腹腔镜胆囊切除术中经胆囊管胆道造影52例临床分析

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中选择性经胆囊管胆道造影的应用价值。方法回顾性分析52例LC中经胆囊管胆道造影者的临床资料。结果除1例患者因胆囊管过细,过短及急性胆囊炎致Calot三角粘连、解剖不清而致插管失败外,余51例(98.1%)均插管成功。术中胆道造影发现胆总管结石4例,其中3例术中经纤维胆道镜取石成功,1例因结石嵌顿中转开腹行胆总管切开取石;胆囊管过长或变异3例,在造影片指导下成功完成LC;胆道损伤2例,转开腹行胆总管修补,T管引流术后痊愈出院,术后随访未见明显手术相关并发症。结论 LC术中选择性经胆囊管胆道造影简单易行,能显著降低胆道结石残留和及时发现胆道损伤等严重并发症,值得推广应用。     

腹腔镜胆囊切除术中经胆囊管胆道造影的价值

目的　探讨在腹腔镜胆囊切除术 (LC)中经胆囊管胆道造影的价值。方法　分析 5 1例因慢性胆囊炎胆囊结石、急性胆囊炎胆囊结石、胆囊息肉和胆源性胰腺炎行LC的患者 ,在术中经胆囊管插管行胆道造影的结果。结果　 5 1例中 ,插管成功 4 7例 ,成功率为 92 .2 % ,其中 4 6例显影满意 ,显影率为 97.9%。术中造影发现胆总管结石 3例 ,中转开腹行胆总管切开取石、T管引流术 ,发现胆囊管走行异常 2例 ,插管造影过程中发现胆囊管结石 4例 ,造影平均时间为 (16 .7± 2 .7)min。结论　LC术中胆道造影操作简便安全 ,显影清晰 ,成功率高 ,能发现胆总管结石、胆囊管结石及胆道解剖变异 ,可降低胆道残留结石和胆管损伤的发生率 ,并能及时发现胆道损伤 ,提高LC的质量和安全性     

超声引导下胆囊穿刺引流术治疗老年急性高危胆囊炎

目的 探讨超声引导下胆囊穿刺引流术（percutaneous transhepatic gallbladder drainage,PTGBD）治疗老年急性高危胆囊炎的疗效。方法 回顾性分析2016年1月至2020年1月浙江省台州市立医院肝胆外科收住的67例老年急性高危胆囊炎行PTGBD的临床资料,比较PTGBD术前术后的疼痛评分、体温、白细胞计数、CRP水平、肝功能、CA199水平,分析PTGBD术后并发症、胆汁培养及进一步治疗情况。结果67例老年急性高危胆囊炎患者均顺利完成PTGBD术。与术前比较,PTGBD术后患者疼痛评分、体温、白细胞计数、CRP、总胆红素、谷丙转氨酶、谷草转氨酶、CA199水平均明显下降（P＜0.01）。PTGBD术后出现并发症7例,其中出血4例,拔管后出现胆瘘3例。胆汁细菌培养阳性33例,其中大肠杆菌19例,肺炎克雷伯菌9例,粪肠球菌3例,铜绿假单胞菌2例。PTGBD术后进一步治疗情况：67例中27例于PTGBD术后1周内行腹腔镜胆囊切除术（LC）,19例于PTGBD术后1～3个月行LC手术,16例因症状缓解拒绝行进一步手术治疗,5例失访。结论对于老年急性高危胆囊炎患者行PTGBD安全有效,不适合急诊手术的患者近期可获得有效缓解。     

电凝法处理胆囊动脉在腹腔镜胆囊切除术中的应用

目的：探讨电凝法处理胆囊动脉在腹腔镜胆囊切除（ laparoscopic cholecystectomy ,LC）术中的安全性、可行性。方法我院2004年5月～2013年9月采用电凝法处理胆囊动脉行三孔法LC 376例。结果中转开腹9例（腹腔粘连致胆囊三角解剖不清）,其余367例在腹腔镜下完成手术,均以电凝法处理胆囊动脉,12例同期行腹腔镜阑尾切除术,1例行左肾囊肿开窗引流术。术后1例因胆总管结石致胆道梗阻行二次手术胆总管切开取石。结论胆囊良性疾病行LC时,电凝法处理胆囊动脉是安全、可行的。     

