Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.

One hundred and twenty patients with known common bile duct stones were entered into a prospective randomised study of preoperative endoscopic sphincterotomy and stone clearance (group 1) versus surgery alone (group 2). Five patients were incorrectly entered; the 55 patients randomised to group 1 and the 60 randomised to group 2 were well matched with respect to clinical features and biochemical and medical risk factors. In group 1 endoscopic stone clearance was successful in 50 patients (91%); five of these patients refused elective surgery, though this was subsequently necessary in one. In group 2 common bile duct stones were cleared surgically in 54 of 59 patients (91.5%); one patient was treated by endoscopic sphincterotomy alone because of a myocardial infarct. The overall major complication rate in group 1 was 16.4% and included two deaths; in group 2 this was 8.5% and included one death. The minor complication rate in group 1 was 16.4% and that in group 2 13.6%. These differences in outcome were not significant. Despite a significant reduction in total hospital stay of patients in group 1, these results do not support the routine use of preoperative endoscopic sphincterotomy in patients having biliary surgery for stones in the common bile duct.     

Electrohydraulic lithotripsy with peroral choledochoscopy.

OBJECTIVE--To determine the efficacy of peroral electrohydraulic lithotripsy performed with an extra large duodenoscope (outside diameter 14.8 mm) and a choledochoscope with a diameter of 4.1 mm (Olympus "mother and baby" endoscope system) in the removal of very large stones from the common bile duct. DESIGN--Prospective study of patients with giant stones in the common bile duct that were resistant to extraction by conventional means. SETTING--Endoscopy unit at a university hospital. PATIENTS--Four women and one man aged 48-82 (mean 66.4 years) with a total of nine stones in their common bile ducts ranging from 2.2 to 3.6 cm in diameter. INTERVENTIONS--Peroral electrohydraulic lithotripsy was performed after intravenous sedation and under antibiotic cover. Two endoscopists took part in each procedure, coordination being achieved by means of a video monitor. The procedures were performed with a Lithotron EL-23 lithotripter and a 3 French lithotripsy probe inserted through the choledochoscope under direct vision. MAIN OUTCOME MEASURE--Complete clearance of the common bile duct confirmed by occlusion cholangiography. RESULTS--All nine stones (mean minimal diameter 2.6 cm; mean maximal diameter 3.1 cm) were successfully fragmented by electrohydraulic lithotripsy, allowing subsequent extraction with the aid of endoscopy and clearance of the common bile duct. A median of three (range two to five) sessions of endoscopic retrograde cholangiopancreatography were required to achieve complete clearance of the ducts. Patients stayed a median of eight days in hospital after lithotripsy (range eight to 14). There were no complications. CONCLUSION--Peroral electrohydraulic lithotripsy offers a safe and effective alternative for the management of patients with large stones in the common bile duct.     

内镜下乳头括约肌切开术联合不同时长气囊扩张术治疗胆总管结石的疗效观察

摘要 目的：探讨内镜下乳头括约肌小切开术( endoscopic sphincterotomy,EST)联合不同时长持续时间十二指肠乳头气囊扩张术（Endoscopic papillary balloon dilatation,,EPBD）对胆总管结石患者治疗效果差异。方法：选择2018年1月至2018年12月于我院接受EST联合EPBD治疗的92例胆总管结石患者为研究对象, 按照其术中气囊扩张时间的不同将其分为A组（46例,扩张时间20 s）、B组（46例,扩张时间40 s）,对比两组患者一次净石率、机械碎石率、操作时间及X线暴露时间,对比两组患者术前及术后肝功能指标,术后12 h血淀粉酶,对比两组患者术后胰腺炎、消化道出血、胆道感染、穿孔等并发症的发生率。结果：（1）对比显示两组患者一次净石率、机械碎石率、操作时间、X线暴露时间及12 h血淀粉酶对比差异不具有统计学意义（P>0.05）;（2）术前两组患者总胆红素(Total bilirubin,TBIL)、谷氨酸转氨酶(Glutamate aminotransferase,ALT)、碱性磷酸酶(alkaline phosphatase,ALP)对比差异不具有统计学意义（P>0.05）,术后两组患者上述指标均较治疗前出现明显的下降,但组间比较无差异（P>0.05）;（3）A组患者术后各类并发症发生率为4.35 %（2/46）,B组患者术后各类并发症发生率为17.39 %（8/46）,两组对比差异具有统计学意义（P<0.05）。结论：EST联合EPBD对胆总管结石具有较好的治疗效果,术中不同气囊扩张时间不会对手术成功率、手术时间等指标造成影响,但长时间扩张存在增加术后出血的风险,建议在能够正常实施手术的情况下尽量控制术中气囊扩张时间。     

