胆管狭窄替代性组织修复的再认识

目的:提高胆管狭窄的治疗水平.方法:报告2例胆管狭窄病人治疗后再手术的经过.结果:1例损伤性胆管狭窄、1例Mirizzi综合征病人均用脐静脉修复,分别于术后半年及2年出现狭窄复发,再行胆管-空肠Roux-Y吻合治愈.结论:用非胆道组织修补胆管取决于胆管缺损大小与奥迪氏括约肌功能正常与否.     

胆总管取石术后发生下端梗阻的原因分析及处理

目的分析胆总管探查取石术后发生下端梗阻的原因及采取的对策效果,为临床治疗胆总管结石及解决梗阻提供参考,减少胆总管探查取石术后发生下端梗阻。方法收集2013年1月至2015年12月间在深圳市第六人民医院行胆总管探查取石术后发生下端梗阻19例病人的一般资料及术前、术中和术后的临床资料,分析胆总管探查取石术后发生下端梗阻的原因,之后对病人采取的医疗对策并随访效果。结果 1胆总管下端良性狭窄引起的下端梗阻5例,行内镜下十二指肠乳头括约肌切开术(EST)治疗,术后随访6个月行腹部彩超、生化检查复查,结果显示均无异常。2胆总管下端嵌顿性结石引起的下端梗阻9例,行内镜逆行胰胆管造影(ERCP)+EST术治疗,术后随访6个月均无异常。3胰头部病变引起的下端梗阻5例,其中胰头慢性胰腺炎2例,行胆肠Roux-en-Y吻合术治疗,术后随访6个月无异常,复查腹部CT胰头无明显炎性改变;肝胰壶腹癌1例,胰头癌2例,均行胰十二指肠切除术治疗,术后随访1年均无复发转移。结论对于不具有典型胆总管结石临床表现的病人,或者胆总管结石直径明显小于胆总管内径,而胆总管却有明显扩张的病人,应该引起重视。术前、术中均应该进行严格排查,术中应"重探查、轻取石",找到胆总管梗阻的真正原因。     

超细胆道镜在术中经胆囊管胆道探查的临床应用

目的探索胆道探查手术中应用超细胆道镜的临床价值。方法开腹或腹腔镜手术切除胆囊后保留残留胆囊管0．5～0．6cm,经胆道探条或血管分离钳机械扩张胆囊管,直至CHF—XP20超细纤维胆道镜随意插进胆总管,观察胆总管、肝总管及左右肝管,同时可以经胆道镜活检孔道插入配置的取石网篮取石,或插入配置的活检钳进行组织活检。结果332例胆总管内小结石（0．3～0．5cm）,其中25例合并肝内一级胆管结石,术中经超细纤维胆道镜检查证实后,使用网篮顺利取出;9例胆总管内隆起样病变取组织活检,其中炎性息肉样病变5例,轻一中度不典型增生病变4例;胆总管下端炎性狭窄及乳头肌收缩功能减退24例。365例经胆囊管进行均顺利完成超细纤维胆道镜检查及治疗,术中未出现胆道持续出血、胆道穿孔及术后胆道感染等并发症。295例随访3～12个月（平均7．5月）,未发现术后残余结石,继续随访13～18个月（平均15．5月）,胆总管结石复发12例。结论超细纤维胆道镜经胆囊管进行胆道探查手术有严格适应征,合理、选择性的应用可避免总胆管切开。     

规则性肝段(叶)切除治疗肝内胆管结石并狭窄

目的探讨规则性肝段(叶)切除治疗肝内胆管结石并狭窄的临床疗效。方法48例肝胆管结石并狭窄患者,行左外叶切除19例,左半肝切除2例,左外叶+右后叶(或单纯Ⅵ、Ⅶ段)切除7例,右半肝(或单纯Ⅵ、Ⅶ段)切除20例;均行胆总管探查、T管引流术;行胆管空肠Roux-en-Y吻合术13例。结果术后胆管残石5例(10.4%),切口感染3例(6.2%),胆漏2例(4.2%)。随访41例(85.4%),2例肝内胆管结石复发,1例右上腹隐痛,其余随访结果优良。结论根据患者结石及狭窄的具体情况采用以肝段切除为主的手术方式是治疗肝内胆管结石并狭窄的有效手段。     

