腹腔镜胆总管探查治疗胆囊切除术后复发或残留胆总管结石的临床疗效
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摘要
目的:探讨腹腔镜下胆总管探查(LCBDE)治疗胆囊切除术后复发或残留胆总管结石的临床疗效。方法:回顾性分析2012年4月—2015年6月52例行LCBDE治疗的胆囊切除术后复发或残留胆总管结石患者临床资料。结果:52例患者中成功完成LCBDE 48例(92.3%),其余4例均因腹腔粘连致密而中转开腹手术。48例患者术中放置T管15例,行胆总管一期缝合33例;手术时间(102.6±19.5)min,术中出血量(38.6±12.7)m L,术后住院时间(4.2±2.5)d;术后发生轻微胆汁漏2例,拔T管后胆汁性腹膜炎1例,均经保守治疗痊愈;术后胆总管残留结石1例,于术后6周经T管窦道胆道镜下网篮取石治愈。结论:LCBDE治疗胆囊切除术后复发或残留胆总管结石成功率高,且微创、恢复快,推荐临床应用。
Objective: To assess the clinical ei cacy of laparoscopic common bile duct exploration(LCBDE) in treatment of recurrent or residual common bile duct stones at er cholecystectomy. Methods: The clinical data of 52 patients with recurrent or residual common bile duct stones after cholecystectomy undergoing LCBDE treatment from April 2012 to June 2015 were analyzed retrospectively.Results: Of the 52 patients, LCBDE was successfully performed in 48 cases(92.3%), and the remaining 4 cases were converted to open surgery due to severe abdominal adhesion. Of the 48 patients, 15 cases underwent T-tube placement during operation, and 33 cases received primary common bile duct closure; the operative time was(102.6±19.5) min, intraoperative blood loss was(38.6±12.7) m L, and length of postoperative hospital stay was(4.2±2.5) d. Mild bile leakage at er operation occurred in 2 cases, and bile peritonitis occurred in one case at er Ttube removal, which were all resolved by conservative treatment; one case had remnant common bile duct stones at er operation, and they were extracted by choledochoscopic net basket via the T-tube sinus tract at 6 weeks at er operation.Conclusion: For recurrent or residual common bile duct stones at er cholecystectomy, LCBDE has high success rate with minimal invasion and fast recovery, so it is recommended to be used.
Objective: To assess the clinical ei cacy of laparoscopic common bile duct exploration(LCBDE) in treatment of recurrent or residual common bile duct stones at er cholecystectomy. Methods: The clinical data of 52 patients with recurrent or residual common bile duct stones after cholecystectomy undergoing LCBDE treatment from April 2012 to June 2015 were analyzed retrospectively.Results: Of the 52 patients, LCBDE was successfully performed in 48 cases(92.3%), and the remaining 4 cases were converted to open surgery due to severe abdominal adhesion. Of the 48 patients, 15 cases underwent T-tube placement during operation, and 33 cases received primary common bile duct closure; the operative time was(102.6±19.5) min, intraoperative blood loss was(38.6±12.7) m L, and length of postoperative hospital stay was(4.2±2.5) d. Mild bile leakage at er operation occurred in 2 cases, and bile peritonitis occurred in one case at er Ttube removal, which were all resolved by conservative treatment; one case had remnant common bile duct stones at er operation, and they were extracted by choledochoscopic net basket via the T-tube sinus tract at 6 weeks at er operation.Conclusion: For recurrent or residual common bile duct stones at er cholecystectomy, LCBDE has high success rate with minimal invasion and fast recovery, so it is recommended to be used.
引文
[1]吴国良,沈根海,高泉根.腹腔镜下胆总管探查治疗胆总管残余结石和复发结石的经验总结[J].肝胆胰外科杂志,2012,24(4):325-326.Wu GL,Shen GH,Gao QG.Experience in laparoscopic common bile duct exploration for remnant or recurrent common bile duct stones[J].Journal of Hepatopancreatobiliary Surgery,2012,24(4):325-326.
[2]Strnad P,von Figura G,Gruss R,et al.Oblique bile duct predisposes to the recurrence of bile duct stones[J].PLoS One,2013,8(1):e54601.doi:10.1371/journal.pone.0054601.
