腹腔镜胆囊切除术后胆总管残留结石7例报告

1992年5月至2001年10月我院施行腹腔镜胆囊切除术（LC）1900例,其中术后胆总管残留结石7例,残留结石率0.36％（7/1900）。本文分析胆总管残留结石发生的原因,并对其治疗和预防进行探讨。1 临床资料 本组男性2例,女性5例,年龄28-78岁,平均52岁。4例为择期手术者。3例入院时为慢性结石性胆囊炎急性发作者,但无黄疸,B超检查胆总管轻度扩张,直径9mm,经治疗症状缓解,术前复查B超胆总管直径均≤7mm,内无结石。LC术后2-20d再发上腹部绞痛,其中5例伴有黄疸,     

腹腔镜胆囊切除术治疗胆囊管结石92例

胆囊管结石在解剖位置和病理改变上有一定的特殊性,行腹腔镜胆囊切除术具有难度大、处理困难的特点[1]。随着腹腔镜胆囊切除术的广泛开展,胆囊管残株结石的发生率有上升趋势[2]。我们于2006年7月—2011年7月,行腹腔镜胆囊切除术治愈92     

腹腔镜胆囊切除术治疗胆囊管结石92例

1.浙江省诸暨市第三人民医院普外科(诸暨311825) 2.浙江省诸暨市人民医院肝胆外科(诸暨311820)     

腹腔镜手术治疗胆囊管结石19例报告

我院1996年9月—2006年4月腹腔镜胆囊切除术中发现有胆囊管结石梗阻19例，由于手术处理得当，均获成功，现报告如下。[第一段]     

合并胆囊管结石的腹腔镜胆囊切除术

目的探讨胆囊管结石的腹腔镜处理方法及手术技巧。方法对巢湖市第二人民医院普外二科2006～2011年收治的52例胆囊管结石患者临床资料加以总结分析。结果本组资料中,采用挤压法处理35例,胆囊管切开取石+钛夹闭合处理10例,胆囊管切开取石+胆囊管残端缝合5例,中转开腹二例;本组无手术并发症,随访1～2年,无胆囊管残留结石,胆管损伤、胆总管继发结石等并发症发生。结论掌握正确的术中处理方法及良好的手术技巧,绝大多数胆囊管结石可以通过腹腔镜成功完成手术,效果满意。     

腹腔镜胆囊切除术后胆囊颈管残留结石10例报告

目的 探讨腹腔镜胆囊切除术中胆囊颈管结石漏诊的原因及其预防.方法 回顾性分析我院自1999年1月～2005年1月收治的腹腔镜胆囊切除术后胆囊颈管残留结石10例的临床资料.结果 本组病例术前均经B型超声、MRCP、ERCP确诊,均经再次手术治愈.结论 手术中忽视或判断失误;急性炎症胆囊三角解剖不清;遗留过长的胆囊管及胆囊管畸形、变异是腹腔镜胆囊切除术中胆囊管结石漏诊的主要原因.术中胆道造影、术前B型超声筛查、术中B型超声引导是及时发现胆囊颈管结石残留的主要方法.     

腹腔镜胆囊切除术后胆囊管残余结石5例报告

本文报道2007年8月～2009年6月腹腔镜胆囊切除术后胆囊管残余结石5例,发生率0.4%（5/1236）。3例行开腹手术,切除残余胆囊管取出残余结石;1例黄疸者行剖腹探查手术,术中证实为Mirizzi综合征Ⅱ型,切除残余胆囊管和结石,修补胆总管瘘口;1例冠心病者行腹腔镜残余胆囊管切除术。5例随访6～12个月,无腹痛、发热、黄疸。     

腹腔镜手术治疗胆囊切除术后胆总管结石

目的:探讨腹腔镜手术治疗胆囊切除术后胆总管结石的方法及可行性。方法:回顾分析11例胆囊切除术后胆总管结石患者行腹腔镜手术的临床资料,总结其手术适应证及疗效。结果:11例患者均采用腹腔镜手术清除结石,随访1~21个月,平均13个月,无异常。结论:腹腔镜手术治疗胆囊切除术后胆总管结石安全、可行。     

腹腔镜胆囊切除术后胆总管残留结石12例

目的探讨基层医院腹腔镜胆囊切除术后胆总管残留结石的原因及防治措施。方法对腹腔镜胆囊切除术后胆总管残留结石12例患者的临床资料进行回顾性分析。结果 12例患者术前均诊断为单纯胆囊结石,胆囊内伴有多发性小结石,均有右上腹或剑突下疼痛病史,1例转氨酶升高,3例伴胆囊颈部结石嵌顿,2例胆总管增粗,所有患者术前均未行MRCP检查。行腹腔镜胆囊切除术后因出现不适症状发现胆总管结石,其大小与胆囊内小结石相当,其中7例在外院行内窥镜括约肌切开取石术治愈,5例开腹胆总管切开取石。结论详细复习病史资料,及时补充检查,正确的操作方法是预防此并发症的关键,治疗采用EST和再次开腹手术。     

