Diagnosis and therapy of common bile duct stones in a patient with a history of hypersensitivity reaction to radiologic contrast media --a case report]

Common bile duct (CBD) stones may occur in patients who had been previously cholecystectomized because of gallbladder stones. CBD stones occur in 15%-20% of patients with symptoms secondary to cholecystolithiasis. After cholecystectomy they occur in 1%-5% of patients, either in the form of retained or recurrent choledocholithiasis. Endoscopic ultrasonography (EUS) is a novel and excellent diagnostic screening procedure for common bile duct stones. Numerous reports confirm an equal success rate for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). However, unanimity of opinion with respect to the best diagnostic procedure for the detection of CBD stones does not exist to date. We report a 74-year-old female patient with CBD stones, who was shown to have a severe allergy to X-ray contrast medium at a previous examination. In view of the pre-existing contraindication for ERCP, we diagnosed the stones by EUS. The majority of patients would require ERCP for endoscopic treatment, but our patient rejected the administration of contrast medium as well as conventional surgical treatment. After introducing a guide wire into the bile duct to assure its position, endoscopic sphincterotomy (EST) without contrast imaging was performed successfully. The CBD stones were extracted with a basket. Based on our results we believe that EUS ranks as an important procedure in the diagnosis of CBD stones, and that successful endoscopic treatment can be performed without previous ERCP. We do realize that EST without ERCP in unsuitable as a routine procedure, but may be used successfully in specific cases such as that of the patient reported here.     

内镜逆行胰胆管造影术在不同类型困难胆管结石中的诊疗体会

目的 探讨内镜逆行胰胆管造影术（ERCP）在胆总管巨大结石、胆总管多发结石和消化道重建术后患者中的治疗效果，分析手术失败的原因及其影响因素。方法 回顾性分析2016年－2019年解放军联勤保障部队第九〇九医院收治的146例经ERCP治疗的困难胆管结石患者的临床资料。其中，A组（n = 43）结石直径 > 15 mm，B组（n = 21）结石数量 > 10枚，C组（n = 82）行上消化道重建。根据ERCP取石是否成功，分为取石成功组（n = 106）和取石失败组（n = 40），比较两组患者ERCP操作时间、插管次数、取石成功率、结石残余率、不良事件发生率、结石直径和消化道重建方式等，采用单因素和多因素分析困难胆管结石患者ERCP手术失败的原因。结果 3组患者操作时间、平均插管次数、结石直径、残余结石和激光碎石比较，差异均有统计学意义（P < 0.05）；单因素分析结果显示：困难胆管结石患者中，ERCP取石成功组与取石失败组ERCP操作时间、插管次数、结石数目、消化道重建和是否首次ERCP比较，差异均有统计学意义（P < 0.05）；多因素分析结果显示：ERCP操作时间、插管次数、多发结石和消化道重建是困难胆管结石患者ERCP取石失败的危险因素（P < 0.05）。结论 ERCP取石在困难胆管结石患者中安全、可行，但需根据个体情况制定合理的治疗方案。     

经内镜乳头气囊扩张时间长短对胆总管结石治疗的有效性及安全性研究

目的研究内镜下逆行胰胆管造影术(ERCP)术中乳头气囊扩张时间长短对胆总管结石取石的成功率及术后并发症的影响。方法选取在该院行ERCP治疗的胆总管结石患者45例,随机分为短时气囊扩张组和长时气囊扩张组,分别比较两组患者的手术时间、术中及术后并发症发生率、住院天数和住院总花费等。结果有48例患者成功入组,3例插管失败未能纳入研究,短时气囊组22例,长时气囊组23例,两组患者在结石大小、结石数目、胆总管直径、术后住院天数和手术总费用上差异无统计学意义(P0.05),但在手术成功率、取石时间、术中并发症、术后胰腺炎发生率上长时气囊组明显优于短时气囊组(P0.05)。结论在行ERCP进行胆总管取石过程中,长时气囊扩张更有利于取石的成功率同时能减少术后相关的并发症。     

The role of ERCP and laparoscopic cholecystectomy in gallstone-related pancreatitis

