EST治疗胆总管结石的实用性分析
摘要
目的:探讨EST治疗胆总管结石的实用性及其与传统开腹术式相比所具有的优点。
方法:回顾性分析了我院2003年5月至2005年8月期间139例胆总管结石的治疗方法和结果。其中56例行内镜下十二指肠乳头括约肌切开取石术,74例行胆总管切开取石T型管引流术,10例行胆肠吻合术。
结果:EST取石组治愈率和术后结石残留发生率明显低于胆总管切开取石T型管引流组(P<0.05),术后并发症发生率两组无显著性差异(P>0.05)。EST取石组中12例由于EST切开不充分、切开后胆汁流出不畅或怀疑结石残留而留置了ERBD管。2例伴有位置较高的胆总管狭窄,EST无法解除狭窄,在取石成功后留置了ERBD管。2例在EST取石失败后留置了ERBD管。EST+LC组中1例先行LC治疗后,因EST取石治疗失败而行开腹手术治疗,1例EST后LC操作失败转行开腹胆囊切除术。
结论:EST治疗胆总管结石是安全有效的治疗方法,与胆总管切开取石T管引流术相比具有创伤小、结石残留率低等优点,胆总管结石合并胆囊结石的患者应先行EST取石,胆囊结石不影响胆总管结石的微创治疗,ERBD是EST治疗胆总管结石的一个较好的补充和完善,对部分EST治疗失败的胆总管结石需行传统开腹手术或LCHTD进行治疗。
Objective: To explore the merit of EST compared withorthodox modus operandi and the clinical practicality of EST for thetherapy of choledocholith.
Methods: Some of the patients were treated by EST.Afterendoscopic retrograde pancreatocholangiography, cut the duodenalpapilla according to the size of stone and the length of stenosis andthen take out stone directly or after be crashed. If the cut length isnot enough, or stone can not be taken out, or bile can not run-outeasily and smoothly, or suspect residual stone, or EST can not relievethe common bile duct stricture and open operation is not suit for thepatient, endoscopic retrograde biliary drainage tube will be set in thebile duct after EST. some patient with pecholecystolithiasis andcholedocholith may excise gallbladder through laparoscope before orafter EST. The others of the patients were treated by open Operation.Open operation include Cholecystectomy and T-tube, and Theend-to-side Cholangiojejunostomy(Roux-en-Y).modus operandi wasdetermined by the condition of calculus obstruction and biliarytract. The investigation retrospecttively analysesed the management
of 139 cases of choledocholith. SPSS11.0 systems software was usedto analysis Clinical data. Patients divided into groups according todifferent index. The comparison of interclass rate apply X2 test.P<0.05 is considered to be statistical significance.Results: 47 cases were treated by EST. Cure rate of patientswith EST was 83.9%.From which 14 cases made use of endoscopicretrograde biliary drainage tube. Two cases was set endoscopicretrograde biliary drainage tube after failure of EST. from which onecase appeared to be calculus fragmentation.67 cases were treated byCholecystectomy and T-tube. Cure rate of which was 90.5%.Fivecases took a turn for the better and found residual stone after T-tubevisualization. Rate of success and residual stone of patients with ESTis obviously lower than those with Cholecystectomy and T-tube(P<0.05).10 cases were treated by Cholangiojejunostomy. cure rateof which was 100%. There are ten patients with choledocholith andcholecystolithiasis treated by EST and LC. From which one caseapplied open operation after LC because of failure of EST. one caseconverted to open operation after EST because of failure of LC. Theothers were treated by LC after EST.