胆囊穿刺造瘘后双通道胆道镜保胆取石与腹腔镜胆囊切除术治疗老年患者结石性胆囊炎疗效的比较

目的比较超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石与胆囊穿刺造瘘后行腹腔镜胆囊切除术（1aparoscopiccholecystectomy,LC）治疗老年患者急性结石性胆囊炎的临床疗效。方法回顾性分析2012年1～9月接受双通道胆囊穿刺造瘘联合胆道镜保胆取石治疗的30例老年结石性胆囊炎（保胆取石组）和胆囊穿刺造瘘后行Lc治疗的30例老年结石性胆囊炎（Lc组）的临床资料,比较2组手术操作时间、术中出血量、住院时间、消化不良症状发生率等。结果60例均穿刺置管成功,带管时间14d-2个月,平均30d。4～8周后,保胆取石组30例成功行胆道镜取石,结石取净率100％,取石过程中无出血、漏胆、继发胆总管结石、切口感染等手术并发症。LC组28例三孔法完成LC,2例因粘连组织难以分离中转开腹手术,术中、术后均无严重并发症。保胆取石组术中出血量（8．8±1．7）ml,显著少于LC组（18．9±1．2）ml（t=-25．968,P=0．000）;保胆取石组住院时间（4．4±0．6）d,显著短于LC组（5．6±0．5）d（t=-8．243,P=0．000）。保胆取石组术后随访3、6、12个月,B超检查1例复发,5例有上腹部不适、腹泻、食欲不佳等消化不良症状,发生率16．7％（5／30）,LC组术后21例有消化不良症状,发生率70．o％（21／30）,2组比较有显著性差异（x2=17．376,P=0．000）。结论超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石操作简便,在术中出血量、住院时间、远期生活质量等方面均优于胆囊造瘘后行LC。     

刮吸解剖法在急性胆囊炎腹腔镜胆囊切除术中的应用

目的探讨刮吸解剖法在急性胆囊炎腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中的应用价值。方法2002年8月-2008年1月,借助腹腔镜多功能手术解剖器（laparoscopic Peng,s multifunctional operative dissector,LPMOD）应用刮吸解剖法对820例急性胆囊炎施行LC。对有胆道相对探查指征的158例（143例有胆总管扩张）行术中胆道造影,发现胆总管结石17例,其中14例完成腹腔镜下胆总管探查术（laparoscopic common bile duct exploration,LCBDE）。结果812例LC成功,8例中转开腹。LC平均手术时间55 min（25-120 min）,LC＋LCBDE平均手术时间95 min（80-130min）,术中平均出血量25 ml（0.5-80 ml）,术后平均住院5 d（3-9 d）。无胆管损伤、胆漏、术后出血等并发症。804例随访2-18个月,平均11个月,2例胆总管残余结石（1例行开腹胆总管切开取石,1例行EST取石）,其余患者未发现与手术相关并发症。结论在急性胆囊炎腹腔镜胆囊切除术中应用刮吸解剖法能有效防止术中胆道损伤,安全可靠,值得临床推广。     

腹腔镜胆囊切除术治疗急性胆囊炎158例临床分析

目的: 分析腹腔镜下治疗急性胆囊炎的临床经验.方法: 对158例行腹腔镜下胆囊切除术的急性胆囊炎的临床资料进行回顾性分析.结果: 152例单纯性胆囊结石中147例LC成功,5例因炎症粘连明显而中转开腹.56例术中胆道造影成功,显示胆总管结石6例,其中2例行LC联合术中胆道镜取石,4例中转开腹行胆总管切开取石T管引流.全组无严重并发症发生.结论: 运用适当的手术技巧,大多数急性胆囊炎行腹腔镜胆囊切除是安全可靠的.     

