腹腔镜手术治疗胆囊结石合并胆总管结石的临床研究

目的 探讨腹腔镜微创手术在治疗胆囊结石合并胆总管结石疾病中的价值。方法 回顾性分析了1996年1月～2004年9月在该院确诊为胆囊结石胆总管结石的病人采用腹腔镜手术的治疗情况，并对多种治疗的选择方案、结果作了分析比较。结果 68例患者中大多数在腹腔镜下一期作了胆囊切除、胆总管切开胆道镜下取石T管引流，未发现有明显并发症。少数胆总管无扩张的病例由内镜下作EST后联合腹腔镜胆囊切除术二期完成治疗，极少数上述方案治疗失败的患者由开腹完成治疗。腹腔镜手术一期治疗与内镜、腹腔镜联合二期治疗和开腹手术相比较，病人住院时间短，恢复快，并发症少，手术成功率高，具有明显的优点，而手术时间并无延长。结论 腹腔镜下手术一期取除结石是治疗胆囊结石合并胆总管结石的主要、较好的选择方案。     

腹腔镜胆道手术用于胆总管结石治疗的临床研究

目的比较腹腔镜胆囊切除+胆总管切开探查取石术和传统开腹胆囊切除+胆总管切开探查取石术的临床效果。方法 75例胆囊结石合并胆总管结石患者分两组,腹腔镜组31例行腹腔镜胆囊切除+胆总管切开取石术;44例传统开腹胆囊切除+胆总管切开取石术。统计手术时间,术后胃肠功能恢复时间,术后住院时间及并发症。结果与开腹组比较,腹腔镜组患者住院时间短[(5.3±1.2)d vs.(7.0±2.5)d],术中出血少[(54±16.7)ml vs.(62±12.3)ml],手术时间短[(58±11.3)min vs.(65±9.67)min],通气时间短[(2.3±0.6)d vs.(2.7±0.4)d]。两组并发症和结石清除率无明显差异。结论腹腔镜胆总管切开取石术完全能达到传统开腹胆道切开取石术的效果,并具有创伤小,痛苦少,恢复快的优点。     

微爆破碎石在腹腔镜胆总管探查术治疗胆总管远端结石嵌顿中的应用效果

目的探讨微爆破碎石在腹腔镜胆总管探查术(LCBDE)治疗胆总管远端结石嵌顿中的应用效果。方法回顾性分析LCBDE中应用体内微电极碎石仪iMES-I-C治疗胆总管远端结石嵌顿的28例患者临床资料。结果28例患者均碎石成功,术中取净结石27例,1例残留小结石,术后7周胆道镜取石成功。碎石过程中未见胆道损伤及出血等并发症。结论LCBDE中采用微爆破碎石治疗胆总管远端结石嵌顿操作简单安全、效果可靠。     

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。     

腹腔镜胆总管探查取石与内镜ERCP/EST联合LC治疗胆囊疾病合并胆总管结石的临床对比研究

【目的】评价腹腔镜胆总管探查取石术(LCBDE)与内镜逆行胆管造影、括约肌切开取石术(ER CP/EST)联合腹腔镜胆囊切除术(LC)治疗胆囊疾病合并胆总管结石的临床效果,探讨胆石症的微创外科治疗策略。【方法】回顾性分析152例胆囊疾病合并胆总管结石病人分别采用LC LCBDE术(68例)、内镜EST联合LC术(84例)治疗的临床资料, 进行胆总管内径、结石大小、手术时间、手术费用、并发症发生率、术后住院日等方面的统计学对比分析。【结果】两种术式的术后住院日差异无显著性(P>0. 05),手术时间、手术费用、并发症发生率等方面比较差异有显著性(P<0. 01 ), 且两者的胆总管内径、结石大小相比较有差别。【结论】胆总管直径小于1. 0cm,尤其胆总管下端结石嵌顿时宜采用内镜、腹腔镜联合手术治疗;胆总管直径大于1. 0cm或多发结石,尤其并存二级支肝管结石者(无胆管狭窄),腹腔镜下一期手术LC LCBDE是治疗胆囊疾病合并胆总管结石的最佳选择。     

570例腹腔镜胆总管探查手术体会

【目的】提高腹腔镜胆总管探查术手术技能,拓展手术适应证。【方法】回顾性总结2003年1月至2008年1月570例腹腔镜胆总管探查术临床病例,阐述手术体会。[结果]10例中转开腹,560例获手术成功。平均手术时间95min,术后5例胆漏,4例胆道残石,术后随访375例6个月到5年无胆道狭窄表现。【结论】腹腔镜胆总管探查手术不仅安全可行,而且将会成为胆道探查的主要术式。     

