胆囊结石合并胆总管结石微创外科联合中药治疗的临床对比研究
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摘要
目的探腹腔镜下胆囊切除、胆总管探查(LC+LCBDE)与内镜逆行性胰胆管造影(ERCP)联合腹腔镜胆囊切除术(LC)治疗胆囊结石合并胆总管结石的术式选择及术后联合中药治疗的临床效果。
方法回顾总结胆囊结石合并胆总管结石患者90例，采用LC+LCBDE52例，ERCP+LC38例手术治疗以及中药治疗的临床资料，从手术适应症、手术时间、并发症发生率、术后效果等进行了对比研究。
结果两种术式手术适应症不同，应根据术前检查选择不同的手术方式，所有患者均无中转开腹，无病例死亡，未出现术后并发症，中药联合疗效好。
结论两种术式各有适应症和优缺点，应根据具体情况采用安全有效的手术方式。无论选择何种术式，术后联合中药治疗值得临床推广。
Objective: To evaluate the effect of LC+LCBDE and ERCP combinedLC on treating cholecysto-choledocholithiasis. Meanwhile observe theclinical effect of Traditional Chinese medicine applied after operation
Methods: fifty-two patients with calculus of extrahepatic bile duct. weretreated by LC+LCBDE, and thirty-eight cases by ERCP combined withLC. The clinical data of the two groups was contrasted in the operationindication, time, cost, incidence rate of complication, operation effect andso on.
Results: There have different operation indication. So we should choosethe different operation ways that LC+ERCP or LC+LCBDE by means ofpre-operation examine. All patients in the group were not transferredinto open—abdominal operation. There was no died case. Nocomplications has been found. Combined with Traditional Chinesemedicine has good clinical effectiveness.
Conclusions: There are respective indication, advantages anddisadvantages in the two groups. Different operation should be adoptedaccording to specific condition. Whatever operative technique may beselected, combined with Traditional Chinese medicine treated afteroperation deserve clinical popularization.
方法回顾总结胆囊结石合并胆总管结石患者90例，采用LC+LCBDE52例，ERCP+LC38例手术治疗以及中药治疗的临床资料，从手术适应症、手术时间、并发症发生率、术后效果等进行了对比研究。
结果两种术式手术适应症不同，应根据术前检查选择不同的手术方式，所有患者均无中转开腹，无病例死亡，未出现术后并发症，中药联合疗效好。
结论两种术式各有适应症和优缺点，应根据具体情况采用安全有效的手术方式。无论选择何种术式，术后联合中药治疗值得临床推广。
Objective: To evaluate the effect of LC+LCBDE and ERCP combinedLC on treating cholecysto-choledocholithiasis. Meanwhile observe theclinical effect of Traditional Chinese medicine applied after operation
Methods: fifty-two patients with calculus of extrahepatic bile duct. weretreated by LC+LCBDE, and thirty-eight cases by ERCP combined withLC. The clinical data of the two groups was contrasted in the operationindication, time, cost, incidence rate of complication, operation effect andso on.
Results: There have different operation indication. So we should choosethe different operation ways that LC+ERCP or LC+LCBDE by means ofpre-operation examine. All patients in the group were not transferredinto open—abdominal operation. There was no died case. Nocomplications has been found. Combined with Traditional Chinesemedicine has good clinical effectiveness.
Conclusions: There are respective indication, advantages anddisadvantages in the two groups. Different operation should be adoptedaccording to specific condition. Whatever operative technique may beselected, combined with Traditional Chinese medicine treated afteroperation deserve clinical popularization.