Summary

Laparoscopic surgery has become the routine for elective cholecystectomy, but its place in the management of gallstone-related pancreatitis has not yet been identified. We prospectively assessed a minimally invasive treatment regime for gallstone pancreatitis combining endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy, over a 24 month period. Twenty-two patients were found to have gallstone pancreatitis. The mean age was 52 ± 18 years. All patients presented with abdominal pain. Five were jaundiced. The Ranson score severity of pancreatitis averaged 1.6 (range 0–6). Our management protocol was to perform ERCP when clinical and biochemical markers had settled, followed by laparoscopic cholecystectomy during the same admission. The time interval between presentation and ERCP was 8.9d (range 2–15d), ERCP to surgery was 4.5d (range 2–35d) and surgery to discharge was 4d (range 1–21 d). The median hospital stay was 16d. ERCP showed stones in the common bile duct in five patients, four of whom had them removed at ERCP. Twenty patients underwent laparoscopy. The gallbladder was removed in 18 and two required conversion (one pseudocyst, one cystic artery bleed). Two patients had elective open cholecystectomy (one pseudocyst, one previous surgery). Only one patient developed a post-operative complication (pseudocyst). The majority of patients had multiple small stones in their gallbladder and it was not possible to predict the presence of common bile duct stones prior to ERCP. No patient developed post-operative pancreatitis. There was no mortality. This study shows that combined ERCP and laparoscopic cholecystectomy is an efficient and safe minimally invasive management for gallstone pancreatitis.     

内镜逆行胰胆管造影术取石失败后即行腹腔镜胆总管探查术的临床观察

目的对于胆囊结石合并肝外胆管结石患者,探讨内镜逆行胰胆管造影术(ERCP)治疗肝外胆管结石不成功时如何选择治疗方式及时机。方法 12例胆囊结石合并肝外胆管结石拟分期行腹腔镜胆囊切除术(LC)+ERCP患者,行常规ERCP治疗失败,立即静吸复合全麻下完成LC+胆管探查取石术(LCBDE)。结果12例患者均顺利完成LC+LCBDE,并取净结石。术后3例出现高淀粉血症,全组无胆漏、肠漏、胆管炎、胰腺炎和胆道出血等并发症发生。结论对于ERCP治疗不成功的患者,急诊行LCBDE是安全、可行的补救措施。     

老年患者胆总管结石继发急性梗阻性化脓性胆管炎伴胆囊结石的临床诊治分析

目的：探讨老年患者胆总管结石继发急性梗阻性化脓性胆管炎伴胆囊结石的适宜诊治方法.方法：回顾分析2008年1月-2013年6月诊治的83例70岁以上的胆总管结石继发急性梗阻性化脓性胆管炎伴胆囊结石患者的临床资料.83例患者中,接受传统的开腹胆囊切除术加胆总管探查取石术的患者53例（传统组）,接受经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）加内镜下乳头括约肌切开取石联合腹腔镜胆囊切除术的患者30例（微创组）,对2组患者的治疗效果进行比较.结果：传统组的治疗成功率较微创组高,差异有统计学意义.2组术后并发症发生率差异无统计学意义.与传统组比较,微创组总的手术时间较长,但住院时间较短,差异有统计学意义.结论：ERCP联合腹腔镜手术治疗胆总管结石继发急性梗阻性化脓性胆管炎伴胆囊结石患者具有微创、术后恢复快等优点,但应用于老年患者时有其局限性,有时开腹手术对患者更为有利,应针对具体情况采取个体化治疗方案.     

选择性ERCP在LC术前的应用

32例拟行腹腔镜胆囊切除术(LC)的胆囊结石患者,选择性地进行术前ERCP检查,成功率为93.7％。18例术前临床表现怀疑有胆总管结石存在,ERCP发现8例(44.4％)有胆总管结石;12例无胆总管结石依据,1例(8.3％)存在胆总管结石。另外,发现胆道变异1例。通过资料分析,认为LC术前选择性ERCP的适应证为:胆总管直径大于0.8cm,B超怀疑或发现胆总管结石,胆管炎病史,胆源性胰腺炎病中及肝功能异常。     