腹腔镜联合十二指肠镜治疗胆结石合并胆总管结石的临床疗效

目的:探讨腹腔镜联合十二指肠镜治疗胆结石合并胆总管结石的临床疗效。方法:收集我院肝胆科2012年6月到2014年3月住院的胆结石合并胆总管结石60例,按照随机数字表法分为试验组和对照组,各30例,试验组给予腹腔镜联合十二指肠镜治疗,对照组给予传统的开腹胆囊切除以及胆总管探查取石,观察对比两组的临床疗效。结果:试验组手术时间、住院时间、术后恢复时间及术中出血量明显的短于或少于对照组,差异均具有统计学意义(均P0.05),试验组治愈率为96.7%明显的高于对照组的66.7%,差异有统计学意义(P0.05)。两组主要不良反应有:结石残留、感染、十二指肠穿孔、恶性呕吐及伤口疼痛等,试验组不良反应发生率为16.67%明显的低于对照组总的73.33%,差异有统计学意义(P0.05)。结论:腹腔镜联合十二指肠镜治疗胆结石合并胆总管结石较传统的开腹手术治疗的效果好、恢复时间短、手术创伤小,且具有一定的安全性,不良反应发生少,值得临床推广使用。     

INDICATIONS FOR AND RESULTS FOLLOWING EXPLORATION OF THE COMMON BILE DUCT FOR STONES

Among 100 consecutive patients who had removal or drainage of the gallbladder and exploration of the common bile duct for stones, there were no serious, immediate or late complications and there were no operative deaths. Ninety-six of the 100 patients had stones in the gallbladder, in the common duct, or in both, and 52 of these patients had one or more stones in the common duct.Ten patients died subsequently of unrelated causes. Six patients were lost to followup. Of the 84 patients whose present condition is known, 75 or 89 per cent have had a completely satisfactory result. Six more patients have minor residual symptoms, and for them the result has been classified as good. In three patients, the results were unsatisfactory. Cholangiograms taken before the removal of the T-tube showed residual stones in two patients. In each instance, the stone or stones have been subsequently passed and both patients are in excellent condition.     

肝外胆管结石微创治疗的研究进展

肝外胆管结石是肝胆外科临床常见病,严重威胁患者健康。目前该病治疗主要以手术治疗为主,以往的手术方式主要以剖腹胆总管切开取石为主,但创伤较大,恢复较慢,后遗症较多。随着微创技术的发展,腹腔镜、胆道镜及十二指肠镜等微创治疗技术以其创伤小、恢复快等优势越来越多的被肝外胆管结石患者采用。微创治疗肝外胆管结石的方法也日趋多样化,如经消化内镜治疗,经腹腔镜治疗,腹腔镜联合消化内镜治疗及腹腔镜、胆道镜、十二指肠镜三镜联合治疗等。本文就肝外胆管结石治疗中各种微创技术的研究进展做一综述。     

Indications for and results following exploration of the common bile duct for stones

Among 100 consecutive patients who had removal or drainage of the gallbladder and exploration of the common bile duct for stones, there were no serious, immediate or late complications and there were no operative deaths. Ninety-six of the 100 patients had stones in the gallbladder, in the common duct, or in both, and 52 of these patients had one or more stones in the common duct. Ten patients died subsequently of unrelated causes. Six patients were lost to followup. Of the 84 patients whose present condition is known, 75 or 89 per cent have had a completely satisfactory result. Six more patients have minor residual symptoms, and for them the result has been classified as good. In three patients, the results were unsatisfactory. Cholangiograms taken before the removal of the T-tube showed residual stones in two patients. In each instance, the stone or stones have been subsequently passed and both patients are in excellent condition.     

