十二指肠镜在胆囊切除术后的应用

目的 通过分析124例胆囊切除术后综合(PCS)征临床资料，探讨PCS的病因和诊断方法以及评价ERCP的诊断价值。方法 对124例临床诊断为PCS的患者行B超、胃镜或上消化道钡餐检查，以明确病因。结果124 例患者插管，成功率93．5％，胆管结石68例，胆管扩张47例，胆管狭窄26例，胆囊管残留过长及残余小胆囊11例，十二指肠乳头憩室内或憩室旁开口11例，胆道未见异常23例，非胆道疾病15例。结论 PCS最为常见的病因为胆管结石和胆管狭窄，其他较为少见原因包括十二指肠憩室、Oddi括约肌运动功能障碍、胆囊管残留过长、残余小胆囊及非胆道疾病等。ERCP是明确PCS病因较为理想和可靠的方法，如结合B超、胃镜检查以及上消化道钡餐，可对PCS的病因作出较为全面的诊断。     

ERCP在腹腔镜胆囊切除术中的作用15例分析

本文对15例内镜逆行胰胆管造影(ERCP)结果与腹腔镜胆囊切除术术中所见进行了对比分析,认为ERCP可以预测手术难度、显示胆囊管与胆总管的关系,预防手术并发症,能代替术中胆道造影。     

腹腔镜胆囊切除术前MRCP的应用价值分析

目的 讨论磁共振胰胆管成像(MRCP)在腹腔镜胆囊切除术(LC)前的应用价值.方法 分析本院2008年10月至2010年5月拟行LC、术前怀疑胆总管结石而行MRCP检查的56例患者的临床诊治资料.结果 经MRCP检查发现胆总管结石15例,均成功行EST+LC术.未发现胆总管结石的41例仅行LC术,术后3例出现胆管炎表现,经ERCP证实胆总管结石,行EST取石.结论 腹腔镜胆囊切除术前,对于可疑伴有胆总管结石的胆囊结石患者,MRCP检查具有重要的诊断价值,同时可根据MRCP检查结果,选择不同的微创治疗方法.     

ERCP在腹腔镜胆囊切除术前,术后的应用

目的：观察逆行胰胆管造影术（ＥＲＣＰ）在腹腔镜胆囊切除术前、术后的作用。方法：对３０例临床诊断为胆石症患者术前作Ｂ超及ＥＲＣＰ，腹腔镜胆囊切除术后仍出现临床症状的９例再次作ＥＲＣＰ。结果：术后９例ＥＲＣＰ中２例胆总管有残余结石，３例乳头狭窄，乳头水肿及毛细胆管瘘各１例，２例正常。对仍有病变患者增经内镜治疗而愈。结论：术前ＥＲＣＰ可明显胆系全部情况，术后ＥＲＣＰ可对有症状者寻找原因，及时治疗。     

ERCP在诊治胆囊切除术后综合征中的作用

我院自１９９３年１０月至１９９５年１０月，共行ＥＲＣＰ检查治疗１２５７例，其中胆囊切除术后综合征（ＰＣＳ）行ＥＲＣＰ检查治疗１０１例。为进一步降低ＰＣＳ的发生率，提高ＰＣＳ的疗铲，结合１０１例ＰＣＳ行ＥＲＣＰ诊治的体会，进一步探讨ＰＣＳ的病因及处理。我们认为，胆囊切除手术前行ＥＲＣＰ检查有助于减少ＰＣＳ的发生，同时ＥＲＣＰ有明显ＰＣＳ的病因并进行适当的治疗。     

十二指肠镜技术在腹腔镜胆囊切除术前术后的应用经验

目的探讨内镜逆行胰胆管造影(ERCP)检查及内镜治疗在腹腔镜胆囊切除(LC)术前、术后的应用价值。方法对61例拟行LC的患者术前或术后行ERCP检查,发现异常再行内镜治疗。结果LC术前行ERCP者42例中39例显影,其中37例伴有其他胆管疾病,占94.9%。术后行ERCP者19例均显影,总的插管成功率为95.1%。LC术前或术后42例行EST治疗,4例行EPBD,2例行ERBD,15例行ENBD,另4例在行ERCP检查后改开腹手术,取石成功率为92.9%。结论诊治性ERCP在LC前、后的应用,对进一步明确诊断、选择手术方式、预防LC的并发症和提高LC的成功率具有重要价值。     

