腹腔镜胆囊切除术联合胆总管探查术治疗胆囊结石合并胆总管结石临床观察

目的分析腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)联合胆总管探查术(laparoscopic common bile duct exploration,LCBDE)治疗胆囊结石合并胆总管结石的临床效果。方法选取2015-07~2016-03该院收治的胆囊结石合并胆总管结石患者90例,按手术方法不同分为对照组和观察组,各45例。对照组采用经内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)治疗,观察组采用LC+LCBDE治疗,对比两组患者手术情况及并发症发生率。结果两组患者住院时间、住院费用、手术成功率及残余结石率比较差异无统计学意义(P0.05);观察组一期治愈率明显高于对照组,手术时间短于对照组,差异有统计学意义(P0.05);观察组并发症发生率为11.11%,明显低于对照组的31.11%,差异有统计学意义(P0.05)。结论 LC+LCBDE治疗胆囊结石合并胆总管结石临床效果显著,取石率高,可有效缓解患者临床症状,降低二次手术的风险,并发症少,安全性高,值得在临床应用中推广。     

腹腔镜胆总管切开探查术

目的 探讨腹腔镜胆总管切开探查手术的方法与优缺点。方法 选择胆管结石或胆道蛔虫患行腹腔镜胆总管切开探查术。结果 50例患中48例术中取出直径为0．6-2．9cm的结石1-11枚、2例患术中取出死蛔虫1、2条,有6例患因结石嵌顿或取石网故障,术中无法取净结石,其中2例肋缘下作一6cm小切口开腹取净、4例术后经T管窦道取净结石,1例患中转开腹止血。手术时间117．2(45-180)min,术后6．8(3-12)d出院,30例患置T管引流。未置T管直接缝合胆总管20例,1例出现轻度胆汁渗漏。结论 腹腔镜胆总管切开探查取石术是安全的,患术后痛苦小,恢复快、住院期短,部分患不置T管直接缝合胆总管更加体现微创效果。     

内镜腹腔镜联合与腹腔镜下联合方法治疗胆囊结石合并胆总管结石的临床对照

目的比较内镜下乳头括约肌切开术（EST）联合腹腔镜胆囊切除术（LC）和腹腔镜胆总管探查取石术（LCBDE）联合LC治疗胆囊结石合并胆总管结石的效果及术式选择。方法回顾性分析60例胆囊结石合并胆总管结石分别采用EST联合LC（30例）和LCBDE联合LC（30例）治疗的临床资料，对结石清除率、并发症、中转开腹率和住院时间等指标进行比较。结果EST联合LC组结石清除率96．7％（29／30）、并发症发生率16．7％（5／30）、中转开腹率10．0％（3／30）、住院时间中位数17d。LCBDE联合LC组结石清除率100．0％（30／30）、并发症发生率6．7％（2／30）、中转开腹率6．7％（2／30）、住院时间中位数13d。两组病例在结石清除率（P=1．000）、并发症率（P=0．421）、中转开腹率（P=1．000）和住院时间（P=0．055）等方面无明显差异。结论EST联合LC和LCBDE联合LC都是治疗胆囊结石合并胆总管结石安全合理的方法，应根据具体情况采用个体化的治疗方法。     

腹腔镜胆总管探查术67例临床分析

腹腔镜胆囊切除术已成为良性胆囊疾病的首选术式 [1]随着内镜及其手术器械的开发和内镜医师技巧的提高,使胆道结石的微创治疗成为新的发展方向。腹腔镜微创手术治疗胆道结石,取代部分开腹手术,我院自 1996年 9月至 2000年 4月施行腹腔镜胆总管探查 67例,现总结如下。 　　一、资料和方法 　　1．一般资料：本组 67例中男 26例,女 41例;年龄 25～ 69岁,平均年龄 45.3岁。术前 B超及内镜逆行胰胆管造影（ ERCP）确诊胆囊炎并胆管结石,其中肝内外胆管结石 20例,胆总管结石 47例;经行内镜乳头括约肌切开术（ EST）取石术后结石残…     

