腹腔镜联合胆道镜实施保胆手术446例

目的 观察腹腔镜联合胆道镜实施保胆手术的临床疗效.方法 对446例胆囊结石（息肉）患者采用腹腔镜联合胆道镜保胆治疗.胆囊结石患者术后常规口服利胆药物3个月,再间断口服3个月.结果 446例患者均顺利完成腹腔镜联合胆道镜保胆取石（息肉）术,其中68例采用三孔法腹腔镜联合胆道镜保胆取石（息肉）术.手术时间25 ～132（52±6）min.结石数量1～136枚,结石取净率100％.无胆道损伤、胆漏、肠管损伤、出血、气胸等手术相关并发症发生.随访3 ～ 88个月,确认结石复发7例,复发率2.02％,但无1例需要再次手术;保胆摘除息肉的患者无1例复发.结论 腹腔镜联合胆道镜行保胆术治疗胆结石（息肉）有很高的结石取净率和较低的复发率.     

腹腔镜联合胆道镜经胆囊管治疗胆囊结石合并胆总管结石的临床分析

目的探讨应用腹腔镜联合胆道镜经胆囊管行胆道探查治疗胆囊结石合并胆总管结石的临床效果。方法对2014年1月-2015年12月陕西省核工业二一五医院收治的52例胆囊结石合并胆总管结石患者行腹腔镜联合胆道镜经胆囊管胆道探查取石术,观察其临床效果。结果 52例患者中40例顺利完成手术,手术成功率为76.92%。7例改为腹腔镜下胆总管切开取石、T管引流术,5例中转开腹行胆总管切开取石、T管引流术,中转开腹率9.62%。43例患者一次取石成功,占82.69%;剩余9例患者行二次取石,其中行经胆囊管胆道探查取石术者8例,行腹腔镜下胆总管切开取石术者1例。所有患者术后留置网膜孔引流管,术后3~10 d拔除,1例行腹腔镜下胆总管切开取石患者术后出现胆漏,经保守治疗后康复。无胆道出血、胆道感染等发生,平均住院时间(8.24±2.52)d,所有患者均得到随访1年,B超及磁共振胰胆管造影检查肝内外未见结石残留,肝功能胆红素指标正常。结论腹腔镜联合胆道镜经胆囊管进行胆道探查取石术具有创伤小、患者恢复快、并发症少、安全等优点,临床应用需严格掌握其适应证。     

腹腔镜联合胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石5年随访效果分析

背景胆囊结石合并胆总管结石的治疗方法有多种,当前较为常用的有腹腔镜下胆囊切除、胆总管探查术,内镜下乳头括约肌切开取石术加腹腔镜胆囊切除术,但前者因术后需放置T管引流、后者因破坏Oddi括约肌而有一定的争议.本研究经胆囊管途径取石,避免了损伤胆总管和Oddi括约肌切开所造成的损伤,在临床中取得了良好的效果.目的探讨腹腔镜下应用胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石的临床效果.方法对2013-01/2013-12的成功实施腹腔镜联合胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石的125例患者进行5年随访,分析其临床治疗效果.结果122例患者成功完成了腹腔镜胆囊切除加联合胆道镜经胆囊管胆总管取石术,手术成功率97.6%,平均年龄58.21岁±13.01岁,手术时间为87.95min±39.12min,术中出血11.27 mL±6.85 mL.所有患者均行球囊扩张,其中33例行胆囊管汇合处微切开, 5例行胆道镜下碎石术.患者术后排气时间为32.48 h±17.85 h.术后住院时间为2.03 d±1.62 d.短期随访并发症5.74%,共7例,其中术后胰腺炎4例,经奥曲肽、乌司他丁等对症治疗后治愈,发生胆漏2例,经ENBD引流后治愈,手术切口感染1例,经换药后治愈. 5年远期并发症4.92%,共6例,胆总管复发结石4例,其中1例合并肝内胆管结石,胰腺炎2例.死亡患者4名, 2例心梗, 1例肺部感染, 1例车祸,均与本手术无关.结论腹腔镜联合胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石近期及远期效果较好,患者创伤小,恢复快,并发症少,在临床掌握适应证的前提下,值得推广.     

