纤维胆道镜在肝胆管结石治疗中的价值

目的 探讨手术和纤胆镜联合治疗肝胆管结石的应用价值。方法 回顾分析1998年9月～2003年6月共380例手术和纤胆镜联合治疗肝胆管结石病人的临床资料。结果 380例肝胆管结石病人术中应用纤胆镜技术后。残留结石率由38％降到12．9％,132例术中纤胆镜发现合并肝内胆管狭窄，其中30例为假性狭窄，经纤胆镜扩张后治愈，其余采用了相应的手术方式。49例残留结石的病人术后均采用纤胆镜取石，残留结石率为1．9％，4例因多次取石费用高而放弃，3例因胆道出血而放弃。结论 肝胆管结石的手术中联合应用纤胆镜可使肝内结石的诊断更明确、取石更有效，并对手术方式的选择有指导意义，术后经T管窦道纤胆镜取石是治疗肝H日管残留结石的的主要手段.     

胆道镜在胆道疾病诊治中的应用价值

目的：探讨胆道镜在胆道疾病诊治中的应用价值。方法：于1990年10月—2002年10月应用胆道镜诊治胆道疾患，术中应用580例，术后应用780例，进行总结。结果：术中应用取石成功率84％，成功确诊治疗胆管肿痛22例。术后取石成功率94．9％。无严重并发症。结论：胆道镜可大大降低胆道残石率，提高胆道疾病的确诊率，对其治疗方案起到合理的指导作用，胆道镜在胆道疾病诊治中作用显著。     

内镜治疗胆总管结石34例临床分析

目的:探讨经内镜乳头括约肌切开(EST)治疗胆总管结石的疗效及临床价值。方法:经十二指肠镜选择性胰胆管插管造影了解胰胆管情况,34例胆总管结石患者根据胆管结石大小及壶腹部隆起决定切开长度,一般为1.0～1.8cm,结石直径大于最大切开长度时,可先行碎石后再取石,如标准切开刀不能插入胆管,可用针刀开窗术切开乳头,切口过小或者胆管内泥沙样结石可用气囊扩张后反复冲洗,其中采用网篮取石15例,气囊扩张取石6例,体内碎石后用网篮或气囊扩张取石13例。结果:34例乳头括约肌切开全部成功,33例治疗有效,有效率97.05％;33例胆总管结石均一次性清除;并发急性胰腺炎3例(8.82％)。结论:EST是目前治疗胰胆疾病最重要的方法之一,具有操作简便,疗效肯定,并发症少及死亡率低优点。     

经内镜鼻胆管引流术在腹腔镜胆管探查中的作用

目的：应用经内镜鼻胆管引流术(ENBD)作为腹腔镜胆管探查术(LCBDE)胆管引流方式，探讨其应用价值。方法：对拟行腹腔镜下胆管探查的患者术前进行ENBD，后经胆总管探查切口应用液电碎石、胆道镜取石，将肝内外胆管结石取净，保留鼻胆管于胆管内，将胆总管探查切口一期缝合，常规放置腹腔引流管。术后经鼻胆管造影，肝内外胆管无残余结石，无胆漏，择期拔除腹腔引流管及鼻胆管。结果：共43例患者术前行ENBD，平均6．1d后行LCBDE。36例(83.7％)患者成功进行LCBDE，胆管探查切口一期缝合。术后经鼻胆管造影，发现1例(2．6％)术中胆道镜漏诊--小结石，经内镜取石后痊愈；无胆管狭窄及胆漏等并发症发生。另有7例患者(18．6％)中转开腹手术，其中2例保留鼻胆管，胆管切口行一期缝合，术后顺利拔除鼻胆管。38例患者(88．4％)均成功应用：ENBD进行胆管引流，平均3．2d拔除腹腔引流管，6.7d拔除鼻胆管，无相关并发症发生。结论：ENBD作为LCBDE胆管引流，是安全有效的方式，且术后引流时间短，并发症少，可充分发挥出腹腔镜治疗胆管结石微创的优势。     

