经胆囊管胆道镜探查治疗继发性胆总管结石

近年来广泛开展腹腔镜或小切口胆囊切除术,极易忽略继发性胆总管结石,胆囊结石继发性胆管结石的发生率为6%～19.5% [1],因此应予以高度重视[2].     

开腹或腹腔镜胆总管探查一期缝合术230例报告

我们1998年5月～2003年5月,对230例胆总管结石实施常规开腹或腹腔镜胆总管探查术中,经胆囊管置胆道引流后,行胆总管一期缝合,取得良好疗效,报道如下。     

腹腔镜联合胆道镜经胆囊管诊治胆总管结石适应证探讨

目的探讨腹腔镜经胆囊管胆总管探查取石术的手术适应证及临床疗效。方法总结分析2004年4月至2009年6月间行腹腔镜联合胆道镜经胆囊管胆道探查取石术116例的临床资料。结果 116例中完成腹腔镜经胆囊管胆道探查取石术109例,中转开腹手术3例,改腹腔镜下胆总管切开取石4例。平均手术时间86 min。术后2～4 d拔腹腔引流管,4～11 d出院,术后平均住院7.2 d。无术后胆漏、胆管炎、胰腺炎、出血、胃肠道损伤及胆管狭窄的发生,无胆道残余结石的发生,无手术死亡,均痊愈。结论腹腔镜经胆囊管胆道探查取石术适用于继发性胆总管结石患者,对直径1 cm结石疗效更佳,更能体现出微创的优势,是该手术的最佳适应证。     

经胆囊管纤维胆道镜治疗继发性胆总管结石36例

目的探讨经胆囊管纤维胆道镜治疗继发性胆总管结石的效果。方法对36例胆囊结石继发性胆总管结石患者行胆囊切除术中经胆囊管纤维胆道镜探查取石术,术中均行胆道造影。结果本组36例均痊愈出院,无胆漏腹腔感染、出血、胆管狭窄、结石残留等并发症的发生,住院时间明显缩短。结论经胆囊管纤维胆道镜治疗继发性胆总管结石是安全有效的。     

腹腔镜和胆道镜治疗胆囊胆总管结石的体会

目的探讨腹腔镜和胆道镜治疗胆囊胆总管结石的临床效果。方法2003年7月-2005年8月我院有18例胆囊并胆总管结石手术先行腹腔镜胆囊切除，然后切开胆总管用胆道镜探查，取出胆总管结石。结果1例腹腔镜胆囊切除术中转开腹，17例均顺利完成腹腔镜胆囊切除、胆道镜胆总管探查术。结论腹腔镜和胆道镜治疗胆囊胆总管结石的临床效果可靠。     

腹腔镜术中经胆囊管胆道镜治疗胆总管结石

我院于1993年10月至1996年10月,在16例腹腔镜胆囊切除术中,经腹腔镜转换器,应用OlympusP20型纤维胆道镜(Φ4.9 mm),经切开的胆囊管进入胆总管,治疗胆总管继发结石,取得了较好的疗效,现报告如下. 1.一般资料:本组男8例,女8例,年龄39～62岁(平均50岁),术前均经ERCP确诊为胆囊结石,继发胆总管结石.结石大小0.3～1.1 cm,胆总管内径约0.7～1.7 cm,平均约1.0 cm.     

经胆囊管纤维胆道镜胆总管探查的临床应用

目的 探讨经胆囊管纤维胆道镜胆总管探查的临床应用效果.方法 我院2004年1月至2008年6月期间用该方法治疗胆囊结石合并胆总管结石患者28例(研究组); 另选择同期行胆总管切开取石T管引流术患者30例(对照组),比较观察2组患者的手术和住院时间、输液量、住院费用、术后恢复情况、手术并发症等.结果 研究组较对照组术后住院时间更短[(6.0±1.1) d比(9.6±1.8) d,P＜0.05],肛门排气时间[(28.2±3.8) h比(46.3±5.9) h,P＜0.05]和恢复正常生活时间[(10.3±2.1) d比(35.7±5.8) d,P＜0.01]更快,输液量[(5 515±368) ml比(9 542±834) ml,P＜0.01]和住院费用[(8 100±425)元比(12 100±756)元,P＜0.05]更少.研究组发生手术并发症2例(2/28); 对照组发生手术并发症6例(6/30),其中需再次外科手术治疗的严重并发症2例(2/30),严重并发症均由放置T管引起.结论 对于合适的胆囊结石合并胆总管结石的患者,可首选经胆囊管纤维胆道镜胆总管探查,避免了放置T管引起的一系列弊端,是安全、可行的.     