[3]彭颖,侯纯升,徐智,等.腹腔镜手术治疗残余胆囊结石合并胆总管结石[J].中国微创外科杂志,2015,15(2):107-110.Peng Y,Hou CS,Xu Z,et al.Laparoscopic Management for Gallbladder Remnant Calculi Complicated with Choledocholithiasis[J].Chinese Journal of Minimally Invasive Surgery,2015,15(2):107-110.
[4]Zhu JG,Zhang ZT.Laparoscopic remnant cholecystectomy and transcystic common bile duct exploration for gallbladder/cystic duct remnant with stones and choledocholithiasis after cholecystectomy[J].J Laparoendosc Adv Surg Tech A,2015,25(1):7-11.
[5]耿春蕊,刘其雨,陈刚,等.腹腔镜下胆总管探查术后一期缝合与T管引流的效果比较[J].中国普外基础与临床杂志,2014,21(12):1561-1563.Geng CR,Liu QY,Chen G,et al.Effect of primary closure versus T-Tube drainage after laparoscopic common bile duct exploration[J].Chinese Journal of Bases and Clinics in General Surgery,2014,21(12):1561-1563.
[6]Hungness ES,Soper NJ.Management of common bile duct stones[J].J Gastrointest Surg,2006,10(4):612-619.
[7]胡旭光,郑成竹,柯重伟,等.腹腔镜胆囊切除术后胆总管残留结石的转归[J].腹腔镜外科杂志,2007,12(2):155-156.Hu XG,Zheng CZ,Ke ZW,et al.Resolution of residual common bile duct calculi after laparoscopic cholecystectomy[J].Journal of Laparoscopic Surgery,2007,12(2):155-156.
[8]王军.腹腔镜胆囊切除术后胆总管残留结石的预防和处理[J].河南职工医学院学报,2014,26(5):564-565.Wang J.Prevention and treatment of residual common bile duct stones after laparoscopic cholecystectomy[J].Journal of Henan Medical College for Staff and Workers,2014,26(5):564-565.
[9]陈勇,曾艳凌,林志辉.ERCP术前胆总管结石诊断238例[J].世界华人消化杂志,2013,21(19):1811-1816.Chen Y,Zeng YL,Lin ZH.Diagnosis of common bile duct stones before ERCP:An analysis of 238 cases[J].World Chinese Journal of Digestology,2013,21(19):1811-1816.
[10]郑志海,暨玲,阮小蛟,等.LCBDE与EST治疗胆总管结石疗效分析[J].肝胆胰外科杂志,2011,23(6):463-465.Zheng ZH,Ji L,Yuan XJ,et al.Analysis of clinical efficiency on LCBDE and EST for the treatment of common bile duct stones[J].Journal of Hepatopancreatobiliary Surgery,2011,23(6):463-465.
[11]戴国清,胡海.腹腔镜胆囊切除联合胆总管探查治疗胆囊并胆总管结石的临床研究[J].中国普通外科杂志,2010,19(8):843-845.Dai GQ,Hu H.Clinical research of gallbladder and common bile duct stones treated by LC and LCBDE[J].Chinese Journal of General Surgery,2010,19(8):843-845.
[12]张智勇,杜立学,郑伟,等.腹腔镜胆总管探查术与内镜下十二指肠乳头括约肌切开术治疗胆总管结石的临床对照研究[J].中国普通外科杂志,2015,24(8):1088-1092.Zhang ZY,Du LX,Zheng W,et al.Clinical comparative study of laparoscopic common bile duct exploration versus endoscopic sphincterotomy for choledocholithiasis[J].Chinese Journal of General Surgery,2015,24(8):1088-1092.
[13]康生朝,耿闻男,刘鑫,等.胆总管结石取石后复发结石的内镜再治疗[J].西北国防医学杂志,2014,35(6):518-520.Kang SC,Geng WN,Liu X,et al.Endoscpoic therapy for the recurrent stones of common bile duct after lithotomy[J].Medical Journal of National Defending Forces in Northwest China,2014,35(6):518-520.
[14]Kageoka M,Watanabe F,Maruyama Y,et al.Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis[J].Dig Endosc,2009,21(3):170-175.
[15]Dong ZT,Wu GZ,Luo KL,et al.Primary closure after laparoscopic common bile duct exploration versus T-tube[J].J Surg Res,2014,189(2):249-254.
