胆总管结石治疗后复发因素的研究进展

胆总管结石是外科最常见的良性疾病之一,随着科技的进步、医疗技术的提升以及医院硬件设施的完善,经内镜逆行性胰胆管造影术(ERCP)及腹腔镜胆总管探查术(LCBDE)已经成为胆总管结石的主要治疗手段,且具创伤小、恢复快的临床优势.但是,临床多中心研究数据显示,胆总管结石术后复发率为4％～24％,因此,胆总管结石术后复发是外...     

胆总管结石患者的可视化仿真手术研究

目的 研究胆总管结石患者CT扫描数据的图像分割、三维重建和胆总管切开取石与T管引流术的可视化仿真手术.方法 采用64排螺旋CT扫描收集患者的数据;运用医学图像处理系统(MIPS)对患者的CT数据进行自动分割和三维重建,得到肝胆的三维模型,然后在FreeForm Modeling System(FreeForm)对模型进行加工;利用系统的GHOST SDK的软件进行虚拟手术器械的二次开发并实施胆总管结石的可视化仿真手术.结果 共采集平扫、动脉期、门静脉期、肝静脉期的数据,并由DICOM转换成BMP格式;MIPS分别对各期数据进行自动分割和三维重建,得到含胆总管结石的肝胆三维模型,并以STL格式输出;三维模型导人FreeForm进行平滑加工,不同的组织结构以不同的颜色渲染,三维模型更有立体感,形态逼真,将自行开发的手术器械T管等导入系统,利用力反馈设备PHANToM操纵下可以完成胆总管结石的可视化仿真手术.结论 MIPS可以有效、快速地完成胆总管结石的CT图像自动分割、三维重建.在FreeForm进行二次手术器械的开发后,利用力反馈设备PHANToM操纵下可以模拟胆总管结石的仿真手术.     

腹腔镜手术治疗胆囊结石合并胆总管结石术后结石复发危险因素的meta分析

目的:采用meta分析的方法系统评价腹腔镜手术治疗胆囊结石合并胆总管结石术后复发的相关危险因素。方法:计算机检索PubMed、Cochrane Library、Embase、中国生物医学文献数据库、中国知网、维普、万方等数据库,收集截至2019年10月公开发表的研究腹腔镜治疗胆囊结石合并胆总管取石术后结石复发危险因素的相关文章,采用RevMan 5.3软件进行meta分析。结果:共纳入12项研究、1 658例患者。meta分析结果显示,复发组中有碎石手术史患者的比例高于未复发组(OR=4.41,95%CI=2.63~7.38,P<0.01);复发组中合并胆管炎、胰腺炎患者的比例高于未复发组(OR=3.40,95%CI=2.25~5.13,P<0.01);复发组中合并胆囊管扩张患者的比例高于未复发组(OR=4.08,95%CI=2.81~5.93,P<0.01);复发组中合并胆总管扩张患者的比例高于未复发组(OR=4.12,95%CI=2.96~5.75,P<0.01);复发组中合并胆总管直径>1.0 cm患者的比例高于未复发组(OR=4.96,95%CI=3.59~6.86,P<0.01);腹腔镜胆囊切除联合胆道镜胆总管切开取石组的复发比例低于腹腔镜胆囊切除联合十二指肠镜乳头切开取石组(OR=0.27,95%CI=0.09~0.81,P<0.05)。结论:既往碎石史、合并胆管炎与胰腺炎、胆囊管扩张、胆总管直径>1 cm、内镜乳头切开术均是促进腹腔镜胆囊切除联合胆道镜胆总管切开取石术后结石复发的危险因素。     

胆总管结石的内镜治疗

目的总结内镜下乳头括约肌切开术（endoscopic sphincterotomy，EST）治疗胆总管结石的疗效及随访结果，分析可能导致取石失败的危险因素。方法2001年4月～2006年1月我院96例经内镜逆行胰胆管显影（endoscopic retrograde cholangiopancreatography，ERCP）证实胆总管结石后行EST及内镜下取石。通过随访术后疗效．对可能影响EST取石结果的因素进行分析。结果第1次EST未取出或未取净结石15例，第1次EST结石清除率84．4％（81／96）。第1次取石失败后5例再次行EST取净结石，3例自发排石，2例服中药或其他药物后排石，术后B超或ERCP检查证实结石已经排出，总结石清除率为94．8％（91／96）。术后近期并发症10例，其中急性胰腺炎5例、明显出血3例、急性胆囊炎和（或）急性胆管炎2例。5例因并发症或结石未取净行开腹手术。单因素和多因素分析表明，胆总管结石〉1．5cm和既往有胆总管探查手术史是取石失败的危险因素。85例随访10—59个月，胆总管结石复发3例、急性胆管炎1例；19例单纯胆总管结石在EST取净结石后没有切除胆囊，随访未见异常。结论EST是治疗胆总管结石安全有效的方法。结石〉1．5cm和既往有胆总管探查手术史时，应警惕EST有取石失败的可能。对于单纯性胆总管结石，在EST清除胆总管结石后不必预防性切除胆囊。     

