胆囊切除术后残余胆囊的声像图研究

目的 :探讨胆囊切除术后残余胆囊的声像图 ,分析其形成原因。方法 :对 3 7例残余胆囊的术前、术后声像图对比分析 ,设对照组对其胆总管进行测量及统计学分析。结果 :萎缩性胆囊炎术后发生残余胆囊概率较高 ,残余胆囊结石复发率 86.2 % (2 5/ 2 9) ,残余胆囊组的胆总管宽度大于对照组 (P=0 .0 0 0 1)。结论 :超声显像在残余胆囊的诊断及预防中均有较好的应用价值     

传统开放术式与腔镜联合术式治疗老年胆囊结石合并胆总管结石的临床对比研究

目的探讨传统开放术式与腔镜联合术式治疗老年胆囊结石合并胆总管结石临床效果及安全性差异。方法研究对象选取该院2013年1月-2015年6月收治老年胆囊结石合并胆总管结石患者共130例,以随机区组法分别分为对照组(65例)和观察组(65例),分别采用传统开放术式和腔镜联合术式治疗;比较两组患者围手术期临床指标水平、结石完全清除率,术后镇痛药物使用率及并发症发生率等。结果观察组患者手术时间、术中出血量、术后首次排气时间及住院时间均明显优于对照组,差异有统计学意义(P0.05);两组患者结石完全清除率比较差异无统计学意义(P0.05);观察组患者术后镇痛药物使用率明显低于对照组,差异有统计学意义(P0.05);观察组患者术后切口感染、肺部感染及胆漏发生率均明显低于对照组,差异有统计学意义(P0.05)。结论腔镜联合术式治疗老年胆囊结石合并胆总管结石可有效缩短手术时间,加快术后康复进程,减轻术中创伤和术后疼痛程度,并有助于预防术后并发症发生,临床价值优于传统开放术式。     

腹腔镜联合胆道镜微创治疗胆道结石210例分析

目的：总结腹腔镜联合胆道镜微创治疗胆道结石的手术技巧和临床应用。方法：回顾分析总结腹腔镜联合胆道镜微创治疗胆道结石210例患者的临床资料。结果：210例患者中,胆囊合并胆总管结石171例,单纯性胆总管结石26例,胆总管结石合并肝吸虫病8例,胆总管结石合并左肝右肝管结石5例。患者平均手术时间为69min,平均术后住院日为5.4d。结论：腹腔镜联合胆道镜微创治疗胆道结石手术创伤小,时间短,疗效好,安全可靠。     

选择性ERCP在LC术前的应用

32例拟行腹腔镜胆囊切除术(LC)的胆囊结石患者,选择性地进行术前ERCP检查,成功率为93.7％。18例术前临床表现怀疑有胆总管结石存在,ERCP发现8例(44.4％)有胆总管结石;12例无胆总管结石依据,1例(8.3％)存在胆总管结石。另外,发现胆道变异1例。通过资料分析,认为LC术前选择性ERCP的适应证为:胆总管直径大于0.8cm,B超怀疑或发现胆总管结石,胆管炎病史,胆源性胰腺炎病中及肝功能异常。     

Improved sonographic visualization of choledocholithiasis

Ultrasonographic diagnosis of gallstones in the distal part of extrahepatic duct is not easy. A number of new techniques have been used by the authors to improve the detection rate of these stones. They include filling the duodenum and gastric antrum with drinking water, scanning after a fatty meal, and changing the patient's position during scanning. Ultrasound successfully identified choledocholithiasis in 78 of 104 patients for a sensitivity of 75%. There were 26 false-negative cases. The chief causes of the false negatives were obscuration of the distal duct by overlying bowel gas, missing of small stone in a nondilated bile duct, and misdiagnosis of soft pigment or an impacted stone having an atypical hypoechoic image in the distal duct as a tumor. False-positive diagnosis occurred in 32 out of 188 noncalculous cases, giving a specificity of 83%. These cases represent various hyperechoic lesions in the neck of gallbladder, cystic duct, and periampullary region. The overall diagnostic accuracy of gallstones in the extrahepatic bile duct by ultrasound was 80% (234/292).     

