输尿管导管胆管造影见胆总管切口缝合区狭窄2例(未处理),无其他严重并发症,无死亡。结论只要选择合适的病例,腹腔镜胆总管切开取石术治疗细径胆总管结石是可行、有效和安全的。     

Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures.

OBJECTIVE: To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates. SUMMARY BACKGROUND DATA: For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed. METHODS: Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE. RESULTS: Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients. CONCLUSIONS: Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.     

Surgical treatment of lithiasis of the common bile duct: our experience

On the basis of their personal experience of biliary pathology, the authors present their opinion of surgical treatment of benign diseases of the common bile duct. From 1980 to 1988 a total of 930 patients were assessed, 140 of whom were affected by choledocholithiasis. Data confirmed that, with the exception of choledochotomy as a direct approach for removing stones, good results were achieved using papillosphincterotomy, since this technique best restores the physiology of the biliary tract. In cases where common duct dilation exceeded 20 mm or where the patient was in poor clinical condition, bile was drained into the gut forming a side-to-side choledochoduodenostomy.     

腹腔镜、胆管镜同期治疗胆囊结石合并正常直径胆总管结石

目的 总结运用腹腔镜、胆管镜同期治疗胆囊结石合并正常直径胆总管结石的临床经验.方法 完成腹腔镜胆囊切除后,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、液电碎石、经胆囊管残端输尿管导管胆管引流、T管引流或胆总管切口即时缝合等,有选择地对205例胆总管内径≤0.8 cm的正常直径胆总管结石患者进行治疗.结果 腹腔镜胆总管探查取石术205例中,腹腔镜联合术中胆管镜取尽结石162例,中转为术中十二指肠镜下乳头切开取石43例,无中转开腹.胆管镜组162例患者平均手术时间112 min,术后并发症率5.5% (9/162),无残余结石;十二指肠镜组43例患者平均手术时间95 min.术后并发症率9.3%(4/43),术后残余结石1例.无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症,无死亡.结论 只要选择合适的病例,腹腔镜、胆管镜同期联合手术治疗胆囊结石合并正常直径胆总管结石是可行、有效和安全的.     

Surgical interventions for obstruction of the extrahepatic bile ducts]

The results of surgical correction of obstruction of the extrahepatic bile ducts in 279 patients are presented. The operation of choice was choledocholithotomy, which was added by papillosphincterotomy and external drainage of the common bile duct in indications. In obstruction of bile ducts of the tumor genesis, the different biliodigestive anastomoses were created. The postoperative lethality was 4.6%.     

腹腔镜胆道探查术后胆管一期缝合与T管引流的疗效比较

目的 比较分析腹腔镜胆道探查术后胆管一期缝合与T管引流两种方法治疗胆囊结石继发胆总管结石患者的疗效。方法 依据6项病例筛选标准,将2000年1月至2003年2月55例因胆囊结石继发胆总管结石行腹腔镜胆管切开取石治疗的患者,随机分为胆管一期缝合组和T管引流组,比较观察两组的手术和住院时间、输液量、住院费用、术后恢复情况及手术并发症等。结果 胆管一期缝合组27例患者,T管引流组28例患者,一期缝合组较T管引流组术后住院时间更短,肛门排气和恢复正常工作更快,输液量和住院费用更少。一期缝合组手术并发症3例(11．1％),T管引流组手术并发症8例(28．6％),其中需再次外科手术治疗的严重并发症3例(10．7％),严重并发症均由放置T管造成。两组患者随访结果差异无显著性意义。结论 腹腔镜胆管切开取石术后胆管一期缝合避免了放置T管引起的一系列弊端,体现出微创外科技术的优越性,治疗适合的胆囊结石继发胆总管结石患者是安全可行的。     

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. Received: 7 May 1996/Accepted: 19 November 1996     

腹腔镜联合胆道镜行胆总管切开取石探查术156例临床体会

目的:总结腹腔镜联合胆道镜行胆总管切开探查取石、T管引流术的临床体会。方法:先行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC),再切开胆总管,用特制的腹腔镜胆总管取石钳取石,胆道镜主要观察胆总管及肝内外胆管有无结石残余及是否通畅,必要时经胆道镜取石。结果:术后拔T管时出现胆漏3例,1例术后10d T管自胆总管脱出至腹腔,1例术后24h胆漏达400ml,6例中转开腹,余均痊愈出院,无残石及术后胆管狭窄等并发症发生。结论:腹腔镜联合胆道镜行胆囊切除、胆总管切开探查取石、T管引流术具有安全可靠、患者损伤小、康复快、住院时间短等优点,是治疗胆囊结石、胆总管结石的有效术式。