血吸虫病肝硬变伴症状性胆结石患者腹腔镜胆囊切除

目的 探讨血吸虫病肝硬化伴症状性胆结石患者腹腔镜胆囊切除(LC)的效果。方法 回顾性分析4年来我院血吸虫病性肝硬化伴胆囊结石行胆囊切除术265例的临床资料。行LC的74例，与常规开腹手术(OC)组进行对比，比较两组术中出血量、手术时间、住院时间、并发症、术后恢复情况等。结果 手术平均时间LC组为63min，OC组为53min；平均术后住院时间LC组为1．2d，OC组为8．9d；平均手术出血量LC组为15．6ml，OC组为85ml；LC组中转手术6例(8．1％)，无1例发生并发症；OC组术后胆漏1例。结论 血吸虫病性肝硬化胆结石患者只要严格掌握腹腔镜手术适应证，采取正确的手术操作方法，LC是安全可行的。     

腹腔镜胆囊切除联合阑尾切除130例

目的 探讨腹腔镜胆囊切除(LC)同时行阑尾切除术的可行性。方法 对胆囊结石、胆囊炎合并有急慢性阑尾炎l30例患者，在行腹腔镜胆囊切除术同时行腹腔镜阑尾切除术(LA)。结果 129例成功，1例中转开腹手术。术后无并发症发生。结论 对胆囊结石、胆囊炎合并有急慢性阑尾炎患者可行LC联合LA。LC加LA充分体现了腹腔镜手术的优越性，有推广使用的价值。     

Is Routine Cholecystectomy Required During Laparoscopic Gastric Bypass?

Background: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of our study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. Results: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 39 patients developed gallstones (22%) and 12 developed sludge (8%), as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients developing stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). Conclusions: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.     

针刺与硬膜外腔复合麻醉用于胆囊切除术的临床研究

81例胆囊切除术分为 3组 : 组针刺与单纯硬膜外低浓度局麻药复合麻醉 ; 组单纯硬膜外低浓度局麻药麻醉 ; 组硬膜外常规浓度局麻药麻醉。临床观察麻醉效果 , 、 组进行同位素放射免疫测定进行比较研究 ,其结果显示针刺与硬膜外复合麻醉既减少麻醉药用量又对机体有调整作用 ,对手术刺激反应具有保护性抑制作用 ,使循环系统更稳定。     

腹腔镜胆道探查取石T管引流术术式的研究

目的　探讨腹腔镜胆总管探查取石的最佳手术方法及手术适应证。方法　对我中心实施12 4例腹腔镜胆囊切除与胆总管切开探查取石、T管引流术的临床资料进行分析。结果　 82例改进术式 ,中转开腹 4例 (4 .9% ) ,平均手术时间 (80± 3 0 )min。常规术式 42例 ,中转开腹 6例 (14 .3 % ) ,平均手术时间 (170± 40 )min。改进术式在手术时间上明显缩短于常规术式 (P <0 .0 1) ;中转开腹率显著低于常规术式 (P <0 .0 5 )。疗效和住院日两者无明显差异。结论　改进后的胆总管切开探查取石、T管引流术是治疗胆总管结石更为安全有效的措施。     

Is Prophylactic Cholecystectomy Useful in Obese Patients Undergoing Gastric Bypass?

Background: Obesity constitutes a clear risk factor for cholelithiasis, especially if it is associated with a rapid weight loss, as is the case of patients following bariatric surgery. Prophylactic cholecystectomy is indicated in biliopancreatic diversions due to the high incidence of postoperative cholelithiasis. However, there is no agreement on gastric bypass. This study was conducted to establish the incidence of cholecystopathy demonstrated by histology and to assess the indication for prophylactic cholecystectomy in a systematic way on patients undergoing gastric bypass. Methods: The evaluation is based on 100 consecutive morbidly obese patients undergoing open gastric bypass surgery with concomitant prophylactic cholecystectomy. Variables studied were: age, gender, body mass index, preoperative ultrasound and the anatomopathologic analysis of the gallbladder that was removed. Results: Of the 100 patients who took part in the trial, 11 had had a previous cholecystectomy. Among the 89 patients remaining, preoperative ultrasound diagnosis of cholelithiasis was 16.8%, and the actual postoperative incidence was 24.7%. Other histologic alterations were: cholesterolosis 46.1%, chronic unspecified cholecystitis 22.5%, and granulomatous cholecystitis 1.1%. The total incidence of cholecystopathy was 93.3%. The morbi-mortality related to cholecystectomy was 0%. Conclusions: Based on these results and given the absence of morbidity, we believe that prophylactic cholecystectomy is suitable during open gastric bypass.     