胆总管巨大结石内镜下治疗效果的评价

目的探讨胆总管巨大结石内镜下分次取石治疗的临床效果。方法183例胆总管结石大于1.5 cm的患者,在内镜下按照机械碎石、网篮和气囊取石、胆管引流(鼻胆管、塑料支架)等方法进行胆管内取石,记录乳头肌切开的大小、结石大小与碎石、取石次数和并发症。结果胆总管结石越大所需碎石、取石的次数越多,需要置放胆管引流的患者越多,需要外科手术的患者也多,但其他并发症未见明显增多。结论胆总管巨大结石内镜下分次治疗的方法是安全的、可靠的。     

腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石

目的:探讨腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石的临床疗效.方法:回顾分析2009年1月-2010年12月腹腔镜胆囊切除术(LC)联合十二指肠镜治疗35例胆囊结石合并胆总管结石患者的临床资料.所有患者均采取经十二指肠镜逆行胰胆管造影(ERCP),内镜下十二指肠乳头括约肌切开术(EST),取出胆总管结石,放置胆道塑料支架引流(ERBD).ERCP后3d内行LC,术后4d出院.出院后1～2周内再次行十二指肠镜取出胆道支架并行ERCP了解胆管有无残余结石.结果:35例患者均1次取净胆总管结石,1例EST术中出血,34例成功行LC,1例中转开腹行胆囊切除术.术后并发急性胰腺炎2例,所有患者均无胆漏、十二指肠穿孔、黄疸等并发症.结论:腹腔镜联合十二指肠镜治疗胆囊结石合并胆总管结石具有疗效确切、创伤小、恢复快等优点.     

胆囊切除术后残留胆总管结石的内镜诊治

目的：探讨经内镜逆行胰胆管造影（ERCP）在胆囊切除术后残留胆总管结石诊治中的应用价值。方法：对胆囊切除术后腹痛、发热、黄疸或肝功能异常而经B超、CT或磁共振胰胆管造影（MRCP）证实或怀疑残留胆总管结石的患者进行ERCP检查，对发现胆总管结石的患者行EST或EPBD后取石。结果：ERCP检查的成功率为96．4％（108／112）。85例证实胆总管结石的患者行EST或EPBD后取石，79例（92．9％）取石治疗成功；6例因合并肝内胆管多发结石而行外科手术治疗。并发症发生率为4．5％，其中消化道出血2例，急性胰腺炎3例。结论；对于胆囊切除术后残留胆总管结石的患者，ERCP是理想的诊断方法，而且还可以同时进行治疗。     

Postendoscopic sphincterotomy stenosis

We report on two patients. The first patient is a 62-year-old female patient who had cholecystectomy in 1970, and in whom two small bile duct stones were removed after endoscopic sphincterotomy in 1987. Within two months of this procedure, she developed three episodes of documented acute pancreatitis. The other patient, a 58-year-old female, developed acute pancreatitis three months after an endoscopic sphincterotomy for stones in the common bile duct. In both patients, ERCP revealed a cicatricial stenosis of the common bile duct and the pancreatic duct. The condition was resolved by repeat sphincterotomy. The first patient needed repeated endoscopic insertion of bilioduodenal endoprostheses and an endoprosthesis in the pancreatic duct. It is interesting to note that, in contrast to surgical reports, very few postpapillotomy stenoses are reported by endoscopists.     

Endoscopic papillary large balloon dilation for bile duct stones in elderly patients

AIM: To investigate whether endoscopic papillary large balloon dilation(EPLBD) can be safety and effectively performed in patients aged ≥ 80 years. METHODS: Lithotomy by EPLBD was conducted in 106 patients with bile duct stones ≥ 13 mm in size or with three or more bile duct stones ≥ 10 mm. The patients were divided into group A( 80 years) and group B(≥ 80 years). Procedure success rate, number of endoscopic retrograde cholangiopancreatographies(ERCP), and incidence of complications were examined in both groups.RESULTS: Group B tended to include significantly more patients with peripapillary diverticulum, hypertension, hyperlipemia, cerebrovascular disease/dementia, respiratory disease/cardiac disease, and patients administered an anticoagulant or antiplatelet agent(P 0.05). The success rate of the initial lithotomy was 88.7(94/106)%. The final lithotomy rate was 100(106/106)%. Complications due to treatment procedure occurred in 4.72(5/106)% of the patients. There was no significant difference in procedure success rate, number of ERCP, or incidence of complications between group A and group B.CONCLUSION: EPLBD can be safely performed in elderly patients, the same as in younger patients.     