经皮经肝胆囊穿刺引流术在治疗老年急性结石性胆囊炎中应用

随着社会逐步进入老龄化,老年人（≥60岁）胆囊疾病的发病率逐年增加,胆囊结石为老年人最常见的胆系疾病。我院从2002年5月至2007年4月对31例老年急性结石性胆囊炎伴严重疾病的病人．先行经皮经肝胆囊穿刺引流术（percutaneous transhepatic gallbladder drainage,PTGBD）,待合并疾病得到控制且胆囊炎症消退后,再择期行腹腔镜下胆囊切除术（LC）或开腹手术,效果满意,现报告如下。     

急性胆囊炎腹腔镜胆囊切除术93例体会

目的总结腹腔镜下处理急性胆囊炎的临床经验。方法回顾性分析2003年5月-2005年5月93例急性胆囊炎行腹腔镜手术治疗的临床资料，其中15例术前确诊胆总管结石而先行内镜逆行胰胆管造影（endoscopic retrograde cholangiopancreatography，ERCP）联合内镜括约肌切开（endoscopic sphincterotomy，EST）取石，6例疑似胆道结石者行术中胆道造影。均于48h内完成LC。结果91例（97．8％）手术成功，2例（2．2％）中转开腹。手术时间35—160min，平均65min。术后胆囊管残端漏3例（3．2％），胆道残余结石3例（3．2％），经开腹手术结合ERCP、EST、鼻胆管引流（endoscopic nasobiliary drainage，ENBD）治愈，全组无医源性损伤。结论选择性应用ERCP和EST，腹腔镜胆囊切除术治疗急性胆囊炎是安全可行的，但中转开腹及并发症的发生率高。     

经皮经肝胆囊穿刺引流术在复杂胆道外科中的应用

目的:探讨经皮经肝胆囊穿刺引流术(PTGBD)在复杂胆道外科中的应用价值。方法:回顾分析2015年6月至2018年6月为50例患者行PTGBD减黄的临床资料。其中急性胆囊炎伴胆道梗阻20例,急性化脓性胆管炎伴胆囊扩张10例,胆管周围淋巴结肿大致胆总管梗阻伴胆囊扩张2例,胆道炎性狭窄导致胆总管梗阻伴胆囊扩张3例,胆源性胰腺炎伴胆总管梗阻6例,肿瘤引起的胆总管梗阻性黄疸9例。结果:50例患者均成功完成PTGBD,穿刺成功率为100%;与术前相比,PTGBD术后第3天患者腹痛、腹胀、呕吐、皮肤瘙痒等症状及白细胞计数、中性粒细胞比值、天门冬氨酸氨基转移酶水平、总胆红素水平及体温均好转。PTGBD术后2例患者因肿瘤进展,术后3个月加行经皮肝穿刺胆道引流术; 4例患者未行其他手术治疗;44例患者行下一阶段手术前胆红素水平降至正常或术前理想水平。住院3～27 d,平均(20.4±6.2) d;带管时间2～21周,平均(5.6±3.8)周。结论:PTGBD应用于胆道外科中减黄效果确切,具有安全、简便、创伤小及康复快的优点,符合胆道外科疾病微创化治疗的策略。     

彩超引导下经皮经肝胆囊穿刺置管引流治疗41例高危人群急性胆囊炎

目的评价彩超引导下经皮经肝胆囊穿刺引流(PTGBD)治疗高危人群急性胆囊炎的价值。方法回顾性分析从2014年3月至2017年4月江门市中心医院肝胆外科41例高危人群急性胆囊炎临床资料。结果所有患者均顺利完成PTGBD,术后2例出现胆道出血,经保守治疗后治愈,无胆漏、穿孔等并发症发生,无死亡病例。3例患者院外出现导管脱落,因症状好转,患者不同意手术而未进一步治疗;3例因心肺功能无法耐受手术、6例因患者不同意手术拔除引流管。以上病例随访6~24月未见胆囊炎急性发作。29例顺利接受LC术,无中转开腹病例。PTGBD后2周~3月施行LC,平均手术时间74.9±67.3 min,术中出血约7.2±9.2 m L,术后住院时间2.6±2.1天,术后有1例出现腹腔出血,经保守治疗后治愈出院,无胆道出血、胆道损伤、胆漏等术后并发症发生。胆囊壁厚度与LC时间呈正相关,相关系数为0.455(P=0.013)。结论彩超引导下PTGBD可有效控制胆囊急性炎症,为后续施行腹腔镜下胆囊切除术创造条件。     

Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis

Many surgeons have found it difficult to decide whether to apply percutaneous transhepatic gallbladder drainage (PTGBD) in patients with acute cholecystitis that is not responsive to initial medical management (IMMx), because the indications of PTGBD are ambiguous. The aim of this study was to evaluate the appropriate treatment for acute cholecystitis that is not responsive to IMMx. Specifically, we focused on differences in surgical outcomes between elective and emergency laparoscopic surgeries. Between March 2006 and February 2009, 738 patients with acute cholecystitis who had undergone laparoscopic cholecystectomy (LC) at our institution were retrospectively studied. We divided them into 3 groups. Group I included 494 patients who underwent elective LC without pre-operative PTGBD, group II included 97 patients who intended to undergo elective LC after preoperative PTGBD, and group III included 147 patients who underwent emergency LC without preoperative PTGBD. We compared age, sex, symptom duration, body temperature, leukocyte counts, and American Society of Anesthesiologists (ASA) class on admission as clinical characteristics. We compared the time interval from symptom development and admission to surgery, operative time, the conversion rate to open surgery, postoperative complications, the total length of stay, and the postoperative length of stay as perioperative surgical outcomes. For patients with ASA 2 and 3, the conversion rate to open surgery in group II was significantly less than that in group III (P<.05, P<.01, respectively). We recommend PTGBD as the first choice for acute cholecystitis in patients who show no improvement after IMMx, to allow the patient to undergo an elective LC rather than emergency surgery for patients with ASA 2 and 3.     

回顾性分析经皮经肝胆囊穿刺引流治疗高危急性胆囊炎患者疗效

目的:了解经皮经肝胆囊穿刺引流(PTGBD)治疗高危急性胆囊炎患者的临床疗效.方法:回顾性分析217例高危急性胆囊炎患者的临床资料,其中急诊行开腹或腹腔镜胆囊切除手术治疗125例(对照组),PTGBD治疗92例(治疗组),观察两组间治疗效果.结果:对照组术后并发胆漏2例、胆管炎3例、肝周积液1例、不完全性肠梗阻1例、2例胆囊床渗血,伤口脂肪液化延迟愈合6例,死亡4例.治疗组92例均穿刺置管成功,术后24～72 h内腹痛缓解,体温降至正常,并发1例胆漏,2例侧孔堵塞,1例引流管脱出;死亡2例.与对照组相比并发症发生率具有统计学意义(P <0.05).结论:对于高危急性胆囊炎患者,经皮经肝胆囊穿刺引流术和急诊胆囊手术都是有效的治疗措施,PTGD简便、安全、有效,减少并发症发生率.     

损伤控制理念在老年中重度急性胆囊炎治疗中的应用

目的探讨损伤控制理念在老年中重度急性胆囊炎治疗中的应用。方法回顾性收集2014年1月至2016年1月上海市浦东医院收治的148例老年中重度急性胆囊炎患者的临床资料;比较患者行经皮经肝胆囊穿刺引流术(PTGBD)后择期行LC(择期LC组,n=52例)和急诊行LC(急诊LC组,n=96例)的有效性及安全性。结果 PTGBD后择期LC组患者术中出血量较少(P0.05);两组中转开腹率差异虽无统计学意义(P0.05),但PTGBD后择期LC组中转开腹率较低(5.77%vs 12.50%);PTGBD后择期LC组并发症总发生率为40.38%,显著低于急诊LC组的59.38%(P0.05)。结论结合损伤控制理念,对老年中重度急性胆囊炎患者PTGBD后行择期LC手术能有效降低手术风险,是治疗老年中重度急性胆囊炎的优选方案。     