急诊腹腔镜手术治疗胆总管结石合并轻、中度急性胆管炎的疗效

目的:探讨腹腔镜胆总管探查取石术(common bile duct exploration,CBDE)联合胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆总管结石(common bile duct stones,C B D S)合并轻、中度急性胆管炎的安全性及有效性.方法:对2009-01/2012-12收治的37例胆囊结石伴CBDS合并轻、中度急性胆管炎患者行腹腔镜CBDE联合LC.除外有重度急性胆管炎、上腹部手术史、严重心肺及其他影响全麻或手术等疾病的患者.常规四孔法完成经胆总管切开的腹腔镜CBDE、T管引流及LC.根据术前MRCP了解结石大小、数量和位置,用推挤、冲吸及胆道镜等方法取石,病情不稳定者,不行术中胆道镜取石.所有患者均不行术中胆道造影.Winslow孔处常规放置腹腔引流管.有胆道残余结石者,术后8 wk行胆道镜取石.结果:37例胆囊结石伴CBDS合并轻、中度急性胆管炎患者,均顺利完成腹腔镜CBDE及LC.手术时间105.54 min±6.30 min;胆总管直径12.86 mm±0.58 mm;单发CBDS 14例(37.8%),多发CBDS 23例(62.2%);术后胆囊病理结果,急性胆囊炎9例(24.32%),慢性胆囊炎28例(75.68%);术后住院天数为11.27 d±0.82 d;总住院天数16.41 d±1.03 d.腹腔镜CBDE术后胆管炎症状及体征明显缓解,实验室检查结果改善.无中转开腹、术后腹腔出血、胆道损伤、手术死亡及伤口感染.术后胆漏4例,经保守治疗治愈.术后胆道残余结石4例,术后经T管窦道胆道镜取净结石.结论:对部分CBDS合并轻、中度急性胆管炎患者,腹腔镜CBDE及LC治疗是安全、有效及可行的.     

胆囊结石合并胆总管结石的现代外科治疗模式

微创化理念的迅速普及, 微创设备的高速发展, 外科医师可以熟练的运用各种微创化器械使患者在短期内迅速康复. 胆总管结石的治疗方式也发生了巨大变化, 由传统的开腹胆总管切开取石、T管引流, 转变为腹腔镜下胆总管切开取石一期缝合或腹腔镜下胆总管切开取石、T管引流, 腹腔镜下经胆囊管胆道镜取石,或胆囊切除, 术前或术后应用十二指肠镜取出胆总管结石. 腹腔镜、十二指肠镜、胆道镜的三镜联合应用将会是今后治疗胆囊结石合并胆总管结石的现代外科治疗模式.     

两种不同术式治疗胆囊结石合并胆总管结石临床疗效对比分析

目的对比传统开腹胆总管切开取石+胆囊切除术与经十二指肠镜逆行胰胆管造影(endoscopic retrograde cholangio-pancreatography,ERCP)+内镜乳头括约肌切开取石术(endoscopic sphincterotomy,EST)+腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆囊结石合并胆总管结石临床疗效。方法回顾性分析2016-09～2017-09在该院接受治疗的88例胆囊结石合并胆总管结石患者的基本资料。将上述患者分为开腹组(开腹胆总管切开取石+胆囊切除术,44例)和ERCP+EST+LC组(44例)。比较两组患者的一般临床资料、手术时间、住院时间、住院费用、术前术后肝功能及术后并发症情况。结果两组术前谷丙转氨酶(ALT)、谷草转氨酶(AST)方面比较差异无统计学意义(P 0. 05),而在手术时间、住院时间、住院费用、术后ALT、术后AST、术后总并发症发生率方面比较差异有统计学意义(P 0. 05)。结论 ERCP+EST+LC组治疗胆囊结石合并胆总管结石总体优于传统开腹胆总管切开取石+胆囊切除术,且手术时间及住院时间短,住院费用少,术后肝功能损伤小,安全性较高,值得推广。     