经胆囊管腹腔镜胆道探查术治疗胆总管结石的临床研究

目的:比较分析腹腔镜下经胆囊管和经胆总管切开T管引流两种方法胆道镜取石治疗胆囊结石继发胆总管结石的疗效,以评价经胆囊管腹腔镜胆道探查术治疗胆总管结石的临床价值。方法:2001年3月至2003年3月按胆道探查途径不同将28例胆石症患者分为胆囊管组(n=8)和胆总管切开组(n=20)。患者经B超和术中胆道造影或加内窥镜逆行胆管造影(ERC)确诊。观察两组病例的术后肛门排气时间、腹腔引流时间、术后住院日、住院费用及手术并发症的发生情况,术后对患者进行全程跟踪随访。结果:胆总管切开组肛门排气时间、腹腔引流时间、术后住院日、住院费用明显长于或高于胆囊管组(P>0.05)。胆囊管组发生手术并发症1例(12.5%);胆总管切开组5例(25.0%),其中胆道并发症4例(20.0%),需要再次微创处理2例(10.0%),需再次手术治疗的严重并发症2例(10.0%);手术并发症发生率胆总管切开组明显高于胆囊管组(P<0.05)。随访两组患者均无胆管狭窄、急性胆管炎及急性胰腺炎发生和结石复发。结论:经胆囊管途径的腹腔镜胆道探查术充分体现了微创外科技术的优点,适于胆囊结石继发胆总管结石患者,其疗效优于胆总管切开T管引流途径的腹腔镜胆道探查术。     

胆道镜在开腹胆总管探查术中体会

胆道系统结石在我国的发病率高达4％～7％,目前手术是治疗胆道系统结石最有效的手段,经典的手术方式是开腹行胆囊切除胆总管前壁切开探查后取出结石,并留置T管引流胆汁,但具有较高的并发症和残石率.胆道镜技术的出现与迅猛发展给肝胆外科带来了革命性改变.纤维胆道镜可直视胆道内部,可作组织学检查,还可治疗狭窄胆管及取石等,我院自2010年4月至2012年12月开展胆道镜胆总管探查术128例,获得了良好的效果,现将临床经验总结报告如下:     

Transcystic common bile duct exploration in the management of patients with choledocholithiasis

Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis of choledocholithiasis is made at the preoperative workup, it is common practice to refer the patient for endoscopic retrograde cholangiography and endoscopic sphincterotomy. However, if the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma-that is, the choice between laparoscopic common bile duct exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. We have opted to treat patients with choledocholithiasis in only one session during the laparoscopic cholecystectomy; we use the transcystic common bile duct exploration technique employing the choledochoscope. We report our early experience in terms of success of stone removal, operative time, morbidity and mortality, and length of hospital stay. From 1992 to 2002, we performed 350 laparoscopic cholecystectomies. Selective cholangiography was used in 105 patients (30%); 40 of them were found to have common bile duct stones, for an incidence of 11.4%. Among this group, we performed laparoscopic transcystic common bile duct exploration in all but six patients. Our success rate for stone removal was 94.1% (32 of 34 patients), with only two failures related to multiple stones and impaction at the ampulla, for a conversion rate of 5.8%. The mean operative time was 120 ± 40 minutes. The morbidity rate was 8.8%, and there were no deaths. Length of hospital stay was 24 to 48 hours. Mean recovery time was 7 days, and time to return to work was 15±3 days. We concluded that most of the patients with common bile duct stones found during laparoscopic cholecystectomy could be treated successfully by means of the transcystic technique with choledochoscopy, with no increase in morbidity or mortality and a shortened hospital stay and recovery time, similar to patients who undergo only laparoscopic cholecystectomy. On the basis of our results, we recommend that this method become the primary strategy in the great majority of patients with common bile duct stones found during intraoperative cholangiography. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