[16]Shelat VG,Chan CY,Liau KH,et al.Laparoscopic exploration can salvage failed endoscopic bile duct stone extraction[J].Singapore Med J,2012,53(5):313-317.
[17]周皓岚,付英,黄涛.腹腔镜下胆总管探查一期缝合治疗肝外胆管结石的安全性研究[J].中国内镜杂志,2015,21(3):311-314.Zhou HL,Fu Y,Huang T.The safety studies of primary closure after laparoscopic common bile duct exploration for common bile duct stone[J].China Journal of Endoscopy,2015,21(3):311-314.
[18]潘步建,徐迈宇,陈峰,等.腹腔镜联合胆道镜或十二指肠镜治疗胆总管结石合并胆囊结石的对比研究[J].中国微创外科杂志,2014,14(10):906-909.Pan BJ,Xu MY,Chen F,et al.Laparoscopic Cholecystectomy Combined with Laparoscopic Common Bile Duct Exploration or Endoscopic Sphincterotomy for Cholecystolithiasis with Choledocholith[J].Chinese Journal of Minimally Invasive Surgery,2014,14(10):906-909.
[19]张新洽,华沪玮,曾可伟,等.腹腔镜下胆总管探查术在治疗复发性胆总管结石中的应用[J].深圳中西医结合杂志,2014,24(4):117-118.Zhang XQ,Hua HW,Zeng KW,et al.Application of laparoscopic common bile duct exploration in recurrent common bile duct stones[J].Shenzhen Journal of Integrated Traditional Chinese and Western Medicine,2014,24(4):117-118.
[20]李贵全,吴本华,黄家斌,等.一期缝合与术中留置T管在腹腔镜胆总管探查取石术中的应用效果比较[J].蚌埠医学院学报,2015,40(8):1032-1035.Li GQ,Wu BH,Huang JB,et al.The effects between primary suture and intraoperative indwelling T tube in laparoscopic common bile duct exploration[J].Journal of Bengbu Medical College,2015,40(8):1032-1035.
[21]张宏,黄汉源,李定文.胆总管探查术后一期缝合与留置T管引流临床比较分析[J].岭南现代临床外科,2012,12(3):179-180.Zhang H,Huang HY,Li DW.Clinical comparison between primary closure and T-tube placement following laparoscopic common bile duct exploration[J].Lingnan Modern Clinics in Surgery,2012,12(3):179-180.
[22]杨义官.胆道术后T管拔除的最佳时间及危险因素的临床实践与探讨[J].吉林医学,2010,31(30):5375.Yang YG.Optimal time for T-tube removal and risk factors after biliary surgery[J].Jilin Medical Journal,2010,31(30):5375.
[23]王刚,杨彬.T管拔除后胆漏的防治(附10例报告)[J].医学新知杂志,2005,15(3):69.Wang G,Yang B.Prevention and management of bile leakage after T-tube removal:a report of 10 cases[J].Journal of New Medicine,2005,15(3):69.
[24]何群,汤恢焕,周军.腹腔镜胆总管探查拔除T管后胆瘘16例临床分析[J].中国普通外科杂志,2012,21(9):1172-1174.He Q,Tang HH,Zhou J.Clinical analysis of bile leakage after removal of T-tube inserted during laparoscopic common bile duct exploration:a report of 16 cases[J].Chinese Journal of General Surgery,2012,21(9):1172-1174.
[25]喻海波,王存川,李进义,等.经腹腔镜T型管引流术拔管后胆汁漏的诊断与处理[J].中国内镜杂志,2012,18(4):442-444.Yu HB,Wang cC,li JY,et al.Diagnosis and treatment of bile leakage after removal of laparoscopically placed T-tube[J].China Journal of Endoscopy,2012,18(4):442-444.
[26]牛锦全,张震波.T管拔除后胆漏致胆汁性腹膜炎的临床分析[J].当代医学,2013,19(3):107-108.Niu JQ,Zhang ZB.Clinical analysis of bile peritonitis caused by bile leakage after T-tube removal[J].Contemporary Medicine,2013,19(3):107-108.
[2]Strnad P,von Figura G,Gruss R,et al.Oblique bile duct predisposes to the recurrence of bile duct stones[J].PLoS One,2013,8(1):e54601.doi:10.1371/journal.pone.0054601.
