双频激光碎石在腔镜外科难取性胆管结石中的应用(附23例报告)

目的探讨双频激光碎石治疗腔镜外科难取性胆管结石的疗效及安全性. 方法 2002年1月～2004年6月,对23例难取性胆管结石进行双频激光碎石治疗.其中腹腔镜胆道探查术中应用14例,术后胆道镜取石中应用9例. 结果 19例取净胆管中结石,结石取净率为82.6%(19/23),无胆管损伤、窦道损伤等并发症. 结论双频激光碎石具有创伤小、效率高、并发症少的优点,对腔镜外科难取性胆管结石是一种可选择的有效方法.     

腹腔镜、胆道镜联合微爆破碎石仪治疗难取性胆总管结石的临床分析

目的:探讨腹腔镜胆总管探查术中采用胆道镜下微爆破碎石术治疗难取性胆总管结石的安全性及临床疗效。方法:回顾分析2014年1月至2018年10月施行腹腔镜胆总管探查术中应用纤维胆道镜联合iMES-I型体内微爆破碎石仪治疗73例难取性胆总管结石患者的临床资料。观察分析碎石成功率、结石取净率及并发症发生率。结果:73例腹腔镜手术均成功完成,无一例死亡。碎石成功率100%,手术时间50~143 min,平均(72±21)min;术中出血量30~100 mL,平均(55±21)mL。术后胆道残石2例,结石取净率97.3%,无胆漏、出血、胆道感染等并发症发生。住院6~10 d,平均(6.3±1.4)d。随访3月~半年,未发生胆道相关并发症。结论:掌握一定的手术技巧,腹腔镜胆总管探查术中应用胆道镜联合微爆破碎石仪治疗难取性胆总管结石是安全、易行、有效的,具有较好的临床应用价值。     

胆道镜联合体内微爆破碎石仪治疗难取性胆道结石的临床研究

目的:探讨胆道难取性结石实施碎石治疗的方法、疗效和安全性。方法:回顾分析2005年12月至2007年11月采用体内微爆破碎石仪治疗难取性胆道结石61例患者的临床资料,观察碎石成功率、结石取净率和并发症发生率。结果:碎石成功率为100%,结石取净率为96.7%,无胆道大出血、穿孔及胆漏等严重并发症发生。结论:体内微爆破碎石仪可显著提高胆道难取性结石的治疗效果,安全可靠,适于临床推广。     

自制腹腔镜胆道取石钳在腹腔镜治疗胆总管结石中的应用研究 (附64例报告)

目的:探讨自行设计的腹腔镜胆道取石钳在腹腔镜治疗胆总管结石中的取石效果及应用价值。方法:64例患者在腹腔镜下切开胆总管,先用胆道镜探查,取石网篮取石失败后,用胆道取石钳在胆总管内碎石并取出结石,同时可交替使用取石网篮取石。结果:22例胆总管中有<1.0 cm的游离结石,用腹腔镜胆道取石钳直接取出;31例胆总管中有≥1.0 cm的游离结石,由腹腔镜胆道取石钳联合取石网篮顺利在胆总管内碎石和取石;16例胆总管中有嵌顿的难取性结石,用腹腔镜胆道取石钳在胆总管内碎石后单独或联合取石网篮取出结石。3例术后胆总管残余小结石,经胆道镜取净残余结石。无一例因无法取出结石而中转开腹。结论:腹腔镜胆道取石钳用于腹腔镜胆总管探查取石术,缩短了取石时间,降低了取石难度,避免了因难取性结石而中转开腹手术。在腹腔镜治疗胆总管结石术中有实用性。     

肝内外胆管难取性残留结石经胆道镜钬激光碎石治疗

目的 探讨经胆道镜钬激光碎石治疗肝内、外胆管难取性残留结石的实用性及安全性。方法 观察18例胆道术后肝内、外胆管难取性残留结石患者接受胆道镜下钬激光碎石治疗的临床效果，并进行随访。结果 经1～4次胆道镜下钬激光碎石治疗，18例患者残石全部取尽，未出现近期并发症。16例获得随访，随访时间6月到1年，无结石复发和钬激光碎石相关的胆管狭窄出现。结论 经胆道镜钬激光碎石是治疗肝内、外胆管难取性残留结石的一种安全、有效的方法。     