腹腔镜下经胆囊管取石治疗胆囊结石合并非扩张性胆总管结石

目的探讨腹腔镜下经胆囊管取石治疗胆囊结石合并非扩张性胆总管结石的临床价值。方法腹腔镜下切除胆囊之前切开胆囊管,插入C管行胆道造影,发现胆总管结石后,在C形臂X线机透视下,经胆囊管插入金属网篮或取石球囊,取出胆总管结石同时经胆囊管放置C管引流。结果36例手术均获成功,结石全部取净。手术时间90～150min,平均125.4min;术后住院时间4～7d,平均5.4d;C管引流时间3～4d。36例术后随访3个月,B超检查均无胆漏,无胆道残余结石,无胆总管狭窄或扩张。结论腹腔镜下经胆囊管取石治疗胆囊结石合并非扩张性胆总管结石,具有创伤小、效果好、并发症少、恢复快等优点,是一种值得推荐的微创治疗方法。     

腹腔镜经左肝断面胆管行硬质胆道镜探查胆总管取石的研究

【摘要】 目的 对比腹腔镜肝左外叶切除后经左肝断面胆管行硬质胆道镜胆总管探查与腹腔镜肝左外叶切除、胆总管探查、T管引流术在治疗胆总管合并左肝外叶胆管结石的疗效,探讨前者的可行性、安全性。方法〓将我院2011年11月~2014年11月收治的59例行胆总管结石合并左肝外叶胆管结石患者根据手术方式分为观察组和对照组,观察组(n=32)采用经肝断面行硬质胆道镜探查胆总管取石;对照组(n=27)采用肝左外叶切除胆总管切开胆道镜探查取石及T管引流术,比较两组的手术时间、手术出血量、结石取出情况、术后肛门排气时间、术后住院时间、并发症发生率以及WBC、CRP、肝功能Child-Pugh评分、ICG R15等指标。结果〓两组患者手术出血量、结石取出情况、术后肛门排气时间、术后并发症总发生率、术后第1、5天WBC、CRP、肝功能Child-Pugh评分、ICG R15等比较,差异无统计学意义(P>0.05);两组中,观察组的平均手术时间、术后住院时间少于对照组,差异有统计学意义(P<0.05)。结论〓腹腔镜肝左外叶切除后经左肝断面胆管行硬质胆道镜探查胆总管取石在治疗胆总管合并左肝外叶胆管结石,在临床上是可行、安全有效的,具有很好的临床应用价值。     

Heterotopic pancreas: A rare cause of bile duct dilatation —Report of a case and review of the literature—

A case of a 77 year old woman with a heterotopic pancreas in the distal common bile duct is reported herein. The patient had no symptoms, but an ultrasound examination showed bile duct dilatation and subsequent endoscopic retrograde cholangiography demonstrated a spherical filling defect in the distal common bile duct. Under suspicion of a benign neoplasm in the common bile duct, resection of the common bile duct and hepaticojejunostomy using a Roux-en Y jejunal limb were successfully performed. Pathological examination revealed heterotopic pancreatic tissue in the distal common bile duct. This is only the ninth reported case of heterotopic pancreas occurring in the common bile duct or ampulla of Vater, and thus, a review of the literature is also given.     

再次胆肠吻合术的围手术期处理

目的　探讨多次胆道手术后胆肠吻合术的围手术期处理方法。方法　回顾分析经治的10 2例病人的临床资料 ,总结取得的临床经验。结果　 10 2例中男性 41例 ,女性 61例 ,年龄在 17-77岁 ,平均年龄 47岁。胆囊切除术后胆肠吻合术 2 4例 ,胆囊切除、胆总管探查后胆肠吻合术 3 9例 ,二次胆肠吻合术 3 3例 ,三次胆肠吻合术 6例。多次手术后需要再次行胆肠吻合术的原因主要为胆道狭窄和结石 ,主要表现为腹痛及黄疸 ,二次及三次胆肠吻合术病人多为中年人 ,再次手术的原因多数与首次手术不当有关。全部病例经过积极的术前准备施行了胆管空肠Roux -en -Y吻合术 ,部分病例加行肝方叶或者肝左外叶切除术 ,术后部分病例出现了切口感染、肺炎、消化道出血等并发症 ,但均获得了成功救治。结论　明确既往手术史 ,应用CT、MRCP、PTC、ERCP、B超等手段明确肝内外胆道影像 ,纠正肝功能及出凝血功能是术前处理的要点 ;沿肝脏脏面解剖游离出胆管 ,切开肝纤维板或者切除肝方叶显露及整形二、三级胆管 ,形成尽可能大的吻合口 ,清除肝内结石或切除充满结石的肝脏左外叶是术中处理的要点 ;调控好肝脏及出凝血功能 ,通畅胆道引流 ,防治各种感染是术后处理的关键     

