胆囊结石合并胆总管结石的可行性探索（含视频）

探讨内镜经胃保胆取石术（endoscopic trans-gastric cholecystolithotomy, ETGC）联合经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography, ERCP)治疗胆囊结石合并胆总管结石的可行性及安全性。回顾性分析2018年11月—2019年4月于复旦大学附属中山医院行ERCP胆总管取石术后行ETGC的病例资料。本研究共纳入6例胆囊结石合并胆总管结石患者。其中男4例、女2例。患者行ERCP取石至内镜ETGC的时间间隔1~77 d（中位天数5 d）。6 例患者均成功完成ERCP胆总管取石后保胆取石术。患者均为多发胆囊结石,合并胆囊息肉患者1例。ETGC手术时间22~100 min（中位时间65 min）,住院天数3~9 d（中位天数6.5 d）。２例患者术后出现上腹部隐痛,体温升高,其中1例超声提示右上腹局部积液可能;2例患者均经保守治疗后好转。术后随访患者均未再发胆囊炎、胆管炎相关症状,随访率100%,中位随访时间18个月。6位患者术后均接受了超声复查,其中5例无复发,其中1例术后9个月超声显示胆囊壁胆固醇结晶,胆泥淤积。ERCP取石联合内镜经胃保胆取石术治疗胆囊结石合并胆总管结石是安全可行的。     

经皮胆镜碎石术治疗胆石症552例

目的:研究经皮胆镜碎石术(PCLC)治疗胆囊结石的疗效。方法:1990年11月—1993年5月作者采用PCLC治疗胆囊结石症552例。采用X光片胆囊目测定位法寻找胆囊,切开皮肤将胆囊牵至切口处后即行经皮胆镜碎石取石治疗胆囊结石。结果:对552例胆囊结石患者行经皮胆镜碎石术成功538例,碎石成功率97.5％,14例改行胆囊切除术。有3例发生胆汁性腹膜炎,3例出现急性胆囊感染,其中1例行胆囊切除术证实有结石残留。对184例患者作18—30个月的随访,结石残留7例,占3.8％,结石复发14例,占7.6％。结论:经皮胆镜碎石术是治疗结石的有效方法,创伤小,能保留胆囊,但应注意提高结石清除率,并预防结石复发。     

乳头切开术治疗胆总管结石远期并发症及其与胆囊结石关系的研究

目的 探讨内镜下十二指肠乳头括约肌切开术（EST）治疗胆总管结石患者的远期治疗效果,评估EST术后胆囊切除的必要性.方法 对2006年1月至12月因胆总管结石而行EST治疗257例患者进行随访,所有患者平均随访时间为34.8个月（26～48个月）.根据不同病情和处理情况分为3组进行比较,合并有胆囊结石的患者EST术后行胆囊切除为A1组,EST术后未行胆囊切除为A2组;B组为未合并胆囊结石者.结果 出现远期并发症者31例（12.1%）,胆总管结石复发25例（9.7%）,胆管炎27例（10.1%）,胰腺炎2例（0.8%）,胆管癌1例（0.4%）;A2组患者远期并发症发生率、胆总管结石复发率均高于A1组（P均〈0.05）.结论 从远期疗效来看,EST是治疗胆总管结石的安全、有效的方法,对于合并有胆囊结石的患者EST术后行胆囊切除是有必要的.     

内镜保胆取石术后结石复发的相关因素分析

目的分析内镜保胆取石术后结石复发的相关危险因素。方法对68例胆囊结石患者行内镜保胆取石术,分析术后23例结石复发患者的临床资料,先用χ2检验进行单因素分析,再行COX多因素回归分析。结果单因素分析结果显示,胆囊功能、胆囊壁厚度、家族史、血甘油三酯水平、术后是否服用熊脱氧胆酸与内镜保胆取石术后结石复发有关(P均<0.05)。多因素分析显示,胆囊功能和胆囊壁厚度与微创内镜保胆取石术后结石复发有关(P均<0.05)。结论胆囊功能减低和胆囊壁厚度≥0.4 cm是内镜保胆取石术后结石复发的危险因素。     

