十二指肠镜、腹腔镜联合治疗肝外胆管结石

目的探讨十二指肠镜联合腹腔镜治疗胆囊结石并胆管结石的临床效果。方法回顾分析7年间106例胆囊结石并胆管结石患者的临床资料。106例均先行内镜下十二指肠乳头切开(EST)取石、鼻胆引流(ENBD)然后行腹腔镜胆囊切除术(LC)。结果EST取石成功101例(95.3%);并发症包括胰腺炎(高淀粉酶血症)11例(10.4%),出血1例,急性胆管炎2例,均经对症处理治愈。全组病例无死亡,均痊愈出院。85例获平均3.1年随访,术后复发胆管结石5例(5.9%),十二指肠乳突部再狭窄1例;另发生胆管癌2例,其他原因死亡2例。结论联合EST和LC治疗肝外胆管结石是一种安全有效的微创手术方法。     

Percutaneous nephrolithotripsy under assisted local anaesthesia for high risk patients: Is it effective?

ObjectivesThe aim of the present study is to evaluate the feasibility and safety of performing PNL under local anesthesia in a selected group of patients who are at high risk for general anesthesia.Patients and methodsForty seven patients underwent PNL under local anesthesia. There were 38 males and 9 females with a mean age of 62 years. All patients were at medical high-risk for general anesthesia, with an American Society of Anesthesiologists (ASA) score of 3. The indications for local anesthesia in this study were obstructed single functioning kidney with azotemia in 29 patients, hepatic insufficiency in 8 patients, cardiac problems in 7 patients and 3 patients had hepatocellular carcinoma. The mean stone size was 2.7 cm (range 2–3.1 cm). Local infiltration with 10–20 cc of 2% lidocaine at the site of puncture was used in all cases. Narcotics were given 30 min prior to the procedure and medazolam was given intraoperatively upon demand. Utrasound guided puncture was performed in all cases and tract dilatation was then done under fluoroscopy using high pressure balloon catheter in 35 and Alken's metal dilators in 12 cases. Stones were then retrieved after disintegration in the same cession in 33 patients, while the other 14 patients underwent staged PNL, where a 12 Fr. nephrostomy tube was placed in the first stage, followed by tract dilatation and stone retrieval one week later.ResultsOut of 47 patients included, 44 had successful PNL either one stage (30 patients) or two stages (14 patients). Only 3 patients could not tolerate pain and the procedure was terminated after placement of nephrostomy tube and stone retrieval was completed later under general anesthesia.ConclusionOur results demonstrated that PNL under local anesthesia with narcotics and sedatives seems to be a satisfying solution for the treatment of a selected group of patients with renal pelvic stones and who have high anesthetic risk. However, additional studies with different groups of patients are required to validate our results.     

Ureteroscopy for treatment of obstructing ureteral calculi in pregnant women: Single center experience

ObjectivesTo evaluate our experiences with ureteroscopic treatment of ureteral calculi in pregnancy.Patients and methodsBetween April 2006 and October 2013, 41 pregnant women with persistent renal colics and/or hematuria refractory to conservative measures were treated with ureteroscopy. The patients’ mean age was 23 (range 19–37) years. Most of the patients (56.1%) presented in the 2nd trimester.Loin pain and colic were the most common presenting symptoms (90.2%). Twenty-seven patients (65.9%) had an obstruction on the right side. All patients underwent ureteroscopy under epidural anesthesia.ResultsUreteroscopy revealed the presence of ureteric stones in 36 of the 41 cases. The stone size ranged from 5 to 16 (mean 8.9) mm. Distal ureteric stones were found in 29 patients. The pneumatic lithoclast was used for stone fragmentation in 22 of them (75.9%), while the stone was directly extracted in 4 patients. In 3 patients the stone migrated proximally and was not accessible any more. Proximal ureteric stones were detected in 7 of the remaining 12 cases. When attempting to manipulate these stones, they migrated more proximally and became unreachable. In the last 5 patients the entire ureter was free of stones; they only had edema at the ureteric orifice. A long lasting JJ stent was left until the end of the pregnancy in all cases with migrated inaccessible stones. In all patients successfully treated, a JJ stent with dangle extraction strings was left for two weeks. Minor urologic complications were encountered in the form of mild dysuria in 12 cases (29.2%) and mild hematuria in 5 cases (12.2%). All patients completed their pregnancy until full term without any serious obstetric complications requiring intervention.ConclusionUreteroscopy is a safe and effective therapeutic option for the treatment of obstructing ureteral stones in pregnancy with stone-free and complication rates comparable to the non-pregnant population.     

