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Larparoscopy Combined with Choledochoscopy for Common BileDuct Exploration in Treatment Bile Duct Calculus

Clinical Experience of Laparoscopic Common Bile Duct Exploration with Choledochoscopy for Cholecystolithiasis and Choledocholithasis in 67 Cases

目的　探讨腹腔镜胆总管探查联合胆道镜治疗胆囊结石合并胆总管结石的手术方法及其临床应用价值。方法　回顾性分析2008年3月至2012年6月期间笔者所在医院收治并行腹腔镜胆总管探查联合胆道镜治疗的67例胆囊结石合并胆总管结石患者的临床资料。结果　67例胆囊结石合并胆总管结石患者中，6例经胆囊管探查取石并行胆囊管一期结扎，15例行胆总管探查取石并行胆总管一期缝合，46例行胆总管探查取石后经T管引流。所有患者的手术均获成功，无中转开腹，无术后大出血及手术死亡。手术时间为（120±30）min（90～150min），术中失血量为（30±10）mL（20～40mL），平均住院时间为8.3d（7～14d）。术后3例患者发生轻度漏胆，经引流后痊愈；4例发生切口感染，经引流并给予抗生素治疗后治愈；1例发生术后早期炎性肠梗阻，经胃肠减压、灌肠、给予生长抑素加地塞米松等保守治疗后痊愈。术后所有患者均获访，随访时间为1个月～3年，平均随访时间为2.1年。随访期间，均无胆道感染和胆管狭窄发生，无结石复发。结论　腹腔镜胆总管探查联合胆道镜治疗胆囊结石合并胆总管结石安全有效。

腹腔镜胆总管探查术后一期缝合与T管引流的临床研究

目的探讨腹腔镜胆总管探查术后一期缝合与T管引流的手术疗效。 方法回顾性分析2012年1月至2013年12月期间太仓市第一人民医院肝胆外科行腹腔镜胆总管探查术50例患者的临床资料，其中18例行胆总管一期缝合，32例行胆总管T管引流，分析2组患者的临床疗效。 结果50例患者无中转开腹，均治愈出院。缝合组及引流组平均胆总管直径分别为（10.6±1.5）mm及（11.3±1.5）mm，胆总管结石数分别为（3.0±2.0）枚及（3.2±2.2）枚，平均结石直径分别为（5.5±1.6）mm及（5.8±2.1）mm，其差异均无统计学意义（P＞0.05）。缝合组和引流组手术时间分别为（107.9±20.3）min和（101.6±36.4）min，分别于手术后（3.8±1.0）d和（3.3±1.0）d拔除腹腔引流管，总住院时间分别为（11.6±3.1）d和（12.0±2.2）d，术后恢复时间分别为（8.9±0.9）d和（7.4±1.1）d，其差异也无统计学意义（P＞0.05）。缝合组和引流组患者住院总费用分别为（14 525.1±2 274.6）元和（16 568.3±2 701.5）元，缝合组住院总费用低于引流组（P＜0.05）。引流组术后有结石残留1例，发生胆汁漏1例；缝合组无并发症发生。 结论与T管引流相比，腹腔镜胆管探查术后一期缝合不增加手术时间、总住院时间、术后恢复时间及术后引流时间，而能减少住院总费用，在合适的病例中，腹腔镜下胆总管探查术后一期缝合安全有效。

Clinical Experience of Laparoscopic Common Bile Duct Exploration

目的 探讨腹腔镜胆总管切开取石术的优势，总结手术操作经验及常见并发症的预防与处理。方法回顾性分析我院1999年6月至2010年4月期间收治的108 例胆管结石患者行腹腔镜胆总管探查取石术的手术方法、操作要点及并发症的处理。结果 腹腔镜手术成功 105例, 中转开腹3例; 手术时间（120±20） min,出血量（25±5） ml,住院时间（9±1） d; 术后发生胆道出血3例,漏胆7 例,残余结石6 例; 全组无死亡病例。结论 腹腔镜胆总管切开取石术具有创伤小、痛苦轻、恢复快、对腹腔脏器干扰小、住院时间短等优点，值得临床推广。