腹腔镜胆总管探查术与内窥镜下括约肌切开术治疗胆总管结石的临床应用比较

目的 比较腹腔镜胆总管探查术(LCBDE)和内镜下括约肌切开术(EST)治疗不同胆总管结石的疗效及并发症,探讨其适应证的差异,指导临床合理应用.方法 202例胆总管结石患者,按手术方式分为腹腔镜胆总管探查术组(LCBDE组,45例)和内镜下括约肌切开术组(EST组,157例);评价两组操作成功率、一期手术治愈率、残余结石和(或)病变率、并发症率、平均住院时间和费用.结果 LCBDE组和EST组操作成功率分别为97.8％(44/45)和98.7％(155/157)(P> 0.05).一期手术治愈率分别为84.4％(38/45)和45.2％(71/157) (P<0.01).LCBDE组术后残余病变主要为残石,残石率为15.6％(7/45); EST组主要为术后遗留未处理的胆囊病变和肝内外胆管结石,残留率为54.8％(86/157)(P<0.01).LCBDE组并发术后胆漏4例、残余感染1例,并发癌率为11.1％;EST组并发术后胆漏3例、出血4例、高淀粉酶血症32例(其中急性胰腺炎14例)、急性胆管炎15例,并发症率34.4％ (P< 0.05).平均住院时间为(10.0±2.8)和(9.4±4.1)d (P>0.05);住院费用为(17504±4128)和(16453±3541)元(P>0.05).结论 LCBDE和EST均有操作成功率高、住院时间短等优点;但LCBDE并发症率、残余病变率均低于EST; LCBDE主要适于胆囊合并胆总管结石的患者,尤其是Oddi括约肌功能完好者;EST主要适于单纯胆总管结石或胆管炎患者,特别是年老体弱、Oddi括约肌无功能或既往有胆道手术史且不愿再次手术者.     

腹腔镜胆道镜治疗胆囊结石合并胆总管结石两种术式的疗效比较

目的对比腹腔镜胆囊切除+经胆囊管胆道探查术(LC+LTCBDE)与腹腔镜胆囊切除术+胆总管切开探查+T管引流术(LC+LCHTD)两组微创手术方式治疗胆囊结石合并胆总管结石的临床疗效。方法 130例胆囊结石合并胆总管结石患者,其中70例行LC+LTCBDE,60例行LC+LCHTD。比较两组患者手术时间、术后住院时间、住院费用、术后恢复正常生活时间和并发症情况(胆漏、出血、胆管狭窄,胆管残余结石等)。结果 LC+LTCBDE组的手术时间、术后住院时间、住院费用、术后恢复正常生活时间均低于LC+LCHTD组,差异有统计学意义(P0.05)。两组术后并发症比较,差异无统计学意义(P0.05)。结论 LC+LTCBDE可作为胆囊结石合并胆总管结石的首选治疗,难以经胆囊管胆道探查时,LC+LCHTD仍为明智选择。     

不同缝合方式在腹腔镜胆总管探查术一期缝合中的应用

目的比较不同缝合方式在腹腔镜胆总管探查术一期缝合中应用的临床疗效。方法我院2008年7月~2014年6月外科收治的胆囊结石合并胆总管结石患者105例。均实施腹腔镜胆囊切除+胆总管探查+胆总管一期缝合术,分为两组,可吸收线连续锁扣缝合组51例,Quill免打结缝合线组54例。结果两组患者在术后胃肠功能恢复时间、术后住院时间比较差异有统计学意义(P0.05),手术中出血量、住院总费用、术后并发症发生率两组比较差异无统计学意义(P0.05)。两组患者均随访6~24个月,随访期内均未发现胆管狭窄及胆管炎?残余结石等情况。结论在具备丰富的腹腔镜操作技术的基础上,胆总管一期缝合是安全的,疗效确切。使用Quill免打结缝合线具有手术时间短,操作更加简便等优点。     

腹腔镜胆总管探查手术适应证探讨

目的 探讨腹腔镜胆总管探查术（LCBDE）的手术适应证及其临床疗效。方法 总结分析吉林大学第一医院普外科2005年11月至2008年3月成功开展腹腔镜胆囊切除联合纤维胆道镜胆总管探查术83例病人的临床资料。 结果 成功完成LCBDE 81例,其中二次胆道手术3例,手术成功率97.6％;中转开腹2例,中转率2.4％。平均手术时间90min,平均肠蠕动恢复时间2.6d,平均术后住院8d。胆总管一期缝合1例术后胆汁瘘,术后1周自愈;术后胆道残余结石2例,经T管窦道行胆道镜治愈。无腹腔出血、胃肠道损伤等并发症,全部治愈,带T管出院。术后4周回院常规T管造影拔管。 结论 胆囊结石及胆囊炎合并胆管结石是腹腔镜胆管探查取石术的最佳手术适应证。     