LC术中胆道镜检查的价值：附385例报告

目的　探讨运用腹腔镜联合胆道镜术中诊断治疗肝外胆管疾病的价值 ,以及其在减少腹腔镜胆囊切除 (LC)后胆管残留结石率中的作用。方法　LC术中对有胆总管探查指征者同时行胆道镜检查 ,操作中采用自制的胆道镜导入器和胆道探头。结果　近 4年来 ,笔者行LC手术 10 3 96例 ,其中术中行胆道镜检查 3 85例 ,占 3 .7% ;有阳性发现 10 2例 ,占 2 6.49% (占同期LC手术的 0 .98% )。其中发现胆道结石 67例 ,胆总管下端良性狭窄 2 6例 ,Mirizzi综合征 5例 ,壶腹部癌 2例 ,肝门部胆管癌 1例。结论　LC术中联合胆道镜检查成功率高 ,显像清晰 ,可观察到术前常规检查不易发现的胆道系统疾病 ;同时可进行定位及定性诊断 ,为选择合理的手术方式提供依据 ,并可有效地预防LC术后并发症的发生。     

Laparoscopic Cholecystectomy in Obese Patients

Background: Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. Obesity was initially considered a contraindication to this approach. The aim of this report is to review our experience with LC, to evaluate the role of BMI in the outcome. Methods: The records of 1,804 patients who underwent LC for symptomatic cholelithiasis from May 1992 to January 2004 were analyzed retrospectively. Patients were divided into 5 groups according to their BMI: ≤24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and ≥40 kg/m². Results: Of the 1,804 patients [1,379 females (76.4%) and 425 males (23.6%)] who underwent LC, 431(23.9%), 924 (51.2%), 355 (19.7%), 68 (3.8%) and 26 (1.4%) had BMI values of ≤24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and ≥40 kg/m², respectively. Conversion to open cholecystectomy was required in 94 patients (5.2%), and complications occurred in 39 patients (2.2%). There was no correlation between BMI and the conversion rate (P=0.593) and complication rate (P=0.944), while the hospital stay was similar between the groups with successful LC. The only significant difference was the longer operating time in the two obesity groups (P<0.001). Conclusions: LC is effective and safe in patients with morbid obesity. As it carried low risks of conversion and perioperative complications, we suggest that LC is the select approach for these patients. Moreover, the rapid mobilization and hospital discharge following LC may provide extra benefit to these patients.     

Transcutaneous Electrogastrography in the Perioperative Period in Patients Undergoing Laparoscopic Cholecystectomy and Laparoscopic Non-Adjustable Gastric Banding

Background: Transcutaneous electrogastrography (EGG) is a non-invasive method of examination that allows monitoring of gastric myoelectric activity. The goal of this prospective study was to describe changes in gastric motility in the early postoperative period in extremely obese patients, who underwent planned surgery - Laparoscopic Non-Adjustable Gastric Banding (LNGB) and to establish the specificity of observed differences for this intervention. Patients and Methods: Myoelectric gastric activity was evaluated in the perioperative period in 20 extremely obese patients undergoing LNGB. The results of monitoring up to +24 h after the intervention were compared to a group of 15 healthy volunteers, and to a group of 20 patients undergoing laparoscopic cholecystectomy (LC). The recording was performed in both the patient and control groups 24 h before the operation and +5 h, +24 h and +48 h after the surgery, both in the fasting state and after stimulation with a liquid bolus. The data were recorded using the Microdigitrapper device and analyzed using the spectral analysis and Fourier transformation. Results: The finding characteristic in the early postoperative period was a decrease in frequency of both spontaneous and stimulated gastric contractions (bradygastria) at +5 h after the intervention, that was followed by rapid return to baseline activity. In patients after LNGB, the normalization of motility was seen within 24 h, and in patients after LC within 48 h after the intervention. Tachygastria was not found in any patient who did not have complications, but on the contrary it was found in both patients with significant dyspepsia after LC. Conclusions: In the early postoperative period after LNGB, significant changes in myoelectric gastric activity were seen and were characterized by transient bradygastria. Comparison with the reference group of patients after LC shows that the intensity and duration of basal and stimulated bradygastria has a non-specific relationship with the extent of tissue trauma caused by the intraabdominal surgery. It is not specific for the gastric banding itself. The method of measuring the basal stimulated EGG potentials can be used in routine surgical practice as an auxiliary method for evaluation of the functional status of the gastrointestinal tract after intraabdominal surgery.     

腹腔粘连患者腹腔镜胆囊切除术闭合法建立气腹

目的 探讨腹腔粘连患者腹腔镜胆囊切除术（LC）闭合法建立气腹的方法。方法 回顾性分析1991年9月－1999年9月6600例LC中1046例腹腔粘连患者闭合法建立气腹的经过。建立气腹困难分为真性建立气腹困难及假性建立气腹困难2种。由于气腹针穿入腹腔脏器或腹腔广泛粘连导致气体弥散困难引起的建立气腹困难称真性建立气腹困难,需中转开腹手术;由于气腹针位置错误如位于腹膜外脂肪层、肝园韧带或大网膜内引起的建立气腹困难称假性建立气腹困难,调整气腹针位置,均能满意建立气腹。结果 1046例中1028例成功建立气腹。5例因真性建立气腹困难,13例因假性建立气腹困难而中转开腹。本组腹腔粘连患者闭合法建立气腹成功率为98．3％。结论 腹腔粘连患者闭合法建立气腹是安全可行的。缺乏自信、经验不足、误把假性建立气腹困难当作真性建立气腹困难是腹腔粘连患者闭合法建立气腹失败的主要原因。