From December 1981 to October 1997, we had performed 1559 cases of intrahepatobiliary tract stones by surgery alone/or with cholangioscopy, of which 332 cases were left intrahepatobiliary tract stones (accounted for 33.9%), 111 right intrahepatobiliary tract stones (accounted for 11.3%) and 545 cases in both sides (54.7%). 324 patients complicated with stricture of biliary tract (32.3%), of which 156 cases (48.2%) were stricture of left intrahepatobiliary tract, 107 cases (33.0%) stricture of right intrahepatobiliary tract, 61 cases (18.8%) stricture of hepatic hilus biliary tract. The operative procedure were: ①hapatic lobe or segment resection, ②high cholangiotomy and palstic repair, ③choledochojejunostomy and ④T-tube or U-tube drainage with removal of stones by cholangioscopy later. The operative procedure should be based on different types of intrahepatobiliary tract stones and patholigical features. The result indicates that cholangioscopy may play an important role in the treatment of intrahepatobiliary tract stones.
Objective To investigate the clinical significance of routine application of choledochoscope during operation of biliary duct. Methods The clinical data of 136 patients with the routine application of intraoperative choledochoscope dealing with bile duct diseases in this hospital from October 2003 to July 2009 were analyzed and summarized. Results Intraoperative choledochoscope inspection, taking stones and targeted surgery were performed in 116 cases with extrahepatic and (or) intrahepatic bile duct stones. The taking out rate of extrahepatic bile duct stones was 100% (85/85), the residual stone rates of extrahepatic and intrahepatic bile duct were 0 (0/85) and 22.6% (7/31), respectively, with the total residual stone rate was 6.0% (7/116). By using intraoperative choledochoscope, benign intrahepatic bile duct stricture was found in 13 cases, malignant extrahepatic and intrahepatic bile duct stricture in 8 cases. Four cases of hilar cholangiocarcinoma and 4 cases of common bile duct cancer, 2 cases of lower segment of common bile duct polyp, 3 cases of hepatolithiasis with the left hepatic bile duct carcinoma were diagnosed by biopsy via choledochoscope. Causes were confirmed by applying choledochoscope in 16 patients with obstructive jaundice. The use of choledochoscope with surgical treatment enabled benign and malignant bile duct stricture to achieve good results, without serious complications such as bile duct dilaceration, subphrenic abscess or acute cholangitis. Conclusions Using choledochoscope can tremendously reduce the residual rate of stone in biliary duct surgery, increase the definite diagnosis rate of biliary duct diseases and play a role of reasonable instruction in its treatment options. It has unique advantages in identifying causes of jaundice. It is remarkable that the role of applying choledochoscope to diagnose and cure biliary duct diseases. It should be widely used.
目的 探讨金属银夹标记胆道通道，利用胆道镜技术治疗胆肠吻合术后肝胆管结石复发的可行性、安全性和有效性。方法 回顾性分析大连市友谊医院47例胆管结石行胆肠Roux-en-Y吻合术患者的资料，在空肠盲袢或输出袢处使用银夹作标志，术后通过胆道镜行胆管残留结石或复发结石或狭窄的治疗。结果 11例术后胆管残留结石和5例残留结石合并胆管狭窄者经T管窦道行胆道镜探查、取石及肝胆管狭窄的治疗而治愈。2例结石复发的患者根据空肠的金属银夹标记物，在数字减影血管造影（DSA）下进行穿刺置管建立胆道镜通道，通过胆道镜成功取出了结石，避免了再手术。结论 发挥胆道镜技术治疗肝胆管结石的优势，经以银夹标志的胆道通道，可望成为治疗胆肠吻合术后复发结石手段的有益补充。
目的探讨胆管残余和复发结石的原因、特点和处理经验。方法回顾性分析128例胆管残余和复发结石再手术临床资料。 结果残余或复发结石位于肝外胆管68例，肝内胆管48例，肝内、外胆管12例。再手术行残株胆囊切除术2例（1.5%）， 胆总管探查、T管引流术64例（50.0%），肝左外叶切除或肝左叶切除术+胆总管切开取石29例（22.7%），肝右叶、段切除加胆总管切开取石6例（4.7%），同时行狭窄胆管切开整形胆管空肠吻合术13例（10.2%），单独或联合行胆管空肠Roux-en-Y吻合术14例（10.9%）。术后痊愈出院124例，自动出院2例，死亡2例。 术后出现并发症18例（14.1%），其中切口感染 10例，胸腔积液3例，胆肠瘘3例，上消化道出血2例，均经保守治疗治愈。出院的124例中117例获随访1～2年，89例（76.1%）恢复满意，18例（15.4%）恢复较好， 10例（8.5%）经B超、CT、MRCP等检查证实再次复发胆管结石，其中6例经再次手术治愈，4例经中西医结合药物治疗好转。 结论术前全面了解病情，选择合适的手术时机，术中认真仔细的探查确认，并结合术中造影、胆道镜以及术者的经验技术，术后有效的治疗，是降低残石、结石复发及再手术的关键因素。
Objective To expand the utilization of minimally invasive technologies for parapancreatic abscess, and summarize the application experience of choledochoscope for treatment of parapancreatic abscess. Methods The clinical data and treatment effectiveness of 36 patients with parapancreatic abscess from Dec. 2000 to Dec. 2008 were analyzed retrospectively. These patients had experienced percutaneous puncture and been placed drainage tube under the ultrasound guidance first, then expanded the sinus tract gradually, and performed debridement by choledochoscope. The flexibility of choledochoscope was used to remove the necrotic tissue and pyogenic membrane repeatedly by clamping, netting and vacuum aspiration in every domain. Results Thirty-six patients were performed percutaneous puncture and placed drainage tube, 3 cases were given canalis singularis, 7 cases were double tube, 26 cases were over three tube. The debridement times were 3-14 by choledochoscope, average 