Combined endoscopic and laparoscopic treatment of common bile duct stones

In a consecutive series of 228 patients reterred to Kalundborg Sygehus, Surgical Department, for treatment of gall bladder disease, 17 patients had common bile duct (CBD) stones. Nine were found pre-operatively and treated with endoscopic retrograde cholangiography (ERC), papillotomy and stone extraction. In two cases, however, the ERC procedure failed and the patients were treated successfully using laparoscopic therapy. Six CBD stones were found during laparoscopic surgery. Four of these patients were treated with laparoscopic stone extraction. In two patients laparoscopic stone extraction was not possible and they were treated post-operatively with ERC and stone extraction. Two CBD stones were discovered after laparoscopic cholecystectomy. One was treated with ERC and stone extraction, the other with open surgery. By combining endoscopic and laparoscopic procedures, it is possible in most cases to avoid open surgery for the treatment of CBD stones.     

治疗性内镜下逆行胰胆管造影术在老年患者胰胆疾病中的临床应用

目的评价治疗性内镜下逆行胰胆管造影术(ERCP)在老年患者胰胆疾病中的临床应用。方法回顾分析总结成都大学附属医院2007年7月至2009年12月完成的73例70岁以上老年患者治疗性ERCP的临床治疗结果。结果 73例患者共完成治疗69例,成功率94.5%。胆管结石49例,胆管癌6例,胰头癌4例,乳头癌3例,乳头良性狭窄7例,失败4例。其中49例胆道结石组中,48例经乳头奥狄氏括约肌切开(EST)或气囊扩张乳头后,取石成功,7例合并急性梗阻性化脓性胆管炎,以及6例合并胆源性胰腺炎的患者症状均很快缓解。1例因结石较多并且合并肝内胆管结石,转外科行开腹手术,13例肿瘤组中,4例胰头癌、6例胆总管癌患者均安置金属支架,引流通畅,均顺利出院。本组无严重的并发症及死亡发生。结论经过认真的术前准备和术中监护及操作,治疗性ERCP对老年患者是安全和有效的,可代替部分传统开腹手术。     

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage,hybrid techniques in gastrointestinal and biliary diseases

In recent years, a wide range of gastrointestinal endoscopy techniques have been developed, such as endoscopic submucosal dissection (ESD) and endoscopic retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an important role in gastrointestinal and biliary diseases, each technique has its limitations. Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time. Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area. Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate. The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction, stenosis and bile duct injuries. For patients with simultaneous presence of stones in the gallbladder and the common bile duct, the laparo-endoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction. The most common used approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-assisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.     

胆总管结石术后经鼻胆引流管注射生理盐水在超声检查残留结石中的应用

目的 探讨胆总管结石术后经鼻胆引流管注射生理盐水在超声检查残留结石中的应用价值。方法 对50例经内镜逆行胰胆管造影术（ERCP）、十二指肠镜下乳头括约肌切开术（EST）、内镜鼻胆管引流术（ENBD）诊治胆总管结石的术后患者行常规超声及超声联合鼻胆引流管注射生理盐水检查,对比注射生理盐水前后超声测量胆总管长度、宽度及残留结石的检出率。结果 50例患者注射生理盐水前后胆总管全程显示率分别为18.00%（9/50）、90.00%（45/50）;注射生理盐水前后超声检查胆总管长度分别为（2.63±0.26）cm、（5.79±2.17）cm,宽度分别为（0.49±0.35）cm、（0.99±0.35）cm,差异均有统计学意义（t=11.03、10.81,P均<0.01）。注射生理盐水前疑似胆总管结石1例,注射生理盐水后另增5例疑似存在胆总管结石,其中5例行ERCP检查：ERCP检查4例证实为胆总管结石,1例未见明显结石;1例经手术证实为胆总管结石。结论 经鼻胆管引流管注射生理盐水可提高胆总管显示率,进而提高对残留结石的检出率。     