胆道镜联合钬激光治疗难取性胆管残余结石的体会

目的:探讨胆道镜联合钬激光治疗难取性胆管残余结石的临床疗效及安全性。方法:对38例胆道术后"T"管引流的患者拔除"T"管后,因嵌顿结石、铸型结石或巨大结石(直径>1.0cm)先行单纯胆道镜取石不成功,联合钬激光碎石后再取石。结果:对38例患者采用胆道镜下钬激光碎石、取石治疗,经过1～3次碎石、取石治疗,共有35例患者的结石取净,3例因结石位于三级以上胆管,胆道镜及光道纤维不能到达,未完全取净。术后有4例出现发热、轻微腹痛、寒战等胆道感染的表现,3例出现胆道出血,出血量均小于100ml,无胆道穿孔,窦道破裂等严重并发症。结论:胆道镜联合钬激光治疗难取性胆管残余结石创伤小,并发症少,安全有效,是目前治疗胆道术后难取性残余结石最有效的补救措施。     

经胆囊管超细胆道镜联合双频激光碎石治疗胆道结石

目的 探讨腹腔镜下经胆囊管超细胆道镜（管径3.7mm）联合双频激光碎石术治疗胆道结石的安全性和可行性。方法 2011年8月～2013年6月,治疗胆囊结石合并胆道结石63例。行腹腔镜胆囊切除术,经胆囊管通过胆道镜工作通道,用双频双脉冲激光碎石技术将结石击碎,注水冲出或用取石网篮套出。结果 63例胆道结石均一次清除取出。无胆道损伤、胆漏。全组术后3个月复查B超或MRCP,未发现胆道残余结石、胆道狭窄。结论 腹腔镜下经胆囊管超细胆道镜联合双频激光碎石术直观,准确,方便,疗效确切,是治疗胆囊合并胆道结石的安全、有效的新方法。     

胆道镜联合钬激光碎石治疗肝内外胆管难取性残留结石

目的探讨经胆道镜钬激光碎石治疗肝内、外胆管难取性残留结石的实用性及安全性。方法观察18例胆道术后肝内、外胆管难取性残留结石患者接受胆道镜下钬激光碎石治疗的临床效果，并进行随访。结果经1～4次胆道镜下钬激光碎石治疗，18例患者残石全部取尽，未出现近期并发症。16例获得随访，随访时间6个月-1年，无结石复发和钬激光碎石相关的胆管狭窄出现。结论经胆道镜钬激光碎石是治疗肝内、外胆管难取性残留结石的一种安全、有效的方法。     

腹腔镜、胆道镜联合钬激光碎石术治疗难取性胆道结石16例报告

目的探讨腹腔镜、胆道镜联合钬激光碎石在治疗难取性胆道结石的安全性和疗效。方法 2008年3月～2010年3月应用腹腔镜、胆道镜联合激光碎石治疗16例复杂性胆道结石,胆总管结石合并胆囊结石者先行腹腔镜胆囊切除术,再通过胆道镜工作通道,应用钬激光,功率为1.5 J/10 Hz,直径为400μm光导纤维,在直视下接触结石,将胆总管结石击碎后注水冲出,或用取石篮套出。结果 16例结石均一次性完全清除,碎石22枚。无胆道损伤、胆漏。16例术后随访5～30个月,平均16个月,腹部B超或磁共振胆胰管造影(magnetic resonance cholangiopancreatography,MRCP)检查未发现结石复发及残留,无胆道狭窄。结论腹腔镜、胆道镜联合激光碎石治疗胆道结石具有直观、准确、方便、疗效确切的特点,是治疗复杂性胆道结石的一种安全、有效的新手段。     