[3]彭颖,侯纯升,徐智,等.腹腔镜手术治疗残余胆囊结石合并胆总管结石[J].中国微创外科杂志,2015,15(2):107-110.Peng Y,Hou CS,Xu Z,et al.Laparoscopic Management for Gallbladder Remnant Calculi Complicated with Choledocholithiasis[J].Chinese Journal of Minimally Invasive Surgery,2015,15(2):107-110.
[4]Zhu JG,Zhang ZT.Laparoscopic remnant cholecystectomy and transcystic common bile duct exploration for gallbladder/cystic duct remnant with stones and choledocholithiasis after cholecystectomy[J].J Laparoendosc Adv Surg Tech A,2015,25(1):7-11.
[5]耿春蕊,刘其雨,陈刚,等.腹腔镜下胆总管探查术后一期缝合与T管引流的效果比较[J].中国普外基础与临床杂志,2014,21(12):1561-1563.Geng CR,Liu QY,Chen G,et al.Effect of primary closure versus T-Tube drainage after laparoscopic common bile duct exploration[J].Chinese Journal of Bases and Clinics in General Surgery,2014,21(12):1561-1563.
[6]Hungness ES,Soper NJ.Management of common bile duct stones[J].J Gastrointest Surg,2006,10(4):612-619.
[7]胡旭光,郑成竹,柯重伟,等.腹腔镜胆囊切除术后胆总管残留结石的转归[J].腹腔镜外科杂志,2007,12(2):155-156.Hu XG,Zheng CZ,Ke ZW,et al.Resolution of residual common bile duct calculi after laparoscopic cholecystectomy[J].Journal of Laparoscopic Surgery,2007,12(2):155-156.
[8]王军.腹腔镜胆囊切除术后胆总管残留结石的预防和处理[J].河南职工医学院学报,2014,26(5):564-565.Wang J.Prevention and treatment of residual common bile duct stones after laparoscopic cholecystectomy[J].Journal of Henan Medical College for Staff and Workers,2014,26(5):564-565.
[9]陈勇,曾艳凌,林志辉.ERCP术前胆总管结石诊断238例[J].世界华人消化杂志,2013,21(19):1811-1816.Chen Y,Zeng YL,Lin ZH.Diagnosis of common bile duct stones before ERCP:An analysis of 238 cases[J].World Chinese Journal of Digestology,2013,21(19):1811-1816.
[10]郑志海,暨玲,阮小蛟,等.LCBDE与EST治疗胆总管结石疗效分析[J].肝胆胰外科杂志,2011,23(6):463-465.Zheng ZH,Ji L,Yuan XJ,et al.Analysis of clinical efficiency on LCBDE and EST for the treatment of common bile duct stones[J].Journal of Hepatopancreatobiliary Surgery,2011,23(6):463-465.
[11]戴国清,胡海.腹腔镜胆囊切除联合胆总管探查治疗胆囊并胆总管结石的临床研究[J].中国普通外科杂志,2010,19(8):843-845.Dai GQ,Hu H.Clinical research of gallbladder and common bile duct stones treated by LC and LCBDE[J].Chinese Journal of General Surgery,2010,19(8):843-845.
[12]张智勇,杜立学,郑伟,等.腹腔镜胆总管探查术与内镜下十二指肠乳头括约肌切开术治疗胆总管结石的临床对照研究[J].中国普通外科杂志,2015,24(8):1088-1092.Zhang ZY,Du LX,Zheng W,et al.Clinical comparative study of laparoscopic common bile duct exploration versus endoscopic sphincterotomy for choledocholithiasis[J].Chinese Journal of General Surgery,2015,24(8):1088-1092.
[13]康生朝,耿闻男,刘鑫,等.胆总管结石取石后复发结石的内镜再治疗[J].西北国防医学杂志,2014,35(6):518-520.Kang SC,Geng WN,Liu X,et al.Endoscpoic therapy for the recurrent stones of common bile duct after lithotomy[J].Medical Journal of National Defending Forces in Northwest China,2014,35(6):518-520.
[14]Kageoka M,Watanabe F,Maruyama Y,et al.Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis[J].Dig Endosc,2009,21(3):170-175.