胆道系统探查中术中超声的应用及临床价值

目的:探讨胆管系统探查中术中超声(intraoperative ultrasound,IOUS)的应用及临床价值。方法:2007年3月至2014年8月应用术中超声对胆道系统进行探查的病例资料58例,对其术前影像学表现、手术过程、术中超声所见以及术中和术后诊断进行分析,研究术中超声对胆道探查的应用价值。结果:(1)58例应用术中超声病人中,肝内外胆管结石35例、肝门部胆管癌及胆总管癌11例,急性胆囊炎8例,胃癌1例,先天性胆总管囊肿1例,胆总管炎性狭窄1例,胰腺癌1例。术中超声确认取净结石或胆总管未见明显异常34例,定位肝内胆管残余结石6例,发现胆总管内尚有结石2例,术中超声确诊胆管癌2例;另发现胆总管先天性解剖异常2例;(2)在发现胆管结石方面,与术前MRCP无显著性差异(P=0.643);与术前CT、B超比较有显著差异(P0.05),诊断率分别为B超74.3%,MRCP 91.4%,CT 77.1%,IOUS 94.3%。结论:术中超声胆道系统的探查可以在广泛的疾病中得到应用,可以对术前影像学检查起到验证和补充的作用,且在术中引导各种介入操作中起到独特作用。     

腹腔镜下胆道镜经胆囊管行胆道探查取石术的临床分析

目的：探讨腹腔镜下胆道镜经胆囊管行胆道探查取石术（LTCBDE）的可行性以及安全性。方法：124 例胆囊合并胆总管结石 患者,根据手术方式分为LTCBDE 组和腹腔镜胆总管切开取石T管引流术（LCTD组）,各62 例,比较两组的手术情况、疗效及安 全性。结果：LTCBDE 的手术时间、术后引流时间、肛门排气时间、术后住院时间及补液量较LCTD 组显著减少（P<0.05）;LTCBDE 组并发症发生率及复发率分别为3.23%、1.61%,显著低于LCTD 组的20.97%、11.29%（P<0.05）。结论：LTCBDE 创伤小、患者痛 苦少、术后恢复快、并发症少且复发率低,是治疗胆囊结石合并胆总管结石的一种安全可行的微创治疗手段,值得在临床中推广 应用。     

Migration of gall stones.

The factors influencing the migration of gall stones are ill understood. Altogether 331 patients undergoing cholecystectomy were studied prospectively. The diameters of the cystic and common bile ducts and of stones in the gall bladder and bile ducts were measured. Increasing pressure was applied to the freshly excised gall bladder in an attempt to evacuate stones through the cystic duct. Stones passed in 33 (60.0%) of patients with choledocholithiasis, 45 (67.2%) of patients with pancreatitis, and 7 (3.2%) of patients without either pancreatitis or choledocholithiasis. Stones migrated in 6 (3.0%) who had a normal cystic duct diameter (less than or equal to 4 mm) and in 46 (32.5%) with a duct over 4 mm diameter. Common bile duct stones were often larger than the diameter of the cystic duct and when reintroduced into the gall bladder would not migrate. The passage of debris (less than or equal to 1 mm) through the cystic duct bore no relation to the presence or absence of choledocholithiasis or a dilated cystic duct. Small stones (1-4 mm diameter) must migrate to initiate and facilitate further migration; some must increase in size in the common bile duct. Increased biliary pressure consequently dilates the duct system retrogradely, allowing larger stones to follow. Patients at risk of stone migration and thereby pancreatitis and jaundice have large ducts that can be detected by ultrasound assessment.     

Comparative Evaluation of Two Laparoscopic Procedures for Treating Common Bile Duct Stones

Cholesystolithiasis is often associated with common bile duct stones (CBDS). In order to assess the choice of surgery in terms of effectiveness and complications in the treatment of CBDS, we have compared three surgical procedures, viz., laparoscopic choledocholithotomy T-tube drainage (LCH-TD), laparoscopic cholecystectomy with endoscopic sphincterotomy (LC-EST), and the traditional open choledocholithotomy with T-tube drainage (OCHTD). This study is a retrospective comparative analysis of LCH-TD (77 patients), LC-EST (43 patients), and OCHTD (60 patients) for CBDS. The success of the surgical procedures was assessed in terms of recovery duration, hospitalization, and post-operative complications. Both the micro-invasive procedures, LCH-TD and LC-EST, with a success rate of 92.5%, are found to be superior to the traditional OCHTD. Between the two micro-invasive procedures, patients in LCH-TD group had shorter operation time and hospital stay, and fewer post-operative complications. Although the size of the stones is comparable between these two groups, the CBD diameter was significantly larger in patients who underwent LCH-TD. In comparison to OCHTD, both LCH-TD and LC-EST are micro-invasive, safe, and suitable for routine use in patients with CBDS. Moreover, when the CBD diameter is wider than 1 cm, LCH-TD is strongly advocated.     

