目的探讨腹腔镜联合胆道镜治疗胆囊及胆总管结石的临床疗效。 方法回顾性分析2010年1月至2013年1月期间收治于笔者所在科室的96例胆囊及胆总管结石患者的临床资料，根据手术方式分为开腹组、腹腔镜联合胆道镜＋T管引流术组和腹腔镜联合胆道镜＋放置鼻胆管一期缝合组3组。对3组患者的手术时间、术中出血量、肛门排气时间、住院时间、残石率、复发率、并发症发生率、手术有效率及术后淀粉酶和肝功能指标水平进行对比分析。 结果微创手术组与开腹组比较，患者的出血量、肛门排气时间、住院时间、残石率、复发率及并发症发生率均减少、缩短或降低，同时手术的有效率提高（P＜0.05）；腹腔镜联合胆道镜＋放置鼻胆管一期缝合组术后淀粉酶和肝功能指标的水平较其他2组明显降低（P＜0.05）。 结论微创手术创伤小，残石率及复发率低，并发症少，患者术后恢复快，是一种安全有效的治疗方式，值得临床推广应用。
ObjectiveTo explore the clinical efficacy and surgical techniques of laparoscopic choledocholithotomy and primary suture. MethodsWe retrospectively analyzed the clinical data of 58 patients who underwent laparoscopic choledocholithotomy and primary suture between January 2009 and December 2014. ResultsAll the 58 patients underwent the surgery successfully. Operation time was 45-125 minutes, averaging 75 minutes. Intraoperative blood loss was between 10 and 50 mL with an average of 20 mL. Postoperative hospital stay was 5-14 days with an average of 7 days. Four cases of biliary leakage were cured by conservative treatment. ConclusionWith operation indications strictly grasped and skillful operation techniques, laparoscopic choledocholithotomy and primary suture are safe and reliable with a good curative effect.
目的探讨胆管残余和复发结石的原因、特点和处理经验。方法回顾性分析128例胆管残余和复发结石再手术临床资料。 结果残余或复发结石位于肝外胆管68例，肝内胆管48例，肝内、外胆管12例。再手术行残株胆囊切除术2例（1.5%）， 胆总管探查、T管引流术64例（50.0%），肝左外叶切除或肝左叶切除术+胆总管切开取石29例（22.7%），肝右叶、段切除加胆总管切开取石6例（4.7%），同时行狭窄胆管切开整形胆管空肠吻合术13例（10.2%），单独或联合行胆管空肠Roux-en-Y吻合术14例（10.9%）。术后痊愈出院124例，自动出院2例，死亡2例。 术后出现并发症18例（14.1%），其中切口感染 10例，胸腔积液3例，胆肠瘘3例，上消化道出血2例，均经保守治疗治愈。出院的124例中117例获随访1～2年，89例（76.1%）恢复满意，18例（15.4%）恢复较好， 10例（8.5%）经B超、CT、MRCP等检查证实再次复发胆管结石，其中6例经再次手术治愈，4例经中西医结合药物治疗好转。 结论术前全面了解病情，选择合适的手术时机，术中认真仔细的探查确认，并结合术中造影、胆道镜以及术者的经验技术，术后有效的治疗，是降低残石、结石复发及再手术的关键因素。
Objective To evaluate effectiveness and safety of electronic choledochoscopy in treatment of intrahepatic bile duct stones. Methods From July 2013 to February 2016, 280 patients with intrahepatic bile duct stones in the Department of General Surgery of the Affiliated Hospital of Shandong Academy of Medical Sciences were selected as the research objects. All the patients were randomly divided into a choledochoscopy treatment group and a conventional treatment group by envelope principle method. There were 140 patients in each group. The safety and short- and long-term effectiveness were compared in these two groups. This study was approved by the ethics committee of the hospital. Results ① The age, gender, body mass index, course of disease, and location of stone had no significant differences in these two groups (P>0.05). ② The operations and the net stones were successfully completed in all the patients. The operative time was shorter, the blood loss was less, the incision length was smaller, the postoperative anal exhaust time was earlier, and the hospitalization time was shorter in the choledochoscopy treatment group as compared with the conventional treatment group (P<0.05). ③ The total postoperative complication rate on day 14 in the choledochoscopy treatment group was 2.9% (4/140), which was significantly lower than that in the conventional treatment group (11.4%, 16/140, P<0.05). ④ The curative excellent and good rates was 97.9% and 85.0% in the choledochoscopy treatment group and conventional treatment group respectively, which was a significant difference in these two groups (P<0.05). ⑤ The postoperative serum ALT and AST values on month 6 in the choledochoscopy treatment group were significantly lower than those in the conventional treatment group (P<0.05). Conclusion Electronic choledochoscopy in treatment of intrahepatic bile duct stones could promote rehabilitation of patient, reduce incidence of postoperative complications, and it is conducive to promoting recovery of liver function and improving follow-up effect.