内镜十二指肠乳头切开联合腹腔镜胆囊切除术治疗胆囊结石并胆总管结石

目的探讨运用腹腔镜胆囊切除术联合内镜十二指肠乳头切开术治疗胆囊结石并胆总管结石的方法。方法对胆囊结石并胆总管结石患者,92例行开腹胆囊切除 胆总管切开取石、T管引流术,86例行内镜下十二指肠乳头切开术(EST) 腹腔镜胆囊切除术(LC)。比较两种术式的临床效果、住院时间、并发症等。结果开腹组术中结石取净率为94.8%,住院时间为23.8±7.6d,术后并发胆瘘2例,肝功能衰竭1例,腹腔感染3例,肺部感染1例。内镜组有4例取石失败,改行开腹手术,余均取石成功,取石成功率为94%,住院时间为10.2±5.3d,并发胆道感染2例,十二指肠乳头出血3例。结论与传统开腹胆囊切除 胆总管切开取石、T管引流术相比,EST LC治疗胆囊结石并胆总管结石具有创伤小、住院时间短、患者恢复快、并发症少等优点,临床效果可靠。EST与LC的联合应用可替代大部分开腹胆囊切除 胆总管切开取石、T管引流术。     

腹腔镜联合胆道镜治疗老年胆囊结石合并胆总管结石的临床分析

目的探讨腹腔镜联合胆道镜行胆囊切除胆总管切开取石术治疗老年胆囊结石合并胆总管结石病人的安全性和可行性。方法选取我院2012年6月至2014年6月70岁老年胆囊结石合并胆总管结石病人24例作为观察组,行腹腔镜胆囊切除胆总管切开取石术。收集同期开腹胆囊切除、胆总管切开取石病人26例作为对照组。分析比较2组病人的临床疗效。结果 2组病人的手术成功率、手术时间比较,差异无统计学意义(P0.05);观察组较对照组术中出血量少,术后疼痛程度轻,术后通气时间及住院时间明显缩短,2组比较差异均有统计学意义(P0.05)。结论腹腔镜联合胆道镜治疗老年胆囊结石合并胆总管结石可明显减轻术后疼痛程度,缩短住院时间,是一种安全有效的微创治疗方法。     

LC联合术中ERCP一期治疗胆囊结石合并胆总管结石的临床分析

目的探讨腹腔镜胆囊切除术（LC）联合术中内镜下逆行胆胰管造影（ERCP）及乳头切开（EST）取石一期治疗胆囊结石合并肝外胆管结石的可行性和安全性。方法回顾分析应用LC联合术中ERCP一期治疗胆囊结石合并肝外胆管结石36例的临床资料,分析原发病、手术方式、术后康复、住院时间及并发症。结果术前明确胆总管结石31例中10例先行术中ERCP取石,取石成功后再行LC;余21例和5例术前怀疑胆总管结石、术中经胆囊管胆道造影（TCC）证实胆总管结石者先行LC,继而行ERCP取石。LC手术均获成功,ERCP取石成功率为97.22%。术后5例出现一过性血淀粉酶升高,无明显出血、胆漏等并发症,术后住院平均为4 d。结论 LC联合术中ERCP一期治疗胆囊结石合并肝外胆管结石安全、有效,可避免不必要的ERCP及因术后ERCP失败而致患者再次手术。     

放射性核素肝胆显像对腹腔镜联合硬镜微创保胆取石术前胆囊收缩功能的评估作用

目的探讨放射性核素肝胆显像在评估胆囊收缩功能中的作用,为腹腔镜联合硬镜保胆取石患者术前评估胆囊收缩功能提供理论依据。方法选取2016年6月-12月就诊于空军军医大学第二附属医院且行锝依替菲宁注射液(99mTc-EHIDA)肝胆显像评价胆囊收缩功能的胆囊结石患者47例,检测脂餐后胆囊放射性计数并依次计算胆囊收缩功能,结合术中探查情况及最终保胆结果,对二者之间的评估情况进行比较分析。结果 26例EHIDA提示胆囊收缩试验阴性患者均顺利实施了保胆手术,且该部分患者随访24个月未见结石。12例EHIDA提示胆囊收缩功能不同程度受损的患者,有1例因胆囊内壁毛糙并大量胆固醇结晶沉积,给予胆囊切除;余下11例患者均行保胆取石术。9例胆囊始终未见显影患者中,1例术中探查发现直径约2 cm结石嵌顿于胆囊颈部,实施保胆手术,随访24个月未见胆囊结石复发;余下8例患者均行胆囊切除。结论放射性核素肝胆显像在评估胆囊收缩功能试验中有一定的价值,但不能作为选择手术方式的唯一证据,腹腔镜联合硬镜的术中探查是决策保胆取石术最有力的证据,值得制订更加规范的行业标准。     