ERCP/EST-LC治疗胆囊结石合并胆总管结石临床疗效及并发症

目的:考察内镜下逆行胰胆管造影术/十二指肠乳头括约肌切开术加腹腔镜胆囊切除术(endoscopic retrograde pancreatic angiography/endoscopic sphincterotomy-1 aparoscopic cholecystectomy,ERCP/EST-LC)对胆囊结石合并胆...     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的:探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法:在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果:158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论:在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的：探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法：在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果：158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论：在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

The Prevention of Residual Biliary Calculi

Residual calculi following cholecystectomy may be expected in approximately seven percent of cases. The vast majority of these are overlooked during operation; truly re-formed stones are rare.Calculi are missed during cholecystectomy because of failure to explore the common bile duct. This is due to (1) the presence of silent choledochal stones, and (2) reliance on negative cystic duct cholangiograms in the presence of indications for common duct exploration.Overlooking of silent stones during cholecystectomy may be prevented by routine operative cholangiography. Ideally, false-negative cystic duct cholangiograms should be eliminated by the use of fluoroscopic cholangiography.Retained calculi following duct exploration may be prevented by (a) routine biliary endoscopy and (b) completion fluoroscopic cholangiography.Re-formation of ductal calculi can probably be prevented by appropriate biliary drainage procedures performed during the initial choledochotomy. Selection of patients for primary biliary decompression remains an experimental problem.     

小切开EST联合EPBD与单纯EST对85岁以上老年胆总管结石患者疗效的比较

目的:对比内镜下十二指肠乳头括约肌(expressed sequence tags,EST)小切开术联合内镜下十二指肠乳头括约肌扩张术(endoscopic papillary balloon dilation,EPBD)与单纯EST对85岁以上老年胆总管结石患者的疗效。方法:选择我院于2014年1月～2020年2月收治的85岁以上老年胆总管结石患者150例,根据入院顺序随机分成两组,每组各75例,给予对照组单纯小切开EST术治疗,给予研究组小切开EST+EPBD术治疗。对比两组的一次取石成功率、机械碎石、结石复发率等指标;术中操作时间、术中出血量、住院天数、术后排便天数等临床指标;术后胆道感染、急性胰腺炎、高淀粉酶血症、术后腹痛等并发症的总发生率。结果:研究组一次取石成功率显著高于对照组,机械碎石、结石复发率均显著低于对照组(P0.05);研究组的术中操作时间、术中出血量、住院天数、术后排便天数均显著低于对照组(P0.05);研究组术后胆道感染、急性胰腺炎、高淀粉酶血症、术后腹痛、术后迟发性出血等并发症的总发生率为9.33%(7/75),显著低于对照组37.33%(28/75),差异具有统计学意义(P0.05)。结论:小切开EST联合EPBD对85岁以上老年胆总管结石患者的疗效显著,该方法可有改善患者临床指标,降低术后并发症发生率,值得推荐至临床广泛应用。     

不同术式的经内镜下行乳头括约肌切开术（EST）对肠胆反流的影响

目的：目前认为,十二指肠胆道反流是引起胆道反复感染,进而导致胆道结石再发和胆道狭窄的原因之一。近年来应用以内镜下逆行胆胰管造影术（endoscopicretrogradecholangiopancreatography,ERCP）为基础的微创治疗胆总管结束的技术开展颇为广泛。它主要包括ERCP、Oddi括约肌切开术（endoscopicsphincterotomy,EST）、十二指肠乳头球囊扩张术（endoscopicpapillarybal—Iondilation,EPBD）、胆管结石碎石取石术、胆总管支架植入术和鼻胆管引流术六大技术。本文主要研究了采用不同术式的EST,即EST中切口和EST小切口＋EPBD术,在术后早期对患者十二指肠胆道反流的影响。方法：63例胆总管结石患者,男30例,女33例,予行经内镜下逆行的胆胰管造影（ERCP）后分别采用不同术式EST,术后安放胆总管引流管。术后l周留取胆汁采用口服核素和测定胆汁中的胃蛋白酶I、II的浓度,对十二指肠胆道反流进行定量和定性的测定。结果：EST中切口术组、EST小切口＋球囊扩张（EPBD）组分别与无EST组相比,年龄和性别无统计学意义（P=0．07,P=0．416）。行EST中切开和小切开＋球囊扩张患者胆汁中的锝计数明显高于无EST组,且这两组不同术式的患者锝计数存在显著的统计学差异（P〈0．05）。行EST中切口者、EST小切口＋球囊扩张术者胆汁中的PGII质量浓度明显低于无EST组（P〈0．05）,但是EST中切口者和EST小切口＋球囊扩张术后两组间胆汁中PGII的质量浓度无统计学差异。结论：行EST中切口取胆总管结石的患者在手术早期较易发生十二指肠胆道的反流。因此,建议对于胆总管结石患者尽量选择行EST小切口＋球裳扩张术（EPBD）的手术方式。     