Laparoscopic management of common bile duct stones

Background While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the management of common bile duct stones. Besides preoperative endoscopic papillotomy followed by laparoscopic cholecystectomy and open common bile duct surgery, management of common bile duct stones can be conducted by laparoscopy, if respective experience is available.Method During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicion of malignancy, severe pancreatitis, or cholangitis.Results From November 1991 to March 2002, 200 patients primarily underwent laparoscopic therapy of bile duct stones. Retrieval was performed via cystic duct and common bile duct incision in 115 and 85 cases, respectively. Complete removal was achieved in 91%; complication rate and mortality was 7% and 0.5%, respectively. During the same period primary endoscopic papillotomy was necessary in 40 patients because of the above contraindications.Conclusions When correct indications and surgical expertise are observed, simultaneous laparoscopic management of common bile duct stones represents a safe and minimally invasive alternative to a two-procedure approach.     

胆囊切除术与术后胆总管结石的关系研究

目的探讨胆囊切除术与术后罹患原发性胆总管结石的关系。方法检索中国医科大学附属第一、第二医院普通外科1994年1月至2003年12月478例胆总管结石患者行开腹手术或经内镜十二指肠乳头括约肌切开治疗的病例资料。计算胆囊切除术后罹患原发性胆总管结石患者中的比例,并对行单纯胆囊切除术组与未行任何胆道手术组的相关分类变量和连续变量进行分析。结果胆囊切除术后原发性胆总管结石的病例共61例,占全部原发性胆总管结石病例的14.2%(61/430)。自行胆囊切除术至发现原发性胆总管结石的间隔时间平均为8.23年,最长者28年,最短者2年。多发结石或泥沙样结石多见(χ2=9.030,P<0.01),且易并发急性化脓性胆管炎(χ2=8.259,P<0.01)。结论胆囊切除有可能是原发性胆总管结石发病的一个危险因素。既往行单纯胆囊切除术的原发性胆总管结石患者发生胆系感染的可能性更大,同时提示我们感染亦可能是胆囊切除术后发生原发性胆总管结石的重要原因。     

胆囊切除术与术后胆总管结石的关系研究

目的探讨胆囊切除术与术后罹患原发性胆总管结石的关系。方法检索中国医科大学附属第一、第二医院普通外科1994年1月至2003年12月478例胆总管结石患者行开腹手术或经内镜十二指肠乳头括约肌切开治疗的病例资料。计算胆囊切除术后罹患原发性胆总管结石患者中的比例,并对行单纯胆囊切除术组与未行任何胆道手术组的相关分类变量和连续变量进行分析。结果胆囊切除术后原发性胆总管结石的病例共61例,占全部原发性胆总管结石病例的14．2％（61／430）。自行胆囊切除术至发现原发性胆总管结石的间隔时间平均为8．23年,最长者28年,最短者2年。多发结石或泥沙样结石多见（X^2=9．030,P〈0．01）,且易并发急性化脓性胆管炎（X^2=8．259,P〈0．01）。结论胆囊切除有可能是原发性胆总管结石发病的一个危险因素。既往行单纯胆囊切除术的原发性胆总管结石患者发生胆系感染的可能性更大,同时提示我们感染亦可能是胆囊切除术后发生原发性胆总管结石的重要原因。     

腹腔镜胆囊切除联合十二指肠镜技术治疗选择性胆总管结石

目的探讨腹腔镜胆囊切除(laparoscopic cholecystectomy, LC)联合十二指肠镜技术治疗选择性胆总管结石的价值. 方法回顾性分析2002年1月～2003年12月32例选择性胆总管病变行LC联合内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography, ERCP)治疗的临床资料. 结果 LC术前ERCP 24例,发现胆总管结石19例,括约肌狭窄3例,正常2例,病变均经ERCP EST(内镜乳头括约肌切开术, endoscopic sphincterotomy)后行LC术.LC术后ERCP 8例,发现胆总管结石4例,括约肌狭窄3例,正常1例,除1例取石失败开腹手术外,所有病变均经EST治愈. 结论 LC与ERCP相结合对选择性胆总管结石的治疗有很高的临床应用价值,扩大了胆道微创治疗的范围.     

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

Background : The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Methods : Over the three‐year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio‐pancreatography. Results : Transcystic stenting was the ‘intention‐to‐treat’ basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1–15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio‐pancreatography, was 98%. A second endoscopic retrograde cholangio‐pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. Conclusion : A treatment option open to all surgeons for non‐jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.     