Laparoscopic cholecystectomy for acute cholecystitis

From October 1991 to March 1994, 35 patients (20 men and 15 women) with acute cholecystitis (AC) underwent laparoscopic cholecystectomy (LC). They ranged in age from 17 to 82 years (mean, 51.7 years). Nine of the 35 patients (25.7%) had either percutaneous transhepatic gallbladder drainage (PTGBD) or percutaneous transhepatic gallbladder aspiration (PTGBA) performed preoperatively. The mean operative time was 183.7 min. Four of the 35 patients (11.4%) required conversion to open laparotomy. The mean postoperative hospital stay was 11.2 days and postoperative morbidity rate was 2.9%. There were no major complications and no deaths. In this retrospective study, we divided the patients into three groups according to the surgical timing of LC in relation to onset. Two of the three groups had LC performed more than 7 days after onset; these groups were termed, collectively, the delayed LC group. The group that had LC performed within 7 days of onset we termed the early LC group. The early LC group had a shorter operative time, less blood loss, and a shorter postoperative hospital stay than the delayed LC group, but the differences were not significant. Nevertheless, we suggest that early LC for AC should be employed for patients who are in a stable condition and who have no preoperative associated medical problems. In the delayed LC group, there were no significant differences in findings between patients who received or did not receive either PTGBD or PTGBA. PTGBD and PTGBA are useful procedures for the relief of acute severe symptoms in patients whose condition is refractory to treatments such as i.v. antibiotic infusion and no oral feeding. We conclude that a laparoscopic procedure for patients with AC, when performed by experienced surgeons, is safe, technically feasible, and useful.     

Early scheduled laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for patients with acute cholecystitis

Aim: The present study was conducted to evaluate the effectiveness of early scheduled laparoscopic cholecystectomy (LC) following percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute cholecystitis. Patients and methods: 31 patients with acute cholecystitis were treated by early scheduled LC following PTGBD (group 1). These patients were compared with 9 patients treated by early LC without PTGBD (group 2) and with 12 patients treated by delayed LC following conservative therapy (group 3) for the success rate of intraoperative cholangiography, the conversion rate to open cholecystectomy, operative time, and hospital stay. Early scheduled LC following PTGBD was defined as scheduled LC when the patient's condition recovered and it was performed 1–7 days (mean: 4 days) after admission. The patients' age in group 1, 2, and 3 was 66 ± 13, 65 ± 10, and 64 ± 9 years, respectively, without significant difference. Most of the patients had additional diseases. Results: The success rate of intraoperative cholangiography was 97% (30/31) in group 1, 67% (6/9) in group 2, and 67% (8/12) in group 3. The conversion rate to open cholecystectomy was 3% (1/31) in group 1, 33% (3/9) in group 2, and 33% (4/12) in group 3. The operative time for LC was 89 ± 33 min in group 1, 116 ± 24 min in group 2, and 135 ± 30 min in group 3. The mean hospital stay after LC was 9 ± 4 days in group 1, 9 ± 3 days in group 2, and 17 ± 7 days in group 3. In group 1, the success rate of intraoperative cholangiography was higher, the conversion rate to open cholecystectomy was lower, and operative time was shorter than in groups 2 and 3 with significant difference (p <0.05, p <0.05, and p <0.01, respectively). Conclusion: The findings of this study indicate that early scheduled LC following PTGBD is a safe and effective therapeutic option for patients with acute cholecystitis especially in elderly and complicated patients.     