腹腔镜胆总管探查对具有上腹部手术史患者的经验总结

［摘要］ 目的 总结对有上腹部手术史的患者行腹腔镜下胆总管探查的经验及疗效。方法 回顾性分析17例有上腹部手术史患者行腹腔镜下胆总管探查治疗胆总管结石的临床资料。术前常规行影像检查包括 B超、CT、ERCP、MRCP等。结果 17例手术均成功。术后1例出现胆漏，经引流管通畅引流一周后停止。手术时间约110～215 min，平均160 min。术中出血约5～50 mL，平均23 mL。术后一周左右拔掉腹腔引流管，经过8～10天切口拆线、出院。鼻胆管术后8～10天予以拔除，4～8周后行T管造影无结石，予拔除T管，无不良并发症发生。结论 上腹部有手术史的患者并不是微创手术的绝对禁忌症，对其进行腹腔镜下胆总管探查是安全可靠的。     

Microsurgical technique used in right anterior segmentectomy and pancreatoduodenectomy with reconstruction of the right posterior hepatic artery for widespread bile duct cancer involving the hepatic hilus

A microsurgical technique was used in performing anterior hepatic segmentectomy and pancreatoduodenectomy with reconstruction of the posterior hepatic artery in a 64-year-old man with widespread bile duct cancer from the intrapancreatic bile duct over the hepatic hilus. The anterior hepatic artery was obviously involved and the posterior hepatic artery just behind common hepatic duct was very close to the cancer. Microsurgical anastomosis between the remnant gastroduodenal artery and the posterior hepatic artery at the hepatic hilus made it possible to preserve the posterior segment of the liver and to perform a curative resection of the cancer. The patient had pyrexia because of suprahepatic abscess after the operation, but the abscess drained spontaneously. Postoperative arteriogram showed neither obstruction nor kinking of the reconstructed artery. He was discharged 2 months after surgery and has been enjoying a normal quality of life for 10 months since, with no signs of recurrence. It is suggested that a microsurgical technique is useful for performing an accurate anastomosis with good patency that allows not only a safe but also a highly curative operation for advanced bile duct cancer.     

Epithelial cell proliferation activity of the biliary ductal system with congenital biliary malformations

Congenital biliary malformations such as anomalous arrangement of the pancreaticobiliary ductal system (AAPB), congenital cystic dilatation of the common bile duct (CCDB), and congenital biliary strictures at the hepatic hilum (CBSH) are newly designated disease entities and are frequently found in adult patients with biliary malignancy such as gallbladder carcinoma, common bile duct carcinoma, and intrahepatic bile duct carcinoma. In the present study, the relationship of these malformations and biliary malignancy was investigated. We studied 61 gallbladders of patients with AAPB and 56 gallbladders of patients without AAPB; 16 common bile ducts of patients with CCDB (12 with AAPB and 4 without AAPB) and 11 gallbladders of patients without CCDB; and 17 intrahepatic bile ducts of patients with CBSH and 6 intrahepatic bile ducts of patients without CBSH. Tissue sections from the mucosa of the gallbladder, common bile duct, and intrahepatic bile duct were stained for proliferating cell nuclear antigen (PCNA). The PCNA labeling indexes of patients with these malformations were significantly higher than those of patients without these malformations (P < 0.05). Cell proliferation of the epithelia in the biliary ductal system in patients with these congenital biliary malformations was accelerated. Consequently, these congenital malformations appear to be an important risk factor for the occurrence of biliary malignancy. Received for publication on Feb. 15, 1999; accepted on March 29, 1999     

Adenomyoma of the Common Hepatic Duct Mimicking Bile Duct Cancer: Report of a Case

We report an unusual case of adenomyoma of the common hepatic duct mimicking bile duct cancer. A 50-year-old woman was referred to our hospital for the investigation of general fatigue. Laboratory data showed abnormal liver test results and computed tomography showed a mass lesion in the hepatic hilum and dilatation of the intrahepatic bile ducts. These findings led to a preoperative diagnosis of hilar bile duct carcinoma, and we performed a left lobectomy with resection of the extrahepatic bile duct. Macroscopically, an elevated lesion was found in the common hepatic duct, which was confirmed histologically to be an adenomyoma. Bile duct strictures are rarely caused by benign tumors of the biliary tract, such as adenomyoma. Surgical resection of the bile duct should be considered for all bile duct strictures because it is often difficult to differentiate malignant from benign lesions in this location preoperatively, and malignant cells may be present in the lesion.     