MANAGEMENT OF COMMON BILE DUCT CALCULI WITH LAPAROSCOPIC CHOLEDOCHOTOMY， COMMON BILE DUCT EXPLORATION AND PLACEMENT OF T TUBE

Objective To study the effect of laparoscopic common bile duct exploration via choledochotomy and T tube drainage. Metheods Laparoscopic exploration of common bile duct with choledochoscopy via choledochotomy was performed in 105 patients, T tube was placed in all patients with laparoscopic suturing technique.Results Except negative exploration in 2 cases, duct clearance was achieved in 99 per cent (102/103) of patients. Conclusion Laparoscopic exploratoin of common bile duct via choledochotomy and T tube drainage is one of the safe and effective management options for common bile duct calculi.

Clinical Study for Patients with Cholecystolithiasis and Extrahepatic Bile Duct Stones by Laparoscopic Treatment

目的比较腹腔镜胆囊切除联合胆总管探查术（LC＋LCBDE）与内镜下Oddi括约肌切开取石联合腹腔镜胆囊切除术（EST＋LC）治疗胆囊结石合并肝外胆管结石的临床疗效。 方法回顾性分析45例行LC＋LCBDE及60例行EST＋LC患者的临床资料，观察2组在单次结石清除率、中转手术率、手术并发症、住院时间等指标方面的效果。 结果2组患者的基线资料相近，无手术死亡病例；2组术后并发症发生情况的差异无统计学意义（P＞0.05）；LC＋LCBDE组单次治疗成功率高于EST＋LC组，而住院时间及中转手术率则短于或低于EST＋LC组（P＜0.05）。 结论LC＋LCBDE是治疗胆囊结石合并肝外胆管结石患者安全有效的方法。

Laparoscopic Common Bile Duct Exploration:A Report of 1221 Cases

目的：总结运用腹腔镜胆总管探查术的治疗经验。方法：回顾性分析1992年3月～2006年12月运用腹腔镜胆总管探查术对1221例患者进行治疗的经验。结果：即时缝合671例中634例和T管引流550例中501例治疗获得成功。中转开腹9例，胆漏46例，术后残余结石内镜未取净11例，死亡5例。结论：只要选择合适的病例，腹腔镜胆总管探查术对于有较高内镜和腹腔镜技术者是可行、有效和安全的。

Is prophylactic gastrointestinal decompression necessary in patients undergoing laparoscopic common bile duct exploration?

ObjectiveTo investigate safety and feasibility of laparoscopic common bile duct exploration (LCBDE) without preoperative prophylactic gastrointestinal decompression.MethodsA prospective study was conducted on the patients with choledocholithiasis and cholecystolithiasis scheduled to undergo LCBDE plus laparoscopic cholecystectomy in this hospital from January 2016 to December 2017. All the patients were randomly divided into a gastrointestinal decompression group and a non-gastrointestinal decompression group by the same researcher according to the random number table method. The general conditions, intraoperative status and postoperative status of patients in the two groups were compared.ResultsA total of 286 patients were enrolled in this study, including 120 in the non-gastrointestinal decompression group and 166 in the gastrointestinal decompression group. There were no significant differences in the general data such as the age, gender, smoking history, drinking history, preoperative complications, results of preoperative laboratory examination, and preoperative anesthesia score between the two groups (P>0.050). The time of oral feeding in the non-gastrointestinal decompression group was significantly earlier than that in the gastrointestinal decompression group (t=2.181, P=0.030). There were no significant differences in the bleeding volume, operative time, anal ventilation time, total hospitalization time, and postoperative hospitalization time between the two groups (P>0.050). The incidences of nausea/vomiting and poor appetite in the non-gastrointestinal decompression were significantly lower than those in the gastrointestinal decompression group (χ2=5.098, P=0.024; χ2=4.905, P=0.027). There were no significant differences in the incidences of other complications between the two groups (P>0.050).ConclusionFrom results of this study, prophylactic gastrointestinal decompression should not be recommended for patients undergoing LCBDE.