Laparoscopic management of common bile duct stones

We reviewed our experience with the management of common bile duct (CBD) stones in 100 consecutive patients treated laparoscopicaly during the past 9 years (1990–1998) and evaluated the advantages, disadvantages, and feasibility of the treatment, to elucidate reasonable therapeutic strategies for patients harboring CBD stones. We conclude that the most rational management of CBD stones is that which is decided according to the size of the CBD, which, in turn, depends on the size, number, and location of stones. The cystic duct in patients with a non-dilated CBD is narrow, because the size of the CBD depends on the size and number of stones that have migrated through the narrow cystic duct, and the stones in the non-dilated CBD are therefore usually small in size and number. Patients with a dilated CBD, however, are good candidates to undergo single-stage laparoscopic treatment. In our Department, therefore, even if complete removal of stones has failed in patients with non-dilated CBD, further choledochotomy is not carried out, and a C-tube is placed through the cystic duct for a subsequent postoperative transduodenal approach, because laparoscopic transcystic CBD exploration and choledochotomy may not be always feasible in those patients with non-dilated CBD, and spontaneous migration of small stones into the duodenum is frequently noted. In fact, some stones demonstrated on intraoperative cholangiograms were not revealed by postoperative cholangiography. In contrast, retained stones detected postoperatively were successfully removed by postoperative endoscopic sphincterotomy (EST), the endoscopic papillary balloon dilatation technique (EPBDT), or postoperative cholangioscopy (POCS) without any injury to the sphinter of Oddi. With this approach, we believe that the causes of stone recurrence can be avoided in the majority of cases. Received for publication on Aug. 21, 1999; accepted on Sept. 2, 1999     

腹腔镜胆总管切开取石方法探讨

目的 :探讨腹腔镜下胆总管探查胆道取石的方法。方法 :于腹腔镜下对胆总管结石 4 5例按由简单到复杂 ,由损伤轻到损伤重的原则应用冲洗、挤压及分离钳、胆道镜、改良取石钳取石。结果 :用冲吸法取净结石 3例 ,占 6 .6 % ;挤压和分离钳取净结石 13例 ,占 2 8 9% ;胆道镜取净结石 11例 ,占 2 4 % ;取石钳取净结石 18例 ,占 4 0 %。结论 :腹腔镜下胆总管取石应遵循由简到繁的原则 ,用取石钳取石较为可靠     

Carcinoma of the cystic duct protruding into the common bile duct: Report of a case

We report herein the case of 65-year-old man in whom a diagnosis of primary carcinoma of the cystic duct was made on the basis of Farrar's criteria. The patient was admitted with upper abdominal pain, and although there was no evidence of jaundice or a palpable mass, there was tenderness in his right upper quadrant. Carcinoma of the cystic duct was suspected on the basis of computed tomography and magnetic resonance imaging findings. Cholecystectomy with resection of the bile duct and lymph node resection was performed, and percutaneous transhepatic cholangiography revealed a filling defect in the common bile duct (CBD). The tumor was found to have arisen from the cystic duct and demonstrated papillary growth into the CBD intraluminally through the orifice of the cystic duct. Microscopically, the tumor was identified as papillary adenocarcinoma with invasion limited to the subserosal layer of the cystic duct. There were no signs of nodal metastasis.     

腹腔镜下经胆囊管胆总管汇合处切开治疗胆总管结石

目的探讨腹腔镜经胆囊管胆总管汇合处切开治疗胆总管并发结石的可行性。方法对187例患者,术中应用CB30L超细胆道镜确诊183例,胆道造影确诊4例,均再经胆囊管胆总管汇合处切开胆总管侧壁,应用P20胆道镜实施胆管探查取石术。结果经汇合处切开胆总管侧壁成功取出结石179例（95.7%）,改行切开胆总管前壁取石8例（4.3%）。一期直接缝合85例,其中胆漏11例,均一周内愈合。放置胆囊管导管74例,胆漏6例,3-5d停止。放置T形管20例,胆漏2例,3d停止。改行前壁取石的患者成功5例,中转开腹3例。术后残留结石3例,经内镜十二指肠乳头括约肌切开取石2例,经T形管窦道取石1例。随访185例患者,时间3个月-3年,未见胆管狭窄。结论采用经胆囊管胆总管汇合处切开入路治疗胆总管并发结石,创伤小,恢复快。     

Laparoscopic management of common bile duct stones: Study of 13 cases

In recent years, laparoscopic surgery for common bile duct (CBD) stones has been gaining wider acceptance. We report our experience with the laparoscopic management of CBD stones in 16 patients (9 males and 7 females; mean age, 62 years; range, 27–81 years). We considered two options for the laparoscopic procedures: (1) transcystic CBD exploration for those patients with fewer than 3 CBD stones, 5 mm or less in diameter, in whom the diameter of the cystic duct exceeded that of the CBD stones and (2) choledochotomy with T-tube drainage for other patients, unless a preoperative percutaneous transhepatic cholangio-drainage (PTCD) tube had been inserted. We successfully removed CBD stones by laparoscopic management in 13 of the 16 patients. The procedures employed were laparoscopic choledocholithotomy in 10 patients and laparoscopic transcystic CBD exploration and stone extraction in 3 patients. We converted to open choledochotomy in 3 patients, because of severe inflammation and dense adhesions due to acute cholecystitis in 2 patients and because of wide adhesions due to previous surgery in 1. We conclude that laparoscopic procedure is a safe and effective method for the removal of CBD stones.