5.6 times. There were 6 cases with improving systemic symptoms, blood routine and temperature recovering normal, and drink and food recovering, then discharged from hospital with tube after 1-2 times of debridement. Length of stay was 25-132 d, average 76 d. The curing rate was 91.7% (33/36). Two cases were turned into open surgery because of broad necrotic tissue range combined with many abdominal cavity abscess with good postoperative recovery and cured. One case was dead of severe multiple organ failure combination. There were 2 patients with hemorrhage, 3 patients with external intestinal fistula. Conclusions The debridement of choledochoscope for parapancreatic abscess treatment is a simple, flexible and effective method. It changes the viewpoint that parapancreatic abscess can be cured only by operation drainage, decreases the patients’ trauma and accomplishes the idea of damage control by minimally invasive technologies.
Objective To investigate feasibility and curative effect of ultrasound-guided percutaneous transhepatic cholangioscopy in treatment of complicated hepatolithiasis. Methods The data of 42 patients with complicated hepatolithiasis from June 2012 to June 2017 in the Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University were retrospectively analyzed. All the patients were treated with ultrasound-guided percutaneous transhepatic cholangioscopy, including the first stage of dilation and drainage and the second stage choledochoscopy. Results The operations of the 42 patients were successfully performed. No case was converted to the conventional laparotomy. The puncture sites of 10 cases were at the right intrahepatic bile duct, 25 cases were at the left intrahepatic bile duct, and 7 cases were at the bilateral intrahepatic bile duct. The residual stones were removed by two stage choledochoscopy in the 31 patients, 11 patients had the residual stones. After the first stage, there were 4 cases of the bile duct hemorrhage, 8 cases of the cholangitis, 1 case of the pleural effusion and 1 case of the infection, 2 cases of the postoperative drainage tube shedding. After the second stage, there were 3 cases of the cholangitis and 3 cases of the postoperative drainage tube shedding. The stones of the 10/31 patients with stone removal occurred and the diseases of 9/11 patients with stone residual were stable during the following-up of (18.6±7.8) months. Conclusion Ultrasound-guided percutaneous transhepatic cholangioscopy including the first stage of dilation and drainage plus the second stage choledochoscopy is safe and effective in treatment of complex intrahepatic bile duct stones, it is an effective supplement to traditional surgery.
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。
Objective To explore and summarize the application of minimally invasive technique to every stage of severe acute pancreatitis (SAP). Methods The treatment of 101 SAP patients admitted to our hospital between January 1995 and December 2008 were retrospectively analyzed. After calculi were removed by endoscopic retrograde cholangiopancreatograpy (ERCP) and endoscopic sphincterotomy (EST), endoscopic nasobiliary drainage (ENBD) were applied, then rhubarb liquid was perfused into gut with a nutrient canal and ultrasound-guided abdominal drainage tube were simultaneously placed at the early stage. Some patients received continuous renal replacement therapy (CRRT) at the same time. Laparoscopic cholecystectomy (LC) was performed at the subacute stage, and choledochoscope was introduced to remove parapancreatic necrotic tissues at the late stage of SAP.Results Of all the 101 cases treated by the method mentioned above, 75 cases received ERCP (or EST) and ENBD, and 31 cases underwent rhubarb liquid perfusion with a nutrient canal. Eight cases underwent continuous renal replacement therapy (CRRT). Forty-eight cases underwent LC and ultrasoundguided abdominal drainage. Thirtysix cases with infected peripancreatic tissue or abscess underwent debridement under choledochoscope 3 to 14 times at the later stage. Five cases died of multiple organ failure (MOF) and acute respiratory distress syndrome (ARDS). The hemobilia ocurred in 2 patients during choledochoscopy and was cured under direct visualization by electric coagulation. Intestinal fistula happened in 3 cases and cured by drainage. Pancreatic pseudocyst was latterly seen in 3 cases and treated by the anastomosis of cyst with jejunum through selective operation. After the hospitalization of 9-132 d (mean 24 d), 96 cases completely recovered. Conclusion Timely application of minimally invasive technique to every stage of SAP can avoid the defects of traditional operations, decrease the injury and interference to the maximum, and raise the cure rate.