引文
[1] 黄志强．黄志强胆道外科手术学．北京：人民军医出版社，1995．186．
[2] Sugiyama M, Atomi Y, Acutebiliary pancreatitis: the roles of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography [J]. Surgery, 1998; 124: 14～21
[3] Chak A, Hawes RH, Cooper GS, et al. Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis[J]. Gastrointest Endosc, 1999; 49: 599～604
[4] Gross BH. Hatter LP, Gore RaM. Ultrasonic evaluation of common bile duct stones: prospective comparison with endoscopic retrograde cholan, giopancreatography[J]. Radiology, 1983; 146-471-477
[5] 周康荣．胆石征．见周康荣．腹部CT[M]．第1版．上海：上海医科大学出版社，1993：73-78
[6] 赵振国，张拓塞，青科，等．胆总管结石的CT诊断[J]．中华放射学杂志。1995；29：850～853
[7] Polkowski M, Palucki J, Regula J, et al. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: arospectiveblinded study in non jaundiced patients[J]. Gut, 1999; 45:744——749
[8] 中国人民解放军总后勤部卫生部．临床疾病诊断依据治愈好转标准[M]．北京：人民军医出版社，1987．655—656．
[9] Hopt UT, Adam U. Therapeutic splitting as standard treatment for cholelithiasis[J]. Chirurg, 2006,77(4):307-314
[10] Rojas Ortega S, Arizpe Bravo D, Matin Lopez E. Exploration of biliary tracts for laparoscopy for treatment of choledocholithiasis[J].Rev Gastroenterol Mex. 2004, 69(3):112-6
[11] Tang CN, Tsui KK, Ha JP, et al. Laparoscopic exploration of the common bile duct: 10-year experience of 174 patients from a single center [J]. Hong Kong Med J.2006, 12(3):191-6
[12] Chen CN, Tay KH, Hoe NN, et al. Endoscopic retrograde cholangiopancreatography management of common bile duct stones in a surgical unit[J]. ANZ J Surg. 2005,75(12):1070-2
[13] 陶凯雄，王国斌，张杰等．腹腔镜胆总管切开取石T管引流术治疗胆囊结石并胆总管结石研究[J]．临床外科杂志，2005，13(10)：619-21
[14] Hong DF, Xin Y, Chen DW. Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis [J]. Surg Endosc.2006, 20(3):424-7
[15] Griniatsos J, Karvounis E, Isla A. Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis [J].Am Surg, 2005, 71(8):682-6
[16] 李霖，梁驰，韦涌初，等．胆总管结石的微创治疗进展[J]．医学文选．21Y-4，23(5)：678—680．
[17] 许军，赵金鹏，孙备，等．联合应用LC与EST治疗胆囊胆总管结石[J]．肝胆胰外科杂志，2002，14(1)：13—14．
[18] Khan MR, Naureen S, Hussain D, et al. Manageaaaent outcome of residual commom bile duct stones at Aga Khan University Hospital[J]. J Ayub Med Coil Abbottabad, 2005. 17(3): 7—10.
[19] 陈志坦．孔文涛，王川，等．经内镜乳头括约肌切开治疗胆总管结石298例体会[J]．中华消化内镜杂志，2003，20(4)：281—282
[20] 孙振兴，许国铭，李兆申，等．ERCP和EST在LC术前术后的应用价值．肝胆胰外科杂志，2002，14(2)：80—81
[21] Isla AM, Griniatsos J, Wan A. A technique for safe placement of a biliary endoprosthesis after laparoscopic cholecystectomy[J]. Laparosc Endosc Adv Surg Tech A, 2002, 12:207—211
1 Dubios F. Celioseope cholecystectomy prelimimary report of 36 eases. Ann Surg. 1990, 21 1: 60
2 苟祖武． 电视腹腔镜胆囊切除100例． 中华外科杂志，1991，20：616
3 黄文东．方药中，邓铁涛，等．实用中医内科学．上海：上海科学技术出版社，1985．402
4 陈灏珠主编．实用内科学·下册．第11版．北京：人民卫生出版社，2001．1893．1895，1898
5 于频主编．系统解剖学．第4版．北京：人民卫生出版社，2000．130
6 朱宏李翔．腹腔镜联合胆道镜治疗胆总管结石体会局解手术学杂志2003年第12卷第2期138．
7 舒柏荣 赵红炜．陆显斌 腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石8例报告．中国微创外科杂志，2006年12月第6卷第12期992．
8 梁中骁，罗建强，黄顺荣，等．腹腔镜联合纤维胆道镜治疗肝内外胆管结石．中国微刨外科杂志，2003，3(1)：63—64．
9 薛冰川，柳万里，马艳波，等．肝胆管结石的内镜治疗．中国微创外科杂志，2005，5(4)：274—275．
10 耿红超 孟克飞 高永峰．胆道镜和腹腔镜联合胆总管探查术82例体会．中原医刊．2005年11月第32卷第22期 10-11．
11 Yasuda I, TomitaE, EnyaM , et al. Can endoscopic papillary balloon dilation really preserve sphincter of Oddi function? Gut, 2001, 49(5): 686—691.