SpyGlass直视下激光碎石术与腹腔镜胆总管探查术治疗胆总管巨大结石的非劣效对照

目的评价SpyGlass直视下激光碎石术治疗胆总管巨大结石（直径＞2 cm）的临床疗效及安全性。方法2015年8月—2018年8月,山东第一医科大学第一附属医院收治的157例胆总管巨大结石患者纳入研究,采用随机数字随机分入SpyGlass组（78例）或腹腔镜胆总管探查术（laparoscopic common bile duct exploration,LCBDE）组（79例）,SpyGlass组采用SpyGlass直视下激光碎石术治疗,LCBDE组采用LCBDE治疗。主要观察结石取净率和一次性结石取净率,非劣效检验的非劣效界值设为10%。次要观察指标包括中转率、短期并发症发生率、住院时间、患者生活质量（采用胃肠道生活质量指数评分）。结果结石取净率SpyGlass组和LCBDE组分别为92.3%（72/78）和96.2%（76/79）（P=0.023）,非劣效假设成立;一次性结石取净率SpyGlass组和LCBDE组分别为83.3%（65/78）和96.2%（76/79）（P=0.124）,非劣效假设不成立。与LCBDE组比较,SpyGlass组中转率略高[7.7%（6/78）比3.8%（3/79）,P=0.294],短期并发症总体发生率略低[5.1%（4/78）比10.1%（8/79）,P=0.246],住院时间更短[（5.65±0.94）d比（8.84±1.54）d,P=0.001],术后1个月、术后3个月胃肠道生活质量指数评分更高[术后1个月：（99.85±4.36）分比（91.51±5.47）分,P=0.001;术后3个月：（131.24±3.32）分比（112.32±7.77）分,P=0.001]。结论对于胆总管巨大结石,SpyGlass直视下激光碎石的疗效不劣于LCBDE,且更加微创,可作为LCBDE之外的治疗胆总管巨大结石的重要选择。     

腹腔镜胆总管探查术后胆道内置管引流胆总管一期缝合的临床应用

目的探讨腹腔镜胆总管切开探查胆道内置引流管、胆总管一期缝合的临床应用可行性、安全性和有效性。方法选用16F普通硅胶管制作胆道内置引流管,对过去5年开展腹腔镜胆总管切开取石术后胆道内置管引流胆总管一期缝合病例资料进行回顾性分析,并与同期放置T管引流的临床资料进行对照。结果自2001年9月至2006年2月共156例术中明确无残余结石、无肝内胆管结石及胆道狭窄患者行腹腔镜胆道探查术,其中107例患者放置胆道内置管引流,胆总管一期缝合,其余49例仍按传统方法放置T管引流。2组平均手术时间分别为115·2±26·7min、127·5±24·2min(P<0·05),术后住院4·8±0·92d、8·4±1·48d(P<0·05),术后平均输液量7278·5±1381、11270·2±2026ml(P>0·05),平均住院费用8932·7±1553·6元、10242·9±1594·5元(P<0·05),恢复日常工作时间14·44±1·89d、31·93±3·52d(P>0·05)。2组术后肝功能的恢复、并发症发生率无明显差异(P>0·05)。2组病人随访1~51月,平均28月,均未发现胆总管残余结石及其它胆道相关并发症。结论腹腔镜胆总管切开探查后放置胆道内置管引流胆总管一期缝合是一种安全、有效、可行的胆道引流方法。     

