腹腔镜胆囊切除联合手术

目的　探讨腹腔镜胆囊切除联合其他手术的临床应用价值。方法　回顾分析 2 0 6例腹腔镜胆囊切除 (LC)联合手术的临床资料。结果　 2 0 6例腹腔镜胆囊切除联合手术中 ,LC联合总胆管探查 64例 ,联合阑尾切除术 2 9例 ,联合肝囊肿开窗术 3 8例 ,联合其他肝脏手术 13例 ,联合肾囊肿去顶术 15例 ,联合腹腔粘连松解 3 1例 ,联合其他手术 16例。 2 0 4例获成功 ,2例中转开腹手术。术后发生胆漏 2例 ,1例经非手术疗法治愈 ,1例再手术治愈。结论　腹腔镜胆囊切除联合手术能安全、有效、经济地处理多种腹部疾病 ,能充分体现微创外科手术的优越性     

Simultaneous Gastric Banding and Cholecystectomy in the Treatment of Morbid Obesity: Is it Feasible?

Background: In the last decade, laparoscopic surgery for morbid obesity has become widely employed, including a marked increase in the placement of adjustable gastric bands (AGB). Among the co-morbidities of morbid obesity is cholelithiasis. The question arises whether concomitant cholecystectomy increases the risk of postoperative infectious complications due to the association of a potentially contaminated procedure with a clean operation, placement of an AGB. The aim of this study is to evaluate the postoperative outcome in patients submitted to laparoscopic AGB with cholecystectomy. Methods: From January 2000 to January 2004, 308 patients (85 men and 223 women) had AGB placed. BMI ranged from 38.9 to 65.6 kg/m² (mean 41.6). In 17 patients (5.5%), gallstones were detected by ultrasonography, and cholecystectomy was performed together with the AGB. Mean operative time for placement of the AGB was 58 ± 18 min, and in those with cholecystectomy 86 ± 17min (P =0.20). Results: All patients that had placement of AGB and cholecystectomy had satisfactory postoperative outcome. No infectious complications were observed. Conclusion: Laparoscopic cholecystectomy performed simultaneously with placement of an AGB has been a safe procedure.     

Gallbladder Management in Obesity Surgery

Background: In the 1980s, some surgeons recommended routine cholecystectomy for patients undergoing bariatric surgery.This was based on the high prevalence of gallstones in the obese and concern that rapid weight loss would increase the risk of gallbladder disease. Others recommended waiting for a lower weight and a definite need.With increasing prevalence and severity of obesity and increased use of gastric reduction surgery for weight control, it seemed appropriate to review the current standard of care for cholecystectomy.A survey was also made of ursodeoxycholic acid usage for prevention of gallstone formation. Methods: Data collected from active contributors for the 28th Report of the International Bariatric Surgery Registry (IBSR) were examined. Two questionnaires were also sent to members of the American Society for Bariatric Surgery (ASBS). The first (Q1) asked about the indications for cholecystectomy. The second (Q2) asked about ursodeoxycholic acid usage for prevention of gallstone formation during rapid weight loss following surgical treatment of obesity. Results:There has been an increase in concurrent cholecystectomy during the last 15 years. Some of this is due to a shift from simple gastric restrictive operations to gastric bypass with gastric restriction. When the most extensive bypass of intestine is used, as in distal Roux-en-Y gastric bypass (RYGBPX) or biliopancreatic diversion with a duodenal switch (BPD-DS), all patients were reported to have undergone cholecystectomy. Only 30% of surgeons performing standard Roux-en-Y gastric bypass (RYGBP) remove normal-appearing gallbladders. Ursodeoxycholic acid is used to prevent gallstone formation in one-third of patients when a normal-appearing gallbladder is left in place. Conclusions: Prophylactic cholecystectomy is left to the discretion of the surgeon when RYGBP is used. There has been an increase in cholecystectomy and malabsorptive operations during the last 15 years.When most of the small bowel is bypassed, all remaining gallbladders are removed. For patients with simple restriction operations, normal-appearing gallbladders are usually left in place. Urso-deoxycholic acid during rapid weight loss for prevention of gallstone formation is used in one-third of patients with remaining gallbladders.     

医源性胆道损伤的处理

目的 探讨医源性胆道损伤的防治方法。方法 对1990年3月－2000年9月收治的118例医源性胆道损伤资料进行回顾性分析。结果 胆囊切除时胆囊三角区解剖不清是医源性胆道损伤发生的主要原因,占50．8％（60／118）。医源性胆道损伤的诊断主要依赖于临床症状、体征、腹部穿刺和影像学检查,其中B超诊断率可达93．2％（110／118）。按损伤部位作者将其分为6个类型,临床上以肝总管和胆总管部分切除的损伤类型（Ⅲ型）多见,占83．9％（99／118）。根据损伤类型而选择相应的外科手术中明显提高治愈率,本组治愈率达100％（118／118）。结论 胆囊切除时遵循“辨、切、辨”三字原则是预防医源性胆道损伤的关键,损伤类型则决定手术方式的选择。     

