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.
Objective To evaluate the clinical effectiveness of laparoscopic cholecystectomy and laparoscopic common bile duct exploration （LC＋LCBDE） and endoscopic retrograde cholangiopancreatography/endoscopic sphincterectomy with LC（ERCP/EST＋LC） in treatment for cholecystolithiasis with choledocholithiasis. Methods From January 2008 to July 2011， 127 patients suffered from cholecystolithiasis with choledocholithiasis underwent either LC＋LCBDE（85 cases， LC＋LCBDE group） or ERCP/EST＋LC（42 cases， ERCP/EST＋LC group） were collected retrospectively. The clearance rate of calculus， hospital stay， hospitalization expenses， and the rate of postoperative complications were compared between two groups. Results Eighty-five patients were performed successfully in the LC＋LCBDE group， out of which 54 patients had primary closure of common bile duct （LC＋LCBDE primary closure group）， whereas in 28 patients common bile ducts were closed over T tube （LC＋LCBDE＋T tube group）. Forty-two patients were performed successfully in the ERCP/EST＋LC group. There were no differences in the clearance rate of calculus〔100%（82/82） versus 97.37%（37/38）， P=0.317〕 and postoperative complications rate 〔（4.71% （4/85） versus 4.76%（2/42）， P=1.000〕 between the LC＋LCBDE group and ERCP/EST＋LC group. The median （quartile） hospital stay in the LC＋LCBDE group was shorter than that in the ERCP/EST＋LC group 〔12 （6） d versus 17（9） d， P＜0.001〕. In the LC＋LCBDE primary closure group， both median （quartile）?hospital stay and median（quartile） hospitalization expenses were less than those of ERCP/EST＋LC〔hospital stay：11（5） d versus 17（9） d， P＜0.001；hospitalization expenses：27 054（8 452） yuan versus 31 595（11 743） yuan， P=0.005〕 . Conclusions In the management of patients suffered from cholecystolithiasis with choledocholithiasis， both LC＋LCBDE and ERCP/EST＋LC are safe and effective. LC＋LCBDE， especially primary closure after LCBDE， is associated with significantly less costs as compared with ERCP/EST＋LC. Moreover， patients can be cured by LC＋LCBDE through one-stage treatment with the protection of the papilla function and no limits to the amount or size of the choledocholithiasis. The LC＋LCBDE is a preferable choice for the appropriate cases of cholecystolithiasis with choledocholithiasis.
Objective To evaluate the use of fast track surgery （FTS） in the treatment for cholecystolithiasis combined with calculus of common bile duct （CBD） by combination of laparoscope and duodenoscope. Methods One hundred and twenty patients with cholecystolithiasis combined with calculus of CBD underwent laparoscopic cholecyst-ectomy （LC） and endoscopic retrograde cholangiopancreatography （ERCP） were divided into FTS group （n=55） and conventional group （n=65），which were accepted the perioperative therapy of FTS or conventional therapy，respectively. After operation，the incision pain，nausea and vomiting，infusion time，loss of body weight，out-of-bed time，dieting time，postoperative hospitalization，hospital costs，and complications were compared in two groups. Results Compared with the conventional group，the postoperative infusion time，dieting time，out-of-bed time，and postoperative hospitali-zation were shorter，the incidence rates of pulmonary infection，and urinary systems infection，pancreatitis，nausea and vomiting， and incision pain were lower，the loss of body weight was lower in the FTS group （P＜0.05），but the differences of WBC and serum amylase at 24 h after operation were not significant between the FTS group and conventional group（P＞0.05）. Conclusion The FTS is safe，economic，and effective in the treatment for cholecystolithiasis combined with calculus of CBD by combination of laparoscope and duodenoscope.
Objective To evaluate the clinical effectiveness of ERCP/S+LC and LC+LCBDE in cholecystolithiasis and choledocholithiasis. Methods A fully recursive literature search was conducted in MEDLINE, EMbase, Cochrane Central Register of Controlled Trials in any language. By using a defined search strategy, both the randomized controlled trials (RCTs) and controlled clinical trials on comparing ERCP/ S+LC with LC+LCBDE in cholecystolithiasis and choledocholithiasis were identified. Data were extracted and evaluated by two reviewers independently. The quality of the included trials was evaluated. Meta-analyses were conducted using the Cochrane Collaboration’s RevMan 5.0.2 software. Results Fourteen controlled clinical trials (1 544 patients) were included. The results of meta-analyses showed that: a) There were no significant difference in the stone clearance rate between the two groups (RR=0.96, 95%CI 0.92 to 1.01, P=0.14); b) There were no significant difference in the residual stone rate between the two groups (OR=1.05, 95%CI 0.65 to 1.72, P=0.83); c) There were no significant difference in the complications morbidity between the two groups (OR=1.12, 95%CI 0.85 to 1.55, P=0.48); d) There were no significant difference in the mortality during follow-up visit between the two groups (RD= 0.00, 95%CI –0.03 to 0.03, P=0.84); e) The length of hospital stay in the LC+LCBDE group was shorter than that of the ERCP/S+LC group with significant difference (WMD= 1.78, 95%CI 0.94 to 2.62, Plt;0.000 1); and f) The LC+LCBDE group was superior to the ERCP/S+LC group in the aspects of procedure time and total hospital charges. Conclusion Although there aren’t differences in the effectiveness and safety between the ERCP/S+LC group and the LC+LCBDE group, the latter is superior to the former in procedure time, length of hospital stay and total hospital charges. For the influencing factors of lower quality and astable statistical outcomes of the included studies, this conclusion has to be verified with more strictly designed large scale RCTs.