腹腔镜下胆总管探查一期缝合术后引流方式的研究进展

随着腹腔镜、胆道镜及缝合技术的快速发展,腹腔镜下胆总管探查（LCBDE）+一期胆总管缝合（PDC）已成为了治疗胆总管结石的主要方法。相比传统T管,该方法能降低患者术中出血,缩短手术及住院时间等,然而单纯的PDC往往缺乏有效的支撑引流,术后胆总管压力较大,增加了患者胆漏及胆总管狭窄的风险,因此有人提出了一期缝合胆总管兼顾内外引流的手术方式,不仅能降低术前胆总管压力,减轻胆道炎症水肿,提高缝合质量,术后还能保持一定引流,减少患者术后胆漏及胆道狭窄的发生。     

腹腔镜胆总管探查术联合腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石患者临床疗效研究

目的 探讨采用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患者的临床疗效.方法 2016年5月 ～2020年7月我院诊治的85例胆囊结石合并胆总管结石患者,其中41例接受LCBDE联合LC术,另44例接受在ERCP下行十二指肠镜Oddi括约肌切开术(EST)联合LC术治疗,术后...     

腹腔镜胆管探查术并发症

目前，腹腔镜下胆管探查术已经部分取代开腹手术，成为治疗胆总管结石的常用术式：但由于术中三维立体感觉变成二维视觉平面，丧失了手指触摸等优势，其术后并发症较开腹手术高。     

腹腔镜术中联合胆道镜或十二指肠镜治疗胆总管结石

目的总结腹腔镜术中联合胆管镜或十二指肠镜治疗胆囊疾病合并细径胆总管（≤0．8cm）结石的治疗经验。方法首先完成腹腔镜下胆囊切除术。胆管镜法：经胆囊管残端扩张、经胆囊管胆总管汇合部切开或经胆总管前壁切口入路,采用胆管镜取石网取石和液电碎石取净结石,经胆囊管残端输尿管导管胆管引流、T管引流或行胆总管切口即时缝合术。十二指肠镜法：经胆囊管残端插入输尿管导管或斑马导丝至十二指肠腔,经口插入十二指肠镜至十二指肠乳头,针式刀或弓式刀在输尿管导管或斑马导丝指引下对乳头施行切开术,用十二指肠镜取石网或球囊取石。结果191例患者进行了联合治疗。联合胆管镜法治疗117例,术中胆管镜下均取净结石,平均手术时间114min;术后胆漏7例,均经术中常规放置的胆管引流和腹腔引流管引流治愈;术后影像学复查,胆总管切口即时缝合区呈现轻度狭窄影像2例。联合十二指肠镜法治疗74例,68例乳头切开和取石成功,5例乳头切开成功,1例中转为其他术式,平均手术时间97min;术后轻症胰腺炎6例。两组均无肠穿孔、胆管穿孔、大出血、重症胰腺炎等严重并发症,无死亡。结论只要选择病例合适,腹腔镜术中联合胆管镜或十二指肠镜治疗细径胆总管结石是安全、有效且可行的。     

胆管疾病的腹腔镜内镜联合治疗

目的：探讨腹腔镜、内镜联合治疗胆管疾病的方法及疗效。方法：总结分析两家医院应用腹腔镜、十二指肠镜、胆道镜联合治疗1990例胆管疾病的资料。结果：腹腔镜、十二指肠镜联合治疗胆囊结石合并胆总管结石1350例，1次治愈率为93．6％；腹腔镜、胆道镜联合治疗胆管结石332例，治愈率为100％；三镜联合治疗胆管结石258例(29例合并胰腺炎)，Mirizzi综合征24例，治愈率为100％；腹腔镜胆肠吻合术，术前放置鼻胆引流管26例，治愈率为100％。均无严重手术并发症发生。共有1051例患者随访3个月～12年(平均7．8年)，结石复发10例，无胆管狭窄等远期并发症发生。结论：腹腔镜、内镜联合治疗胆管疾病较传统开腹手术创伤轻、痛苦小、手术并发症少。     