急诊腹腔镜下胆总管探查

目的探讨腹腔镜联合胆道镜急诊处理胆总管结石的可行性。方法回顾分析46例腹腔镜联合胆道镜急诊处理胆总管结石的临床效果。结果46例急诊腹腔镜下胆总管探查均成功，结石取净率为100％。其中腹腔镜下胆总管切开取石35例，腹腔镜下经胆囊管胆道镜探查取石11例，两者术后平均住院时间分别为4d、2．5d，1例T管拔后并发胆漏经保守治疗后治愈。结论腹腔镜联合胆道镜能安全、有效急诊处理胆总管结石。     

腹腔镜联合术中胆道镜治疗胆总管结石的临床研究

目的探讨腹腔镜胆总管切开探查术(LCBDE)联合术中胆道镜治疗胆总管结石的可行性和临床应用价值。方法分析11例LCBDE联合胆道镜治疗胆总管结石的临床资料,并与同期开腹手术组11例行对比研究。结果两组手术全部成功,恢复顺利,无严重并发症。LCBDE组无中转开腹,术后24~26 h胃肠功能恢复开始进食并下床活动,而开腹组需要在术后48~72 h。结论腹腔镜联合术中胆道镜治疗胆总管结石疗效好、安全、微创、恢复快、并发症少。     

Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: a systematic review

Background: There is still no consensus on the ideal management of common bile duct (CBD) stones. This article aims to review the management of concomitant gallbladder stones and CBD stones in the laparoscopic era. Method: A PubMed database search was performed to identify MEDLINE articles from 1986 to 2010 using the key terms “common bile duct stones,”“cholecystectomy,”“bile duct exploration,”“ERCP” (endoscopic retrograde cholangiography), and “endoscopic sphincterotomy.” Results: There were five randomized comparative trials (RCT) comparing sequential preoperative ERCP and laparoscopic cholecystectomy (LC) to laparoscopic common bile duct exploration (LCBDE). Two RCTs showed similar stone clearance rates and shorter hospital stays in the LCBDE group, while three RCTs showed similar stone clearance rates and hospital stays in sequential preoperative ERCP, LC and LCBDE groups. There were two RCTs comparing LCBDE to sequential LC and postoperative ERCP. One showed similar stone clearance rate and shorter hospital stay in LCBDE group, while the other showed similar stone clearance rate and hospital stay. There were three RCTs comparing sequential preoperative ERCP and LC against LC with intraoperative ERCP. All three studies showed similar stone clearance rates and shorter hospital stays in the intraoperative ERCP group. There was only one RCT comparing sequential preoperative ERCP and LC against sequential LC and postoperative ERCP. This showed a similar stone clearance rate and shorter hospital stay in the postoperative ERCP group. Conclusion: Different management approaches of concomitant gallbladder stones and CBD stones were equivalent in efficacy. However, one‐stage management had the advantage of providing a shorter hospital stay.     

胆囊并发胆总管结石患者的微创外科治疗研究

目的探究胆囊并发胆总管结石患者的微创外科治疗。方法选取2013年1月-2018年1月该院收治的92例胆囊并发胆总管结石患者为研究对象,采用随机数字表法将患者分为对照组(n=46)和观察组(n=46)。两组患者中存在胰腺炎的患者先行控制腹膜炎,对照组患者行腹腔镜胆囊切除术(LC)联合胆总管探查取石术(LCBDE),观察组患者行十二指肠乳头括约肌切开取石术(EST),术后3 d行LC治疗。比较两组患者围术期情况、费用情况和并发症情况。结果两组患者均未出现中转开腹手术情况,观察组患者的手术时间、止痛药使用率、住院时间均低于对照组患者,耗材费用和住院总费用多于对照组患者,差异具有统计学意义(P0.05);两组患者的术中出血量、术后排气时间和手术费用比较差异无统计学意义(P0.05)。观察组患者各项并发症总发生率为6.51%低于对照组患者的19.53%,差异具有统计学意义(P0.05)。结论胆囊并发胆总管结石患者控制腹膜炎后行EST+LC治疗较LC+LCBDE治疗能够缩短手术时间,减轻术后疼痛,降低并发症发生率,缩短住院时间,但所需费用较高。     

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。     

腹腔镜胆总管探查术后胆管一期缝合的临床应用分析

目的 探讨腹腔镜胆总管切开探查术后胆管一期缝合的可行性、疗效及适应证.方法 回顾2007年1月～2011年3月99例因胆囊胆总管结石病行腹腔镜胆管切开取石治疗的临床资料.结果 一期缝合组39例,T管引流组60例,一期缝合组较T管引流组手术时间及术后住院时间短、住院费用少和恢复正常生活快(P＜0.05).一期缝合组手术并发症1例(2.6％),T管引流组手术并发症2例(3.3％),与放置T管有关.两组随访结果差异无显著性.结论 LCBDE一期缝合具高效、创伤小、术后恢复快、并发症少等优点,是当前微创治疗胆囊胆总管结石病的最合适的选择.     