肝内外胆管结石的内镜、腹腔镜联合治疗

目的 探讨肝内外胆管结石的内镜、腹腔镜联合治疗的最佳方法. 方法 2000年10月～2005年12月,我院收治肝内外胆管结石1 669例,根据病人结石具体情况分别采用内镜、腹腔镜联合微创治疗方案：一镜方案（单纯十二指肠镜治疗）,二镜方案①（十二指肠镜、腹腔镜联合治疗）或②（腹腔镜、胆道镜联合治疗）,三镜方案（十二指肠镜、腹腔镜、胆道镜联合治疗）,手助腹腔镜肝切除方案治疗,对术后情况进行观察分析. 结果 应用内镜、腹腔镜联合的微创方案治疗肝内外胆管结石1 636例,总成功率为98.0%（1 636/1 669）,术后无严重并发症发生. 结论 针对不同类型、不同程度的肝内外胆管结石病人,将内镜、腹腔镜联合应用,进一步扩大了微创治疗的范围,提高了成功率,充分体现了内镜、腹腔镜联合治疗的优越性.     

钬激光联合胆道镜治疗胆总管结石

目的探讨钬激光联合胆道镜在治疗复杂性胆总管结石中的价值。方法通过胆道镜工作通道，应用钬激光，功率为1．0J／10Hz，直径为200μm光导纤维，在直视下接触结石，将胆总管结石击碎后注水冲出，或用取石篮套出。结果17例均取石成功，取石时间10—50min，平均20min。探查后胆总管一期缝合8例，T管引流6例，经窦道取石3例，术后无胆道出血，胆漏。16例随访6—15个月，平均10个月，腹部B超或磁共振胆胰管造影（magnetic resonance cholangiopancreatography，MRCP）检查，未发现结石复发及残留，无胆道狭窄。结论钬激光联合胆道镜治疗复杂性胆总管结石，具有创伤小、恢复快、碎石确切、操作容易、安全有效等优点，为治疗复杂性胆总管结石开辟了一条新的治疗途径。     

术后纤维胆管镜取石治疗肝胆管残余结石100例疗效观察

目的：对提高肝胆管术后残余结石取尽率的观察。方法：回顾性分析我院2004～2010年应用纤维胆管镜及体内冲击波碎石仪经术后＂T＂管窦道治疗术后胆管残余结石100例的临床资料。结果：100例患者共取石、碎石治疗270例次,结石取净98例,取净率为98%,2例取石未净者均为重度胆管狭窄患者,且结石的大小与时间呈正相关。结论：运用纤维胆管镜及体内冲击波碎石仪经＂T＂管窦道取石、碎石是治疗胆管残余结石的理想方法,操作简单,用时短,损伤轻,患者痛苦小,可以避免再次或多次胆管手术,在胆管残余结石的治疗中具有重要的价值。     

Choledochoscopy during biliary surgery for reducing the risk of overlooked stones

Summary Although cholangiography is routinely performed during biliary surgery to ensure the removal of all stones, it is not always successful. Some investigators have claimed that intraoperative choledochoscopy is more effective in detecting all stones, although reports on the efficacy of this method have been contradictory. Furthermore, no study has systematically examined either of these procedures in terms of the actual incidence of overlooked stones. Thus, to evaluate the merits of intraoperative cholangiography as opposed to choledochoscopy, we studied the incidence of overlooked bile duct stones after surgery. We investigated 126 patients who had undergone surgery during which choledocholithotomy was performed within the past 10 years; 117 of these cases involved common bile duct stones and 22, intrahepatic stones. After the exclusion of 13 subjects whose stones were deliberately left for postoperative treatment due to severe complications, 126 patients were finally analyzed. Overlooked stones were found postoperatively in 13 (10%) of these 126 subjects, including 11 (14%) of 63 patients who had been inspected by intraoperative cholangiography alone and 2 (3%) of 63 who had undergone both choledochoscopy and cholangiography during surgery. Therefore, the incidence of overlooked stones proved to be significantly lower in those who had undergone choledochoscopy combined with cholangiography (P <0.01). Our results suggest the value of combining choledochoscopy with cholangiography during surgery for reducing the risk of overlooked bile duct stones.     

Technique and result of intraoperative choledochoscopy

Summary The use of intraoperative choledochoscopy represents a significant advance in biliary surgery. Flexible instruments are ideal for examining the intrahepatic bile ducts, while rigid instruments are best suited for the extrahepatic ductal system. The cystic duct stump may be occasionally used for access, but, as a rule, a supraduodenal choledochotomy is necessary. Our experience with 776 examinations is reported. A total of 348 patients (44.8%) had ductal stones. In 10 patients (2.8%), a stone was overlooked. Equivocal cholangiograms, ductal stones, and obstructive tumors constitute the most important indications for endoscopic examination.