双镜微创术联合术后吲哚美辛栓治疗胆囊结石合并胆总管结石患者效果研究*

目的 研究双镜微创术联合术后吲哚美辛栓治疗胆囊结石合并胆总管结石患者的效果及其对血清视黄醇结合蛋白(RBP)水平的影响。方法 2017年2月～2018年4月我院治疗的胆囊结石合并胆总管结石患者120例,被随机分为对照组和观察组,每组60例,分别行双镜微创术和双镜微创术后给予吲哚美辛栓治疗。采用ELISA法检测血清RBP、肿瘤坏死因子-α(TNF-α)、白介素-6(IL-6)和IL-8水平,应用WHO推荐的生命质量(QOL)量表评估生命质量。结果 两组均全部取净胆囊和胆总管结石;在治疗后7 d,观察组血清RBP水平为(45.8±3.2)mg/L,显著高于对照组【(32.5±3.2) mg/L,P<0.05】;血清TNF-α、IL-6和IL-8水平分别为(2.1±0.4)μg/L、(15.8±7.8)μg/L和(11.6±9.5)μg/L,显著低于对照组【分别为(4.1±0.4)μg/L、(30.8±7.7)μg/L和(37.6±9.5)μg/L,P＜0.05】;术后3个月,两组患者胆管狭窄、切口感染、残留结石和胆漏发生率之间的差异不存在统计学意义(P＞0.05);在术后1 m和3 m,观察组患者QOL评分分别为(45.8±3.2)和(47.2±3.0),显著高于对照组【分别为(32.5±3.3)和(36.1±3.1),P＜0.05】。结论 采用双镜微创术联合术后给予吲哚美辛栓治疗胆囊结石合并胆总管结石患者可显著抑制机体应激反应,降低血清细胞因子水平,提升血清RBP水平,治疗效果显著。     

Diagnosis and management of choledocholithiasis in the golden age of imaging,endoscopy and laparoscopy

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones(CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound(EUS) and magnetic resonance cholangiography(MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and costeffectiveness of imaging techniques used to identifyCBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.     

Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis: A systematic review and meta-analysis

Background: Common bile duct(CBD) stones may occur in up to 3%–14.7% of all patients with cholecystectomy. Various approaches of laparoscopic CBD exploration plus primary duct closure(PDC) are the most commonly used and the best methods to treat CBD stone. This systematic review was to compare the effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC for choledocholithiasis.Data sources: Randomized controlled trials(RCTs) and non-randomized controlled trials(NRCTs)(casecontrol studies or cohort studies) were searched from Cochrane library(until Issue 2, 2015), Web of Science(1980-January 2016), Pub Med(1966-January 2016), and Baidu search engine. After independent quality assessment and data extraction, meta-analysis was conducted using Rev Man 5.1 software.Results: Four RCTs and 18 NRCTs were included. When compared with choledochotomy exploration(CE) plus T-tube drainage(TTD)(CE + TTD), CE plus PDC(CE + PDC) and CE + PDC with biliary drainage(BD)(CE + PDC + BD) had a lower rate of postoperative biliary peritonitis(OR = 0.22; 95% CI: 0.06, 0.88;P 0.05; OR = 0.27; 95% CI: 0.08, 0.84; P 0.05; respectively) where T-tubes were removed more than3 weeks. The operative time of CE + PDC was significantly shorter(WMD =-24.82; 95% CI:-27.48,-22.16; P 0.01) than that of CE + TTD in RCTs. Cystic duct exploration(CDE) plus PDC(CDE + PDC) has a lower rate of postoperative complications(OR = 0.39; 95% CI: 0.23, 0.67; P 0.01) when compared with CE + PDC. Confluence part micro-incision exploration(CME) plus PDC(CME + PDC) has a lower rate of postoperative bile leakage(OR = 0.17; 95% CI: 0.04, 0.74; P 0.05) when compared with CE + PDC.Conclusion: PDC with other various approaches are better than TTD in the treatment of choledocholithiasis.     

ASGE high-risk criteria for choledocholithiasis — Are they applicable in cholecystectomized patients?