ObjectiveTo investigate the feasibility and safety of percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) in the treatment of recurrent type Ⅱa hepatolithiasis.MethodsAll of 293 patients with recurrent type Ⅱa hepatolithiasis admitted to the Second Affiliated Hospital of Chongqing Medical University from December 2010 to December 2017 were collected retrospectively, 82 of whom were treated with the PTCSL (PTCSL group), 211 of whom were treated with traditional open surgery (open group). The patients were matched according to the ratio of 1∶1 by using the method of propensity score matching, then the patients were compared after matching.ResultsA total of 59 pairs were successfully matched, that was, there were 59 patients in the PTCSL group and open group, respectively. Compared with the open group, the PTCSL group had the similar conditions such as the gender, age, preoperative Child-Pugh classification, and times of previous biliary operations, etc. (P>0.050). There was no perioperative death in both groups. There were no significant differences between the two groups in the success rate, operation time, times of operations, time of T tube removal after operation, stone residual rate, and stone recurrence rate (P>0.050). Although the hospital costs of the PTCSL group was higher than that of the open group (P<0.050), the PTCSL group had various advantages, such as less intraoperative bleeding, smaller incisional scar, shorter hospital stay and postoperative ventilation time, and lower rate of total postoperative complications (P<0.050).ConclusionsAfter learning curve, PTCSL has many advantages over traditional open surgery in treatment of recurrent type Ⅱa hepatolithiasis. PTCSL is a minimally invasive surgery, which is safe and effective.
目的 探讨金属银夹标记胆道通道，利用胆道镜技术治疗胆肠吻合术后肝胆管结石复发的可行性、安全性和有效性。方法 回顾性分析大连市友谊医院47例胆管结石行胆肠Roux-en-Y吻合术患者的资料，在空肠盲袢或输出袢处使用银夹作标志，术后通过胆道镜行胆管残留结石或复发结石或狭窄的治疗。结果 11例术后胆管残留结石和5例残留结石合并胆管狭窄者经T管窦道行胆道镜探查、取石及肝胆管狭窄的治疗而治愈。2例结石复发的患者根据空肠的金属银夹标记物，在数字减影血管造影（DSA）下进行穿刺置管建立胆道镜通道，通过胆道镜成功取出了结石，避免了再手术。结论 发挥胆道镜技术治疗肝胆管结石的优势，经以银夹标志的胆道通道，可望成为治疗胆肠吻合术后复发结石手段的有益补充。
目的 探讨腹腔镜下胆道镜联合微爆破碎石术仪治疗肝胆管结石的安全性及治疗效果。 方法 回顾分析2008年7月－2012年6月183例胆道结石患者，行腹腔镜下胆道镜联合微爆破碎石仪治疗或单纯经内镜Oddi括约肌切开取石治疗的临床资料。87例患者在术中均应用微爆破碎石仪碎石（微爆破组），96例患者行单纯经内镜Oddi括约肌切开术或经内镜乳头切开术碎石（对照组）。 结果 微爆破组碎石成功率100%，结石取净率85.06%（74/87），微爆破组的碎石时间、平均住院时间、平均住院总费用、并发症发生率均明显低于对照组（P＜0.05）。 结论 腹腔镜下胆道镜联合微爆破碎石术在治疗肝胆管结石病方面，具有微创、安全、经济有效的优点，能降低结石残留率及取石次数，值得临床推广。
Objective To explore the effect of gallbladder preserving surgery with laparoscope and choledochoscope.Methods The data of 60 cases of gallbladder preserving surgery with laparoscope and choledochoscope （observation group） and carried out with the same period 61 cases of small incision gallbladder preserving surgery （control group） between June 2008 to January 2013 were retrospective analyzed. Results All patients were followed up for （18±2.4）months （6-36 months）. The intraoperative blood loss， postoperative gallbladder hemorrhage rate， gallbladder dysfunctionrate， postoperative hospitalization time， stone recurrence rate， and reoperation rate in observation group were less orlower or shorter than the control group （P＜0.05）. The operative time and hospital costs in observation group were longeror higher than that of the control group （P＜0.05）. The rest of the observation index of two groups were no significant differences （P＞0.05）. Conclusions The gallbladder preserving surgery with laparoscope and choledochoscope is safeand feasible in technique level， and the short-term effect after operation is better. But the operation indications must be controlled strictly. The long-term efficacy needs further accumulation of cases and collect enough evidence to verify.
【摘要】目的 探讨经胆囊管行术中胆道镜胆道探查的临床应用价值。 方法 对1997年9月至2004年12月期间60例开腹胆囊切除术患者经胆囊管行术中胆道镜胆道探查术，8例腹腔镜下经胆囊管行胆道镜胆道探查术的资料进行回顾性分析。结果 所有患者结石清除率为100%，术后平均住院7.2 d。结论 在无禁忌证的前提下，无论是开腹还是腹腔镜手术，应首先考虑经胆囊管途径行胆道镜胆道探查取石术。