同期三镜联合手术与分期两镜手术治疗胆囊结石 合并胆总管结石的疗效对比*

目的探讨同期三镜联合手术(腹腔镜+十二指肠镜+胆道镜)与分期两期两镜手术[内镜下逆行胰胆管造影(ERCP)+腹腔镜下胆囊切除术(LC)]治疗胆囊结石合并胆总管结石的疗效。方法回顾性分析2017年1月-2019年3月54例胆囊结石合并胆总管结石患者,分别行同期三镜手术和分期两镜手术,其中同期三镜手术29例,分期两镜手术25例,分析比较两组手术成功率、住院时间、住院费用、并发症和胆汁引流量等指标的差异。结果54例患者中,采取同期三镜手术患者均手术成功,无残余结石,无中转开腹,术后1例出现急性胰腺炎,1例出现梗阻性黄疸,转氨酶升高;采取分期两镜手术患者中,1例因十二指肠镜取石失败,改为择期同期三镜手术,其余手术均成功,结石完全被取出,术后轻症急性胰腺炎3例,1例出现电解质紊乱,1例行胆囊切除术后出现发热,1例出现黄疸。两组患者全麻术后肛门排气时间、住院总费用、术后第1天、第2天胆汁引流量比较,差异均无统计学意义(P>0.05),两组患者手术时间、术中出血量、住院时间和术后第3天胆汁引流量比较,差异均有统计学意义(P<0.05)。结论同期三镜手术较两期手术住院时间更短、术后恢复更快、并发症更少,但手术时间和出血量明显较分期两镜手术多。在合适的患者及其自身要求下,同期三镜手术可能会取得更好的治疗效果。     

Hepatic parenchymal calcifications--differentiation from intrahepatic stones

Intrahepatic hyperechoic lesions with acoustic shadows could be stones or nonspecific calcifications. To verify this, 9 patients with hepatic parenchymal calcifications were compared with 40 patients with intrahepatic stones. A set of criteria are proposed for the diagnosis of intrahepatic stones: (A) dilated intrahepatic duct; (B) pneumobilia; or (C) 2 or more of the following: (1) common hepatic duct more than 6 mm in diameter, (2) multiple lesions in one lobe, (3) left lobe involvement, and (4) elevated serum alkaline phosphatase. The sensitivity, specificity, and overall accuracy were 97.5%, 88.9%, and 95.9, respectively. The criteria help in the selection of patients for evaluation of intrahepatic stones.     

胆囊并发胆总管结石患者的微创外科治疗研究

目的探究胆囊并发胆总管结石患者的微创外科治疗。方法选取2013年1月-2018年1月该院收治的92例胆囊并发胆总管结石患者为研究对象,采用随机数字表法将患者分为对照组(n=46)和观察组(n=46)。两组患者中存在胰腺炎的患者先行控制腹膜炎,对照组患者行腹腔镜胆囊切除术(LC)联合胆总管探查取石术(LCBDE),观察组患者行十二指肠乳头括约肌切开取石术(EST),术后3 d行LC治疗。比较两组患者围术期情况、费用情况和并发症情况。结果两组患者均未出现中转开腹手术情况,观察组患者的手术时间、止痛药使用率、住院时间均低于对照组患者,耗材费用和住院总费用多于对照组患者,差异具有统计学意义(P0.05);两组患者的术中出血量、术后排气时间和手术费用比较差异无统计学意义(P0.05)。观察组患者各项并发症总发生率为6.51%低于对照组患者的19.53%,差异具有统计学意义(P0.05)。结论胆囊并发胆总管结石患者控制腹膜炎后行EST+LC治疗较LC+LCBDE治疗能够缩短手术时间,减轻术后疼痛,降低并发症发生率,缩短住院时间,但所需费用较高。     

腹腔镜下胆囊壶腹皱襞入路胆囊切除术预防胆道损伤的临床效果

目的探讨经胆囊壶腹皱襞入路的腹腔镜胆囊切除术(LC)在预防胆道损伤中的临床效果,为临床应用提供指导。方法选择2015年12月至2016年5月鄂尔多斯市中心医院康巴什部经胆囊壶腹皱襞入路精细解剖胆囊三角技术行LC的120例胆囊结石及胆囊息肉患者为研究对象,对其临床资料进行分析。结果以胆囊壶腹与肝十二指肠韧带之间的凹陷或切迹(即胆囊壶腹皱襞)为解剖学标志,显露胆囊管、肝总管、胆总管及胆囊动脉,120例患者均顺利完成了LC,术中未发生胆道损伤。结论在LC中采用经胆囊壶腹皱襞入路可有效预防术中胆道损伤的发生,值得临床推广应用。     

Laparoscopic ultrasonographic appearance of the common bile duct mucosa: a predictor of choledocholithiasis.

