EST+ERCP术后早期并发急性坏疽性胆囊炎的外科诊治

目的 探讨EST+ERCP术后并发急性坏疽性胆囊炎(AGC)的外科诊治.方法 回顾性分析2005年12月至2007年6月浙江省杭州市第一人民医院收治的1468例行EST+ERCP手术病人的资料.结果 16例病人术后并发AGC,发生率为1.09%,主要表现为术后1～3 d突发右上腹疼痛伴局限性腹膜炎和发热.血白细胞总数>15.0×109/L 15例(93.8%).B超呈高张胆囊、双边影征改变等,术前诊断准确率为81.3%.该组行胆囊切除术10例,胆囊切除+胆总管切开取石+T管引流术2例,胆囊大部切除术3例,胆囊造瘘术1例,术后病理报告均为急性坏疽性胆囊炎.结论 术后1～3 d潜伏期、局限性腹膜炎、血白细胞升高及胆囊B超是EST+ERCP术后并发AGC诊断的主要依据,应与乳头区穿孔、重症胰腺炎等仔细鉴别,诊断明确后宜尽早手术.

Diagnosis and surgical management of acute gangrenous cholecystitis early after endoscopic sphincterotomy and endoscopic retrograde cholangiopancreatography

Objective To discuss the diagnosis and surgical management of acute gangrenous cholecystitis (AGC) early after EST and ERCP. Methods Clinical and pathological data of 1468 cases receiving EST and ERCP in our hospital from 2005 to 2007 were retrospectively analyzed. Results AGC occurredin 16 cases and the incidence was 1.09%. Its main manifestations were pain in the right upper abdomen with local pertonitis and fever 1 to 3 d after operation, blood WBC exceeding 15.0× 109/L in 15 cases (93.8%), gallbladder tumefaction and double layer structure by B mode ultrasound, the diagnostic accuracy before operations was 81.3 %. We performed cholecystectomy in 10 cases, cholecystectomy and choledochotomy for common bile duct exploration and stone removal and T-tube drainage in 2, partial cholecystectomy in 3, cholecystostomy in 1. Pathological examination showedthat it was AGC in all the patients. Conclusion Latency in 1 to 3 d, local pertonitis, high blood WBC and B mode ultrasound are main managements in diagnosis of AGC and it should be diagnosed carefully distinguished from perforation and severe acute pencreatitis. It is suggested to undergoing early surgi-cal management once diagnosed definitely.