胆囊十二指肠瘘伴胆石性肠梗阻1例分析并文献复习

目的:探讨胆囊十二指肠瘘合并胆石性肠梗阻的术前评估、诊断和手术方式。方法:回顾性分析1例胆囊十二指肠瘘合并胆石性肠梗阻术前及术中的临床资料,并复习相关文献。结果:患者术前CT检查考虑胆囊结石与胆石性肠梗阻。术中探查见回盲部40cm处结石嵌顿,随后成功行肠切开取石、十二指肠瘘口修补、胆囊切除。术后痊愈出院,随访至目前未见相关并发症。结论:胆囊十二指肠瘘合并胆石性肠梗阻临床罕见,早期的明确诊断及精确的评估是关键,应根据患者具体情况选择合适的手术方式。     

Bile flow before and after cholecystectomy: a study with 99mTc-HIDA

Computer-assisted 99mTc-HIDA cholescintigraphy was performed before and after elective cholecystectomy in 24 patients. Preoperative cholecystography had shown gallstones in a well visualized gallbladder in 12 of the patients, and in 12 the gallbladder had not been visualized. Liver function tests gave normal results in all 24 patients, and peroperative cholangiography showed no common duct stones in any patient. In the series with functioning gallbladder, comparison of the preoperative and postoperative scintigrams showed that cholecystectomy was followed by significantly earlier visualization of the lower part of the common duct and of the duodenum. The number of times that passage of activity to the duodenum was observed also rose significantly. Comparison of the time-activity curves showed that after cholecystectomy the liver activity reached its maximum value significantly earlier post-injection as compared with the preoperative values. All of these changes were absent in the series with nonfunctioning gallbladder. Removal of a functioning gallbladder results in accelerated, though still irregular flow of activity to the duodenum.     

Bile duct injury during laparoscopic cholecystectomy: Mechanism of injury,prevention, and management

Although several studies have shown a low incidence of bile duct injuries during laparoscopic cholecystectomy, concerns remain because of the sustained increase in the number of referrals for biliary reconstruction after the procedure. Twenty-one patients have been referred to our institution because of major bile duct injuries after laparoscopic cholecystectomy. The injury was recognized during the laparoscopic procedure in only 6 of the 21 (29%). Nineteen patients underwent hepaticojejunostomy at least once, one patient required hepaticojejunostomy and repair of a choledochoduodenal fistula, and one patient needed repair of a biliary colonic fistula. Hepaticojejunostomy above the bifurcation was required in 10 patients (50%), at the bifurcation in 3, and below the bifurcation in 7. Nine of the eleven patients in whom the initial repair was performed at the local hospital presented with early stricture (median 7 months). The common denominator of the development of bile duct injuries during laparoscopic cholecystectomy is the failure to identify the structures of the triangle of Calot. Specific steps during laparoscopic cholecystectomy to avoid bile duct injuries are described. Expertise in hepatobiliary surgery appears to optimize results of biliary reconstruction.

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Resumen Aunque varios estudios han demostrado una baja incidencia de lésión de la vía biliar durante la colecistectomía laparoscópica, existe preocupación por un sostenido incremento en el número de pacientes que son referidos para reconstrucción biliar después de este procedimiento. Veintiún pacientes han sido referidos a nuestra institución debido a lesiones mayores luego de colecistectomía laparoscópica. La lesión fue reconocida en el curso del procedimiento laparoscópico en sólo 6 pacientes (29%); en diecinueve se realizó hepaticoyeyunostomía y reparación por lo menos una vez, 1 requirió hepaticoyeyunostomía y reparación de una fístula coledocoduodenal y 1 reparación de una fístula biliocolónica. Fue necesario practicar la hepaticoyeyunostomía en 10 casos (50%), al nivel de la confluencia en 3 y por debajo en 7. Nueve de 11 pacientes en quienes la reparación inicial fue realizada en el hospital local desarrollaron estrechez temprana (media, 7 meses). El común denominador de la lesión de la vía biliar en el curso de la colecistectomía laparoscópica es la falla en identificar las estructuras del triángulo de Calot. Se describen las maniobras específicas para evitar lesiones de la vía biliar en el curso de la colecistectomía laparoscópica. La experiencia y la destreza técnica optimizan los resultdos de la reconstrucción.

