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。     

难取性胆道结石的微创治疗

目的:探讨胆道难取性结石微创治疗的方法、疗效和安全性。方法:回顾分析2005年12月至2010年11月采用腹腔镜、胆道镜、体内微爆破碎石仪联合治疗难取性胆道结石72例患者的临床资料,观察碎石成功率、结石取净率和并发症发生率。结果:碎石成功率100%,结石取净率97.2%,无胆道大出血、穿孔及胆漏等严重并发症发生。结论:腹腔镜、胆道镜、体内微爆破碎石仪可显著提高胆道难取性结石的治疗效果,安全可靠,为临床治疗胆道结石提供了更多选择。     

难取性胆道结石的微创治疗

目的：探讨胆道难取性结石微创治疗的方法、疗效和安全性。方法：回顾分析2005年12月至2010年11月采用腹腔镜、胆道镜、体内微爆破碎石仪联合治疗难取性胆道结石72例患者的临床资料,观察碎石成功率、结石取净率和并发症发生率。结果：碎石成功率100%,结石取净率97.2%,无胆道大出血、穿孔及胆漏等严重并发症发生。结论：腹腔镜、胆道镜、体内微爆破碎石仪可显著提高胆道难取性结石的治疗效果,安全可靠,为临床治疗胆道结石提供了更多选择。     

腹腔镜联合胆道镜治疗胆总管结石行胆管一期缝合的可行性研究

目的:探讨应用腹腔镜联合胆道镜胆总管切开取石并行一期缝合胆总管的方法治疗胆总管结石病的可行性。方法:采用前瞻性研究方法,将我院2013年6月~2016年6月收治的76例胆总管结石患者随机分成A、B两组,A组给予腹腔镜联合胆道镜胆总管切开取石后行胆管一期缝合;B组给予腹腔镜联合胆道镜胆总管切开取石后留置T管引流。比较分析两组术中、术后及并发症情况。结果:胆总管一期缝合组较留置T管组住院时间更短,住院费用更低,且术后出现的并发症几率更小。结论:腹腔镜联合胆道镜胆总管切开取石后一期缝合胆总管是治疗胆总管结石病的安全可行的方法,既为患者节省了费用又避免留置T管带来的并发症,在合适的适应症下可行此手术方法治疗胆总管结石病。     

塑料胆道支架引流术治疗复杂性胆总管结石的临床研究

目的:探讨内镜下逆行胰胆管造影术(ERCP)下塑料胆道支架引流术治疗复杂性胆总管结石的临床疗效和安全性。方法:回顾性分析2011年9月至2013年9月在我院经ERCP下胆道支架引流术治疗的32例复杂性胆总管结石患者的临床病例资料。结果:32例患者塑料胆道支架引流术全部成功,平均手术时间15-30分钟。术后,2例发生高淀粉酶血症,经禁食72小时后恢复正常,无穿孔、消化道大出血等ERCP严重并发症发生。术后1周,患者腹痛、发热消失,转氨酶及胆红素水平明显下降,平均住院时间6-15天。3个月复查B超,发现结石缩小19例,结石碎裂1例,支架脱落1例。术后7天、术后3个月的肝功能指标与术前比较均显著改善,差异均有统计学意义(P0.05)。结论:ERCP下塑料胆道支架引流术是一种复杂性胆总管结石安全有效的治疗方法,具有创伤小、风险较低、操作时间短、患者易耐受及手术成功率高等优点。     

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。     

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。     

胆道镜联合腹腔镜治疗胆总管结石的疗效及预后

目的:观察胆道镜联合腹腔镜治疗胆总管结石的临床疗效以及预后情况,探讨胆道镜联合腹腔镜在胆总管结石治疗中的意义。方法:选择我院收治的胆总管结石患者共106例,根据手术方案分为两组,其中实验组共53例,采取胆道镜联合腹腔镜手术治疗;对照组共53例,给予腹腔镜手术治疗,记录两组的手术相关情况、术后并发症以及住院情况,应用统计学软件对两组数据进行分析。结果:1实验组的手术时间短于对照组,术中出血少于对照组,术后胃肠功能恢复正常时间短于对照组,差异具有统计学意义(P0.05);2实验组住院时间与住院费用均少于对照组,差异具有统计学意义(P0.05);3实验组术后并发症发生率为18.87%,显著低于对照组(35.85%),差异具有统计学意义(P0.05)。结论:胆道镜联合腹腔镜能够安全有效的治疗胆总管结石。     