经胆道镜钬激光碎石治疗肝内外胆管难取性结石

目的探讨经胆道镜联合钬激光碎石治疗肝内外胆管难取性结石的价值。方法纤维胆道镜窥视下用钬激光碎石治疗肝内外胆管难取性结石29例,观察临床效果。结果经1～3次胆道镜下钬激光碎石治疗,28例患者结石全部取尽,1例未完全取净,成功率为96.55%（28/29）;近期无胆道出血、漏胆、黄疸等并发症发生。26例获得随访,随访时间6～20个月,平均13个月,未发现结石复发及胆管狭窄。结论经胆道镜钬激光碎石是一种治疗肝内外胆管难取性结石简便、安全及有效的方法。     

双频激光碎石术在复杂性胆管结石中的应用

目的探讨双频激光碎石技术在治疗复杂性胆管结石中的疗效、安全性及应用价值。方法回顾2003年11月-2006年3月,对25例复杂性胆管结石患者进行的28例次双频激光碎石治疗的临床资料。其中术中应用22例次,术后经T管窦道应用6例次。结果24例患者取净结石,除1例发生一过性胆道出血外,无其他并发症。结论双频激光碎石治疗复杂性胆管结石具有有效性高、创伤小及并发症少等特点,拥有良好的推广前景。     

Laparoscopic Transcystic Treatment Biliary Calculi by Laser Lithotripsy

Methods:From August 2011 through September 2014, 89 patients at our hospital were treated for cholecystolithiasis with biliary calculi. Patients underwent laparoscopic cholecystectomy and exploration of the CBD via the cystic duct and the choledochoscope instrument channel. A dual-band, dual-pulse laser lithotripsy system was used to destroy the calculi. Two intermittent laser emissions (intensity, 0.12 J; pulse width 1.2 μs; and pulse frequency, 10 Hz) were applied during each contact with the calculi. The stones were washed out by water injection or removed by a stone-retrieval basket.Results:Biliary calculi were removed in 1 treatment in all 89 patients. No biliary tract injury or bile leakage was observed. Follow-up examination with type-B ultrasonography or magnetic resonance cholangiopancreatography 3 months after surgery revealed no instances of retained-calculi–related biliary tract stenosis.Conclusion:The combined use of laparoscopic transcystic CBD exploration by ultrathin choledochoscopy and dual-frequency laser lithotripsy offers an accurate, convenient, safe, effective method of treating biliary calculi.     

腹腔镜联合经皮肾镜超声碎石吸引在胆道结石治疗中的应用体会

目的:探讨腹腔镜联合经皮肾镜超声碎石吸引治疗胆道结石的可行性与安全性。方法:回顾分析2009年2月至2012年12月为96例胆道结石患者行腹腔镜联合经皮肾镜超声碎石吸引术的临床资料。结果:95例成功完成手术,1例因胆总管出血中转开腹。47例肝内外胆管结石患者,其中19例一期缝合胆总管,28例放置T管引流。手术时间平均(65±30)min,术中出血量平均(30±20)ml,术后平均(25±7)h胃肠功能恢复,平均(18±6)h下床活动,腹腔引流管于术后(48±24)h拔除;无一例发生胆漏。术后1周复查发现1例肝内胆管结石残留,胆道镜下成功取出残余结石,术后平均住院(5.5±2.5)d。术后平均随访(24±18)个月,无结石复发及胆道相关并发症发生。结论:腹腔镜联合经皮肾镜超声碎石吸引在胆道结石治疗中发挥了重要作用,可有效解决结石取出困难、残留,反复取石导致的损伤、出血,手术时间长等问题。     

胆道镜下U-100双频激光碎石治疗难取性胆管残余结石的体会

目的:探讨胆道镜下U-100双频激光碎石术治疗难取性胆管残余结石的临床疗效。方法:42例胆道术后"T"管引流的患者拔除"T"管后,经B超、"T"管胆道造影或CT检查诊断为肝内外胆管残余结石,行胆道镜下U-100双频激光碎石术。结果:29例(69.0%)1次碎石成功,9例(21.4%)碎石2次,4例(9.5%)碎石3次。碎石成功率100%。1次取净结石19例(45.2%),2次取净结石14例(33.3%),3次取净7例(16.7%),结石取净率95.2%。2例因结石位于三级以上胆管,胆道镜及光导纤维不能到达,未完全取净。2例"T"管脱出,因发现及时,重新置管成功:先置入F14尿管,3d后更换较粗尿管直至F20尿管。结论:胆道镜下U-100双频激光碎石术治疗难取性胆管残余结石安全有效。     