腹腔镜联合纤维胆道镜保胆取石82例临床分析

目的探讨腹腔镜联合纤维胆道镜保胆取石术的应用价值。方法回顾性分析该院82例胆囊结石患者行腹腔镜联合纤维胆道镜保胆取石治疗的临床资料。结果 82例手术均获成功,术后无胆瘘、急性胆囊炎、胰腺炎、继发性胆总管结石等并发症发生,无死亡病例;随访6～12个月,无复发病例。结论腹腔镜联合纤维胆道镜保胆取石术具有创伤小、安全可靠、并发症少等优点,同时保留了有功能的胆囊,提高患者的生存质量,值得推广应用。     

影响微创保胆取石术难度的相关因素及患者术后长期随访分析

目的探讨腹腔镜下保胆取石术手术难度的影响因素及应用保胆取石术后结石复发的危险因素。方法对150例行腹腔镜保胆取石术治疗的胆囊结石患者进行术前评估及术后24个月内随访,分析可能影响手术难度和术后结石复发的相关因素。结果 (1)胆囊体积≥50 cm2、最大结石直径、胆囊壁厚度≥4 mm、胆囊颈黏连、胆囊底黏连、胆囊颈结石嵌顿是引起手术困难的危险因素;(2)患者年龄≥60岁、体质量指数(BMI)≥25 kg/m2、家族史是引起结石复发的危险因素。结论对于有影响微创手术效果危险因素的患者要对其进行术前综合评估以选择针对性的治疗手段;对于有引起结石复发危险因素的患者术后要进行药物预防性治疗以减少结石复发几率。     

“高危”胆囊结石患者腹腔镜胆囊切除术的要点分析--附115例报告

目的：探讨“高危”胆囊结石的疾病特点,总结其行腹腔镜胆囊切除术的诊治经验。方法对我院自2008年10月至2012年3月收治的115例“高危”胆囊结石患者行腹腔镜胆囊切除术的临床资料进行回顾性分析。结果本组115例患者,其中胆囊充满性型结石并胆囊萎缩、瓷化47例,急性化脓性及坏疽性胆囊炎42例,胆囊颈部结石嵌顿20例,胆囊管结石3例,胆囊十二指肠瘘2例,Mirizzi综合征1例。其中急诊腹腔镜胆囊切除术51例,其余均行择期手术,均康复出院。结论“高危”胆囊结石患者,经积极术前准备,加强围手术期的处理,术中精准、规范及娴熟的手术操作,行腹腔镜胆囊切除术是可行的。     

内镜经胃保胆取石术治疗胆囊结石的初步探讨（含视频）

目的 探讨内镜经胃保胆取石术（endoscopic trans-gastric gallbladder-preserving cholecystolithotomy,ETGC）治疗胆囊结石的疗效和安全性。方法 2017年3月至2019年5月,复旦大学附属中山医院内镜中心完成的84例ETGC纳入回顾性分析,总结手术完成率、手术时间、术后并发症发生情况及结石复发情况。结果 84例中单发结石19例（22.6%）、多发结石53例（63.1%）、胆囊结石合并胆囊息肉12例（14.3%）。其中82例（97.6%）成功行ETGC治疗（包括12例合并胆囊息肉者）,中位手术时间88 min。10例（12.2%,10/82）术后出现不同程度的腹痛,其中6例经保守治疗腹痛缓解;其余4例表现为血腹2例、胆瘘1例、胆总管结石伴阻塞性黄疸1例,均经相应干预后病情缓解。术后随访截至2019年6月14日,失访5例,随访率93.9%（77/82）,2例（2.6%,2/77）发现结石残留,4例（5.2%,4/77）明确结石复发,2例（2.6%,2/77）胆囊内胆固醇结晶形成。结论 ETGC治疗胆囊结石有效而安全,能够保留胆囊功能,并且微创。但如何做到真正取净结石,避免残留和复发,仍需进一步探索,同时其远期疗效也需进一步观察。     