胆总管探查后一期缝合的经验和认识

目的 探讨胆总管探查后一期缝合的经验和认识。方法对1990年1月至2004年6月因肝外胆管结石择期行胆总管探查后一期缝合的271例作一回顾性分析。所有病例不含肝内胆管结石，术中经胆道镜或胆道造影排除胆道残石并常规放置右肝下引流管。结果术后14例腹腔引流液含胆汁，均未特殊处理。术后平均住院8．73d。所有病例术后3个月内门诊B超复查，未发现胆道残石。216例（79．70%）获得远期随访，无一例发现肝外胆管狭窄。结论对经过严格选择的肝外胆管结石病例，胆总管探查后不应强调一律放置T管。术中精细操作和经术中胆道镜或胆道造影检查排除残石后，一期缝合可作为术式选择。     

三孔法双镜联合胆总管探查、T管引流术的临床应用

目的探讨三孔法腹腔镜联合胆道镜行胆总管切开取石、T管引流术的可行性。方法 2010年12月～2012年3月采用三孔法腹腔镜联合胆道镜行胆总管探查、取石及T管引流术35例。脐下、剑突下2 cm稍偏右、右肋缘下锁骨中线处分别置入trocar,切除胆囊,胆总管前壁切口长10 mm,从主操作孔置入胆道镜,以取石网蓝、三爪钳逐一取出结石,将T管从主操作孔完全放入腹腔内,置入胆总管,缝合固定,直视下将T管长臂从主操作孔引出固定。结果 35例手术均获得成功,手术时间(150±32)min,其中胆管探查+放置T管时间(40±12)min。肛门排气时间为术后第1～2天。术后24 h拔除腹腔引流管。术后住院5～6 d。无手术并发症发生。术后2周门诊行胆道造影无异常,拔除T管。35例随访2～13个月,平均9个月,B超或MRCP证实无一例出现肝外胆管狭窄、结石复发,无黄疸、胰腺炎等并发症。结论三孔法腹腔镜联合胆道镜行胆总管探查、取石及T管引流术创伤小、恢复快、安全可行,有利于一并处理胆源性胰腺炎,保留完整Oddi括约肌结构、功能。     

纤维胆道镜观察胆管异位开口与残石

８５０例胆管结石术后患者．在因疑有残石或胆总管远端不明原因的梗阻而经Ｔ管窦道行纤胆镜检查与治疗过程中，发现５２例胆管异位开口．其中存有残石者５０例。异位开口和残石以右肝尤其是右后叶肝胆管为多见．右后叶肝胆管开口于左肝胆管，左尾叶肝胆管开口于右前叶肝胆管，这些异位开口给纤胆镜检查取石带来很大的难度和盲目性．     

Extrahepatic bile duct injury due to abdominal trauma

The diagnosis of bile duct injury due to abdominal trauma is usually not feasible preoperatively, but it must be suspected interoperatively with the presence of bile staining fluid in the subhepatic area. Four patients with bile duct injuries were encountered; these were the results of blunt injury in three and penetrating injury in one. The injury sites were in the common bile duct in two patients, and in the right hepatic duct just proximate to the bifurcation in two patients. One patient was diagnosed on the finding of bile stain discharged from the drainage tube after the first abdominal exploration. The other three patients were diagnosed by the amount of bile stained fluid collected in the subhepatic area during the primary laparotomy. The injuries of the common bile duct were treated by primary repairs and T-tube choledochostomy in two patients. The other two patients with right hepatic duct injuries were treated by right lobectomy because of extensive liver parenchyma injury. The postoperative courses were smooth and there were no deaths. We reviewed 27 reports (1984–1994) from around the world. The total operative mortality of the 75 patients in these reports was 18.67% (14/75) for the primary operation, and 7.14% (1/14) for re-operation in patients in whom reoperation was performed due to overlooked injuries or biliary complications.     

