胰胆管合流异常及其相关疾病

胰胆管合流异常是一种胆管和胰管在十二指肠壁外汇合的先天性畸形。由于失去了Oddi括约肌的控制,胆汁和胰液可以相互返流从而引起胆总管扩张症,胆道结石,胆道肿瘤及其胆源性胰腺炎等疾病。     

胆囊结石患者围术期血栓弹力图与常规凝血试验相关性分析

目的 探讨胆囊结石患者围术期血栓弹力图（TEG）各参数与常规凝血试验各指标的相关性,评价两种方法在围术期检测凝血状况的价值.方法 选择100例需手术治疗的胆囊结石患者和80例正常对照组,所有受试者均同步进行血栓弹力图（TEG）检测与常规凝血试验.结果 胆囊结石组R值和K值明显缩短,α角、MA值和CL值明显增大,表明患者存在血液高凝状态.R值与凝血酶原时间（PT）、凝血酶原时间国际标准化比值（PT-INR）、活化部分凝血酶时间（APTT）呈正相关,与纤维蛋白原（FIB）呈负相关.α角与PT、PT-INR、APTT呈负相关.MA值与FIB呈正相关,与PT、PT-INR、APTT呈负相关.结论 胆囊结石患者围术期血栓弹力图指标与常规凝血试验指标存在明显相关性,两者可起到互补作用.血栓弹力图检测对于评估凝血全貌,判断出血风险、指导输血有重要的意义.     

腹腔镜胆囊切除术治疗急性胆囊炎168例

目的 总结急性胆囊炎行腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的经验体会。方法 2002年1月～2006年12月168例急性胆囊炎行LC。CO2气体建立气腹,常规四孔法。结果 159例成功完成LC,9例因胆囊粘连致密易出血中转开腹,其中1例Mirizzi综合征Ⅱ型。28例温氏孔放置引流管。168例随访3～60个月,平均36.5月,无并发症发生,无死亡病例。结论 严格掌握急性胆囊炎腹腔镜手术治疗的指征,规范腹腔镜操作技术,适时中转开腹,合理放置引流,是保证手术成功的关键。     

A single centre case series of gallstone sigmoid ileus management

Aims/IntroductionGallstone sigmoid ileus is a rare condition that presents with symptoms of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon. This arises because of three primary factors: cholelithiasis causing a cholecystoenteric fistula; a gallstone large enough to obstruct the bowel lumen; and narrowing of the bowel.We describe 3 patients treated in a district general hospital over a 3-year period, and discuss their management.MethodsCases were retrospectively analysed from a single center between 2015 and 2017 in line with the SCARE guidelines.Results3 patients – 2 female, 1 male. Age: 89, 68, 69 years. 2 cholecystocolonic fistulae, 1 cholecystoenteric (small bowel) fistula.Patient 1: Unsuccessful endoscopic attempts to retrieve the (5 × 5 cm) gallstone resulted in surgery. Retrograde milking of the stone to caecum enabled removal via modified appendicectomy.Patient 2: Endoscopy and lithotripsy failed to fragment stone. Prior to laparotomy the stone was palpated in the proximal rectum enabling manual extraction.Patient 3: Laparotomy for gallstone ileus failed to identify a stone within the small bowel. Gallstone sigmoid ileus then developed. Conservative measures successfully decompressed the large bowel 6 days post-operation.ConclusionsThis is the first case series highlighting the differing strategies and challenges faced by clinicians managing gallstone sigmoid ileus. Conservative measures (including manual evacuation), endoscopy, lithotripsy and surgery all play important roles in relieving large bowel obstruction. It is essential to tailor care to individual patients’ needs given the complexities of this potentially life threatening condition.     

Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients

Background Endoscopic sphincterotomy without cholecystectomy is a therapeutic option in selected patients after acute biliary pancreatitis. We conducted a prospective evaluation of the long-term effects of sphincterotomy in terms of the need for of subsequent cholecystectomy and the recurrence of gallstone pancreatitis.Methods We studied 88 patients with acute biliary pancreatitis and an intact gallbladder who, underwent endoscopic sphincterotomy either because they were high-risk candidates for surgery or because they had refused of cholecystectomy. The median follow-up was 51 months (range, 5–86).Results Only two patients (2.2%) experienced recurrent pancreatitis. Subsequent cholecystectomy was performed in 10 patients because of acute cholecystitis in eight cases and biliary colic in two cases. Sixty-six patiens (75%) remained asymptomatic.Conclusions Endoscopic sphincterotomy is a safe and acceptable alternative to cholecystectomy for the prevention of recurring attacks of gallstone pancreatitis. As a result of this procedure, 75% of patients remained free of symptoms in the long term.     

The response to medical litholytic treatment of gallstones according to their specific gravity

Summary The buoyancy of gallstones was observed by taking anterior-posterior scout X-ray films of two patients standing during endoscopic retrograde cholangiography. In case 1, the large and small gallstones differed in buoyancy, and ursodeoxycholic acid treatment dissolved the floating small stones while failing to dissolve the nonfloating large stone. In case 2, both the large and small stones floated and are being dissolved by ursodeoxycholic acid treatment. Since floating or nonfloating and the plane of flotation depend on the specific gravity of the gallstone, the above findings suggest that a gallstone with a low specific gravity is more readily dissolved than one with a high specific gravity. The present method of estimating the buoyancy of gallstones was therefore considered extremely useful in selecting patients for medical litholytic treatment.     

Early ERCP for Gallstone Pancreatitis: For Whom and When?

The indications for early endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis are unclear, and the examination is often requested or performed without substantial supporting evidence. Several trials have been performed to determine the benefit of early ERCP in pancreatitis, yet the results of these studies are inconsistent. To more closely analyze these studies, we performed an evidence-based review of the outcomes of early ERCP in gallstone pancreatitis. To obtain the best available evidence, a PubMed search using the MeSH terms “gallstones” and “pancreatitis” was performed and further refined to identify appropriate studies. We included five randomized trials, a meta-analysis, and a Cochrane Database Systematic Review in our detailed examination of the pertinent literature. Collectively, these studies suggest that early ERCP does not alter mortality in gallstone pancreatitis. In addition, few patients with mild pancreatitis benefit from the procedure, whereas some studies indicate that patients with severe pancreatitis or documented biliary obstruction may experience fewer complications if ERCP is performed. The data in the studies are confounding because of heterogeneity of the patient population and the inability to confirm gallstones in up to one third of patients. In conclusion, ERCP is not indicated for patients with mild pancreatitis. In select patients with severe disease or biliary obstruction, ERCP may be indicated. A multicenter trial designed to study the effect of early ERCP in severe pancreatitis only may provide additional useful information in patients with documented gallstones. Presented at the Postgraduate Course of the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract (Digestive Disease Week 2007), Washington DC, USA, May 20, 2007.     

Recurrent enteric gallstone obstruction

Small bowel gallstone obstruction may recur, most often within a few days after surgery, due to an overlooked intraenteric stone or subsequent passage of another gallstone via the cholecystoenteric fistula. In the case reported herein there was a 6-month interval. A critical review of the radiologic signs of gallstone ileus is presented.