Carcinoma of the Gallbladder and Extrahepatic Bile Duct in Autopsy Cases of the Aged, with Special Reference to Its Relationship to Gallstones

To demonstrate correlation between occurrence of carcinoma and that of gallstone of the gallbladder and biliary tract, we reviewed the protocols of gallbladder and extrahepatic biliary duct carcinoma and cholelithiasis of 4,482 cases (male 2,237, female 2,245, mean age 77.7 yr) autopsied at the Department of Pathology, Tokyo Metropolitan Geriatric Hospital, during the 27 yr from 1960 to 1986. Gallbladder carcinoma was found in 94 cases, or 2.1%. The incidence was higher in the female than in the male (male 24, female 70, p less than 0.01). Gallstone of the gallbladder was found in 957 cases or 21.4%. In the male, incidences of gallbladder carcinoma and stone increased with age until the lower half of the ninety, whereas in the female, no such tendency was found after the sixties. Incidence of gallbladder carcinoma was significantly higher in the cases with cholecystolithiasis than in those without stone (p less than 0.01). Furthermore, the incidence of gallbladder stones in the cases with relatively early carcinoma was significantly higher than that of those without carcinoma (p less than 0.01). Cholesterol stones were more common than bilirubinate in the carcinoma patients. These results suggest the importance of cholecystolithiasis, especially that of the cholesterol stones, as a background factor of gallbladder carcinoma. Extrahepatic bile duct carcinomas were present in 33 cases or 0.7% (male 19, female 14, no sex preference). The incidence was significantly higher in the cases with stones than in those without stones of the extrahepatic bile ducts (p less than 0.01). However, the fact that small stones were found in the upstream portions of obstruction of biliary tracts and no stone was found at operations in the 11 operated cases suggested that stones may be secondary to the cancerous growth.     

内镜保胆息肉切除术治疗胆囊息肉初探

目的评价内镜保胆息肉切除术治疗胆囊息肉的疗效及安全性。方法对2017年9月—2019年8月于复旦大学附属中山医院内镜中心接受内镜保胆息肉切除术治疗的25例胆囊息肉病例进行回顾分析,观察手术完成情况、手术用时、术后住院时间、并发症发生情况及随访情况。结果单发息肉13例、多发息肉12例,单纯胆囊息肉13例、合并胆囊结石12例,息肉最大径0.2~1.5 cm。1例(4%)经胃开窗进入腹腔后,因腹腔严重黏连,探查未见胆囊,终止操作,手术失败;其余24例(96%)成功接受内镜保胆息肉切除术治疗,手术时间(67.1±26.8)min(35~140 min),术后中位住院时间4 d(2~5 d),无迟发性出血、迟发性穿孔、弥漫性腹膜炎、腹腔脓肿等并发症。中位随访时间8个月(0~23个月),无患者失访,无息肉复发,无金属夹相关严重不良反应。结论内镜保胆息肉切除术治疗胆囊息肉安全且短期疗效显著,但其远期疗效仍需进一步大样本研究。     

Rare combination of familial adenomatous polyposis and gallbladder polyps

Familial adenomatous polyposis is associated with a high incidence of malignancies in the upper gastrointestinal tract (particularly ampullary adenocarcinomas). However, few reports have described a correlation between familial adenomatous polyposis and gallbladder neoplasms. We present a case of a 60-year-old woman with familial adenomatous polyposis who presented with an elevated mass in the neck of the gallbladder (measuring 16 mm × 8 mm in diameter) and multiple small cholecystic polyps. She had undergone a total colectomy for ascending colon cancer associated with familial adenomatous polyposis 22 years previously. The patient underwent laparoscopic cholecystectomy under a preoperative diagnosis of multifocal gallbladder polyps. Pathologic examination of the resected gallbladder revealed more than 70 adenomatous lesions, a feature consistent with adenoma of the gallbladder. This case suggests a requirement for long-term surveillance of the biliary system in addition to the gastrointestinal tract in patients with familial adenomatous polyposis.     