腹腔镜手术治疗胆囊切除术后胆总管结石

目的:探讨腹腔镜手术治疗胆囊切除术后胆总管结石的方法及可行性。方法:回顾分析11例胆囊切除术后胆总管结石患者行腹腔镜手术的临床资料,总结其手术适应证及疗效。结果:11例患者均采用腹腔镜手术清除结石,随访1~21个月,平均13个月,无异常。结论:腹腔镜手术治疗胆囊切除术后胆总管结石安全、可行。     

Laparoscopic laser cholecystectomy and choledocholithiasis

Summary The management of common bile duct stones during laparoscopic laser cholecystectomy (LLC) is uncertain. Open common bile duct exploration is the least desirable option since it defeats the purpose of LLC. Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy has become the procedure of choice since it has a high rate of success and results in minimal morbidity. Intraoperative techniques using balloon catheters and the flexible choledochoscope via the cystic duct may obviate the need for ERCP in selected cases.     

A "one-stage" laparoscopic procedure for treating choledocholithiasis.

OBJECTIVES: A minimally invasive approach is considered the treatment of choice for gallbladder stones. We report our experience with the treatment of choledocholithiasis. METHODS: From January 1993 to December 2002, 3118 patients underwent minimally invasive surgery for symptomatic gallstones, 2681 for gallbladder stones and 437 (14%) for cholecysto-choledocholithiasis. RESULTS: We performed endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy in 71 patients (18.7%) with high operative risks, transcystic clearance and transcystic drainage in 96 cases (26.2%) and transcholedochal clearance with a T-tube in 270 cases (73.8%). In 2 patients, residual stones were removed with endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Postoperative stay ranged from 4 days to 12 days. No morbidity or mortality occurred. CONCLUSION: In our experience, "one-stage" laparoscopic procedure for cholecystocholedocholithiasis is safe and effective in skilled hands.     

腹腔镜经胆囊管纤维胆道镜取石术治疗继发性胆总管结石

目的:探讨腹腔镜经胆囊管纤维胆道镜取石术治疗继发性胆总管结石的可行性。方法:2006年7月至2009年6月为32例经磁共振胰胆管成像检查确诊的胆囊结石、继发性胆总管结石患者行腹腔镜经胆囊管纤维胆道镜取石术。结果:32例胆总管结石均用腹腔镜取出,无并发症发生及残余结石。结论:腹腔镜经胆囊管纤维胆道镜取石术是微创治疗胆囊结石继发性胆总管结石安全、有效的理想术式,值得在有设备及有技术条件的医院推广应用。     

腹腔镜胆总管切开术与内镜括约肌切开术治疗胆总管结石的比较

目的 探讨腹腔镜与内镜治疗胆总管结石的安全性有效性及适应证。方法 回顾性对比分析1997年7月至2006年6月腹腔镜胆总管切开术及内镜括约肌切开术治疗胆总管结石213例（腹腔镜组122例，内镜组91例）的临床资料。结果 腹腔镜组与内镜组相比手术成功率（96．7％vs．91．2％）及结石清除率（99．2％vs．94．0％）两组相似，近期并发症率（3．4％vs．13．3％，χ^2=6．864，P=0．009）较低；腹腔镜组的平均住院日（z=-2．713，P=0．007）及住院费用（z=-3．156，P=0．002）较高，主要原因是部分病例合并急性梗阻性胆管炎及胆源性胰腺炎预置鼻胆管引流控制感染，以及部分病例行胆总管T管引流等。内镜组发生重症胰腺炎3例（3．6％），其中死亡1例（1．2％）。结论 腹腔镜胆总管切开术保持Oddi括约肌完整，并发症较少、较轻，是治疗胆总管结石较为安全有效的方法。腹腔镜胆总管切开术适用于合并胆囊结石及胆总管扩张，急性梗阻性胆管炎及胆源性胰腺炎得到有效控制，全身情况好、能耐受麻醉手术者；内镜括约肌切开术适用于合并胆总管下段狭窄及结石嵌顿、急性梗阻性胆管炎、胆源性胰腺炎、全身情况差不能耐受麻醉手术的老年患者。     