LCBDE术后一期缝合与T管引流治疗老年胆总管结石的效果比较

目的 探讨腹腔镜胆总管切开探查取石术（LCBDE）并一期缝合与LCBDE并T管引流治疗老年胆总管结石的临床疗效。方法 回顾性分析汕头市中心医院2017 年1 月至2018 年12 月收治的符合入选标准的老年（年龄≥60 岁）胆总管结石患者158 例,所有患者均行LCBDE术,其中130 例术后行一期缝合（一期缝合组）,28 例行T管引流（T管引流组）。比较两组的术前基线资料、手术时间、术中出血量、术后住院时间、住院费用、术后并发症发生率、结石复发率等资料。结果 两组术前基线资料比较,差异无统计学意义（P＞0.05）。一期缝合组在手术时间、术后住院时间方面明显短于T管引流组,差异有统计学意义（P＜0.05）;两组患者在术中出血量、住院总费用、术后并发症发生率、结石复发率方面比较,差异无统计学意义（P＞0.05）。结论 老年（年龄≥60岁）并不是腹腔镜胆总管切开探查取石术并一期缝合的绝对禁忌。正确把握手术适应证及禁忌证,对于合适的老年患者,腹腔镜胆总管切开探查取石术并一期缝合也是安全可行的。     

Mucin-producing Bile Duct Tumor of the Caudate Lobe Protruding into the Common Hepatic Duct

Mucin-producing tumor in the bile duct is referred to clinically as mucin-producing bile duct tumor (MPBT). Intraductal papillary neoplasm of the biliary tract that resembles an intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a rare category of MPBT and is not well characterized. We, herein, report a case of MPBT of the caudate lobe of the liver that showed papillary growth and communicated with the bile duct of the caudate lobe and protruded into the common hepatic duct. Histologically, MPBT cells showed papillary overgrowth with abundant mucinous secretions, resembling an IPMN of the pancreas. The MPBT cells showed the same immunostaining pattern as that of cells from IPMN of the pancreas.     

Pancreaticobiliary ductal anatomy in Thai People

The complex anatomy of the pancreaticobiliary duct was studied to demonstrate basic data in Thai people. Fresh specimens of the pancreas, common bile duct, and duodenum were obtained en bloc from the autopsies of 103 patients who had died of causes not related to trauma or disease of these organs. The length of the pancreas, the location of the pancreatic ducts in relation to the surface of the pancreas, the length and types of the common channels, as well as the anatomy of the ampulla, were studied, using methylene blue infusion via the pancreatic duct cannulation and careful dissection. Ninety-three male and 10 female patients were included. Their ages ranged from 15 to 76 years (mean 31.38 ± 12.98 years). The length of the pancreas ranged from 10.9–19 cm (mean, 15.60 ± 1.80 cm). The intrapancreatic portion of the common bile duct showed patterns of three types; most common (90/103; 87.38%) was type A, in which the anterior surface of the common bile duct was totally covered, while its posterior surface was partially covered, by the pancreatic parenchyma. On dissection of the accessory duct of Santorini in the pancreatic substance, the accessory duct was traceable to the duodenal wall in 59 specimens (57.26%). The anatomy of the Wirsung-choledochus confluence was grouped into five different types. The common channel (junction of the common bile duct and pancreatic duct) was found in 76.70% of specimens and its length varied from just a common junction (so-called "V-type" anatomy) to 15 mm (Y-type-b). Separate papillae (so-called "II-type") were found in 12.62% of specimens. Separate openings in the same papilla (so-called "U-type") were found in 10.68% of specimens. The Wirsung duct at the pancreatic neck was most often located posterior and superior in relation to the surface of pancreas. This study demonstrated several important points regarding the anatomy of the pancreaticobiliary junction and pancreatic ductal system in a Thai population. Some of these data were different from those reported in the literature for other population groups. Received for publication on March 25, 1998; accepted on Oct. 26, 1998     

胰头癌胆肠梗阻的简易腹腔镜内引流术治疗初探

目的 探讨治疗胰头癌胆管和/或十二指肠梗阻较简易的腹腔镜手术方法。方法 施行腹腔镜探查术(LE)、腹腔镜胆总管支架术(LCBDS)、腹腔镜联合术后胆道镜连续支架术(LCCDS)、腹腔镜肝总管-十二指肠架桥内引流术(LCHDB)、腹腔镜胃空肠吻合及胆囊空肠架桥内引流术(LGCJB)、腹腔镜胃空肠吻合及肝总管空肠架桥内引流术(LGHJB),治疗胰头癌胆管和/或十二指肠梗阻。结果 19例CT增强扫描怀疑胰头癌,临床怀疑转移而行内引流术。LE怀疑转移病灶取标本中9例病理报告胰腺癌,10例未证实。19例中15例手术获成功(无胆漏、内引流通畅、黄疸减轻或消退),1例中转开腹放置塑料支架,1例少量胆漏腹腔引流自愈,1例LCBDS术后15d死于肝肾肺功能衰竭,1例LCBDS术后15d死于肝肾功能衰竭。结论 选择合适病例,采用较简易的腹腔镜内引流术治疗胰头癌胆管和/或十二指肠梗阻有效、可行。