Object To evaluate the significance of double common bile duct （DCBD） in hepatobiliary surgery. Metheds The data of diagnosis and treatment of two patients with DCBD in our hospital between Jul. to Dec. 2010 were analyzed retrospective， and the related literatures were reviewed. Results The right hepatic bile duct of DCBD due to mistaking it for cystic duct in 1 case was accidental injuried during laparoscopic cholecystectomy. Another example，the DCBD was confirmed by intraoperative exploration and choledochoscopic examination， at the same time with chole-dochal cyst， anomalous pancreaticobiliary ductal junction （APBDJ）， primary hepatolithus， and choledocholith， and then operation was performed. Two cases were typeⅤb of DCBD. A total of 32 English literatures were reviewed. Since the beginning of 1932 English literature had reported 100 cases of DCBD. The type Ⅱand typeⅢwere the most common type of DCBD， and the typeⅤonly 10 cases. There were 27 cases of DCBD in twenty-five Chinese articles from 1994 to 2012. The typeⅤwas the most common type of DCBD. The accessory common bile duct （ACBD） opening in the duod-enum， gastric， and pancreatic duct were the most common. The common complications included stone， APBDJ， choled-ochal cyst， tumor etc. Conclusions DCBD is a very rare anatomic variation of extrahepatic bile duct， often accompanied by calculus of bile duct and common bile duct cyst， APBDJ， and other biliary anatomy abnormality， and potentially carci-nogenic potential. The existence of DCBD may increase the risk of iatrogenic bile duct injury and complexity of biliary operation. In view of this， this abnormality of extrahepatic duct should be paid with close attention during operation.
Objective To explore clinical effect of primary suture following laparoscopic common bile duct exploration (LCBDE) in treatment of patients aged over 70 years old with common bile duct (CBD) stones. Methods The clinical data of 62 patients aged over 70 years old with CBD stones underwent the LCBDE from January 2013 to December 2016 were retrospectively analyzed. Among them, 30 patients underwent the T tube drainage (T tube drainage group) and 32 patients underwent the primary suture (primary suture group) following the LCBDE. The intraoperative and postoperative statuses of these two groups were compared. Results There were no significant differences in the gender, age, body mass index, preoperative comorbidities and ASA classification, number and maximum diameter of CBD stone, and diameter of CBD between the two groups (P>0.05). There were no significant differences in the operative time, hospitalization cost, rates of total postoperative complications and readmission between the two groups (P>0.05). Compared with the T tube drainage group, the amount of intraoperative bleeding was less (P<0.05) and the postoperative hospital stay was shorter (P<0.05) in the primary suture group. Conclusion Primary suture is safe and feasible following LCBDE for patients aged over 70 years old with CBD stones in case of strict indications and proficiency intraoperation and it is more beneficial to recovery of patient.
摘要:目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy, LC)后发生严重并发症的原因、治疗措施和经验教训。方法:分析 2007 年 8 月至2009 年 4月期间华西医院胆道外科收治的LC术后发生严重并发症的7例患者的临床资料。结果:2例继发性胆总管结石合并化脓性胆管炎患者,采用内镜下十二指肠乳头切开(endoscopic sphincterotomy, EST)取出结石;3例胆道损伤患者,均进行肝门胆管成形和肝总管空肠吻合术;1例绞窄性肠梗阻患者,切除坏死空肠管后,行空肠对端吻合术;以上6例患者均顺利出院,随访8～20个月,均生活良好。1例患者LC术后发生肺动脉栓塞,积极抢救后因呼吸衰竭而死亡。结论:术中仔细轻柔的操作以及辩清肝总管、胆总管与胆囊管的三者关系是预防LC术后发生严重并发症的关键。合理可行的治疗措施是提高发生并发症的患者生活质量的保障。LC术时,胆道外科医生思想上要高度重视,不可盲目追求速度,必要时及时中转开腹。Abstract: Objective: To investigate the causes and therapeutic measures and the experience and lesson of sever complications after laparoscopic cholecystectomy (LC). Methods:Clinical data of 7 patients with severe complications after LC from August 2007 to April 2009 were analyzed retrospectively. The clinical data was got from biliary department of West China Hospital. Results: Two cases of secondary common bile duct stone with acute suppurative cholangitis got cured by endoscopic sphincterotomy. Three cases of severe bile duct injury after LC had stricture of the hilar bile duct, and all of the cases were performed RouxenY hepaticojejunostomy with the diameter of stoma 2.03.0 centimeters. One case of strangulating intestinal obstruction was cured through jejunum endtoend anastomosis after cutting off the necrotic jejunum. All of the above 6 patients recovered well. Following up for 820 months, all lived well. One patient got pulmonary embolism after LC and dead of respiratory failure after active rescue. Conclusion: Carefully making operation and distinguishing the relationship of hepatic bile duct and common bile duct and the duct of gallbladder are the key points to prevent sever complications during LC. Reasonable and feasible treatment is the ensurement of increasing the living quality of the patients with sever complications after LC. And the surgeons of biliary department must have a correct attitude toward LC and should concern think highly during LC and should not pursue speed blindly. In necessary, the operation of LC should be turned into open cholecystectomy.