LC联合术中ERCP一期治疗胆囊结石合并胆总管结石的临床分析

目的探讨腹腔镜胆囊切除术（LC）联合术中内镜下逆行胆胰管造影（ERCP）及乳头切开（EST）取石一期治疗胆囊结石合并肝外胆管结石的可行性和安全性。方法回顾分析应用LC联合术中ERCP一期治疗胆囊结石合并肝外胆管结石36例的临床资料,分析原发病、手术方式、术后康复、住院时间及并发症。结果术前明确胆总管结石31例中10例先行术中ERCP取石,取石成功后再行LC;余21例和5例术前怀疑胆总管结石、术中经胆囊管胆道造影（TCC）证实胆总管结石者先行LC,继而行ERCP取石。LC手术均获成功,ERCP取石成功率为97.22%。术后5例出现一过性血淀粉酶升高,无明显出血、胆漏等并发症,术后住院平均为4 d。结论 LC联合术中ERCP一期治疗胆囊结石合并肝外胆管结石安全、有效,可避免不必要的ERCP及因术后ERCP失败而致患者再次手术。     

微创保胆取石术联合牛磺熊去氧胆酸预防胆囊结石复发效果观察

目的：观察牛磺熊去氧胆酸（TUDCA）降低微创保胆取石术后胆囊结石复发的临床效果。方法42例胆囊结石患者被随机分为单纯保胆手术组21例和联合治疗组21例,联合治疗组在微创保胆取石术后口服 TUDCA,每个月连续服用5天后,停止口服25天,为期1年。比较两组患者胆囊结石复发率、胆囊壁厚度及胆囊收缩功能的变化。结果在术后2年,单纯手术组患者胆囊结石症状复发率为33.3%（7/21）,显著高于联合治疗组患者的4.8%（1/21）。单纯手术组5例（23.8%）胆囊结石复发,而加服药物组无复发（x2=5.6757,P〈0.05）;单纯手术组患者术前和术后胆囊壁厚度分别为（3.95±0.56） mm 和（3.74±0.68）mm,胆囊收缩功能分别为（38.24±4.33）%和（37.89±6.42）%,而加服药物组患者胆囊壁厚度分别为（2.88±0.67） mm 和（2.43±0.71） mm,胆囊收缩功能分别为（48.78±6.45）%和（59.46±3.64）%,其改善程度均显著优于单纯手术组（P〈0.05）。结论微创保胆取石术后联用 TUDCA 口服能有效降低胆囊结石的复发,改善胆囊收缩功能。     

ERCP在胆道外科治疗中的应用

目的探讨ERCP在胆道外科治疗中的应用价值。方法回顾性分析近3年（2003年1月至2006年1月间）胆道术后残余结石及再生结石行乳头括约肌切开取石122例,腹腔镜胆囊切除术（LC）术后胆瘘行鼻胆管引流（ENBD）13例,原位肝移植术后胆管狭窄行胆管球囊扩张,放置胆管内支架或鼻胆管引流6例。结果122例胆道术后残余结石及再生结石患者经十二指肠镜胆道造影（ERC）成功率95.9%,取石成功率91.5%,其中有5例经2次操作取尽结石。13例胆瘘患者经鼻胆管引流2～3周后,胆瘘处均闭合,无严重并发症发生。6例胆管狭窄患者经ERC胆道介入（球囊扩张、ENBD或内支架）均治愈。结论ERCP在胆道外科治疗中具有重要应用价值,是术后残余结石或再生结石、术后胆瘘及术后胆管狭窄的有效介入方法。     

经胃入路自然腔道内镜保胆手术3例

经自然腔道内镜手术(natural orifice transluminal endoscopic surgery,NOTES)具有无疤痕、微创等优势,近年来得到了临床应用及发展.本文中对胆囊单发、多发结石及合并胆囊息肉3例患者实施经胃入路NOTES保胆手术均取得了成功,且无不良反应发生.经胃入路保胆手术为胆囊结石及胆囊息肉患者提供了一个新的治疗术式和方法,值得进一步研究及探讨.     

腹腔镜胆囊切除术与小切口胆总管探查术的联合应用

目的探讨腹腔镜胆囊切除联合小切口胆总管探查治疗胆囊结石合并胆总管多发结石。方法本组23例胆囊结石合并胆总管多发结石,均来自2007年12月至2012年7月我院收治患者,采用腹腔镜下切除胆囊并解剖显露胆总管前壁,镜下确定腹壁切口位置,做3～5 cm切口入腹,经小切口切开胆总管,取石钳取石后根据情况用纤维胆道镜/硬性输尿管镜行胆道探查取石。结果本组无1例中转扩大切口手术,手术时间90～160 min,平均（120±10）min;住院时间10～20 d,平均13 d;21例拔除＂T＂管痊愈出院;2例术后＂T＂管造影B超检查右肝管残留结石,带管出院,术后6周经胆道镜取石痊愈;2例肺部感染,伤口均甲级愈合。结论该术式治疗胆囊结石合并胆总管多发结石创伤小,较单纯小切口安全,比全腹腔镜术式节省时间,取石彻底,适合基层医院。     