Laser lithotripsy: a review of 20 years of research and clinical applications

Four new technologies have transformed the treatment of urinary calculi: electrohydraulic lithotripsy, ultrasonic lithotripsy, extracorporeal shock wave lithotripsy, and laser lithotripsy. Initial attempts to ablate urinary calculi by continuous wave CO2, ruby, and Nd-YAG lasers failed because of excess thermal injury and inability to pass the laser energy via a flexible fiber. Basic laboratory studies then demonstrated that short pulsed laser energy absorbed by the calculus resulted in fragmentation. The parameters that produced optimal urinary calculus fragmentation were found using the flashlamp pumped tunable dye laser, with the following parameters: wavelength: 504 nm; pulse duration: 1 microsec; fiber: 250 micro silica-coated quartz; repetition: 5-20 Hz. Use of pulsed dye laser caused no tissue damage. The mechanism of fragmentation is light absorption, plasma development, and repetitive acoustic shock wave action with resultant fragmentation. The techniques for application of laser to calculi have been successful, and new, miniature instruments have been developed. Laser lithotripsy is a successful method for fragmenting ureteral calculi. The small caliber of the laser fiber makes this method useful for treating calculi in narrow, tortuous ureters; impacted calculi; distal calculi in ureters that cannot be dilated, via the percutaneous route for stones in calyces or impacted in the upper ureter. Investigations are continuing to optimize fragmentation of harder calculi and to use laser fragmentation within the kidney. Laser lithotripsy may also be used to fragment biliary calculi.     

两镜联合钬激光治疗复杂性胆道结石

目的:探讨腹腔镜下钬激光通过胆道镜通道治疗复杂性胆道结石的临床价值。方法:回顾分析2009年3月至2013年12月为23例复杂性胆道结石患者行两镜联合钬激光碎石术的临床资料,其中19例术前确定行钬激光碎石术,4例因两镜取石困难改行钬激光碎石,采用200μm光导纤维,功率为1.5 J/10 Hz,每次激发点射间隔1 s以上,直视下碎石,击碎后注水冲出或取石篮取出。结果:患者无一例中转开腹,手术时间平均(92.5±23.1)min,碎石时间平均(32.6±15.5)min,碎石时激光点射5~10次,共碎石46枚,术后平均住院(8.5±2.0)d,结石残留2例,发生全身炎症反应综合征3例,胆道出血1例,无胆漏、腹腔脓肿,21例随访3~6个月,未见胆道狭窄。结论:两镜联合钬激光治疗复杂性胆道结石具有患者创伤小、碎石操作直观、安全有效等特点,为复杂性胆道结石的治疗提供了新途径。     

Biliary lithotripsy as an adjunct to laparoscopic common bile duct stone extraction

Summary We investigated various energy sources and delivery systems suitable for fragmentation of common duct calculi by a laparoscopic technique. We evaluated electrohydraulic lithotripsy (EHL) using 1.9-Fr probe delivering 80 W and laser lithotripsy using a 200-m fiber delivering 30–70 mJ/pulse at 5–20 Hz. In vitro biliary stone fragmentation analysis suggested that the laser lithotripsy produced a more controllable fragmentation than EHL. Initial attempts to employ EHL techniques in animal models resulted in common bile duct injury or inadequate fragmentation of stones. In contrast, biliary lithotripsy was accomplished in pigs using the pulsed-dye laser at 10 Hz and 60 mJ/pulse. Histologic evaluation revealed no evidence of ductal injury related to laser stone fragmentation. Subsequently, laser common duct lithotripsy was used in two human subjects. One patient had a 1.8-cm impacted ampullary stone and one patient had a 3-cm intrahepatic stone. In both cases, the stones were removed laparoscopically after laser fragmentation. Our experience suggests that the laser lithotripsy may facilitate laparoscopic common duct stone extraction procedures.