[15]Dong ZT,Wu GZ,Luo KL,et al.Primary closure after laparoscopic common bile duct exploration versus T-tube[J].J Surg Res,2014,189(2):249-254.
[16]Shelat VG,Chan CY,Liau KH,et al.Laparoscopic exploration can salvage failed endoscopic bile duct stone extraction[J].Singapore Med J,2012,53(5):313-317.
[17]周皓岚,付英,黄涛.腹腔镜下胆总管探查一期缝合治疗肝外胆管结石的安全性研究[J].中国内镜杂志,2015,21(3):311-314.Zhou HL,Fu Y,Huang T.The safety studies of primary closure after laparoscopic common bile duct exploration for common bile duct stone[J].China Journal of Endoscopy,2015,21(3):311-314.
[18]潘步建,徐迈宇,陈峰,等.腹腔镜联合胆道镜或十二指肠镜治疗胆总管结石合并胆囊结石的对比研究[J].中国微创外科杂志,2014,14(10):906-909.Pan BJ,Xu MY,Chen F,et al.Laparoscopic Cholecystectomy Combined with Laparoscopic Common Bile Duct Exploration or Endoscopic Sphincterotomy for Cholecystolithiasis with Choledocholith[J].Chinese Journal of Minimally Invasive Surgery,2014,14(10):906-909.
[19]张新洽,华沪玮,曾可伟,等.腹腔镜下胆总管探查术在治疗复发性胆总管结石中的应用[J].深圳中西医结合杂志,2014,24(4):117-118.Zhang XQ,Hua HW,Zeng KW,et al.Application of laparoscopic common bile duct exploration in recurrent common bile duct stones[J].Shenzhen Journal of Integrated Traditional Chinese and Western Medicine,2014,24(4):117-118.
[20]李贵全,吴本华,黄家斌,等.一期缝合与术中留置T管在腹腔镜胆总管探查取石术中的应用效果比较[J].蚌埠医学院学报,2015,40(8):1032-1035.Li GQ,Wu BH,Huang JB,et al.The effects between primary suture and intraoperative indwelling T tube in laparoscopic common bile duct exploration[J].Journal of Bengbu Medical College,2015,40(8):1032-1035.
[21]张宏,黄汉源,李定文.胆总管探查术后一期缝合与留置T管引流临床比较分析[J].岭南现代临床外科,2012,12(3):179-180.Zhang H,Huang HY,Li DW.Clinical comparison between primary closure and T-tube placement following laparoscopic common bile duct exploration[J].Lingnan Modern Clinics in Surgery,2012,12(3):179-180.
[22]杨义官.胆道术后T管拔除的最佳时间及危险因素的临床实践与探讨[J].吉林医学,2010,31(30):5375.Yang YG.Optimal time for T-tube removal and risk factors after biliary surgery[J].Jilin Medical Journal,2010,31(30):5375.
[23]王刚,杨彬.T管拔除后胆漏的防治(附10例报告)[J].医学新知杂志,2005,15(3):69.Wang G,Yang B.Prevention and management of bile leakage after T-tube removal:a report of 10 cases[J].Journal of New Medicine,2005,15(3):69.
[24]何群,汤恢焕,周军.腹腔镜胆总管探查拔除T管后胆瘘16例临床分析[J].中国普通外科杂志,2012,21(9):1172-1174.He Q,Tang HH,Zhou J.Clinical analysis of bile leakage after removal of T-tube inserted during laparoscopic common bile duct exploration:a report of 16 cases[J].Chinese Journal of General Surgery,2012,21(9):1172-1174.
[25]喻海波,王存川,李进义,等.经腹腔镜T型管引流术拔管后胆汁漏的诊断与处理[J].中国内镜杂志,2012,18(4):442-444.Yu HB,Wang cC,li JY,et al.Diagnosis and treatment of bile leakage after removal of laparoscopically placed T-tube[J].China Journal of Endoscopy,2012,18(4):442-444.
[26]牛锦全,张震波.T管拔除后胆漏致胆汁性腹膜炎的临床分析[J].当代医学,2013,19(3):107-108.Niu JQ,Zhang ZB.Clinical analysis of bile peritonitis caused by bile leakage after T-tube removal[J].Contemporary Medicine,2013,19(3):107-108.