Background and aims

The guidelines by the American Society for Gastrointestinal Endoscopy (ASGE) suggest that in patients with gallbladder in situ, endoscopic retrograde cholangiopancreatography (ERCP) should be performed in the presence of high-risk criteria for choledocholithiasis, after biochemical tests and abdominal ultrasound. There are no specific recommendations for cholecystectomized patients. The aim of this study was to evaluate the applicability of ASGE criteria for ERCP in cholecystectomized patients with suspected choledocholithiasis.

内镜超声检查对胆总管无扩张伴可疑胆总管结石的诊断价值

目的 探讨胆总管无扩张伴可疑胆总管结石患者（CBDS）行超声内镜检查（EUS）的价值.方法 对33例经多次腹部B超检查诊断胆囊结石,胆总管直径〈8 mm,未发现CBDS但有急性胰腺炎、阻塞性黄疸或反复胆绞痛等病史之一的患者行EUS,并与手术或ERCP结果进行比较.结果 33例患者行EUS,20例发现CBDS.经进一步手术或ERCP,该20例患者中有16例证实有CBDS.EUS对本组病例CBDS诊断的灵敏度为100%,特异度为76.5%,阳性预测价值为80%,阴性预测价值为100%.结论 对胆总管无扩张但有可疑CBDS者行EUS检查有较高的临床价值.     

Safety advantage of endocut mode over endoscopic sphincterotomy for choledocholithiasis

AIM: To evaluate whether an automatically controlled cut system (endocut mode) could reduce the complication rate of endoscopic sphincterotomy (EST) and serum hyperamylasemia after EST compared to the conventional blended cut mode. METHODS: From January 2001 to October 2003, 134 patients with choledocholithiasis were assigned to either endocut mode group or conventional blended cut mode group at the time of sphincterotomy. The two groups were retrospectively compared for the complications after EST and serum amylase level before and 24 h after the procedure. RESULTS: Of the 134 patients treated, 79 were assigned to conventional blended cut mode group and 55 to endocut mode group. There was no significant difference in age, sex, and serum amylase level before EST between the two groups. Complications were found in 5 patients of the endocut mode group (9%): hyperamylasemia (5 times higher than normal) in 4 and moderate pancreatitis in 1. Complications were found in 13 patients of the conventional blended cut mode group (16%): hyperamylasemia in 12 and moderate pancreatitis in 1. Serum amylase levels were elevated in both groups 24 h after EST (P<0.02). The average serum amylase level 24 h after EST in the conventional blended cut mode group was significantly higher than that in the endocut mode group (P<0.05). CONCLUSION: Endocut mode offers a safety advantage over conventional blended cut mode for pancreatitis after EST by reducing hyperamylasemia.     

Advances of recurrent risk factors and management of choledocholithiasis

Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%–22%, and common bile duct stones (CBDS) accounts for 8%–20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.     

乳头切开术治疗胆总管结石远期并发症及其与胆囊结石关系的研究

目的 探讨内镜下十二指肠乳头括约肌切开术（EST）治疗胆总管结石患者的远期治疗效果,评估EST术后胆囊切除的必要性.方法 对2006年1月至12月因胆总管结石而行EST治疗257例患者进行随访,所有患者平均随访时间为34.8个月（26～48个月）.根据不同病情和处理情况分为3组进行比较,合并有胆囊结石的患者EST术后行胆囊切除为A1组,EST术后未行胆囊切除为A2组;B组为未合并胆囊结石者.结果 出现远期并发症者31例（12.1%）,胆总管结石复发25例（9.7%）,胆管炎27例（10.1%）,胰腺炎2例（0.8%）,胆管癌1例（0.4%）;A2组患者远期并发症发生率、胆总管结石复发率均高于A1组（P均〈0.05）.结论 从远期疗效来看,EST是治疗胆总管结石的安全、有效的方法,对于合并有胆囊结石的患者EST术后行胆囊切除是有必要的.