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Résumé Bien que plusieurs études semblent démontrer que l'incidence des plaies de la voie biliaire est relativement basse durant la cholécystectomie coelioscopique, on peut s'inquiéter du nombre croissant de ces plaies vues dans les centres pratiquant la reconstruction biliaire secondaire. Vingt et un cas de plaies de la voie biliaire principale après cholécystectomie coelioscopique ont été observés en seconde main. La lésion a été reconnue pendant l'intervention coelioscopique chez 6 patients seulement (29%). Dix neuf de ces patients ont eu une anastomose hépatico-jéjunale et une cure d'une fistule cholédochoduodénale et un patient a eu une cure d'une fistule biliocolique. Une anastomose hépatico-jéjunale au-dessus du confluent supérieur a été nécessaire chez 10 (50%) patients, au niveau du confluent chez 3, et en-dessous du confluent chez 7. Neuf des 11 patients ayant eu une réparation initiale dans un autre établissement ont eu une sténose secondaire (médiane d'apparition=7 mois). La cause principale de ces plaies au cours de la cholécystectomie coelioscopique est l'absence d'identification du triangle de Calot. Des conseils spécifiques à chaque moment de la cholécystectomie sont décrits pour éviter de telles plaies. Une expérience dans la chirurgie hépato-biliaire est nécessaire pour obtenir les meilleurs résultats de la chirurgie réparatrice.

     

Gallstone ileus associated with cholecystogastric fistula: Case report,diagnosis and surgical treatment

IntroductionGallstone Ileus is a rare complication of cholelithiasis, associated with multiple episodes of cholecystitis, with the formation of adhesions and fistulas between the gallbladder and adjacent organs. Its diagnosis is difficult, requiring complementary imaging tests such as computed tomography or radiography.Presentation of caseFemale patient, with intestinal obstruction for 7 days, associated with abdominal pain and previous episodes of pain in the right hypochondrium for 3 months. Abdominal CT scan identified aerobilia, gallstone impacted in the ileocecal valve and small loop dilatation, in addition to a probable cholecystogastric fistula. Opted for exploratory laparotomy, enterolithotomy and fistula correction in one surgical time.DiscussionGallstone ileus is rare among the complications of cholelithiasis, in addition to the fact that cholecystogastric fistula is associated with gastric pylorus obstruction and not impaction on the ileocecal valve. Imaging tests are useful to complement the diagnosis, and if Rigler's triad is present, the suspicion of gallstone ileus is increased. The presence of fistula between the gallbladder and stomach presents a frequency between 0 and 13.3%. There is no gold standard treatment for gallstone ileus, but surgery options for each type of patient and severity level.ConclusionThere is no definitive protocol for optimal surgical treatment for biliary ileus, but the possibility of enterolithotomy associated with cholecystectomy and fistula correction can be evaluated in selected patients.     

腹腔镜胆囊切除术胆管损伤9例报告

胆管损伤（BDI）是腹腔镜胆囊切除术（LC）最严重的并发症之一。自1991年10月至2000年4月,我院完成LC8000例,发生胆管损伤9例。现将损伤原因、处理方法及预防体会报告如下。     

Bile duct injuries during laparoscopic cholecystectomy: management and outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux-en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux-en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.     

Bile duct injury during cholecystectomy: causes, prevention and surgical repair in 1979.

Bile duct injury during cholecystectomy is almost always a high injury of the proximal common hepatic duct, because the surgeon mistakes this duct for the cystic duct and a segment of it is removed with the gallbladder. Most of these injuries are preventable by following certain principles of careful surgical dissection of the ductal system during surgery. Surgical reconstruction is always difficult, and restricturing of the anastomosis remains the most important problem. Recent advances in surgical technique have minimized the risk of recurrent stricture formation. At present the most suitable reconstruction for the typical high common hepatic duct lesion is a hepaticojejunostomy Roux-en-Y, using transhepatic intubation and a "mucosal graft" type of procedure. Biliary reconstruction was performed on 32 patients referred to the writer during the past 13 years resulting in six recurrent strictures needing a second reconstruction. At the end of 1978, 10 patients are too early to evaluate, two are dead and 20 have obtained a good final result.     

A novel method of closing a palatal fistula: the free fascial flap

The closure of a large palatal fistula with a free fascial forearm flap based on the radial vessels is described. The benefits of this flap are discussed with particular reference to this site.     

A case of biliary ileus in a subject who had already undergone cholecystectomy

A rare case of biliary ileus in an already cholecystectomized subject is reported. Apart from the rarity of the case, the failure to evidence a bilio-digestive fistula intraoperatively is pointed out and a trans-choledochal migration mechanism for the gallstone is hypothesised. After a short review of the main complications connected with this serious form of intestinal occlusion, stress is laid on the advisability of carrying out, especially in emergency situations, simple entero-lithotomy, confining more invasive surgery, such as the repair of the biliodigestive fistula or cholecystectomy to cases in which recurrent biliary pathology is evident.     

Hepaticoduodenal fistula: an unusual complication of cholecystectomy

This report appears to be the first documented post-cholecystectomy hepaticoduodenal fistula successfully corrected. This complication may be prevented by interposing the omentum between the liver and the duodenum at the time of any operation on the biliary system and the duodenum.