目的 探讨纤维胆道镜在胆道探查术中及术后的应用价值。方法 对113例在胆道探查术中及术后应用纤维胆道镜治疗患者的疗效进行回顾性分析。结果 23例胆总管扩张合并黄疸且术前未见结石的患者，其中19例术中胆道镜发现结石并于术中取净结石，2例炎性狭窄，1例胆管癌，1例未见异常。58例胆总管结石患者术中胆道镜取净结石。32例肝内、外胆管结石患者术中胆道镜取净结石21例; 2例胆道镜发现结石集中于肝左外叶合并肝内胆管狭窄, 行肝左外叶切除; 其余9例患者的结石术中未取净，于术后6～8周再经胆道镜T管窦道取净结石。113例患者术后均无严重并发症发生。术后获随访98例（86.7%），随访时间6～24个月，平均14个月，2例复发，其余96例未见结石复发。结论术中应用纤维胆道镜可明确胆管内病变，降低胆管残余结石的发生率; 术后经T管窦道取石是治疗胆管残余结石的有效方法，可避免再次手术的痛苦。
目的 探讨腹腔镜技术在闭合性腹外伤病例中诊断、治疗的价值。方法 对1999年8月至2004年12月期间26例闭合性腹外伤患者应用腹腔镜进行探查及治疗。结果 26例中肝破裂3例，脾破裂6例，腹膜后血肿2例，肠系膜破裂3例，小肠破裂穿孔8例，结肠破裂穿孔1例，膀胱破裂1例，肠管挫伤2例。14例经腹腔镜顺利完成探查及治疗，另12例中转开腹手术。全部病例未发生术后并发症。结论 腹腔镜技术在闭合性腹外伤患者的探查及治疗过程中是一种有临床应用价值的有效方法。
【摘要】 目的 探讨腹腔镜胆总管探查一期缝合的可行性和适应证及临床价值。 方法 回顾性分析2007年7月—2010年10月72例胆管结石患者的临床资料，采用三孔法腹腔镜胆总管探查术，术中胆道镜配合胆道手术器械取石，一期缝合胆总管进行治疗。 结果 72例手术均获成功，无中转开腹，4例出现术后胆漏，经腹腔引流3~5 d治愈，无严重并发症。术后住院4~7 d（平均4.4 d）。72例均获随访，随访时间1~24个月（平均10个月）。术后1个月B型超声，未发现胆道狭窄及残余结石。 结论 腹腔镜胆总管探查术后一期缝合胆总管，安全、有效、微创效果显著，是临床微创治疗胆囊结石合并胆管结石的一种理想术式，值得临床推广应用。其关键是术中取尽结石和把握适应证，同时需要术者熟练掌握胆道镜技术及腹腔镜下胆总管切开缝合、打结等技术。【Abstract】 Objective To discuss the feasibility, indications and clinical value of laparoscopic common bile duct exploration with primary suture. Methods We analyzed the clinical data of 72 patients with biliary duct stone treated from July 2007 to October 2010. Three-port laparoscopic common bile duct exploration with primary suture was adopted; choledochoscopy and open bile duct operation instruments were used to take out the stones during the operation; and the common bile duct was treated with primary suture after operation. Results All operations were carried out successfully without any case of conversion to open operation. Bile leakage occurred in four cases and was cured with abdominal drainage tube for three to five days without any severe complications. Postoperative hospitalization time ranged from four to seven days, averaging at 4.4 days. All patients were followed up for one to 24 months (averaging at 10 months). B-mode ultrasonography examination one month after operation showed no biliary tract stricture or residual stone. Conclusions Laparoscopic common bile duct exploration with primary suture is safe, reliable, minimally invasive, more effective, and can be regarded as an ideal operative method for the treatment of cholecystolithiasis combined with biliary duct stone in clinical practices. It is worth popularizing. The key elements for a successful operation lie in completely taking out the stones and having a sound knowledge of indications. Furthermore, surgeons should master the skills in choledochoscopy techniques, laparoscopic incision, suture and ligation.