Bedside score predicting retained common bile duct stone in acute biliary pancreatitis

BACKGROUND Retained common bile duct(CBD) stone after an acute episode of biliary pancreatitis is of paramount importance since stone extraction is mandatory.AIM To generate a simple non-invasive score to predict the presence of CBD stone in patients with biliary pancreatitis.METHODS We performed a retrospective study including patients with a diagnosis of biliary pancreatitis. One hundred and fifty-four patients were included. Thirty-three patients(21.5%) were diagnosed with CBD stone by endoscopic ultrasound(US).RESULTS In univariate analysis, age(OR: 1.048, P = 0.0004), aspartate transaminase(OR:1.002, P = 0.0015), alkaline phosphatase(OR: 1.005, P = 0.0005), gamma-glutamyl transferase(OR: 1.003, P = 0.0002) and CBD width by US(OR: 1.187, P = 0.0445)were associated with CBD stone. In multivariate analysis, three parameters were identified to predict CBD stone;age(OR: 1.062, P = 0.0005), gamma-glutamyl transferase level(OR: 1.003, P = 0.0003) and dilated CBD(OR: 3.685, P = 0.027),with area under the curve of 0.8433. We developed a diagnostic score that included the three significant parameters on multivariate analysis, with assignment of weights for each variable according to the co-efficient estimate. A score that ranges from 51.28 to 73.7 has a very high specificity(90%-100%) for CBD stones, while a low score that ranges from 9.16 to 41.04 has a high sensitivity(82%-100%). By performing internal validation, the negative predictive value of the low score group was 93%.CONCLUSION We recommend incorporating this score as an aid for stratifying patients with acute biliary pancreatitis into low or high probability for the presence of CBD stone.     

Uropathogens and urinary tract concretion formation and catheter encrustations

Infection stones (ammonium magnesium phosphate) and catheter encrustations have a common cause—urease producing microorganisms. With their rapid growth and frequent recurrences, infection stones are among the most troublesome of urinary system stones. For many patients with a long-term indwelling catheter, encrustations can be a severe problem. Urine composition is important, because, urine calcium enhances the crystallization process and urine citrate inhibits it. The role of non-urease producing microorganisms in stone forming processes is not well understood. Stones can now be successfully treated with a low morbidity index by percutaneous stone surgery or extracorporeal shock wave lithotripsy (ESWL) and recurrence of stone formation is then avoided by prolonged antibiotic treatment and oral citrate. Catheter encrustations and damage caused by ammonia released during urease activity can, however, be a serious problem in patients with indwelling catheters and our remedies are unsatisfactory.     

腹腔镜治疗胆囊颈部结石临床体会

目的探讨腹腔镜胆囊切除术胆囊颈部结石的处理方法。方法 2002年10月至2008年10月间,我们对286例胆囊颈部结石分别采用腹腔镜胆囊顺行切除、逆行切除和顺逆结合切除术治疗。结果手术均获成功,术后恢复顺利,无严重并发症出现。结论腹腔镜胆囊切除术中对不同情况的胆囊颈部结石采用不同的处理方法,可以有效避免术中胆管损伤等严重并发症。     

延续性护理干预对降低泌尿系结石患者复发率的影响

目的探讨延续性护理干预对降低泌尿系结石患者复发率的影响。方法选择2016年2月至2017年6月250例在达州市中西医结合医院进行治疗的泌尿系结石患者,采用随机数字表法将患者分为两组,每组各125例。对照组实施常规护理,观察组在此基础上加以延续性护理。对比两组患者的复发率、自我护理能力及治疗依从性。结果对照组复发率为14. 4%,明显高于观察组的4. 0%(P<0. 05)。干预后两组患者心理、躯体活动、饮食及治疗方面自我护理能力均得到明显提升,但观察组提升幅度更大(P<0. 05)。观察组治疗依从良好率为96. 0%,明显高于对照组的88. 0%(P<0. 05)。结论延续性护理较常规护理可明显降低泌尿系结石患者复发率,提高其自我护理能力及治疗依从性。