LC+LCBDE和ERCP/EST+LC治疗胆囊结石合并胆总管结石疗效的Meta分析

目的系统评价腹腔镜胆囊切除术(LC)联合胆总管探查取石与内镜逆行胰胆管造影(ERCP)/内镜下十二指肠乳头括约肌切开取石术(EST)联合LC治疗胆囊结石合并胆总管结石的有效性及安全性。方法在Pub Med、EMbase、Cochrane图书馆、中国知网、万方等数据库中检索2010年1月至2018年12月发表的比较LC+LCBDE和ERCP/EST+LC疗效的临床随机对照试验(RCT),按照纳入排除标准进行文献筛选和质量评估后确定纳入文献,阅读文献全文提取相关研究资料,采用Rev Man5. 3软件进行数据分析。结果最终纳入10篇文献,包括1 502例病例,其中LC+LCBDE组756例,ERCP/EST+LC组746例。Meta分析结果示:LC+LCBDE组和ERCP/EST+LC组总并发症率无统计学差异(P> 0. 05),在并发症类型上,LC+LCBDE组术后胰腺炎、胆管炎、出血发生较多,LC+LCBDE组胆漏发生较多。两种术式在结石清除率、中转开腹率、手术时间、住院时间等方面均无统计学差异(P均> 0. 05)。结论 LC+LCBDE与ERCP/EST+LC两种微创术式具有相似的有效性及安全性,两者有各自发生较多的相关并发症,在手术时间及住院时间上均未呈现明显差异,LC+LCBDE组在住院费用上稍具优越性。以上结论尚需进行更多前瞻性RCT进行验证及更新。     

胆道支架和鼻胆管引流在腹腔镜胆总管探查术后一期缝合中的应用

目的 对比胆道支架和鼻胆管引流在腹腔镜胆总管探查术（LCBDE）后一期缝合中的临床疗效。方法 回顾性分析2016年8月－2021年1月在该院行内镜逆行胰胆管造影术（ERCP）取石失败的74例患者的临床资料，分为支架引流组（n = 38）和鼻胆管引流组（n = 36）。支架引流组ERCP取石失败后放置胆道支架引流，鼻胆管引流组ERCP取石失败后放置鼻胆管引流，两组患者均行腹腔镜胆总管切开取石一期缝合术。比较两组患者手术时间、术后住院时间、术后并发症发生率、术后肠道功能恢复时间、术后胆总管结石复发率和住院时间。结果 两组患者胆管缝合方式、手术时间、术中出血量、术后并发症总发生率和住院费用比较，差异均无统计学意义（P > 0.05）。鼻胆管引流组术后胆瘘发生率明显低于支架引流组，住院时间明显短于支架引流组，术后肠道功能恢复时间明显长于支架引流组，术后总补液量多于支架引流组，差异均有统计学意义（P < 0.05）。结论 ERCP取石失败后放置鼻胆管引流，可降低LCBDE术后一期缝合的胆瘘发生率，缩短住院时间，但放置胆道支架引流患者肠道功能恢复更快，补液量更少。因此，在临床操作中，应根据患者具体情况，选择相应的个体化引流方式。     

腹腔镜胆囊切除术致严重胆管损伤的临床分析

目的：探讨腹腔镜胆囊切除术（1aparoscopic cholecystectomy,LC）致胆管损伤的原因、预防措施和经验教训。方法：分析2007年8月～2008年8月期间我院胆道外科收治的3例胆管严重损伤病例资料。结果：3例LC术致胆管严重损伤的患者均发生肝门部胆管狭窄,并均在肝门胆管成形后行胆管空肠Roux-en—Y吻合术,吻合口直径2．0～3．0cm。术后患者恢复良好,均顺利出院,住院时间为10～15天。随访1～6个月,1例于术后2月出现肝区隐痛,日服消炎药可控制,其余未见异常不适。结论：术中仔细辩清肝总管、胆总管与胆囊管的三者关系是预防LC术胆管损伤的关键。胆管空肠Roux-en—Y吻合术是处理胆管损伤的重要手术方式。LC术时,胆道外科医生思想上要高度重视,不可盲目追求速度。     

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUNDLaparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIMTo investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODSA total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.RESULTSIn total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).CONCLUSIONLC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.     

