胆囊切除术后残留胆总管结石的临床特点及腹腔镜治疗
|
摘要
目的探讨胆囊切除术后残留胆总管结石的临床特点和腹腔镜手术的疗效。方法回顾性分析2015年1月～2017年12月笔者医院收治的14例胆囊切除术后残留胆总管结石患者,分析其临床表现、既往手术史、实验室检查、影像学表现和手术相关指标。结果 14例患者首次出现症状与初次手术间隔时间为1～22个月,中位间隔时间为11个月。其中9例以右上腹疼痛伴恶心、呕吐、发热为主要症状,5例以梗阻性黄疸为主要表现,且有2例患者并发急性胰腺炎。既往8例为择期腹腔镜手术,4例为急诊腹腔镜手术,2例为急诊开腹手术。12例次谷丙转氨酶、谷草转氨酶升高,5例次总胆红素、直接胆红素升高,2例次血、尿淀粉酶及脂肪酶升高。所有患者均经过MRCP检查证实胆总管结石。所有患者无中转开腹病例,术后无严重并发症发生。手术时间75～164min,中位手术时间90min;手术出血量15～154ml,中位出血量48ml;术后住院时间5～14天,中位住院时间7天。结论患者胆囊切除术后原症状不缓解或再次出现类似症状时,甚至发热、黄疸、并发急性胰腺炎时均应考虑胆总管结石残留可能,且腹腔镜手术治疗残留胆总管结石安全而有效。
Objective To explore the clinical features and laparoscopic management of residual choledocholithiasis after cholecystectomy. Methods The clinical data of 14 patients with re residual choledocholithiasis after cholecystectomy from Jan. 2015 to Dec. 2017 were reviewed. These patients' clinical manifestation,previous surgical history,laboratory examination,imaging examination and indexes related to surgery were analyzed. Results Initial clinical manifestation occurred at 1-22 months( median,11 months). Among 14 cases,9 cases had right upper abdominal pain with nausea,vomiting and fever,and 5 cases had obstructive jaundice. In additional,2 cases complicated with acute pancreatitis. All the patients had histories of cholecystectomy,including 8 cases with elective laparoscopic cholecystectomy,4 cases with emergency laparoscopic cholecystectomy and the other 2 cases with emergency open cholecystectomy. 12 cases with elevated alanine transaminase and aspartate transaminase,5 cases with elevated total bilirubin and direct bilirubin and 2 cases with elevated serum and urinary amylase and lipase were detected. These 14 cases had positive results of MRCP. No patient was transferred to open procedure and had severe complications. The operation time,blood loss and hospital stay were 75-164 min( median,90 min),15-154 ml( median,48 ml),5-14 days( median,7 days) respectively. Conclusion When the symptoms after cholecystectomy are not relieved or similar symptoms occur again,even with fever,jaundice,acute pancreatitis,the residual choledocholithiasis should be considered. Laparoscopic procedure for residual choledocholithiasis is safe and feasible.
Objective To explore the clinical features and laparoscopic management of residual choledocholithiasis after cholecystectomy. Methods The clinical data of 14 patients with re residual choledocholithiasis after cholecystectomy from Jan. 2015 to Dec. 2017 were reviewed. These patients' clinical manifestation,previous surgical history,laboratory examination,imaging examination and indexes related to surgery were analyzed. Results Initial clinical manifestation occurred at 1-22 months( median,11 months). Among 14 cases,9 cases had right upper abdominal pain with nausea,vomiting and fever,and 5 cases had obstructive jaundice. In additional,2 cases complicated with acute pancreatitis. All the patients had histories of cholecystectomy,including 8 cases with elective laparoscopic cholecystectomy,4 cases with emergency laparoscopic cholecystectomy and the other 2 cases with emergency open cholecystectomy. 12 cases with elevated alanine transaminase and aspartate transaminase,5 cases with elevated total bilirubin and direct bilirubin and 2 cases with elevated serum and urinary amylase and lipase were detected. These 14 cases had positive results of MRCP. No patient was transferred to open procedure and had severe complications. The operation time,blood loss and hospital stay were 75-164 min( median,90 min),15-154 ml( median,48 ml),5-14 days( median,7 days) respectively. Conclusion When the symptoms after cholecystectomy are not relieved or similar symptoms occur again,even with fever,jaundice,acute pancreatitis,the residual choledocholithiasis should be considered. Laparoscopic procedure for residual choledocholithiasis is safe and feasible.