Previously we reported on the use of laparoscopic ultrasonography in detecting common bile duct stones during laparoscopic cholecystectomy. The aim of this study is to describe the laparoscopic ultrasonographic appearance of the common bile duct mucosa in patients with choledocholithiasis. Medical records of 44 patients with an increased risk for common bile duct stones undergoing laparoscopic cholecystectomy between 1993 and 1998 were reviewed. In the operating room, the laparoscopic ultrasonographic appearance of the common bile duct mucosa was scored in real time as normal, mild changes (hyperechoic mucosa), or severe changes (hyperechoic with mucosal thickening). Of the 31 patients (70%) with stones or sludge in the biliary tree, 29 (94%) had either severe (58%) or mild (36%) hyperechoic and 2 (6%) had normal-appearing common bile duct mucosa on laparoscopic ultrasonography. Of the 13 patients (30%) with no documented stones or sludge, 11 (85%) had normal and 2 (15%) had mild hyperechoic common bile duct mucosa on laparoscopic ultrasonography. Both of these patients had laboratory values indicating recent passage of common bile duct stones. The association between common bile duct stones and the presence of hyperechoic common bile duct mucosa was statistically significant (P < .0001, Fisher's exact test). This is the first report of hyperechoic common bile duct mucosa demonstrated by laparoscopic ultrasonography as a predictor of common bile duct stones. This finding is evident in the majority of patients with common bile duct stones and also may be associated with recent passage of a stone into the duodenum.     

Endoscopic sonography in the diagnosis of gallbladder wall lesions in patients with gallstones

PURPOSE: The purpose of this study was to evaluate the diagnostic accuracy of endoscopic sonography (EUS) in the detection of gallbladder wall lesions in patients with and without gallstones. METHODS: We retrospectively reviewed the medical records, sonograms, and sonographic reports of 62 patients who underwent cholecystectomy for gallbladder wall lesions evaluated by EUS. We assessed the accuracy of EUS in diagnosing gallbladder wall lesions in the presence or absence of gallstones and on the basis of the size and number of stones and the size of the gallbladder wall lesions. We also evaluated the effect of acoustic shadowing. The EUS results were compared with the histopathologic results. RESULTS: EUS correctly diagnosed the gallbladder wall lesions in 17 (71%) of 24 patients with gallstones and in 34 (89%) of 38 patients without gallstones. The diagnostic accuracy of EUS was 86% in patients with gallbladder wall lesions smaller than 20 mm and 79% in patients with gallbladder wall lesions 20 mm or larger. The diagnostic accuracy was 75% in patients with gallstones smaller than 5 mm and 67% in patients with stones 5 mm or larger. The accuracy was 67% in patients with 1-5 stones and 83% in patients with 6 or more stones. None of these differences was statistically significant. Acoustic shadowing did not affect the diagnostic accuracy of EUS. CONCLUSIONS: The diagnostic accuracy of EUS for gallbladder wall lesions is not affected by the presence of gallstones. However, better diagnostic criteria must be established based on larger studies, and technical refinements of the equipment are needed to increase the accuracy of EUS in the diagnosis of gallbladder wall lesions.     

单次激发与多次激发MRCP诊断胆系结石的对照研究

目的：对比探讨单次激发快速自旋回波序列（SSFSE）与多次激发FSE序列（FSE）磁共振胰胆管成像（MRCP）诊断胆系结石的价值。方法：应用1.0T超导MRI扫描仪对128例患者（68例胆囊结石和60例胆总管结石）行二维冠状面SSFSE序列和FSE序列MRCP扫描。结果：对于较大的单发或多发胆囊结石以及胆囊泥沙样结石的显示，SSFSE序列图像优于FSE序列MIP图像。对于＜0．5cm的较小的单发或多发胆囊结石，SSFSE序列图像及FSE序列MIP图像均难以准确显示。对于胆总管结石，SSFSE序列和FSE序列MIP图像均可较好地显示。结论：SSFSE序列图像对于较大的单发或多发胆囊结石以及胆囊泥沙样结石的显示优于FSE序列MIP图像；但对于较小的单发或多发胆囊结石以及胆总管结石，SSFSE序列和FSE序列MIP图像的诊断价值相仿。     