Laparoscopic ultrasonographic appearance of the common bile duct mucosa: a predictor of choledocholithiasis.

Previously we reported on the use of laparoscopic ultrasonography in detecting common bile duct stones during laparoscopic cholecystectomy. The aim of this study is to describe the laparoscopic ultrasonographic appearance of the common bile duct mucosa in patients with choledocholithiasis. Medical records of 44 patients with an increased risk for common bile duct stones undergoing laparoscopic cholecystectomy between 1993 and 1998 were reviewed. In the operating room, the laparoscopic ultrasonographic appearance of the common bile duct mucosa was scored in real time as normal, mild changes (hyperechoic mucosa), or severe changes (hyperechoic with mucosal thickening). Of the 31 patients (70%) with stones or sludge in the biliary tree, 29 (94%) had either severe (58%) or mild (36%) hyperechoic and 2 (6%) had normal-appearing common bile duct mucosa on laparoscopic ultrasonography. Of the 13 patients (30%) with no documented stones or sludge, 11 (85%) had normal and 2 (15%) had mild hyperechoic common bile duct mucosa on laparoscopic ultrasonography. Both of these patients had laboratory values indicating recent passage of common bile duct stones. The association between common bile duct stones and the presence of hyperechoic common bile duct mucosa was statistically significant (P < .0001, Fisher's exact test). This is the first report of hyperechoic common bile duct mucosa demonstrated by laparoscopic ultrasonography as a predictor of common bile duct stones. This finding is evident in the majority of patients with common bile duct stones and also may be associated with recent passage of a stone into the duodenum.     

腹腔镜胆总管切开取石术的临床体会

目的 探讨腹腔镜胆总管切开术的方法、注意事项、并发症防治。方法 对该组31例LCBDE的回顾性总结，采用了挤压法、冲洗法、钳夹及常规取石器械取石及胆道镜取石，经历了两个学习操作体会阶段。结果 27例完成LCBDE（其中1例术后因胆漏当晚再次开腹探查），4例分别因T管脱出、粘连、怀疑肿瘤及结石较大不能取出而中转开腹。结论 LCBDE的开展必需要有熟练的腹腔镜操作技术，及必要的硬件设备。对病例有一定的选择，要注意术中的一些操作细节以确保手术成功，强调术后放置T管的必要性。     

腹腔镜胆囊切除术联合胆总管探查取石术治疗胆囊结石合并胆总管结石的临床效果

目的探讨腹腔镜胆囊切除术(LC)联合腹腔镜胆总管探查取石术(LCBDE)治疗胆囊结石合并胆总管结石的临床效果。方法选择2017年3月至2020年3月收治的47例胆囊结石合并胆总管结石患者为研究对象,将其随机分为对照组(n=23)和观察组(n=24),对照组予以LC联合内窥镜括约肌切开术(EST)治疗,观察组予以LC联合LCBDE治疗,比较两组的治疗效果。结果观察组的手术时间、恢复排气时间、住院时间短于对照组,术中出血量少于对照组(P<0.05)。术后3 d,观察组的GAS、MTL水平明显高于对照组(P<0.05)。两组的结石清除率无显著差异(P>0.05)。术后3 d,观察组的E、Cor、NE水平均低于对照组(P<0.05)。结论LC联合LCBDE治疗胆囊结石合并胆总管结石的结石清除率高,且对胃肠功能影响小,可减轻机体应激反应,安全性高。     

腹腔镜胆总管探查术后一期缝合的疗效观察

目的 探讨腹腔镜胆总管探查术（LCBDE）后一期缝合治疗合并急性胆管炎的胆总管结石患者的安全性和可行性。方法 回顾性分析2015年1月－2020年8月合肥市第二人民医院108例在LCBDE后行一期缝合患者的临床资料。根据术前患者有无急性胆管炎分为有胆管炎组和无胆管炎组,对两组患者手术时间、术中出血量、术后拔管时间、术后住院时间和术后并发症等资料进行比较分析。结果 两组患者均成功完成手术,无中转开腹病例,与无胆管炎组相比,有胆管炎组术中出血量较多,差异有统计学意义（P = 0.010）,两组患者手术时间、术后拔管时间、术后住院时间比较,差异均无统计学意义（P > 0.05）;两组患者术后并发症发生率比较,差异无统计学意义（P > 0.05）。结论 在遵循相关手术适应证的前提下,LCBDE后一期缝合治疗合并急性胆管炎的胆总管结石是安全可行的。