气囊鼻胆管在治疗细径胆总管结石中的临床应用59例

目的:探讨腹腔镜、十二指肠镜、气囊鼻胆管探查术(laparoscopic duodenoscopic balloon nasobiliary exploration,LDBNE)同期治疗胆囊结石合并细径胆总管结石的应用体会.方法:回顾性分析2010-04/2015-07成都市第二人民医院运用LDBNE的手术方式,对59例胆囊结石合并细径胆总管(胆总管内径约2-8mm)结石的患者进行治疗的临床材料.结果:LDBNE治疗59例,成功切除胆囊59例;乳头切开取净结石42例(成功率71.2%),联合气囊鼻胆管下取净结石11例(成功率18.6%),中转为经胆囊管汇合部切口和胆总管前壁切口胆管镜下取净结石5例(中转率8.5%);术后胆管残留结石1例(1.7%),排石治愈.术后胆漏1例(1.7%),经术中放置的鼻胆管引流和腹腔引流自愈.术后轻症胰腺炎3例(5.1%),经保守治愈.术后总并发症发生率为8.5%(5/59).术后其他并发症均经非手术综合疗法治愈.无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症,无死亡.结论:只要病例选择合适,LDBNE治疗胆囊结石合并细径胆总管结石是可行、有效和安全的.     

腹腔镜保胆取石术和息肉切除术临床分析53例

目的:探讨腹腔镜下保胆取石和取息肉的手术适应证、方法和疗效.方法:2009-01/2011-09我们完成了53例腹腔镜下保胆取石和取息肉术.单纯胆囊结石患者39例,其中12例为单发结石,27例为多发胆囊结石;胆囊息肉患者8例,其中3例为腺瘤性息肉,5例为胆固醇性息肉;胆囊结石合并息肉患者6例,均为胆固醇性息肉;胆囊结石合并肝硬化2例,合并肝癌1例;胆囊结石伴急性胆囊炎3例.39例结石患者中37例行胆囊底部切开取石,2例行胆囊颈部切开取石成形术;8例胆囊息肉患者中5例胆固醇性息肉行胆囊底部切开取息肉术,3例腺瘤性息肉患者行息肉周围胆囊部分切除术;6例胆囊结石合并息肉的患者均行胆囊底部切开取石(息肉)术,其息肉均为胆固醇性息肉.胆囊切口采用4-0prolene缝线连续缝合10例,采用3-0可吸收线间断缝合或连续缝合43例.术中使用胆道镜33例,20例未用胆道镜,用腹腔镜代替胆道镜查看胆囊内结石或息肉是否取净.术后放置腹腔引流管19例,其余均未放置腹腔引流管.胆囊结石(包括合并胆囊息肉)患者术后服用利胆药物者33例,服药时间为1wk-1mo不等,另12例未服利胆药物.结果:53例保胆患者手术均获成功,没有1例中转剖腹手术.手术时间80-200min,平均109min±33min.1例颈部切开取石患者术后出现上腹疼痛,腹腔引流管每日引出约15mL淡黄色腹水,超声检查显示小网膜腔少量积液,考虑少量胆漏所致,术后5d腹痛缓解,腹腔引流管无液体引出,拔除腹腔引流管后无不适.其余患者术后均恢复顺利,术后住院2-10d,平均3.8d±2.2d,均治愈出院.所有患者均获随访,随访时间3-36mo,1例患者术后12mo胆囊泥沙样结石复发,给予利胆排石药物治疗1mo后复查腹部超声显示胆囊结石消失.结论:腹腔镜下保胆取石和取息肉术保留了胆囊及胆囊功能,有利于维护患者消化系统的正常功能.只要胆囊大小基本正常、胆囊壁增厚不明显、胆囊功能基本正常,排除了胆囊恶性病变,并且患者及家属保胆愿望强烈,均可进行腹腔镜保胆取石(息肉)术.     