Impact of gallbladder status on the outcome in patients with retained bile duct stones treated with extracorporeal shockwave lithotripsy

BACKGROUND AND STUDY AIMS: The use of endoscopic therapy in combination with lithotripsy techniques has become increasingly common in patients with complicated common bile duct stones. In many units, although this is controversial, cholecystectomy is then performed, because of possible subsequent cholecystitis and recurrence of choledocholithiasis. The aim of this study was to investigate whether gallbladder status influences the long-term outcome in patients after extracorporeal shockwave lithotripsy (ESWL) of common bile duct stones. PATIENTS AND METHODS: Recruited for the study were 120 patients with an average age of 68 years (range 28 - 86). They were selected from 137 consecutive patients who presented to our department between January 1989 and June 1996 with complicated common bile duct stones, and in whom ESWL was necessary to achieve complete clearance of stones. Follow-up data were obtained from the patients and their general practitioners. RESULTS: The mean duration of follow-up was 4 years (range 3 - 9). A total of 37 patients had their gallbladder in situ (group A), while 83 had undergone cholecystectomy. Of these 83 patients, 27 had had a cholecystectomy after ESWL (group B), whereas 56 patients had already had the gallbladder removed when choledocholithiasis was diagnosed (group C). During follow-up, 36 patients (30 %) experienced some biliary symptoms. There were no significant differences in the incidence of recurrent biliary symptoms between the three groups. Re-exploration of the bile duct by endoscopic retrograde cholangiopancreatography (ERCP) revealed 28 cases of recurrent bile duct stones. Recurrence developed more often in groups B and C, who had undergone cholecystectomy, without reaching statistical significance ( P = 0.077). In patients with an intact gallbladder (group A), there was no difference in the rate of recurrent biliary symptoms or stones between the patients with or without cholecystolithiasis. Operations were necessary in 28 patients; in only ten was this for biliary reasons. CONCLUSION: The intact gallbladder is not a risk factor for recurrent biliary complications after ESWL of common bile duct stones; therefore, as far as patients with complicated bile duct stones which require additional lithotripsy techniques are concerned, elective cholecystectomy after endoscopic clearance of the bile duct no longer seems appropriate.     

选择性胆道造影在胆囊切除术中的临床应用

目的探讨基层医院在胆囊切除手术中选择性胆道造影的应用价值。方法回顾性分析2004年6月至2007年10月26例术中胆道造影（IOC）患者的临床资料。全部选用经胆囊管或经胆总管穿刺行IOC。结果对胆囊切除术中26例具有胆总管相对探查指征患者经胆囊管或经胆总管穿刺IOC,发现胆总管结石9例（34．62％）,假阳性1例（3．85％）,阴性16例（61．53％）。结论选择性IOC在基层医院可预防胆囊切除手术后胆总管残余结石,避免不必要的胆总管切开探查,降低术后并发症;并能在术中直接了解胆道系统解剖,提高手术安全性,在降低术后残余胆总管结石和避免胆道损伤等方面有重要价值。     

胆囊切除术后残留胆总管结石的内镜诊治

目的：探讨经内镜逆行胰胆管造影（ERCP）在胆囊切除术后残留胆总管结石诊治中的应用价值。方法：对胆囊切除术后腹痛、发热、黄疸或肝功能异常而经B超、CT或磁共振胰胆管造影（MRCP）证实或怀疑残留胆总管结石的患者进行ERCP检查，对发现胆总管结石的患者行EST或EPBD后取石。结果：ERCP检查的成功率为96．4％（108／112）。85例证实胆总管结石的患者行EST或EPBD后取石，79例（92．9％）取石治疗成功；6例因合并肝内胆管多发结石而行外科手术治疗。并发症发生率为4．5％，其中消化道出血2例，急性胰腺炎3例。结论；对于胆囊切除术后残留胆总管结石的患者，ERCP是理想的诊断方法，而且还可以同时进行治疗。     