ObjectiveTo explore the diagnostic value of “Four-Step Procedure” of laparoscopic exploration in patients with peritoneal metastasis of gastric cancer.MethodsWe retrospectively collected the data of 409 gastric adenocarcinoma patients from July 2016 to August 2020 who underwent “Four-Step Procedure” of laparoscopic exploration in West China Hospital. The descriptive case series study was conducted to analyze the outcome of laparoscopic exploration combined with CY (cytology test), stepwise treatment plans, and the rates of CY1 and P1 (peritoneal metastasis) among cT3–4 patients during different periods. SPSS 22.0 software was used to conduct the univariate and multivariate logistic regression to analyze the high risk factors associated with P1 and (or) CY1.ResultsA total of 409 gastric adenocarcinoma patients who underwent laparoscopic exploration were enrolled in our study. Among them, 65 patients were confirmed to be P1 and (or) CY1. Stratified analysis by cT and cN staging showed that there were 7 (7.4%) and 55 (27.9%) patients with peritoneal metastasis in cT3 staging and cT4 staging, respectively. After laparoscopic exploration, 168 patients received laparoscopic gastrectomy, 35 patients received laparotomy, 143 patients received neo-adjuvant chemotherapy, and 63 patients received conversion therapy. The bar chart showed an ascending tendency in the diagnosis rate of P1 over time among cT3–4 patients. Multivariate logistic regression analysis showed that ascites was an independent risk factor of CY1 and (or) P1 (P<0.001). Additionally, the postoperative complication rate was 2.9% in the patients who merely underwent laparoscopic exploration, including 4 patients with pulmonary infection and 2 patients with urinary retention.Conclusions“Four-Step Procedure” of laparoscopic exploration is reliable and feasible for gastric cancer. “Four-Step Procedure” of laparoscopic exploration has high diagnostic value for peritoneal metastasis of gastric cancer. Our study shows that most of peritoneal metastasis distribute in cT3 and cT4 patients. For these patients, laparoscopic exploration should be recommended to identify if peritoneal metastasis exists and avoid unnecessary laparotomy.
目的:总结应用腹腔镜联合胆道镜治疗胆总管结石的体会。方法:回顾分析2003年1月至2009年5月成都市第五人民医院联合应用腹腔镜胆道镜治疗胆总管结石的临床资料。结果:经胆囊颈管取石成功21例,切开胆总管取石27例,其中胆总管I期缝合17例,T管引流31例,3例术后发生胆总管残余结石,经T管窦道胆道镜取石治愈,5例中转开腹。结论:选择合适病例,腹腔镜联合胆道镜治疗胆总管结石患者创伤小,效果好,且安全可靠。
目的 采用腹腔镜、内镜联合技术处理胆囊结石合并肝外胆管结石，对同期及分期治疗的结果进行比较。方法 患者60例，其中同期处理36例，分期处理24例。术前诊断依据B超、ERCP或MRCP检查，术中诊断依据术中胆道镜检查和胆道造影，全部病例均诊断为慢性胆囊炎合并胆总管结石。同期手术者直接行腹腔镜胆囊切除术，胆道镜和（或）造影检查后行腹腔镜经胆囊管或胆总管胆道镜取石，闭合胆管开口或放置T管。分期手术者先行或者后行ERCP+经内镜乳头切开术/经内镜乳头气囊扩张术取石，再行常规的腹腔镜胆囊切除术。结果 60例患者腹腔镜胆囊切除术均成功，同期手术者手术时间40～90 min，平均68 min，术后发生1例漏胆； 分期手术者2次手术时间共60～120 min，平均80 min。同期手术者手术时间明显短于分期手术者（P＜0.01），而术后并发症发生情况二者间差异则无统计学意义（Pgt;0.05）。同期手术者住院费用较少（P＜0.01），同时在胆总管一期缝合或胆囊管一期结扎的情况下，住院时间相对较短（P＜0.01）。结论 腹腔镜胆囊切除术＋腹腔镜下胆道镜胆总管探查术或经胆囊管探查术同期治疗胆囊结石合并肝外胆管结石安全可靠，值得进一步研究、推广。