Ultrasonography in the diagnosis of true gallbladder polyps: the contradiction in the literature

Polypoid lesions of the gallbladder (PLGs) are often incidentally identified during ultrasonographic examination of abdominal pain. The present study was designed to determine the reliability of ultrasonography (US) in the diagnosis of PLGs. The records of 853 patients who underwent laparoscopic cholecystectomy (LC) for PLGs in Gazi Medical School from January 2000 to January 2004 were reviewed. Data were collected regarding the patients' gender, age, symptoms, serum lipid levels, the size and the number of polyps on US, surgical indications for PLGs and histopathological diagnosis. In all, 56 of 853 patients had PLGs and underwent LC. Right upper quadrant pain (59%) was the most common presenting symptom that led to gallbladder US. Nearly 75% of the lesions were smaller than 10 mm. At histopathologic examination cholesterolosis was found in 17 of 56 (30%) patients, and 12 of 56 (21%) demonstrated only cholelithiasis; 17 (30%) patients had both cholesterolosis and stones. Only 10 (18%) patients had adenomatous polyp and 8 of these polyps were larger than 1 cm. Overall US-based diagnosis of gallbladder polyp was inaccurate in 82%. The sensitivity and specificity of US for polyps <1 cm was 20% and 95.1%, respectively, whereas the sensitivity and specificity of US for polyps >1 cm was 80% and 99.3%, respectively. The accuracy of US in diagnosing PLGs was poor, especially in polyps <1 cm.     

经脐胃镜下保胆取石术的临床研究

目的评估经脐胃镜下保胆取石术治疗胆囊结石的临床效果和安全性。方法2018年4月至2018年7月,采用经脐胃镜下保胆取石术治疗的15例胆囊结石病例纳入回顾性分析,汇总手术完成情况、手术时间、术中出血量、并发症等。结果15例均顺利完成手术,术中患者生命体征平稳。手术时间（108±12）min（92～129 min）,术中出血10～30 mL。术后8例右上腹轻微疼痛,7例脐部切口轻微疼痛。无发热、切口感染、脐疝、腹膜炎、腹腔积液等并发症发生。所有患者术后1 d即可流质饮食,2 d可下床活动,4～5 d可出院。出院后1周所有患者恢复正常生活,术后1个月复查脐部手术瘢痕小而隐匿,体表基本无可见切口。4例术后3个月复查彩超提示胆囊收缩功能良好,无胆囊结石复发。结论经脐胃镜下保胆取石术治疗胆囊结石安全、有效,术后瘢痕小而隐匿,美容效果较好。     

Experience with 1904 laparoscopic cholecystectomies at a private hospital

The purpose of this paper is to describe our recent experience in performing laparoscopic cholecystectomies of which we performed 1904, from January 1991 to May 1997, at our private hospital, mainly to treat cholecystolithiasis. The patients included 1563 with gallbladder stones (82.0%), 82 with cholecystocholedocholithiasis (4.3%), 104 with adenomyomatosis (5.5%), 132 with polyps (6.9%), and 23 with gallbladder cancer (1.3%). A difficult pericholecystic dissection led to conversion to open surgery in 61 patients. The average operation time was 63 min. Bile duct injury or cystic artery bleeding occurred in 3 patients with acute cholecystitis, and small intestine injury occurred in 1 patient, while bile leakage or a right subphrenic abscess occurred in 6 patients postoperatively. Although this series included 69 patients with previous upper abdominal surgery, 14 with liver cirrhosis, 267 with a nonvisualized gallbladder, and 148 with acute cholecystitis, the overall conversion rate was only 3.2% and morbidity only 0.5%. Although almost all patients with cholelithiasis are now considered potential candidates for a laparoscopic cholecystectomy, difficulties during cholecystectomy have been encountered in patients with acute cholecystitis. Surgeons should thus be fully prepared to convert to open surgery whenever difficulties are encountered, in order to avoid complication.