Laparoscopic exploration of common bile duct in difficult choledocholithiasis

Background This review investigated the role played by laparoscopic exploration of the common bile duct (LECBD) in the management of difficult choledocholithiasis.Methods This retrospective study reviewed a prospective database of LECBD for difficult choledocholithiasis during the period 1995 to 2003.Results Of the 97 LECBDs performed in the authors center from 1995 to 2003, 25 were performed for difficult choledocholithiasis. Difficult choledocholithiasis was defined as failure of endoscopic stone retrieval for the following reasons: access and cannulation difficulty, the difficult nature of common bile duct (CBD) stones, and the presence of endoscopic retrograde cholangiopancreatography (ERCP)-related complications. There were seven unsuccessful cannulations because of previous gastrectomy (n = 5) and periampullary diverticulum (n = 2). Among the 18 patients with failed endoscopic extraction, there were 10 impacted stones, 2 incomplete stone clearances after multiple attempts, 2 type 2 Mirizzi syndromes, 1 proximal stent migration, 1 repeated post-ERCP pancreatitis, 1 situs inversus, and 1 stricture at the distal common bile duct. There were 14 male and 11 female patients with a mean age of 67.8 ± 15 years. Initial presentations included cholangitis (n = 14, 56%), biliary colic (n = 3, 12%), jaundice/deranged liver function (n = 5, 20%), cholecystitis (n = 2, 8%), and pancreatitis (n = 1, 4%). Regarding the approach for LECBD, there were 2 transcystic duct explorations and 23 choledochotomies. The mean operative time was 149.4 ± 49.3 min, and there were three conversions (12%). The stone clearance rate was 100%, and no recurrence was detected during a mean follow-up period of 16.8 months. Five complications were encountered, which included bile leak (3 patients) and wound infection (2 patients). When the results were compared with the remaining 72 LECBDs for nondifficult stones during the same period, the complication rate, conversion rate, and rate of residual stones were similar despite a longer operation time (149.4 ± 49.4 min vs 121.6 ± 50.5 min).Conclusion When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones.     

腹腔镜胆道探查前瞻性非随机对照研究

目的:探讨腹腔镜胆道手术后不放置T管(胆道)引流的可行性。方法:对2005年2月至2005年11月我院治疗的行腹腔镜胆总管探查的25例患者进行了前瞻性非随机对照研究。分为两组,观察组未放置T管,共15例;对照组放置T管,共10例。结果:患者均恢复良好。随访1~5月,观察组未发现结石复发或其它并发症,对照组1例残余结石,1例胆道下端狭窄,均经保守治疗后痊愈出院。两组结石残留率、近期并发症发生率、住院费用等方面差异无显著性(P>0.05),而在手术时间、住院时间等方面差异有显著性(P<0.05)。结论:腹腔镜胆道探查是较成熟的治疗胆总管结石的方法,根据术前影像学检查及术中胆道镜检查结果,决定是否放置T管引流。     

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。     

腹腔镜与开腹胆总管探查术144例对比研究

目的 探讨胆囊结石合并胆总管结石行胆总管探查术的术式选择。方法 回顾性分析144例胆囊结石合并胆总管结石患者行腹腔镜与开腹胆总管探查术的临床资料。根据手术方式分为腔镜组（n=78）和开腹组（n=66）。结果 腔镜组一期缝合39例,T管引流32例,经胆囊管探查2例,中转开腹5例;术后胆漏7例,胆管炎4例,残余结石2例,肠穿孔1例,MODS 1例,电解质紊乱5例,伤口感染2例。开腹组术后胆漏合并胸、腹腔积液1例,胆管炎1例,残余结石2例,术后出血再次手术1例,电解质紊乱4例,伤口感染4例,肝肾功能不全2例,死亡1例。两组在术后并发症发生率方面比较差别无统计学意义（P＞0.05）。结论 与开腹手术比较,腹腔镜胆总管探查取石术具有微创、术中失血少、术后恢复快、术后住院时间短等优点,但尚不能完全替代传统开腹手术。