12 Costamagna G, Shah SK, Tringali A. Current management of postoperative complications and benign biliary strictures. Gastrointest Endosc Clin N Am, 2003, 13(4): 635—648.
13 Garg PK, Tandon PK, Ahuja V, et al. Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones. Gastrointest Endosc, 2004, 59: 601—605.
14 Watanabe Y, SatoM, Tokui K, et al. Painless lithotripsy by flashlamp—excited dye laser for impacted biliary stones: an experimental and clinical study. Eur J Surg. 2000, 166: 455—458.
15 Hui CK, Lai KC, Ng M, et al. Retained common bile duct stones: acomparison between biliary stenting and complete clearance of stones by electrohydraulic lithotripsy Aliment Pharmacol Ther, 2003, 17: 289—296.
16 Ellis RD, Jenkins AP, Thompson RP, et al. Clearance of refractor), bile duct stones with extracorporeal shockwave lithotripsy. Gut, 2000, 47: 728—731.
17 Garrard CL, Clements RN, Narmey L, et al. Adhesion formation is reduced after laparosoopic surgery[J]. Surg Endosc, 1999, 13: 10—13
18 Kuntz C, Wtmsch A, Bay F, et al. Prospective randomized study of stress and immune response after laparoscopic vs conventional Colon. ic resection[J]. Surg Endosc, 1998, 12: 963—967
19 Berguer R, Dalton Mo Ferrick D. Adrenocortical response and regional T-lymphocyte activation patterns following minimally invasive surgery in a rat model[J]. Surg Endosc, 1998, 12: 236—240
20 Turcu F. Combined laparoscopie and endoscopic treatment of gallbladder and bile duct stones. Chirurgia, 2002, 97: 497—504.
21 Qin MF, Xu fiB. Combined laparoscopie and endoscopic treatment for bile duct diseases. Hepatobiliary Pancreat Dis Int, 2004, 3: 284—287
22 丁志强，俞亚红，卢兴培．内镜联合腹腔镜治疗胆囊结石合并肝外胆管结石．腹腔镜外科杂志．2002年3月第7卷第1期9-10．
23 李兵 龚昭 肖新波．内镜联合腹腔镜治疗胆囊结石合并胆总管结石52例体会．腹部外科．2006年第19卷第5期295．
24 张勇，王雪峰， 董平．十二指肠镜与腹腔镜联合应用治疗胆道结石．上海第二医科大学学报．2003 Vol．23 NO．5，421．
25 邵泉 张继军 蔡荣祥，两镜联合治疗胆囊结石并非扩张性肝外胆管结石(附133例分析)．中国内镜杂志，2003年9月第9卷第9期14
26 赖智德 王耀东 何利平，联合腹腔镜、内镜微创治疗胆囊结石合并胆总管结石．临床外科杂志，2005年12月第13卷第12期758
27 王忠振 吴慧丽 石伟，内镜腹腔镜联合治疗胆囊结石合并胆总管结石．中国微创外科杂志，2004年12月第4卷第6期476
28 周宗庆，王志敏，傅志红，十二指肠镜联合腹腔镜治疗胆囊结石并胆总管结石．肝胆胰外科杂志，2002年12月第14卷第4期227
29 毛志海，王明亮，吴卫泽，腹腔镜联合内镜一期治疗胆囊结石合并肝外胆管结石．腹腔镜外科杂志，2005年4月第10卷第2期92-93
30 刘凤军，智绪亭，寿楠海，等．腹腔镜联合内镜治疗胆石症．中华肝胆外科杂志；2004，10(1)：26—28
31 Tranter SE, Thompson MH. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg, 2002. 89; 1495—1504.
32 Decker G, Borie F, Millat B, et al. One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc, 2003, 17(1): 12—18.
33 Gharaibeh KI, Heiss HA. Biliary leakage following T— tube removal. Int Surg, 2000, 85: 57—66.
34 W ills VL, Gibson K, Karihaloot C, et al. Complications of biliary T—tubes after choledochotomy. ANZ J Surg, 2002, 72(3): 177—180.