超声检查对先天性胆管囊状扩张症的诊断价值

目的探讨超声诊断先天性胆管囊状扩张症的价值。方法回顾性分析50例先天性胆管囊状扩张症患者的临床资料,分析超声检查对其的诊断价值。结果 50例先天性胆管囊状扩张症患者超声正确诊断48例,诊断符合率96.0%,误诊2例,1例Ⅰ型患者误诊为胰腺囊肿,1例Ⅴ型患者误诊为多发肝囊肿。44%患者合并结石,2%患者合并癌变,30%患者合并胆囊炎、胆囊结石。结论超声诊断先天性胆管囊状扩张症具有较高的诊断准确率,在诊断过程中为避免误诊、漏诊应注意鉴别诊断。     

三维超声在胆道疾病诊断中的应用价值

目的评估三维超声在胆道疾病诊断中的应用价值。方法对91例胆道疾病的患者首先应用二维超声进行图像采集,然后应用三维超声进行图像重建。结果三维超声可清晰、直观显示胆囊结石、胆管结石形状、数目、位置;可直观显示胆囊息肉样病变病灶部位和表面特征,准确评价胆囊息肉是否带蒂及胆囊腺瘤基底部的宽窄;还可清晰显示胆囊癌、胆管癌病灶范围、胆囊壁连续性以及肿瘤病灶浸润周围脏器的程度;可清楚显示胆管结石与胆管壁的关系;可形象、直观地显示胆管壁受累程度及病灶位置、生长方式、是否浸润周围组织。本组胆道疾病患者三维超声诊断符合率为90.1%(82/91),高于二维超声诊断符合率76.9%(70/91),且差异有统计学意义(χ2=5.747,P<0.05)。结论三维超声可更直观地显示胆道疾病病灶的形态特点及其与周围组织脏器的关系,能提供较二维超声更丰富的信息,对明确诊断及确定治疗方案有重要的临床意义。     

Ultrasonography of choledocholithiasis

In a retrospective study of patients with ultrasonographically demonstrable choledocholithiasis, 81 stones were demonstrated in 46 patients. The majority of the stones were between 5 and 10 mm in diameter; the smallest was 2 mm and the largest 23 mm. Of the 81 stones, 64 demonstrated acoustical shadowing; 56 were located in the distal segment of the common bile duct. Stones in the common bile duct are best demonstrated by sagittal sections with the patient in the right anterior oblique position. It is possible but more difficult to demonstrate stones within a normal-sized common bile duct. Several possible sources of confusion in the diagnosis of common bile duct stones are discussed. Ultrasonography of the common bile duct is best performed with a high-resolution real-time sector scanner. The accuracy and frequency of detection of common bile duct stones have increased significantly with the advances in technology and improvement in resolution of the mechanical sector real-time scanners.     

腹腔镜手术治疗老年人胆囊并胆管结石 (附75例报告)

目的探讨腹腔镜手术治疗老年人胆囊并胆管结石的可行性及疗效。方法回顾性分析2001年1月～2005年12月腹腔镜手术治疗60岁以上老年人胆囊并胆管结石75例资料。结果72例手术成功,3例中转开腹,手术时间60～270min,胆总管T管引流42例,一期缝合30例;术后有3例发生胆漏,经保守治疗治愈;6例有肝内残余结石,于术后1.5个月经T管窦道取净结石。结论作好充分的围手术期处理,择期的腹腔镜手术治疗老年人胆囊并胆管结石安全、可行,但需娴熟的腹腔镜操作技术。在老年人中严格掌握好适应证胆总管一期缝合亦是安全、可行的。     

Sonography of the distal cystic duct

This prospective study of 139 patients was performed for evaluation of the normal and abnormal distal cystic duct and cystic duct remnant after cholecystectomy. The normal distal cystic duct could be demonstrated in 51% of the patients with normal common bile duct and normal gallbladder. The average diameter of the normal distal cystic duct was 1.8 mm. In 95% of the patients, the distal cystic duct was located posterior to the common bile duct and, in 5% of the patients, anterior to the common duct. Echoes produced by cystic duct insertion into the common bile duct occasionally can be mistaken for stones in the common bile duct. These echoes, however, are not associated with acoustic shadowing. Sludge and stones could be demonstrated in the distal cystic duct as well as in the cystic duct remnant after cholecystectomy.