胆囊结石合并胆总管结石术式选择的临床研究

目的 探讨治疗胆囊结石合并胆总管结石的手术方式选择。 方法 回顾性分析笔者所在医院 2013 年 12 月至 2015 年 12 月期间择期行腹腔镜胆囊切除+胆总管探查术（LC+LCBDE 组，87例）和经内镜乳头括约肌切开+腹腔镜胆囊切除术（EST+LC 组，69例）治疗的 156 例患者的临床资料。 结果 2 组病例均获得了良好的治疗效果。LC+LCBDE 组手术成功率为 100%（87/87），EST+LC 组为 91.30%（63/69）。LC+LCBDE 组的手术成功率、手术时间、住院时间及住院费用方面均明显优于 EST+LC 组（P<0.05）。LC+LCBDE 组术后发生 1 例胆汁漏，EST+LC 组共发生 6 例并发症，其中 2 例胰腺炎、1 例黑便、1 例急性化脓性胆管炎及2 例结石残留，LC+LCBDE 组的总并发症发生率明显低于 EST+LC 组（P<0.05）。尤其是对于胆总管直径≥1.0 cm、结石数目>3 枚及结石直径>1.5 cm 时， LC+LCBDE 组的手术成功率和并发症发生率较 EST+LC 术式的优势更加明显。术后随访至少 1 年 （12～35 个月），LC+LCBDE 组有 1 例发生胆道感染而无结石复发，EST+LC 组共有 13 例发生胆道感染、8 例结石复发，术后胆道感染发病率和结石复发率 LC+LCBDE 组均明显低于 EST+LC 组（P<0.001）。 结论 从本研究有限的病例数据来看，治疗胆囊结石合并胆总管结石可优先考虑 LC+LCBDE，尤其是对于胆总管直径≥1.0 cm、结石数>3 枚及结石直径>1.5 cm 时；但对于 0.6 cm<胆总管直径<1.0 cm 时选择 LC+LCBDE 宜慎重，需权衡利弊；而对于胆总管直径<0.6 cm 时可优先选择行 EST+LC。

Feasibility Through Confluence of Common Bile Duct and Cystic Duct Approach with Mini-Incision in LaparoscopicCommon Bile Duct Exploration

Objective　To investigate the feasibility and patient selection of T-tube free laparoscopic common bileduct exploration through mini-incision in confluence of common bile duct （CBD） and cystic duct. Methods　The clinical data of 52 patients who underwent CBD exploration from January 2009 to December 2011 were retrospectively analyzed. A 3-4mm longitudinal incision of anterior wall of CBD was made along the confluence of CBD and cystic duct， and then the choledochoscope was inserted into CBD through this mini-incision for the exploration and treatment by laparoscopy and choledochoscopy， the incision was sewed up by T-tube free primary suture. Results　All 52 cases were cured and stone clearance rate was 100% as revealed by choledochoscopy and cholangiography. The time of operation， intraoperativecholangiography， removal of stones with help of choledochoscope， and removal drainage tube after operation was from 90 to 200 min with an average of 100min， 3 to 10min with an average of 6min， 5 to 15 min with an average of 8 min，and 3-5d with an average of 3.5d ， respectively. The drainage flow was 20-60mL/d with an average of 30mL/d. No biliary leakage， abdominal pain， and choloplania or infection of incision was observed following operation. The hospital stay was 5 to 12d with an average of 6.5d after operation. No calculus regeneration or bile duct stricture occurred during following-up of 3 to 40 months with an average of 20 months. Conclusion　With proper patient selection， T-tube free laparoscopic CBD exploration through mini-incision in confluence of CBD and cystic duct is safe and feasible by proficient surgeons in laparoscopy and choledochoscopy.