35 张勇，罗鹏．多种腔镜联合治疗胆囊结石并胆管结石408例．实用临床医学2004年第5卷第6期
[2] Sugiyama M, Atomi Y, Acutebiliary pancreatitis: the roles of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography [J]. Surgery, 1998; 124: 14～21
[3] Chak A, Hawes RH, Cooper GS, et al. Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis[J]. Gastrointest Endosc, 1999; 49: 599～604
[4] Gross BH. Hatter LP, Gore RaM. Ultrasonic evaluation of common bile duct stones: prospective comparison with endoscopic retrograde cholan, giopancreatography[J]. Radiology, 1983; 146-471-477
[5] 周康荣．胆石征．见周康荣．腹部CT[M]．第1版．上海：上海医科大学出版社，1993：73-78
[6] 赵振国，张拓塞，青科，等．胆总管结石的CT诊断[J]．中华放射学杂志。1995；29：850～853
[7] Polkowski M, Palucki J, Regula J, et al. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: arospectiveblinded study in non jaundiced patients[J]. Gut, 1999; 45:744——749
[8] 中国人民解放军总后勤部卫生部．临床疾病诊断依据治愈好转标准[M]．北京：人民军医出版社，1987．655—656．
[9] Hopt UT, Adam U. Therapeutic splitting as standard treatment for cholelithiasis[J]. Chirurg, 2006,77(4):307-314
[10] Rojas Ortega S, Arizpe Bravo D, Matin Lopez E. Exploration of biliary tracts for laparoscopy for treatment of choledocholithiasis[J].Rev Gastroenterol Mex. 2004, 69(3):112-6
[11] Tang CN, Tsui KK, Ha JP, et al. Laparoscopic exploration of the common bile duct: 10-year experience of 174 patients from a single center [J]. Hong Kong Med J.2006, 12(3):191-6
[12] Chen CN, Tay KH, Hoe NN, et al. Endoscopic retrograde cholangiopancreatography management of common bile duct stones in a surgical unit[J]. ANZ J Surg. 2005,75(12):1070-2
[13] 陶凯雄，王国斌，张杰等．腹腔镜胆总管切开取石T管引流术治疗胆囊结石并胆总管结石研究[J]．临床外科杂志，2005，13(10)：619-21
[14] Hong DF, Xin Y, Chen DW. Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis [J]. Surg Endosc.2006, 20(3):424-7
[15] Griniatsos J, Karvounis E, Isla A. Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis [J].Am Surg, 2005, 71(8):682-6
[16] 李霖，梁驰，韦涌初，等．胆总管结石的微创治疗进展[J]．医学文选．21Y-4，23(5)：678—680．
[17] 许军，赵金鹏，孙备，等．联合应用LC与EST治疗胆囊胆总管结石[J]．肝胆胰外科杂志，2002，14(1)：13—14．
[18] Khan MR, Naureen S, Hussain D, et al. Manageaaaent outcome of residual commom bile duct stones at Aga Khan University Hospital[J]. J Ayub Med Coil Abbottabad, 2005. 17(3): 7—10.
[19] 陈志坦．孔文涛，王川，等．经内镜乳头括约肌切开治疗胆总管结石298例体会[J]．中华消化内镜杂志，2003，20(4)：281—282
[20] 孙振兴，许国铭，李兆申，等．ERCP和EST在LC术前术后的应用价值．肝胆胰外科杂志，2002，14(2)：80—81
[21] Isla AM, Griniatsos J, Wan A. A technique for safe placement of a biliary endoprosthesis after laparoscopic cholecystectomy[J]. Laparosc Endosc Adv Surg Tech A, 2002, 12:207—211
1 Dubios F. Celioseope cholecystectomy prelimimary report of 36 eases. Ann Surg. 1990, 21 1: 60
2 苟祖武． 电视腹腔镜胆囊切除100例． 中华外科杂志，1991，20：616
3 黄文东．方药中，邓铁涛，等．实用中医内科学．上海：上海科学技术出版社，1985．402
4 陈灏珠主编．实用内科学·下册．第11版．北京：人民卫生出版社，2001．1893．1895，1898
5 于频主编．系统解剖学．第4版．北京：人民卫生出版社，2000．130
6 朱宏李翔．腹腔镜联合胆道镜治疗胆总管结石体会局解手术学杂志2003年第12卷第2期138．
7 舒柏荣 赵红炜．陆显斌 腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石8例报告．中国微创外科杂志，2006年12月第6卷第12期992．
8 梁中骁，罗建强，黄顺荣，等．腹腔镜联合纤维胆道镜治疗肝内外胆管结石．中国微刨外科杂志，2003，3(1)：63—64．
9 薛冰川，柳万里，马艳波，等．肝胆管结石的内镜治疗．中国微创外科杂志，2005，5(4)：274—275．
10 耿红超 孟克飞 高永峰．胆道镜和腹腔镜联合胆总管探查术82例体会．中原医刊．2005年11月第32卷第22期 10-11．
11 Yasuda I, TomitaE, EnyaM , et al. Can endoscopic papillary balloon dilation really preserve sphincter of Oddi function? Gut, 2001, 49(5): 686—691.