预康复干预在老年急性胆囊炎序贯性外科治疗中作用研究

目的 评估预康复干预在老年急性胆囊炎病人行急诊经皮经肝胆囊穿刺置管引流（PTGBD）和二期腹腔镜胆囊切除术（LC）间期的应用价值。方法 收集2019年12月至2021年4月北京医院连续收治的年龄＞65岁的胆囊结石合并急性胆囊炎一期行急诊PTGBD，门诊行预康复干预，二期行LC病人资料，作为预康复组；选取同时期年龄＞65岁、连续入院的胆囊结石合并慢性胆囊炎行择期LC病人作为对照组。比较预康复组和对照组行LC时血实验室检查指标、手术时间、中转开放手术率、严重手术并发症发生率、术后住院日及住院总费用。结果 预康复组共纳入30例病人，对照组纳入33例病人。预康复组相对于对照组，手术时间延长（80 min vs. 60 min，P＜0.01）、放置腹腔引流率高（50.00% vs. 9.09%，P=0.001）、住院总费用增加（21 507.29元 vs. 13 693.07元，P＜0.01）。但两组中转开放手术率（3.33% vs. 0，P=0.223）、手术并发症发生率（6.67% vs. 0，P=0.476）差异并无统计学意义。结论 预康复干预可改善老年急性胆囊炎急诊PTGBD术后至二期LC期间的身体状态，使手术并发症和中转开腹的发生率接近择期LC。     

Percutaneous transhepatic gallbladder stenting for recurrent acute acalculous cholecystitis after failed endoscopic attempt

Endoscopic gallbladder stenting is useful palliative therapy for acute cholecystitis in high-risk patients. Although the success rate of endoscopic gallbladder stenting is 79%–100%, an alternative method has not been reported. We succeeded in employing a method for percutaneous gallbladder stenting (PTGS) and herein describe this new method. A patient with acute acalculous cholecystitis related to ischemic atherosclerotic vascular disease, cholangitis due to Lemmel syndrome, and severe congestive heart failure underwent PTGS through the cystic duct from the gallbladder to the duodenal papilla, because an endoscopic method failed in the treatment of Lemmel syndrome. Because we were unable to place endoscopic transpapillary gallbladder drainage, percutaneous transhepatic gallbladder drainage (PTGBD) was performed and both the cholecystitis and cholangitis ceased. PTGS was performed as an alternative to endoscopic gallbladder stenting. Access to the cystic duct and gallbladder was obtained by the PTGBD route, using a guidewire (0.035-inch diameter) and seeking catheter (6.5 Fr) under fluoroscopic control. A 7-Fr 12-cm double-pigtail biliary polyethylene stent was placed. The patient remained asymptomatic for 3 months after the PTGS until he died, of an acute recurrent myocardial infarction. This new PTGS placement is an alternative treatment for symptomatic gallbladder disease in patients with increased operative risk when the endoscopic method is unsuccessful.     

老年急性胆囊炎患者PTGBD后LC手术实施时机及其影响因素

目的 探讨老年急性胆囊炎患者经皮经肝胆囊穿刺引流（PTGBD）后安全的LC手术时机和影响因素。方法 选取2020年6月至2022年7月间在新疆维吾尔自治区第三人民医院接受PTGBD+择期LC手术治疗的老年急性胆囊炎患者120例进行前瞻性研究,按照PTGBD后不同时期实施LC手术,将患者随机分为4组：4周组（n=30）、6周组（n=30）、8周组（n=30）和10周组（n=30）。对术前资料、术中困难程度评分、手术相关指标、手术损伤和手术并发症进行组间对比,并分析手术时机的影响因素。结果 4组术前资料的比较,差异无统计学意义（P>0.05）;针对胆囊周围表现、胆囊三角表现、胆囊床表现等单项困难程度评分和术中困难程度总评分,4周组均显著高于6周组、8周组和10周组;针对术中胆囊及其周围其他表现评分,4周组高于8周组和10周组;差异均具有统计学意义（P<0.05）;针对手术时间、术中出血量和腹腔引流量,4周组均显著高于6周组、8周组和10周组;差异均具有统计学意义（P<0.05）。4组胆囊部分切除率、术后排气时间和术后住院时间的比较,差异无统计学意义（P>0.05）;...