完全腹腔镜联合胆道镜治疗胆总管结石

目的探讨完全腹腔镜联合胆道镜治疗胆总管结石的临床应用价值。方法自2004年11月至2009年12月间,影像学检查确诊为胆总管结石的患者109例。经胆囊管胆道镜探查胆总管取石术68例;胆总管切开胆道镜探查取石胆总管一期缝合术26例;胆总管切开胆道镜探查加T管引流术15例。结果 109例均顺利完成手术,无中转开腹。胆总管切开胆道镜探查取石胆总管一期缝合术中19例发生短暂胆漏,经3～6d引流后胆漏消失。其余患者术后3～10d出院,随访6～9个月,复查无胆道残留结石发生。结论完全腹腔镜联合胆道镜治疗胆总管结石具有微创手术的优点,安全有效,可以替代传统的胆总管切开探查、T管引流术。     

复杂型胆总管结石的内镜治疗策略

胆总管结石常导致急性胆道梗阻、胆管炎和胰腺炎。内镜下取石术已成为胆管结石的主要治疗方法。使用内镜下常规取石技术可治疗大部分结石,但对于约占10%~15%的复杂型胆总管结石的治疗尚需结合内镜下碎石术,笔者系统回顾和总结目前可用于复杂型胆总管结石的内镜治疗选择方式如内镜下球囊乳头扩张术、内镜引导下碎石术和内镜超声引导下胆道取石术等,以期对难治性胆总管结石临床治疗提供内镜诊疗建议和依据。      

胆囊结石合并胆总管结石的微创治疗体会

目的:比较腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)联合腹腔镜胆总管探查术(laparoscopic common bile duct exploration,LCBDE)与内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)、内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)+LC治疗胆囊结石合并胆总管结石的临床疗效。方法:在2010年1月至2015年11月收治的胆囊结石合并胆总管结石患者中选取可耐受腹腔镜手术、ERCP且ASA分级为Ⅰ~Ⅱ级的成年患者作为研究对象,危急重症胆囊炎、急性胆管炎及要求保守治疗的患者未纳入研究。分为两组:LC+LCBDE组与ERCP/EST+LC组,比较分析两组患者术中出血量、手术时间、住院时间、住院费用及术后并发症等指标。结果:共纳入76例患者,30例行LC+LCBDE,其中2例中转开腹;46例行ERCP/EST+LC,其中2例因ERCP取石失败,不予统计。两组患者术中出血量、术后并发症差异无统计学意义,LC+LCBDE组手术时间、住院时间、住院费用优于ERCP/EST+LC组,差异有统计学意义。结论:两种术式治疗胆囊结石合并胆总管结石的疗效相当,但LC+LCBDE可能更加经济实惠。     

腹腔镜辅助下小切口治疗胆囊结石并胆总管结石的临床研究

目的 比较开腹与腹腔镜胆囊切除+辅助小切口胆总管探查取石术的临床效果.方法 自2012年5月至2013年12月,68例胆囊结石合并胆总管结石适宜行腹腔镜胆囊切除小切口辅助胆总管探查的病人,男性25例,女性43例;年龄23～70岁,平均年龄47.3岁.随机将68例病人分别进入开腹胆囊切除+胆总管探查取石术组(开腹组)与腹腔镜胆囊切除+辅助小切口+胆总管探查取石术组(小切口组).其中,腹腔镜辅助下小切口胆总管探查36例,男性12例,女性24例,平均年龄49.6岁.病程3个月至22年.并比较两组相关临床指标.结果 两组病例手术全部获得成功,腹腔镜辅助下小切口组无中转扩大手术切口,术后病人均恢复良好.温氏孔腹腔引流管均于术后2～3 d无排液时拔除,两组术后4～5周行T管造影,均无胆道残石及狭窄,拔除T管.开腹组与腹腔镜辅助下小切口组比较,手术时间、术中出血、术后肠道功能恢复时间、术后镇痛剂的使用、伤口感染、住院时间,两组组间比较差异存在统计学意义(P＜0.01);两组术后无胆瘘及胆道残石率发生.开腹组平均住院费用(8614.1±246.4)元,小切口组平均住院费用(7451.5±113.5)元,两组平均住院费用差异存在统计学意义(P＜0.05).结论 腹腔镜辅助下小切口行胆囊切除+胆总管探查取石术,疗效满意、安全可行;比开腹手术更具有微创、并发症少、恢复快的优势.     

Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery

INTRODUCTIONGallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones.PRESENTATION OF CASEWe present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB.One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1 cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10 mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up.DISCUSSIONPatients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis.Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively.CONCLUSIONDue to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.     