Multifactorial analysis of recurrence of cholecy_stolithiasis in Shanghai area

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经皮经肝胆囊镜治疗胆囊结石价值的探讨

目的：探讨经皮经肝胆囊镜（PTCCS）治疗胆囊结石的价值。方法：1999年9月至2001年11月选择有胆囊结石临床症状但有全身疾病不能耐受手术或不适宜腹腔镜胆囊切除及不愿接受胆囊切除的患者86例，行经肝胆囊镜(PTCCS)治疗，先行经皮经肝胆囊引流术(PTGBD)，l周后用探条扩张此通路至16—22 F，采用PTCCS取石或液电碎石(EHL)。结果：86例中82例(95．3％)PTGBD成功，80例(93．0％)行PTCCS治疗。结石单发28例，多发52例，结石大小5—32 mm，大于15 mm的结石45例。26例网篮取石，54例EHL，结石清除率97．5％(78／80)，残石率2．5％(2／80)。4例合并腹膜炎和2例引流管脱出未同意再次PTGBD者转外科手术。平均随访16．4个月，2例(2．5％)结石复发。30例结石做红外线光谱定量分析，24例(80％)为胆固醇结石。结论：PTCCS治疗胆囊结石对不能耐受手术或不适合腹腔镜胆囊切除以及不接受胆囊摘除者是一种较安全、有效的方法。正确选择适应证可减少并发症，降低结石复发率。     

A ten-year prospective study on gallbladder stone recurrence after successful extracorporeal shock-wave lithotripsy

OBJECTIVE: The risk of recurrence has limited the acceptability of conservative therapies of gallbladder stones. The aim of the present study was to determine the long-term rate of stone recurrence and its risk factors after successful extracorporeal shock-wave lithotripsy (ESWL). MATERIAL AND METHODS: The study comprised a prospective ultrasound follow-up at yearly intervals or whenever biliary pain was reported. A total of 192 consecutive patients (primary single stones, n=159; primary 2 or 3 stones, n=33) were followed for up to 11.2 years after becoming stone-free and after termination of adjuvant treatment with ursodeoxycholic acid (UDCA). RESULTS: Eighty-four patients developed recurrent stones after a median of 2.6 years (maximum?=?8.8 years). The 108 patients without recurrence were followed for a median of 6.7 years (maximum=11.2 years). By actuarial analysis, the cumulative recurrence rates for these 192 stone-free patients were 27%+/-3%, 41%+/-4% and 54%+/-4% (observed +/-SE) at 3, 5 and 10 years, respectively. Cox's regression analysis was used to identify the presence of slight calcification in the primary stone(s) as a protective feature against recurrence (p=0.03). CONCLUSIONS: 1) The risk of recurrence continues to increase over time, and although it rises less steeply after 5 years, it does not reach a plateau until at least 10 years. 2) Having had slightly calcified stone(s) seems to be associated with a reduced risk of recurrence and might signal a "burnt out" lithogenic process. 3) The long-term results are unsatisfactory and ESWL of gallbladder stones should be offered only in special cases.     

Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones

BACKGROUND: A critical review of the experience with extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is needed to clarify whether this method should continue to be applied to patients. METHODS: Patients with symptomatic gallbladder stones were treated by piezoelectric ESWL according to a prospective protocol between 1988 and 1997. ESWL treatment was limited to a maximum of three (solitary stones <20 mm diameter) to five sessions (larger solitary or multiple stones) and 3000 pulses per session. Univariate and multivariate analyses of pretreatment and treatment variables were performed to investigate their impact on fragmentation efficacy and stone clearance. A tree-based analysis was used to identify prognostically homogenous subgroups of individuals with maximum benefit from ESWL. RESULTS: Four hundred and eight patients, 76% female and 24% male, with a mean age of 46 (SD, 13) years, were selected for evaluation. Cox regression analysis identified three pretreatment variables with significant prognostic impact: (1) number of gallstones >1 (relative risk, 2.6 (95% CI, 1.9-3.5)), (2) size of stones >17 mm (1.7 (1.4-2.2)), and (3) computed tomography (CT) density of stones >55 Hounsfield units (H) (1.4 (1.1-1.8)). According to tree-based analysis, the stone clearance rate after 1 year was 85% (95% CI, 75-91%) for solitary stones <16 mm, 79% (70-86%) for solitary stones > or =16 mm with a CT density <84 H, 45% (32-55%) for solitary stones > or =16 mm with a CT density > or =84 H, and 42% (30-51%) for multiple stones. Five years after stone clearance, recurrence occurred in 43% of patients (95% CI, 39-47%). CONCLUSIONS: ESWL treatment showed an acceptable stone clearance in the case of small solitary gallbladder stones (<16 mm) or larger solitary stones with a CT density <84 H, but a very low success rate in the case of multiple stones. The poor long-term success, however, is an important argument against the use of ESWL of gallbladder stones.     