腹腔镜与开腹手术治疗胆囊并胆总管结石的内镜应用

目的 探讨内镜参与腹腔镜胆囊切除术（LC）、开腹手术治疗胆囊并胆总管结石的效果.方法 对54例胆囊并胆总管结石病人在LC或开腹手术之前行内镜检查、取石.结果 54例十二指肠逆行胰胆管造影（ERCP）均成功,选择性十二指肠乳头括约肌切开术（EST）取胆总管结石成功49例,占90.74%.EST后选择性LC成功47例,内镜加LC总取石成功者占87.05%,1例EST取石后急性胆囊炎加重中转手术;内镜术后选择性开腹手术成功7例,占12.95%.无严重并发症发生.结论 先行内镜检查、取石,再行LC处理,大部分胆囊并胆总管结石病人可治愈而且并发症少,少部分疑难、复杂者仍需开腹手术处理.     

不同手术方案在复杂胆总管结石患者中的效果研究*

目的探讨内窥镜括约肌切开术(EST)或内镜逆行胰胆管造影术(ERCP)和腹腔镜胆总管探查术(LCBDE)联合腹腔镜胆囊切除术(LC)治疗胆囊结石合并胆总管结石的临床治疗效果。方法选取2013年6月-2015年6月该院收治的复杂胆总管结石患者80例为研究对象,根据患者采取的手术方案,将患者分为EST+LC组(38例)和LCBDE+LC+ERCP组(42例)。比较两组患者的一般临床资料、治疗效果、术后并发症发生率及肝功能相关指标情况。结果 LCBDE+LC+ERCP组结石最大直径、胆总管直径均大于EST+LC组,其结石数量明显多于EST+LC组,差异均有统计学意义(P0.05)。与EST+LC组相比,ERCP+LC+LCBDE组单次手术成功率较高,手术时间短,但其手术费用亦较高,差异均有统计学意义(P0.05);取石成功率、中转开腹率及住院时间在两组间差异无统计学意义(P0.05)。ERCP+LC+LCBDE组术后并发症发生率为21.43%(9/42),EST+LC组术后并发症发生率为26.32%(10/38),两组间差异无统计学意义(P0.05)。两组患者术后1 d的血清直接胆红素、丙氨酸转氨酶及天冬氨酸转氨酶均轻度升高,术后3 d两组患者各指标均恢复正常水平。结论 LCBDE+LC+ERCP以及EST+LC两种手术方案均是治疗复杂胆总管结石的有效方法,其中LCBDE+LC+ERCP手术成功率高,手术时间较短,对较大的结石更有优势。     

胆总管结石继发急性梗阻性化脓性胆管炎的急诊内镜治疗

目的：探讨胆总管发急性梗阻性化脓性胆管炎的急诊内镜镜治疗方法,方法：118例胆总管结石继发急性梗阻性化脓性胆管炎患者接受ERCP检查和治疗,112例,人镜括约肌切开（EST）或内镜乳头气囊扩张（EPBD）取石梳 及放置鼻胆管引流（ENBD）,结果：31例经EPBD后取石,39例经EST后取石,或同时放置ENBD,42例单纯放ENBD,105例患者经急诊治疗后症状得到缓解,无严重并发症和死亡,结论：内镜治疗急性胆管炎较传统开腹手术具有操作简单,安全,有效,创伤小和恢复快等优点。     

ERCP在胆管结石诊断和治疗中的应用

目的评价内镜下逆行胰胆管造影(ERCP)对胆管系统结石诊断和治疗的价值。方法对106例ERCP资料作回顾性分析,并将超声(US)、计算机断层扫描(CT)与ERCP的资料进行比较。结果胆囊结石的诊断US优于CT和EPCP,胆总管结石的诊断ERCP优于CT、US。本组病例中ERCP检查的胆管结石患者在明确诊断的同时通过内镜下乳头切开取石和/或鼻胆管引流解除梗阻。其中结石最小直径0.1cm,最大直径5cm,单发19例,多发37例。胆系结石主要位于胆总管和胆囊内,ERCP主要表现为胆总管内的充盈缺损,胆管扩张,下端梗阻时,可出现杯口状的充盈缺损,其上方胆管口径扩张。结论ERCP作为一种微创的诊断兼治疗的手段,对胆管结石有重要的临床应用价值。