CHOLEDOCHOLITHIASIS-Correlation of Preoperative with Operative and Postoperative Data to Enhance Diagnostic Insight

One hundred cases of common bile duct explorations were reviewed in an attempt to obtain information that might give insight into the diagnosis and definitive treatment of choledocholithiasis. Fifty of the hundred patients had common duct stones. Correlations were made between the incidence of choledocholithiasis as proved at operation, and the following factors: Kind and number of choledochal exploratory criteria used, the clinical diagnosis of common duct stones, and the pathologic features of gallbladders removed. The incidence of stones was statistically related to aging. The most frequent choledochal exploratory criteria were common duct dilatation or thickening (63 cases) and history of jaundice (50 cases). The most reliable single criterion in "diagnosing" common duct stones was palpable common or hepatic duct stones, the diagnosis having been correct in 15 of 17 such cases. The most reliable combination of criteria was a history of jaundice, plus palpable stones, with correct diagnosis in all such cases. The clinical diagnosis of choledocholithiasis was correct in only 17 per cent of cases. The correlation of the incidence of common duct stones with the degree of gallbladder disease-that is, acute or chronic-did not provide information that might be helpful in diagnosing choledocholithiasis. The incidence of proven retained common duct stones was 3 per cent, the non-fatal postoperative complication rate was 21 per cent and operative mortality was 1 per cent.     

CHOLEDOCHOLITHIASIS—Correlation of Preoperative with Operative and Postoperative Data to Enhance Diagnostic Insight

One hundred cases of common bile duct explorations were reviewed in an attempt to obtain information that might give insight into the diagnosis and definitive treatment of choledocholithiasis. Fifty of the hundred patients had common duct stones. Correlations were made between the incidence of choledocholithiasis as proved at operation, and the following factors: Kind and number of choledochal exploratory criteria used, the clinical diagnosis of common duct stones, and the pathologic features of gallbladders removed.The incidence of stones was statistically related to aging.The most frequent choledochal exploratory criteria were common duct dilatation or thickening (63 cases) and history of jaundice (50 cases).The most reliable single criterion in “diagnosing” common duct stones was palpable common or hepatic duct stones, the diagnosis having been correct in 15 of 17 such cases.The most reliable combination of criteria was a history of jaundice, plus palpable stones, with correct diagnosis in all such cases.The clinical diagnosis of choledocholithiasis was correct in only 17 per cent of cases.The correlation of the incidence of common duct stones with the degree of gallbladder disease—that is, acute or chronic—did not provide information that might be helpful in diagnosing choledocholithiasis.The incidence of proven retained common duct stones was 3 per cent, the non-fatal postoperative complication rate was 21 per cent and operative mortality was 1 per cent.     

钬激光在胆总管下段嵌顿结石术中的应用

目的探讨钬激光在胆总管下段嵌顿性结石手术中的应用价值。方法通过腹腔镜下胆道镜工作通道,应用钬激光,功率为0．6—0．8J／10Hz,直径为200um光导纤维,在直视下接触结石,将嵌顿结石击碎后注水冲出,或用取石篮套出。结果11例均取石碎石成功,手术时间75—205min,平均95．5min,出血80—130ml,平均89．4ml。平均住院8．2d。术后无胆道出血,胆漏。术后2W照影无结石残留,胆总管下段通畅无胆道狭窄。术后肝功能2W恢复正常6例,5例1月均恢复正常。随访3—6月未见结石复发。结论钬激光治疗胆总管下段嵌顿结石,具有创伤小、恢复快、碎石确切、操作容易、安全有效等优点,为治疗复杂性胆总管结石开辟了一条新的治疗途径。