Analysis: The retrospective analysis demonstrate that Rate ofresidual stone of patients with EST is obviously lower than thosewith Cholecystectomy and T-tube(P<0.05), and Rate of success ofpatients with EST was 83.9%.So EST is the optimal management aslong as if only EST is fit for patient's condition. At the present,Orthodox modus operandi used to treat choledocholith with strictureof common bile duct include oddisphincterotomy and the end-to-sidecholangiojejunostomy(Roux-en-Y). Now oddisphincterotomy hasbeen raplaced gradually by EST. But if obstruction can not be treatedpartly, patients should be treated by the end-to-side cholangiojejuno-stomy. Besides ERBD tube can be used to Support the stricture ofcommon bile duct and is good to drainage bile and prevent residualstone. So patients can be well treated by EST and ERBD, that cannot be treated by end-to-side Cholangiojejunostomy. patients withcholedocholith should insist on microinvasive therapy regardless ofcholecystolithiasis, because that can retain the integrity of bilecommen duct and avoid choledochotomy and prevent fromconverting to open operation after LC for the failure of EST.Conclusion: EST is a safe and effective and Microinvasive
therapy of patients with choledocholith. Rate of residual stone ofpatients with EST is obviously lower than those withCholecystectomy and T-tube(P<0.05).Patients with choledocholithshould insist on Microinvasive therapy regardless ofcholecystolithiasis. ERBD is a supplement to EST. But some patientsstill should be treated by open operation or LCHTD after failure ofEST.
方法:回顾性分析了我院2003年5月至2005年8月期间139例胆总管结石的治疗方法和结果。其中56例行内镜下十二指肠乳头括约肌切开取石术,74例行胆总管切开取石T型管引流术,10例行胆肠吻合术。
结果:EST取石组治愈率和术后结石残留发生率明显低于胆总管切开取石T型管引流组(P<0.05),术后并发症发生率两组无显著性差异(P>0.05)。EST取石组中12例由于EST切开不充分、切开后胆汁流出不畅或怀疑结石残留而留置了ERBD管。2例伴有位置较高的胆总管狭窄,EST无法解除狭窄,在取石成功后留置了ERBD管。2例在EST取石失败后留置了ERBD管。EST+LC组中1例先行LC治疗后,因EST取石治疗失败而行开腹手术治疗,1例EST后LC操作失败转行开腹胆囊切除术。
结论:EST治疗胆总管结石是安全有效的治疗方法,与胆总管切开取石T管引流术相比具有创伤小、结石残留率低等优点,胆总管结石合并胆囊结石的患者应先行EST取石,胆囊结石不影响胆总管结石的微创治疗,ERBD是EST治疗胆总管结石的一个较好的补充和完善,对部分EST治疗失败的胆总管结石需行传统开腹手术或LCHTD进行治疗。
Objective: To explore the merit of EST compared withorthodox modus operandi and the clinical practicality of EST for thetherapy of choledocholith.
Methods: Some of the patients were treated by EST.Afterendoscopic retrograde pancreatocholangiography, cut the duodenalpapilla according to the size of stone and the length of stenosis andthen take out stone directly or after be crashed. If the cut length isnot enough, or stone can not be taken out, or bile can not run-outeasily and smoothly, or suspect residual stone, or EST can not relievethe common bile duct stricture and open operation is not suit for thepatient, endoscopic retrograde biliary drainage tube will be set in thebile duct after EST. some patient with pecholecystolithiasis andcholedocholith may excise gallbladder through laparoscope before orafter EST. The others of the patients were treated by open Operation.Open operation include Cholecystectomy and T-tube, and Theend-to-side Cholangiojejunostomy(Roux-en-Y).modus operandi wasdetermined by the condition of calculus obstruction and biliarytract. The investigation retrospecttively analysesed the management
of 139 cases of choledocholith. SPSS11.0 systems software was usedto analysis Clinical data. Patients divided into groups according todifferent index. The comparison of interclass rate apply X2 test.P<0.05 is considered to be statistical significance.Results: 47 cases were treated by EST. Cure rate of patientswith EST was 83.9%.From which 14 cases made use of endoscopicretrograde biliary drainage tube. Two cases was set endoscopicretrograde biliary drainage tube after failure of EST. from which onecase appeared to be calculus fragmentation.67 cases were treated byCholecystectomy and T-tube. Cure rate of which was 90.5%.Fivecases took a turn for the better and found residual stone after T-tubevisualization. Rate of success and residual stone of patients with ESTis obviously lower than those with Cholecystectomy and T-tube(P<0.05).10 cases were treated by Cholangiojejunostomy. cure rateof which was 100%. There are ten patients with choledocholith andcholecystolithiasis treated by EST and LC. From which one caseapplied open operation after LC because of failure of EST. one caseconverted to open operation after EST because of failure of LC. Theothers were treated by LC after EST.