腹腔镜胆囊切除术在老年人胆囊结石中的应用

目的 探讨老年人胆囊结石腹腔镜胆囊切除术（LC）的临床特点。方法 对1993年5月－2001年3月两院收治的310例60岁以上老年人胆囊结石行胆囊切除术的临床资料进行回顾性分析。结果 本组310例中有193（62．3％）合并有不同程度糖尿病或心血管疾病及支气管疾患。49例（15．8％）粘连严重,操作难度大,其中6例（1．93％）中转开腹,其余顺利完成LC,无胆管损伤,无严重并发症,无手术死亡。结论 尽管老年人机体老化、脏器功能衰退,免疫功能低下,合并症多,但LC损伤小、疼痛轻、并发症少,作好围手术期处理后,LC应为老年人胆囊结石胆囊切除的首选治疗方法。     

医源性肝外胆管损伤的处理

目的 总结医源性胆管损伤的处理经验。方法 对５４例肝外胆管损伤处理进行回顾性分析。结果 ５４例中６例为腹腔镜胆囊切除术损伤,４８例为开腹胆囊切除术损伤。术中及时发现１８例（３３．３％）。术后２４ｈ后发现２４例（４４．４％）,手术１个月以后发现１２例（２２．３％）。５４例经道次处理后２３例（４２．６％）治愈,２８例（５１．９％）经过２次以上胆管手术,死亡３例（５．６％）。结论 正确掌握胆管损伤的处理     

医源性胆管损伤

目的　目的 :探讨医源性胆道损伤的预防和诊治方法。方法　对 91例医源性胆道损伤的临床资料进行回顾性分析。结果　 91例共施行手术 10 3次。其中 2次手术者 8例 ,3次手术者 2例。最后 1次手术方式为胆管端端吻合 18例 ,胆总管十二指肠吻合术 3例 ,胆管壁缺损修补 4例 ,单纯缝线拆除 1例 ,胆管空肠Roux en Y吻合 6 5例。 70例随访 1～ 10年 ,优良率 90 %。结论　胆囊切除术是医源性胆道损伤的主要原因 ,是可以避免的。肝管空肠Roux en Y吻合术是医源性胆道损伤或损伤性狭窄修复重建的首选方法。     

腹腔镜手术治疗胆囊疾病及腹内脏器并存病变

目的　探讨应用腹腔镜技术行胆囊及其它腹内脏器联合切除的可行性。方法　对 14年间施行的 69例经腹腔镜胆囊及其它脏器联合切除病例的临床资料进行回顾分析。结果　 69例均顺利完成腹腔镜手术 ,无中转开腹病例。平均手术时间 (85 .5± 18.6)min ,术后胃肠功能恢复时间(2 7.3± 6.2 )h ,术后平均住院时间 (3 .9± 0 .8)d。无术中及术后并发症 ,治疗效果满意。结论　腹腔镜下胆囊及其它腹内脏器联合切除是安全可行的 ,可同时治疗胆囊合并其它腹内脏器病变 ,一次手术可解除多个脏器病变 ,明显减轻了患者的痛苦 ,降低了治疗费用 ,值得推广应用。     

Outcome of Surgical and Endoscopic Management of Biliary Pancreatitis

The aims of the study were to compare theoutcomes of biliary pancreatitis after endoscopic andsurgical treatment and define the demographic andclinical characteristics that affect the outcomes. Allinpatients with biliary pancreatitis followed at hospitalsof the Department of Veterans Affairs during 1988-1994were included in a case-control study. Of 2075 patientswith biliary pancreatitis, 650 were first treated by biliary endoscopy and 1425 bycholecystectomy. Compared with cholecystectomy, biliaryendoscopy was associated with older age, admission tononsurgical service, more complicated pancreatitis, andcholedocholithiasis. Seventy-one patients died. Death occurred moreoften in older patients with multiple comorbidconditions and complications of biliary pancreatitis.Overall length of hospital stay was positivelycorrelated with complications, choledocholithiasis,comorbidity, and deferment of endoscopic or surgicalprocedure. After adjusting for other confoundingvariables, both types of treatment resulted in similardeath rates and lengths of hospitalization. Inconclusion, compared with cholecystectomy, biliaryendoscopy is chosen preferentially in older patientswith choledocholithiasis or a complication of theirpancreatitis. Despite such selection bias, biliary endoscopyresults in similar outcomes as surgery. Earlyintervention by either strategy reduces the length ofhospital stay.     

小切口胆囊电切术4200例临床分析

目的 探讨小切口胆囊切除术治疗胆囊结石的效果。方法 对1991年1月－2000年1月采用小切口胆囊切除术治疗的4200例临床资料回顾性分析,并将不同手术操作者引起并发症进行比较。结果 4200例全部治愈,发生严重并发症41例（0．98％）;其中术中出血4例（0．09％）,胆道损伤18例（0．43％）,应激性溃疡8例（0．19％）,残余胆管结石11例（0．26％）。结论 小切口胆囊切除术具有创伤小,出血少、手术时间短、术后肠功能恢复快、住院医疗费用低等优点。但在手术过程中,不同手术操作者引起手术并发症有明显的差异,应强调预防并发症的重要性。