肝硬变时腹腔镜胆囊切除术治疗30例胆囊疾病的体会

目的总结肝硬变状态下腹腔镜胆囊切除术（LC）治疗胆囊疾病的经验。方法回顾性分析30例肝硬变合并胆囊疾病患者行LC的临床资料。结果30例患者中肝功能Child-PughA级8例,B级11例,C级11例。LC术后6例（20.0%）发生并发症,其中Child-PughB级2例,C级4例。治愈29例（96.7%）;死亡1例（3.3%）,死亡者为Child-PughC级。结论存在肝硬变时,肝功能Child-PughA及B级者行LC比较安全,C级风险较大,应列为手术禁忌。     

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。     

胆囊切除术后残余病变的诊断和再手术治疗

目的总结胆囊切除术后残余病变的诊断和再手术经验,避免再次发生胆囊残余病变。方法回顾性分析1990年1月～2009年12月间收治的34例胆囊残余病变的临床资料。结果本组术前均经B超、磁共振胰胆管造影(MRCP)、内镜逆行胰胆管造影(ERCP)检查明确诊断。34例全部再手术治愈,病理诊断均为残余胆囊慢性炎,3例合并异物肉芽肿形成,无癌变病例,无再次手术相关并发症。结论有症状的胆囊残余病变需要再次手术治疗,ERCP是诊断胆囊切除术后胆囊残余病变的最佳检查方法。     

逆行胆囊切除术在腹腔镜胆囊切除术中的应用

目的 探讨逆行胆囊切除术在腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）中的应用价值.方法 2008年10月～2012年8月,对67例LC因胆囊三角区解剖结构不清,不易分离者,从胆囊底部开始逆行切除胆囊术.结果 67例LC均获成功,无一例中转开腹.手术时间（73.7±9.6）min,术中出血（35.2±13.7）ml.67例随访12～18个月,平均14个月,恢复良好,无腹痛、腹胀及其他并发症发生.结论 在LC中对于Calot三角区解剖不清者采用逆行胆囊切除术安全可行.     

腹腔镜胆囊切除术前选择性ERC的应用

目的　探索ERC LC对有症状胆囊结石和疑有胆管结石得治疗结果的选择性标准的研究。方法　回顾分析 2 0 0 1年 11月～ 2 0 0 3年 10月我科收治的胆石症患者中 2 0例先行ERC再行LC的情况。结果　本组病人ERC均获成功 ,ERCP EST ESE共取出结石 15例 ,B超等证实者 10例 ,胆总管直径 >8mm 12例 ,有黄疸史者 11例 ,肝功能异常者 11例 ,胰腺炎者 4例。ERC后平均 4 .6d行LC。随访 2月～ 2年未发现胆管残余结石。结论　严格掌握LC前行ERC适应症 ,对于减少不必要ERC率 ,避免LC后胆管残留结石都具有重要作用。     

Incidence and management of biliary pancreatitis in cholecystectomized patients: results of a 7-year study

Data are lacking concerning the frequency of biliary acute pancreatitis in the postcholecystectomy patient. The aim of this study was to identify patients at risk for biliary pancreatitis after cholecystectomy and to describe the therapeutic management of these patients, based on an analysis of 278 unselected patients with acute pancreatitis during a 7-year period. A biliary etiology was presumed in the presence of laboratory findings of cholestasis that could not be explained by another disease, together with the absence of any other known etiology of acute pancreatitis. A biliary cause of disease was found in 132 (47%) of 278 patients. Seventeen (13%) of 132 patients had a history of cholecystectomy. Endoscopic retrograde cholangiopancreatography was performed in all patients with a suspected biliary cause of acute pancreatitis. It showed bile duct stones, microlithiasis, or sludge in 14 patients, and was consistent with typical findings at the papilla of Vater after stone passage in another three patients. No surgical bile duct exploration was necessary. One patient with severe disease and infected pancreatic necrosis died of septic multiorgan failure. Presented, in part, at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation).     

