腹腔镜治疗胆囊结石合并胆总管结石的临床研究

目的:探讨腹腔镜手术治疗胆囊及胆总管结石的应用价值.方法:90例胆囊结石合并胆管结石患者按手术方式随机分为腹腔镜胆道探查术组(简称:腹腔镜组)和常规开腹胆道探查T管引流术组(简称:常规开腹组).观察两组手术切口大小、并发症、胃肠道功能恢复时间和平均住院时间等指标.结果:腹腔镜组术后并发症发生率为2.2%,显著低于常规开腹组(15.9%)(P<0.05);腹腔镜组手术切口显著小于常规开腹组(P<0.05);腹腔镜组术后胃肠道功能恢复时间和平均住院时间与对照组比较显著缩短,相比较有显著性差异(P<0.05).结论:应用腹腔镜治疗胆囊结石合并胆总管结石是一种安全、有效、可行的微创手术方式.     

手术治疗复杂性肝内胆管结石的临床分析

目的:探讨规则性肝段/肝叶切除术治疗复杂性肝内胆管结石的临床疗效。方法:2009年6月至2013年6月期间,我们共同诊治的60例复杂性肝内胆管结石患者,随机将其分为对照组(非规则性肝段/肝叶切除术)和观察组(规则性肝段/肝叶切除术),每组各30例,对两组术中出血量,以及结石清除率、并发症、复发率,进行观察和比较。结果:与对照组相比,观察组术中出血量明显减少,结石清除率明显提高,并发症发生率和复发率显著降低(P0.05),差异有统计学意义。结论:对于复杂性肝内胆管结石患者,规则性肝段/肝叶切除术治疗的疗效显著,明显提高患者的预后质量,值得临床推广。     

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.     

肝内外胆管多发结石肝部分切除术后肝功能衰竭的诊治

目的：探讨肝内外胆管多发结石术后肝功能衰竭的预防、诊断及治疗。方法：我院2011年1 月~2013 年12 月收治肝内外胆 管多发结石行手术治疗患者共126 例,术后发生肝功能衰竭者6 例,均是合并肝叶切除患者。及时准确诊断肝功能衰竭后予抗 炎、护肝、止血、输血、糖皮质激素、抑酸、人血白蛋白、利尿、降血氨、血浆置换及对症支持等治疗。结果：6 例患者出院前复查总胆 红素28.3~ 58.7 mmol/L,谷丙转氨酶16~ 62 U/L,谷草转氨酶12~ 85 U/L,血浆白蛋白32.1~ 37.8 g/L,凝血功能基本正常,腹水消 失,血氨正常,上消化道出血停止。术后12~ 35 d出院,平均18 d。6例患者术后长期随访,目前均存活。结论：肝功能衰竭是肝脏 及胆道术后最为严重的并发症之一,充分的术前准备及评估,术后的及时诊断及治疗,可明显降低其死亡率。     

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。     

胆管结石合并胆管癌的临床特征与诊治分析

目的：探讨胆管结石合并胆管癌的临床特征及诊治方法。方法：回顾性分析2000年1月-2009年12月我院收治的胆管结石合并胆管癌16例患者的临床病理资料。结果：胆管癌的发生率占同期胆管结石患者的3.1%,其临床表现以右上腹疼痛及反复的胆管炎发作为主,但缺乏特异性。术前胆管癌组患者AKP、γ-GT均有不同程度升高,ALT升高12例,总胆红素升高9例,与非胆管癌组相比,AKP、γ-GT、ALT、TBIL均显著升高（P〈0.01）,且胆管癌组术前血清CA19-9及CEA显著高于非胆管癌组（P〈0.01）,而两组间CA125及AFP水平比较无显著差异（P〉0.05）。16例患者中可进行手术治疗10例;其中根治性手术8例,姑息性手术2例。8例根治性手术患者的1、3年生存率分别为78.6%和36.4%;2例姑息性手术患者1、3年生存率分别为50.0%和0%,两组比较具有显著性差异（P〈0.05）。结论：胆管结石合并胆管癌的临床表现缺乏特异性,患者的疗效较差,对血清CA19-9和CEA显著升高者应行病理活检确诊,治疗手段应该力争实行根治性切除,有助于提高患者的生存期。     

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。     

磁共振胰胆管成像（MRCP）检查胆道系统结石的方法探讨

目的探讨磁共振胰胆管成像（MRCP）时不同扫描方法对胆道系统结石的发现率,以期确定合理的检查方法。材料和方法50例接受MRCP检查者,GE1．5T MRI扫描仪,分别采用常规薄层MRCP、厚层单次激发、薄层单次激发的MRCP,并同时行冠状面FIESTA扫描。分析不同方法对胆道系统结石的发现率。结果不同方法对胆道系统结石都有一定的漏诊。以薄层MRCP结合原始图像最少,而薄层单次激发MRCP结合冠状面FIESTA可以达到最佳的诊断效果。结论MRCP检查胆道系统结石时,采用单次激发MRCP结合冠状面FIESTA可以达到最佳的效果。     

Cost-Effectiveness Analysis of Endoscopic Ultrasound versus Magnetic Resonance Cholangiopancreatography in Patients with Suspected Common Bile Duct Stones

Background

Patients with suspected common bile duct (CBD) stones are often diagnosed using endoscopic retrograde cholangiopancreatography (ERCP), an invasive procedure with risk of significant complications. Using endoscopic ultrasound (EUS) or Magnetic Resonance CholangioPancreatography (MRCP) first to detect CBD stones can reduce the risk of unnecessary procedures, cut complications and may save costs.

Aim

This study sought to compare the cost-effectiveness of initial EUS or MRCP in patients with suspected CBD stones.

Methods

This study is a model based cost-utility analysis estimating mean costs and quality-adjusted life years (QALYs) per patient from the perspective of the UK National Health Service (NHS) over a 1 year time horizon. A decision tree model was constructed and populated with probabilities, outcomes and cost data from published sources, including one-way and probabilistic sensitivity analyses.

Results

Using MRCP to select patients for ERCP was less costly than using EUS to select patients or proceeding directly to ERCP ($1299 versus $1753 and $1781, respectively), with similar QALYs accruing to each option (0.998, 0.998 and 0.997 for EUS, MRCP and direct ERCP, respectively). Initial MRCP was the most cost-effective option with the highest monetary net benefit, and this result was not sensitive to model parameters. MRCP had a 61% probability of being cost-effective at $29,000, the maximum willingness to pay for a QALY commonly used in the UK.

Conclusion

From the perspective of the UK NHS, MRCP was the most cost-effective test in the diagnosis of CBD stones.     

腹腔镜胆道探查术胆管一期缝合与T管引流的疗效分析

目的：对腹腔镜弹道探查术胆管一期缝合与T管引流的疗效进行分析。方法：对90例患者进行观察随访,其中一期缝合组45人,T管引流组45人,术后对其手术时间、肛门排气时间、腹腔引流时间、术后平均输液量、术后住院时间、住院费用、术后恢复正常生活时间进行统计分析。结果：一期缝合组除手术时间和腹腔引流时间,其他的各项观察指标以及术后并发症均优于T管引流组。结论：腹腔镜胆道探查术胆管一期缝合的疗效比T管引流的疗效较好,术后并发症也少,但是对于不适合做一期缝合而适合T管引流的患者还是应给予T管引流术。