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy

Background: The purpose of this prospective study was to evaluate if a recently proposed score system based on six preoperative parameters [history of colic pain and/or jaundice, dyspepsia, cholecystitis, ultrasound (US), evidence of common bile duct stones (CBDS), number and size of gallbladder stones at US, level of serum glutamic oxalacetic transaminase and/or alkaline phosphatase is effective in the selection of patients undergoing laparoscopic cholecystectomy (LC) with asymptomatic CBDS and could allow a significant reduction of the total number of preoperative examinations. Methods: In the case group, 408 patients were categorized into low-, medium-, and high-risk classes and underwent, respectively, no further preoperative assessment of the bile duct, intravenous cholangiography (IVC), and endoscopic retrograde cholangiography (ERC). Intraoperative cholangiography (IOC) was performed whenever the surgeon was in doubt as to biliary anatomy or bile duct clearance. These patients were compared with 408 retrospectively matched patients (control group) undergoing routine preoperative IVC and/or ERC. Results: In the case group, significantly lower numbers of IVC (120 vs 392) and IOC (3 vs 16) were performed (p < 0.005), whereas no difference in the total number of ERCs was noted. One patient in the control group had retained CBDS detected during follow-up evaluation, whereas none occurred in the case group. Conclusion: The proposed scoring system allows selective use of IVC, ERC, and/or IOC in patients undergoing elective LC.     

经内镜括约肌切开术治疗胆总管结石125例临床分析

目的 探讨经内镜括约肌切开术( endoscopic sphincterotomy,EST)治疗胆总管结石的适应证及有效性.方法 回顾性分析2004年1月至2009年12月应用EST治疗胆总管结石125例的临床资料.结果 本组手术成功率为92.8％,平均住院费用为1.4万元,平均住院时间为9.8d,近期并发症发生率为9...     

Laparoscopic treatment of choledocholithiasis using modified biliary stents

Background: When common bile duct (CBD) stones are present, the laparoscopic approach is widely used. For postoperative biliary decompression, T-tube insertion is the most traditional method. Antegrade biliary stenting is another method that could eventually replace the T-tube. Methods: This study involved 86 patients with CBD stones who underwent laparoscopic CBD exploration. A simple modification was made to the biliary stent by eliminating the proximal flap, and we adopted this as a routine biliary decompression device. This modified biliary stent (MBS) was inserted in 50 patients (MBS group), and the T-tube was used for 36 patients (T-tube group). Results: The mean operative time and the overall complication rate were similar between the two groups. There was no mortality. The mean hospital stay was significantly shorter for the MBS group. Biliary stents were eliminated spontaneously via the gastrointestinal tract among 36 (81.8%) patients, and for 8 patients, the stents had to be removed endoscopically. Six patients were lost to follow-up evaluation. The mean time that elapsed until spontaneous stent elimination was 11.5 ± 9.5 days. Conclusions: Among the different methods of biliary decompression, MBS renders the patients free of an uncomfortable T-tube. Morbidity and even mortality associated with T-tubes are eliminated, and the hospital stay may be shortened. Therefore, for selected patients, the modified biliary stent may be a better option than the traditional T-tube. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 12–15 March 2003     

腹腔镜胆囊切除联合胆总管探查术治疗胆囊结石并胆总管结石的临床研究

目的:探讨腹腔镜胆囊切除联合胆总管探查术治疗胆囊结石并胆总管结石的临床价值.方法:回顾分析2006年6月至2011年5月256例胆囊结石并胆总管结石患者的临床资料,均于腹腔镜胆囊切除术( laparoscopic cholecystectomy,LC)中切开胆总管,行纤维胆道镜胆总管探查取石.结果:256例手术均获成功...     

胆囊结石合并胆总管结石的微创保胆治疗

目的:评价胆囊结石合并胆总管结石微创保胆治疗的临床效果,探讨胆石症的微创外科治疗新方法。方法:2008年7月至2012年9月为41例胆囊结石并胆总管颗粒状结石患者行内镜逆行胰胆管造影(endoscopic retrograde cholangio-pancreatography,ERCP)+Oddi括约肌切开术(endoscopic sphincterotomy,EST),术后放置鼻胆管引流(endoscopic naso-biliarydrainage,ENBD),并行ENBD管造影以证实胆总管结石是否取尽,术后1～3 d行微创保胆取石术(endoscopic minimally invasivecholecystolithotomy,EMIC)。结果:41例手术均获成功,ERCP胆总管取石时间平均(51±9.1)min,保胆手术时间平均(48±7.3)min,术后均无并发症发生;术后住院2～5 d,平均(3.5±0.6)d。结论:ERCP+EST结合EMIC治疗胆总管结石并胆囊结石是安全、可行的,减轻了患者的痛苦,缩短了住院时间,增加了医疗效率,扩大了保胆手术的治疗范围。