Combined endo‐laparoscopic approach in managing patients with gallstones and common bile duct stones: An early experience

Gallstones with common bile duct stones is a common condition in Hong Kong. Management still remains a challenge nowadays. Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) is a single‐stage approach which improves patient comfort and is associated with less post‐ERCP pancreatitis. With the new endo‐laparoscopic operating theatre in service, the combined endo‐laparoscopic approach becomes simple and practical. We report here our two early experiences using this approach.     

THE ROLE OF ERCP AND ENDOSCOPIC SPHINCTEROTOMY IN THE ERA OF LAPAROSCOPIC CHOLECYSTECTOMY

The advent of laparoscopic cholecystectomy (LC) has led to some controversy regarding the best method of managing bile duct calculi. This paper reviews the cases of 38 patients who underwent LC and endoscopic retrograde cholangiopancreatography (ERCP), from a series of 600 consecutive laparoscopic cholecystectomies. Twenty-nine patients had ERCP performed pre-operatively because of suspicion of choledocholithiasis. Duct stones were confirmed in eight patients. Recent or current jaundice was the best predictor of bile duct stones. Nine patients had ERCP done postoperatively because of duct stones seen on operative cholangiography. In two patients bile duct cannulation was not possible and a third procedure, open duct exploration, was necessary. Techniques in laparoscopic management of duct stones are improving and the role of ERCP and sphinc-terotomy should be limited to jaundiced patients or those with proven bile duct stones in whom laparoscopic procedures have been unsuccessful.     

腹腔镜内镜联合治疗胆囊结石合并胆总管结石疗效分析

目的 比较性分析腹腔镜胆囊切除术联合内镜逆行胰胆管造影取石术治疗胆囊结石合并胆总管结石的效果.方法 选择2012年1月～2013年1月安徽医科大学第一附属医院急诊外科采用腹腔镜联合内镜治疗的21例患者作为观察组,同时选择同期开腹治疗的患者30例作为对照组.观察两组治疗效果、切口愈合情况及平均住院时间.结果 肛门排气时间、平均住院时间、术后切口感染发生率、术后镇痛药物使用率均少于对照组,两组比较差异有统计学意义（P＜0.05）.结论 腹腔镜胆囊切除术联合内镜逆行胰胆管造影治疗胆囊结石合并胆总管结石是一种安全有效的微创治疗方法.     

内窥镜治疗胆胰疾病746例的临床观察

目的 探讨内窥镜下十二指肠乳头括约肌切开术对胆总管结石及缩窄性乳头炎的治疗作用。方法 总结1987年7月至2001年5月间实施的746例次内窥镜十二指肠乳头括约肌切开术的经验。结果 EST治疗胆总管结石572例，结石排出538例(94．1％)；缩窄性乳头炎174例，成功165例(94．8％)；因缩窄性乳头炎至慢性胰腺炎者45例，症状缓解40例(88．9％)。内窥镜十二指肠乳头括约肌切开术后发生重症胰腺炎、切口出血等并发症16例(2．2％)，本组无死亡病例。结论 采用内镜治疗胆总管结石及缩窄性乳头炎是一种理想的微创外科方法。     

Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically

Background: Two recent meta‐analyses suggest that operative common bile duct (CBD) exploration (laparoscopic or open) may be superior to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis when the gall bladder is in situ. Much of the published work regarding laparoscopic exploration comes from enthusiasts of the technique and may not be transferable to other institutions. In our institution, both hepatobiliary and general surgeons carry out cholecystectomy, with differing levels of expertise in laparoscopic bile duct exploration. ERCP and laparoscopic antegrade transampullary endobiliary stents are available. We reviewed the management of choledocholithiasis in this setting. Methods: A retrospective review of all patients undergoing cholecystectomy during 2004 and 2005 at John Hunter and Belmont Hospitals (Newcastle, Australia) was conducted. Results: The overall incidence of choledocholithiasis was 10.3% (70 of 681). Fifty patients underwent preoperative ERCP, with choledocholithiasis confirmed in only 24 patients (therapeutic rate 30%). Thirty‐one patients underwent CBD exploration with 100% clearance through an open approach (12 patients) and 58% clearance through a laparoscopic approach (11 of 19 patients). Hepatobiliary surgeons carried out 22 of 31 CBD explorations (clearance rate 82%) and placed 13 transampullary antegrade endobiliary stents. In comparison, general surgeons carried out nine CBD explorations (clearance rate 56%) and placed only four antegrade stents. Conclusion: This series suggests that preoperative ERCP is significantly overutilized, laparoscopic CBD exploration is less successful than open CBD exploration and that antegrade transampullary intraoperative endobiliary stenting is underutilized by non‐hepatobiliary surgeons.     