12 Costamagna G, Shah SK, Tringali A. Current management of postoperative complications and benign biliary strictures. Gastrointest Endosc Clin N Am, 2003, 13(4): 635—648.
13 Garg PK, Tandon PK, Ahuja V, et al. Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones. Gastrointest Endosc, 2004, 59: 601—605.
14 Watanabe Y, SatoM, Tokui K, et al. Painless lithotripsy by flashlamp—excited dye laser for impacted biliary stones: an experimental and clinical study. Eur J Surg. 2000, 166: 455—458.
15 Hui CK, Lai KC, Ng M, et al. Retained common bile duct stones: acomparison between biliary stenting and complete clearance of stones by electrohydraulic lithotripsy Aliment Pharmacol Ther, 2003, 17: 289—296.
16 Ellis RD, Jenkins AP, Thompson RP, et al. Clearance of refractor), bile duct stones with extracorporeal shockwave lithotripsy. Gut, 2000, 47: 728—731.
17 Garrard CL, Clements RN, Narmey L, et al. Adhesion formation is reduced after laparosoopic surgery[J]. Surg Endosc, 1999, 13: 10—13
18 Kuntz C, Wtmsch A, Bay F, et al. Prospective randomized study of stress and immune response after laparoscopic vs conventional Colon. ic resection[J]. Surg Endosc, 1998, 12: 963—967
19 Berguer R, Dalton Mo Ferrick D. Adrenocortical response and regional T-lymphocyte activation patterns following minimally invasive surgery in a rat model[J]. Surg Endosc, 1998, 12: 236—240
20 Turcu F. Combined laparoscopie and endoscopic treatment of gallbladder and bile duct stones. Chirurgia, 2002, 97: 497—504.
21 Qin MF, Xu fiB. Combined laparoscopie and endoscopic treatment for bile duct diseases. Hepatobiliary Pancreat Dis Int, 2004, 3: 284—287
22 丁志强，俞亚红，卢兴培．内镜联合腹腔镜治疗胆囊结石合并肝外胆管结石．腹腔镜外科杂志．2002年3月第7卷第1期9-10．
23 李兵 龚昭 肖新波．内镜联合腹腔镜治疗胆囊结石合并胆总管结石52例体会．腹部外科．2006年第19卷第5期295．
24 张勇，王雪峰， 董平．十二指肠镜与腹腔镜联合应用治疗胆道结石．上海第二医科大学学报．2003 Vol．23 NO．5，421．
25 邵泉 张继军 蔡荣祥，两镜联合治疗胆囊结石并非扩张性肝外胆管结石(附133例分析)．中国内镜杂志，2003年9月第9卷第9期14
26 赖智德 王耀东 何利平，联合腹腔镜、内镜微创治疗胆囊结石合并胆总管结石．临床外科杂志，2005年12月第13卷第12期758
27 王忠振 吴慧丽 石伟，内镜腹腔镜联合治疗胆囊结石合并胆总管结石．中国微创外科杂志，2004年12月第4卷第6期476
28 周宗庆，王志敏，傅志红，十二指肠镜联合腹腔镜治疗胆囊结石并胆总管结石．肝胆胰外科杂志，2002年12月第14卷第4期227
29 毛志海，王明亮，吴卫泽，腹腔镜联合内镜一期治疗胆囊结石合并肝外胆管结石．腹腔镜外科杂志，2005年4月第10卷第2期92-93
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