引文
1卢绮萍.慢性胆囊炎胆囊结石行保留及切除胆囊的争议与共识[J].中国实用外科杂志,2015,35(1):49-53
2中华医学会外科学分会胆道外科学组.胆囊良性疾病治疗决策的专家共识(2011版)[J].中华消化外科杂志,2011,10(1):14-19
3 Wolfe BM,Gardiner B,Frey CF.Laparoscopic cholecystectomy.a remarkable development[J].Jama,1991,265(12):1573
4刘洪锋.腹腔镜胆囊切除术后近期胆总管结石残留的危险因素分析[J].临床肝胆病杂志,2017,33(2):293-296
5 Cox MR,Budge JP,Eslick GD.Timing and nature of presentation of unsuspected retained common bile duct stones after laparoscopic cholecystectomy:a retrospective study[J].Surg Endosc,2015,29(7):2033-2038
6刘国礼.腹腔镜胆囊切除的现状与展望[J].肝胆胰外科杂志,2000,12(1):1-2
7张达,甘启祥,夏时昌,等.腹腔镜胆囊切除术后胆总管残留结石的防治[J].实用医院临床杂志,2011,8(5):81-83
8胡晋太,蔡晚霞.警惕腹腔镜胆囊切除术后胆总管结石的遗漏[J].中国微创外科杂志,2012,12(2):171-172
9 Sosulski A,Fei J,Demuro J.Partial cholecystectomy resulting in recurrent acute cholecystitis and choledocholithiasis[J].J Surg Case Rep,2012,2012(9):17
10 Mandelia A,Gupta AK,Verma DK,et al.The value of magnetic resonance cholangio-pancreatography(MRCP)in the detection of choledocholithiasis[J].J Clin Diagn Res,2013,7(9):1941-1945
11 Meeralam Y,Al-Shammari K,Yaghoobi M.Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis:a metaanalysis of diagnostic test accuracy in head-to-head studies[J].Gastrointest Endosc,2017,86(6):986-993
12 Chen YI,Martel M,Barkun AN.Choledocholithiasis:should EUSreplace MRCP in patients at intermediate risk?[J].Gastrointest Endoscopy,2017,86(6):994
13 Talukdar R.Complications of ERCP[J].Best Pract Res Clin Gastroenterol,2016,30(5):793-805
14 Desilets DJ.Management of post-ERCP complications[J].Minerva Chir,2017,72(2):157-168
15付庆江,吴治宇,孟晓东,等.开腹与腹腔镜胆道术后再次腹腔镜胆道手术的比较[J].中华肝胆外科杂志,2017,23(1):58-59
16苗江雨,郭炳勋,张静,等.腹腔镜再次胆道手术治疗胆总管结石的有效性及安全性分析[J].中国普通外科杂志,2016,25(2):197-201
17段仁全,王伟,张慧慧,等.腹腔镜胆道再手术治疗60岁以上肝外胆管结石患者的效果观察[J].临床肝胆病杂志,2017,33(2):289-292
18 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].JLaparoendosc Adv Surg Tech A,2015,25(1):7-11
19许俊峰,郭献廷.腹腔镜再次胆道手术治疗胆总管结石的外科技巧与应用价值[J].中国微创外科杂志,2017,17(7):615-617
2中华医学会外科学分会胆道外科学组.胆囊良性疾病治疗决策的专家共识(2011版)[J].中华消化外科杂志,2011,10(1):14-19
3 Wolfe BM,Gardiner B,Frey CF.Laparoscopic cholecystectomy.a remarkable development[J].Jama,1991,265(12):1573
4刘洪锋.腹腔镜胆囊切除术后近期胆总管结石残留的危险因素分析[J].临床肝胆病杂志,2017,33(2):293-296
5 Cox MR,Budge JP,Eslick GD.Timing and nature of presentation of unsuspected retained common bile duct stones after laparoscopic cholecystectomy:a retrospective study[J].Surg Endosc,2015,29(7):2033-2038
6刘国礼.腹腔镜胆囊切除的现状与展望[J].肝胆胰外科杂志,2000,12(1):1-2
7张达,甘启祥,夏时昌,等.腹腔镜胆囊切除术后胆总管残留结石的防治[J].实用医院临床杂志,2011,8(5):81-83
8胡晋太,蔡晚霞.警惕腹腔镜胆囊切除术后胆总管结石的遗漏[J].中国微创外科杂志,2012,12(2):171-172
9 Sosulski A,Fei J,Demuro J.Partial cholecystectomy resulting in recurrent acute cholecystitis and choledocholithiasis[J].J Surg Case Rep,2012,2012(9):17
10 Mandelia A,Gupta AK,Verma DK,et al.The value of magnetic resonance cholangio-pancreatography(MRCP)in the detection of choledocholithiasis[J].J Clin Diagn Res,2013,7(9):1941-1945
11 Meeralam Y,Al-Shammari K,Yaghoobi M.Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis:a metaanalysis of diagnostic test accuracy in head-to-head studies[J].Gastrointest Endosc,2017,86(6):986-993
12 Chen YI,Martel M,Barkun AN.Choledocholithiasis:should EUSreplace MRCP in patients at intermediate risk?[J].Gastrointest Endoscopy,2017,86(6):994
13 Talukdar R.Complications of ERCP[J].Best Pract Res Clin Gastroenterol,2016,30(5):793-805
14 Desilets DJ.Management of post-ERCP complications[J].Minerva Chir,2017,72(2):157-168
15付庆江,吴治宇,孟晓东,等.开腹与腹腔镜胆道术后再次腹腔镜胆道手术的比较[J].中华肝胆外科杂志,2017,23(1):58-59
16苗江雨,郭炳勋,张静,等.腹腔镜再次胆道手术治疗胆总管结石的有效性及安全性分析[J].中国普通外科杂志,2016,25(2):197-201
17段仁全,王伟,张慧慧,等.腹腔镜胆道再手术治疗60岁以上肝外胆管结石患者的效果观察[J].临床肝胆病杂志,2017,33(2):289-292
18 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].JLaparoendosc Adv Surg Tech A,2015,25(1):7-11
19许俊峰,郭献廷.腹腔镜再次胆道手术治疗胆总管结石的外科技巧与应用价值[J].中国微创外科杂志,2017,17(7):615-617