胆源性胰腺炎诊治难点思考

胆源性胰腺炎是急性胰腺炎的第一大病因。尽管当前已经形成了相对规范的诊疗指南,但在临床实践中仍然有一些棘手或容易忽视的问题值得临床医生重视。影像学上发现结石或胆泥的证据以及丙氨酸氨基转移酶升高至正常3倍或以上是目前被广泛接受的诊断标准。当病因不明时,磁共振成像（MRI）或磁共振胰胆管成像（MRCP）、超声内镜甚至诊断性内镜逆行胰胆管造影（ERCP）应该当作为补充性的诊断工具。胆总管梗阻或急性胆管炎是早期ERCP的指征,尚无证据表明早期预防性胰支架置入能否改善急性胆源性胰腺炎（ABP）的预后,对于无条件做ERCP或ERCP失败的病人,经皮经肝胆囊穿刺引流可作为有效的替代方法。胆源性胰腺炎合并胆管炎或疑似胆源性感染的病人,需立即开始抗菌治疗。轻型胆源性胰腺炎病人应在住院期间接受胆囊切除术,重型病人需待临床一般情况稳定后择期手术。即使已行胆囊切除术,仍然存在胰腺炎复发的风险。优化胆源性胰腺炎诊断标准,建立完善的临床干预流程,降低复发率是未来临床研究的方向。     

腹腔镜胆囊切除结合内镜Oddi's括约肌切开取石二期治疗胆道结石

目的:探讨联合应用腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)和内镜Oddi's括约肌切开术(endoscopic sphincterotomy,EST)+内镜下胆总管取石二期治疗胆囊和胆管结石病的方法和价值.方法:对12例胆囊和胆总管结石病病人(术前经MRCP或B超证实),在全麻下一期行LC术后1 w,二期行ERCP+EST+内镜下胆总管取石以清除残余胆管结石.结果:12例病人LC和EST均在2 w内顺利完成,术中和术后无严重并发症发生,术后10~15 d出院.结论:联合应用LC和EST+内镜下胆总管取石分期治疗胆囊和胆管结石病切实可行,该法具有手术成功率高、病人痛苦少和住院时间短的优点.     

Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy

Background : The use of endoscopic retrograde cholangiopancreatography (ERCP) in the management of suspected common bile duct (CBD) stones prior to laparoscopic cholecystectomy is common. The associated morbidity can be significant. The present study determines significant predictors of CBD stones and improves the selection of patients for preoperative ERCP. Methods : All preoperative ERCP for suspected CBD stones in the year 1998 were studied retrospectively. Univariate and multivariate analyses of a number of clinical, biochemical and radiological variables were carried out to determine the best predictors of CBD stones. Results : A total of 112 patients had successful preoperative ERCP. Sixty‐one per cent of these were negative for stones and the morbidity was 9%. Univariate analysis revealed the following variables as predictors: cholangitis (P = 0.006), abnormal serum bilirubin ≥ 3 days (P = 0.002), serum alkaline phosphatase ≥ 130 U/L (P = 0.002), deranged liver function tests (P = < 0.001) and CBD diameter ≥ 8 mm (P = 0.009) with positive predictive values of 80%, 68%, 49%, 38% and 52%, respectively. Multivariate analysis revealed the model with the best ability to discriminate for CBD stones (P = 0.0005) was cholangitis, abnormal serum bilirubin for ≥ 3 days and CBD diameter ≥ 8 mm. The best predictors from this study had a sensitivity of 80% and a specificity of 27%. Conclusions : The predictors of CBD stones are imprecise. Until laparoscopic exploration of CBD becomes widely available, ERCP prior to cholecystectomy will remain popular. The use of stricter selection criteria can reduce the number of negative preoperative ERCP.