Analysis: The retrospective analysis demonstrate that Rate ofresidual stone of patients with EST is obviously lower than thosewith Cholecystectomy and T-tube(P<0.05), and Rate of success ofpatients with EST was 83.9%.So EST is the optimal management aslong as if only EST is fit for patient's condition. At the present,Orthodox modus operandi used to treat choledocholith with strictureof common bile duct include oddisphincterotomy and the end-to-sidecholangiojejunostomy(Roux-en-Y). Now oddisphincterotomy hasbeen raplaced gradually by EST. But if obstruction can not be treatedpartly, patients should be treated by the end-to-side cholangiojejuno-stomy. Besides ERBD tube can be used to Support the stricture ofcommon bile duct and is good to drainage bile and prevent residualstone. So patients can be well treated by EST and ERBD, that cannot be treated by end-to-side Cholangiojejunostomy. patients withcholedocholith should insist on microinvasive therapy regardless ofcholecystolithiasis, because that can retain the integrity of bilecommen duct and avoid choledochotomy and prevent fromconverting to open operation after LC for the failure of EST.Conclusion: EST is a safe and effective and Microinvasive
therapy of patients with choledocholith. Rate of residual stone ofpatients with EST is obviously lower than those withCholecystectomy and T-tube(P<0.05).Patients with choledocholithshould insist on Microinvasive therapy regardless ofcholecystolithiasis. ERBD is a supplement to EST. But some patientsstill should be treated by open operation or LCHTD after failure ofEST.
引文
1 王宪华.腹腔镜胆囊切除与胆总管切开取石 131 例.中华普通外科杂志,2000,15(10):622-623.
2 黄建平,万焕真,朱海炎,等. 腹腔镜下胆总管探查治疗胆囊结石并胆总管结石.上海医学,2005,28(10):832-834.
3 Mellinger JD, et al. Bleeding after endo sceop ic sphinctero-tomy as an underestimated entity. Surg Gundco l Obstct, 1991, 172:465
4 Tocchi A, Mazzoni G, Liotta G, et al. Late development of bile duct cancer in patients who had biliary-enteric drainage for begnin disease: a follow-up study of more than 1000 patients. Ann Surg, 2001, 234(2): 210-214.
5 张仲萍,齐武刚,孟兆瑞,等.内镜下逆行胰胆管造影加乳头 切开对胆总管结石的诊疗价值. 实用放射学杂志,2004, 20(9):790-792.
6 Sugiyama M, Atomi Y. Follow-up of more than 10 year endoscopic sphincterotomy for choledocholithiasis in young patients [J]. Br J Surg, 1998, 85(7): 917-921.
7 张诗诚,杜渊,唐志,等.腹腔镜胆总管探查术 43 例报告.中 华外科杂志,1993,31:404-405.
8 牛军,寿楠海,胡三元,等.电视腹腔镜胆管切开纤维胆道镜取石T管引流术的研究(附 50 例报告).实用外科杂志,1993,13:281-283.
9 姚礼庆,王炳生,高卫东,等.十二指肠镜括约肌切开胆总管结石的处理[J].中华消化杂志,1997,17:328.
10 吴阶平,裘法祖.黄家驷外科学.中册.第 6 版.北京:人民卫生出版社,2000.1278-1285.
11 钱礼.现代普通外科.第 2 版.杭州:浙江科技出版社, 1992.322
12 吴孟超,仲剑平.外科学新理论与新技术.上海:上海教育出版社,1996.373
13 Teilum D, In vitro measurement of the length of the sphincter of Oddi. Endoscopy, 1991, 23(3):114
14 王耀东,何协,邱福南,等.腹腔镜与开腹手术治疗胆总管结石 前 瞻 性 临 床 研 究 [J]. 中 华 肝 胆 外 科 杂 志 ,2001, 7(5):302. Wang YD, He X, Qiu FN, etal. Clinical proceding contrast study of laparoscopy and general operation in treating common bile stone [J]. Chin J Hepatobiliary Surg, 2001;7(5):302.