ObjectiveTo compare the effectiveness and safety of laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE) with LC plus endoscopic retrograde cholangiopancreatography (ERCP) for patients with concomitant cholelithiasis and choledocholithiasis by using meta-analysis.MethodsWe searched PubMed, Cochrane Library、EMBASE, Chinese Biomedical Literature Database, Chinese Science and Technology Academic Journal, Chinese Journal Full-text Database and Wanfang database to identify relevant articles from their inception to 31 October 2018. A meta-analysis was carried out using the RevMan 5.3 software.ResultsA total of 13 RCTs were included in this meta-analysis, 747 cases received LC+LCBDE and 761 cases underwent LC+ERCP. The meta-analysis results showed that no significant difference between the LC+LCBDE group and the LC+ERCP group in terms of common bile duct (CBD) stone clearance rate [RR=0.99, 95%CI (0.95, 1.02), P=0.87] and overall complications [RR=0.94, 95%CI (0.72, 1.22), P=0.64]. The LC+LCBDE group had higher rate of postoperative bile leakage rate [RR=3.87, 95%CI (2.01, 7.42), P<0.000 1] than that LC+ERCP group. However, the LC+LCBDE group had lower rate of postoperative pancreatitis [RR=0.28, 95%CI (0.14, 0.55), P=0.002] than that LC+ERCP group.ConclusionsBoth LC+LCBDE and LC+ERCP are equivalent in CBD stone clearance rate and overall complications, LC+LCBDE is associated with a higher postoperative bile leakage rate and lower rate of postoperative pancreatitis, appropriate treatment should be selected according to the individual patient’s condition.
ObjectiveTo compare difference of therapeutic effects between endoscopic frequency-doubled double pulse neodymium yttrium aluminium garnet (FREDDY) laser and endoscopic traditional mechanical lithotripsy in treatment of common bile duct stones (CBDs).MethodsThe clinical data of 207 patients with CBDs treated with ERCP and lithotripsy in the Ninth People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine from March 2009 to March 2019 were analyzed retrospectively, of which 71 cases treated by FREDDY (FREDDY group) and 136 cases treated by mechanical lithotripsy (mechanical group). The success rate of stone removal, operation time, postoperative hospitalization time, hospitalization cost, consumables cost, and complications were compared between the two groups.ResultsThere were no significant differences in the general condition and the preoperative clinical data between the two groups (P>0.05). There was no perioperative death in the two groups. There were no significant differences in terms of the postoperative routine laboratory biochemical indexes, consumables cost, hospitalization cost, and rates of the bleeding, postoperative pancreatitis, perforation and biliary tract infection between the two groups (P>0.05). Although the operation time of the FREDDY group was significantly longer than that of the mechanical group (P<0.05), the success rate of stone removal was significantly higher, the postoperative hospitalization time was shorter, the total complications rate and stone residual rate were significantly lower in the FREDDY group as compared with the mechanical group (P<0.05).ConclusionEndoscopic FREDDY laser lithotripsy has a better curative effect and less complications in treatment of large CBDs than mechanical lithotripsy, but operation time needs further to be improved.
【Abstract】ObjectiveTo explore risk factors of bile leakage after primary ductal closure following choledochotomy. MethodsA retrospective clinical analysis was made in 148 cases of Ttube drainage and 154 cases of primary common bile duct suture following choledochotomy admitted to our hospital from January 1999 to June 2003. Results Postoperative bile leakage was seen in 11 patients of the group with Ttube drainage and in 16 patients of the group with primary suture respectively, there was no significant difference(Pgt;0.05).In the group with primary common bile duct suture,the occurrence of bile leakage was relative with hyperglycemia(Plt;0.05)，hypoproteinemia (Plt;0.01)，bile duct repeated sutures(Plt;0.01)and positive bacterial culture in bile(Plt;0.05). Bile leakage was not relative with elder age (Pgt;0.05).Conclusion It is the key factors,including chosing appropriate patients, intraoperative special examination, careful manipulation and effective medical treatment that can reduce the morbidity of bile leakage.