Endoscopic and ultrasonographic evaluation before and after Roux-en-Y gastric bypass for morbid obesity

BACKGROUND: Esophagogastric abnormalities are recognized prior and after bariatric procedures, but frequency and severity are debated. Liver and biliary tract findings are also of clinical importance, especially gallstones and liver steatosis. AIM: To compare pre-operative findings of hepatobiliary ultrasound and upper digestive endoscopy with post-operative results in patients submitted to open Roux-en-Y gastric bypass for morbid obesity. METHODS: A total of 80 patients were enrolled 16.8 +/- 12.1 months after operation, all of them on routine follow-up program, and 8 were excluded. Retrospective analysis aimed at pre-operative clinical, endoscopic and ultrasonographic examinations and were prospectively repeated. RESULTS: Pre-operative endoscopical report was available in 42 cases, and 52 examinations were performed post-operatively. Frequency of esophagitis changed from 16.7% (7/42) to 15.4% (8/52), and of gastritis from 45.2% (19/42) to 21.2% (11/52). Gastric or gastrojejunal ulcers were initially present in 4.8% (2/42) and increased to 9.6% (5/52). Post-operatively, an unusual abnormality was silastic band erosion: 7.7% (4/52). Helicobacter pylori was present in 50.0% (21/42) before and 3.5% (2/52) after operation. Ultrasonographic study had been done before intervention in 63 subjects, and 57 were executed on follow-up. Liver steatosis occurred previously in 58.7% (37/63) and in 43.9% (25/57) later on. Only 12.7% (8/63) of the patients had undergone cholecystectomy before bariatric operation, 29.1%(16/55) suffered simultaneous resection of gallbladder because of stones during Roux-en-Y gastric bypass, and an additional 26.8% (10/36) developed gallstones post-operatively. CONCLUSIONS: Liver steatosis did not statistically improve, nor did inflammatory conditions of the upper digestive tube, despite reduction of H. pylori infections; gallbladder stones requiring intervention were common.     

Black pigment gallstones with cholesterol gallstones in the same gallbladder

We studied 1312 consecutive patients who underwent surgery for gallstones in the biliary tract at one university hospital in Siena, Italy, with a systematic classification of gallstones found within the gallbladder. Of these patients, 1226 were found to have gallbladder stones; 94 of these had black pigment gallstones. Of these, 13 patients were found to have black pigment gallstones and cholesterol gallstones within their gallbladder. They all had multiple black pigment gallstones, usually very small (all <6 mm diameter), in association with larger cholesterol stones in the gallbladder lumen. The cholesterol gallstones were single in seven cases, double in two cases, and multiple in four cases. All 13 of these patients with black pigment stones in association with cholesterol stones had histologic evidence of either adenomyomatosis or Rokitansky-Aschoff sinuses in the gallbladder wall. In nine of the 13 patients, the black pigment stones were located both in the gallbladder lumen and in close association with the gallbladder wall (in areas of adenomyomatosis or in Rokitanski-Aschoff sinuses). In the other four patients, the stones were found in close association with the gallbladder wall alone and not freely mobile within the gallbladder lumen. It is concluded that cholesterol stones and black pigment stones may be found in the same gallbladder. This association is infrequent with an incidence of 13 of 1226 (1.06%) in our series. There appears to be some relationship between the formation of the black pigment stones and the presence of adenomyomatosis or Rokitanski-Aschoff sinuses. However, the pathogenesis of these two compositionally distinctly different types of stones within the same gallbladder is not understood and deserves further study.     

Sensitivity and specificity of microscopic examination of gallbladder bile for gallstone recognition and identification

During cholecystectomy, gallbladder bile and gallstones were obtained from 77 patients and gallbladder bile was obtained from 39 patients free of stones (11 patients had biliary stenosis). According to their chemical composition, gallstones were classified as cholesterol (n = 46) or pigment (n = 31) stones. In patients with gallstones (a) cholesterol crystals better helped to identify cholesterol gallstones (sensitivity, 87%; specificity, 97%; positive predictive value, 97%) than did an abnormal cholesterol saturation index of bile (sensitivity, 93%; specificity, 48%; positive predictive value, 73%); (b) the presence of cholesterol crystals was significantly related to the cholesterol content of gallstones and the bile cholesterol saturation index; and (c) bilirubinate crystals, when present alone (without cholesterol crystals), were good predictors of pigment gallstones (sensitivity, 71%; specificity, 93%; positive predictive value, 88%). In the absence of stones, bilirubinate crystals were present in 9 of 28 patients without biliary stenosis (4 with alcoholic cirrhosis and 2 with alcoholic pancreatitis) and 8 of 11 patients with biliary stenosis. In the absence of stones, cholesterol crystals were present in 2 of 28 patients without biliary stenosis and in 4 of 11 patients with biliary stenosis, suggesting that bile stasis can induce cholesterol crystal formation.