Objective To investigate feasibility and clinical efficacy of exploration and stone removal through choledochoscope via hepatic cross-section during laparoscopic left lateral hepatectomy for hepatolithiasis. Methods The patients who had left extrahepatic bile duct stones with choledocholithiasis from January 2012 to December 2016 were retrospectively collected. Among these patients, 29 cases underwent an exploration and stone removal through choledochoscope via hepatic cross-section during laparoscopic left lateral hepatectomy (observation group) and 26 cases underwent an exploration and stone removal through choledochoscope via incision of common bile duct during laparoscopic left lateral hepatectomy (control group). The operative time, intraoperative blood loss, postoperative hospital stay, postoperative nutritional, and complications rate were compared between these two groups. Results The operations were performed successfully and no perioperative death happened in both groups. There were no significant differences in the operative time and intraoperative blood loss between the two groups (P>0.05). Moreover, the postoperative hospital stay of the observation group was significantly shorter than that of the control group (P<0.05). In addition, there were no significant differences in the complications of the bile leakage, subphrenic infection, and biliary residual stones between the two groups (P>0.05). Also, the levels of prealbumin and the lymphocytes in the observation group were significantly higher than those in the control group on the 3rd and 6th day after the operation (P<0.05). Conclusions Preliminary results of limited cases in this study show that exploration and removal of stones through choledochoscope via hepatic cross-section during laparoscopic left lateral hepatectomy for hepatolithiasis is relatively safe and reliable, its procedure is simplified, could avoid relevant complications due to biliary incision and T tube drainage.
目的 比较腹腔镜胆道探查术后胆总管一期缝合与T管引流两种术式治疗胆囊结石合并胆管结石的疗效。方法 回顾性分析2011年4月至2012年5月期间笔者所在科室收治的因胆囊结石合并胆管结石接受腹腔镜胆囊切除＋胆道探查治疗的109例患者的临床资料，其中58例行T管引流，51例行一期胆总管缝合。比较2组患者的手术时间、住院时间、治疗费用、术后恢复正常生活时间以及手术并发症情况。结果 T管引流组术后发生胆瘘2例（3.4%），一期缝合组术后发生胆瘘1例（2.0%），其差异无统计学意义（P＞0.05）。2组患者的手术时间、住院时间及住院治疗费用的差异均无统计学意义（P＞0.05）。一期缝合组患者术后恢复正常生活时间为（7.2±1.1） d，短于T管引流组的（28.2±2.7）d（P=0.001）。结论 经腹腔镜胆道探查术后一期胆总管缝合是安全可行的，可缩短患者的康复时间，提高患者围手术期生活质量。
Objective To evaluate the safety and efficacy of primary closure (PC) and T-tube drainage (TD) after laparoscopic common bile duct exploration (LCBDE). Methods The randomized controlled trials of PC and TD after LCBDE were retrieved from the Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until April 2015. All calculations and statistical tests were performed using ReviewerManager 5.2 software. Results Both of the two groups had no postoperative deaths within 30 days. The operative time and hospital stay of PC gourp were shorter than TD group statistically〔OR=–24.76, 95CI (–29.21, –20.31),P<0.000 01〕and〔OR=–2.68, 95%CI (–3.69, –1.67),P<0.000 01〕. The reoperative rate of PC group was lower than that of TD group, and the difference was statistically significant〔OR=0.20, 95%CI (0.05, 0.81),P=0.02〕. There was no significant difference between the two groups in the occurrence of postoperative severe complications〔OR=0.54, 95%CI (0.26, 1.12),P=0.10〕. Conclusions Compared with the TD group, the operative time and hospitalization time are shorer in PC group, and complication rate is similar, but the cost of treatment of the TD group is higher than PC group, so after LCBDE a primary closure of common bile duct is safe and effective method.