腹腔镜联合硬质胆道镜治疗复发性肝胆管结石的临床应用

目的:观察腹腔镜联合硬质胆道镜治疗复发性肝胆管结石的临床应用。方法:选取2013年1月-2014年1月期间在广州医科大学附属第一医院治疗的复发性肝胆管结石患者64例,随机分为研究组和对照组,研究组患者给予腹腔镜联合硬质胆道镜治疗,对照组患者采取开腹治疗。观察并比较两组患者的临床效果。结果:研究组患者手术出血量、手术时间、肛门排气时间、术后胆红素恢复时间、平均住院时间和抗生素应用时间均少于或短于对照组,差异均有统计学意义(均P0.05);研究组患者术后发生感染、胆漏、出血、结石残余与对照组比较差异均无统计学意义(均P0.05);研究组患者术后疼痛3例显著高于对照组的15例(P0.05)。结论:腹腔镜联合硬质胆道镜治疗复发性肝胆管结石对患者损伤小、手术过程中出血量少、结石取出率高、残留可能性小、结石复发率低、术后恢复快、并发症发生率低,其可行性和安全性高,适应范围广,值得推广应用。     

术中胆道镜诊治肝胆管结石的应用（附64例报告）

术中应用胆道镜治疗胆道疾病６４例,使残余结石发生率由１１％下降至２％左右,认为纤维胆道镜对明确诊断减少残余结石的发生有重要价值。     

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。     

SPECIALTY CONFERENCE: The Treatment of Retained Gallstones

Various techniques are available to evaluate patients suspected of having common duct stones before an operation on the biliary tract. In patients without jaundice, intravenous cholangiography with tomography may provide satisfactory visualization of the biliary system and its contents. Sonography and computerized axial tomography are useful noninvasive methods. Endoscopic retrograde and transhepatic cholangiography are invasive techniques; but, when successful, they provide the most precise preoperative information obtainable about the presence or absence of stones in the biliary system. The most appropriate diagnostic procedures must be carefully selected for each patient. Each year in 3,000 to 4,000 cases, stones are found remaining in the bile ducts after common duct exploration for the removal of stones. Retained stones can be treated by nonoperative extraction, by irrigation techniques and by surgical removal. Extraction methods probably deserve first consideration, if experienced personnel are available. The technique of irrigation of the common bile duct with cholic acid or other solutions, although limited in success, may also be tried; if these procedures fail, then reoperation is indicated.     

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.     

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.     

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。     

侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的临床应用价值

目的：探讨侧卧体位下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石的可行性及临床应用价值。方法：回顾性分析2009年8月至2011年9月我院采用侧卧体住下经皮肾穿刺取石术联合经尿道输尿管镜取石术治疗复杂上尿路结石患者52例的临床资料：患者同时存在肾脏铸型结石或多发结石和或输尿管上段结石,单个结石最大径8-30mm。结果：平均手术时间60分钟（50—120分钟）;术前血红蛋白116±30g／L,术后第一天复查105±26g／L,无大出血需要输血病例;一次结石取净率为86．5％（45／52）,总取净率为92．3％（48／52）。结论：侧卧体位下经皮肾穿刺取石术及经尿道输尿管镜取石术两种术式联合应用具有可行性及互补性,在预防及减少术中出血、获得清晰的手术视野、减少灌注液外渗、增加结石清除速度及碎石成功率、缩短手术时间、减少术后发热等方面疗效显著,为治疗复杂上尿路结石提供了一个可行的新方法。