15 陈孝平,石应康,段德生.外科学.第 1 版.北京:人民卫生出版社,2002.341
16 Kubota Y, Takaoka M,Fujimura K et al. Endoscopic endo-prosthesis for large stones in the common bile duct. Tnte ma Med, 1994, 33(4):597.
17 黄志强.当代胆道外科学[M].上海:上海科技文献出版社,1998.350-361.
18 周利国,刘志坚,钟燎原,等.内窥镜与胆道镜联合治疗胆囊合并胆总管结石.中华普通外科杂志,2001,16:538-539.
19 Wojtun S, GilJ, GietkaW, et al. Endoscopic sphincterotomy For choledocholithiasis:aprospective singlecenter study on the short-term and long-term treatment results in 483 patients [J]. End oscopy, 1997, 29:258.
20 黄允宁,杨世杰,徐强,等.内镜治疗胆总管结石的经验体会 [J].宁夏医学杂志,2003,25(2):82.
2 黄建平,万焕真,朱海炎,等. 腹腔镜下胆总管探查治疗胆囊结石并胆总管结石.上海医学,2005,28(10):832-834.
3 Mellinger JD, et al. Bleeding after endo sceop ic sphinctero-tomy as an underestimated entity. Surg Gundco l Obstct, 1991, 172:465
4 Tocchi A, Mazzoni G, Liotta G, et al. Late development of bile duct cancer in patients who had biliary-enteric drainage for begnin disease: a follow-up study of more than 1000 patients. Ann Surg, 2001, 234(2): 210-214.
5 张仲萍,齐武刚,孟兆瑞,等.内镜下逆行胰胆管造影加乳头 切开对胆总管结石的诊疗价值. 实用放射学杂志,2004, 20(9):790-792.
6 Sugiyama M, Atomi Y. Follow-up of more than 10 year endoscopic sphincterotomy for choledocholithiasis in young patients [J]. Br J Surg, 1998, 85(7): 917-921.
7 张诗诚,杜渊,唐志,等.腹腔镜胆总管探查术 43 例报告.中 华外科杂志,1993,31:404-405.
8 牛军,寿楠海,胡三元,等.电视腹腔镜胆管切开纤维胆道镜取石T管引流术的研究(附 50 例报告).实用外科杂志,1993,13:281-283.
9 姚礼庆,王炳生,高卫东,等.十二指肠镜括约肌切开胆总管结石的处理[J].中华消化杂志,1997,17:328.
10 吴阶平,裘法祖.黄家驷外科学.中册.第 6 版.北京:人民卫生出版社,2000.1278-1285.
11 钱礼.现代普通外科.第 2 版.杭州:浙江科技出版社, 1992.322
12 吴孟超,仲剑平.外科学新理论与新技术.上海:上海教育出版社,1996.373
13 Teilum D, In vitro measurement of the length of the sphincter of Oddi. Endoscopy, 1991, 23(3):114
14 王耀东,何协,邱福南,等.腹腔镜与开腹手术治疗胆总管结石 前 瞻 性 临 床 研 究 [J]. 中 华 肝 胆 外 科 杂 志 ,2001, 7(5):302. Wang YD, He X, Qiu FN, etal. Clinical proceding contrast study of laparoscopy and general operation in treating common bile stone [J]. Chin J Hepatobiliary Surg, 2001;7(5):302.
15 陈孝平,石应康,段德生.外科学.第 1 版.北京:人民卫生出版社,2002.341
16 Kubota Y, Takaoka M,Fujimura K et al. Endoscopic endo-prosthesis for large stones in the common bile duct. Tnte ma Med, 1994, 33(4):597.
17 黄志强.当代胆道外科学[M].上海:上海科技文献出版社,1998.350-361.
18 周利国,刘志坚,钟燎原,等.内窥镜与胆道镜联合治疗胆囊合并胆总管结石.中华普通外科杂志,2001,16:538-539.
19 Wojtun S, GilJ, GietkaW, et al. Endoscopic sphincterotomy For choledocholithiasis:aprospective singlecenter study on the short-term and long-term treatment results in 483 patients [J]. End oscopy, 1997, 29:258.
20 黄允宁,杨世杰,徐强,等.内镜治疗胆总管结石的经验体会 [J].宁夏医学杂志,2003,25(2):82.