'三镜'联合一次麻醉序贯治疗肝外胆管结石

摘要

目的同顾性评估腹腔镜、胆道镜、十二指肠镜(三镜)联合,一次麻醉序贯治疗肝外胆管结石和胆源性急性胰腺炎(ABP)的可行性.方法总结112例肝外胆管结石(其中23例ABP)治疗经验,对术式选择、操作要点、胆漏防治、注意事项等做分析.结果102例成功,10例中转开腹手术.其中16例内镜胰胆管造影(ERCP)+腹腔镜胆囊切除(LC)、胆总管切开、胆道镜取石、T管引流(LCTD),18例ERCP+LC、胆道镜经胆囊管胆总管取石;22例内镜乳头括约肌切开(EST)取石未完成或禁忌,继续LC、胆总管切开、胆道镜取石、一期缝合;46例鼻胆管引流(ENBD)+LC、胆总管切开、胆道镜取石、一期缝合.内镜治疗时间平均35 min,腹腔镜手术时间平均110 min,术后住院平均6.5 d.无手术死亡,ERCP和EST并发症9例,其中6例急性胰腺炎,2例十二指肠乳头部出血,1例十二指肠穿孔.胆总管一期缝合术后胆漏11例,腹腔引流治愈.拔T管后胆漏2例,再次腹腔镜下置管引流治愈.随访1～3年,B超或MRCP检查无胆管狭窄;胆总管残石和再发结石各3例,EST取石治愈.结论一次麻醉"三镜"序贯治疗肝外胆管结石和ABP,手术环节衔接更为合理,无内镜治疗的恐惧感,能从严掌握EST适应证和减少并发症,提高微创手术成功率等.一旦遇有解剖不清、出血、结石未取净或胆管狭窄等,及时改变术式.%Objective A retrospective study to evaluate the feasibility of the sequential treatment of extrahepatic bile duct calculus and acute gallstone pancreatitis using the technique of combination of duodenoscope, laparoscope and choledochoscope in one anesthetic session. Methods 112 patients with extrahepatic bile duct calculus (including 23 patients associated with acute gallstone pancreatitis) were treated using this technique. The data were analyzed. Results The technique was successfully carried out in 102 patients but 10 patients had to be treated by conventional open operation.For the patients treated by this technique, 16 patients were treated by endoscopic sphincterotomy (EST) plus choledochotomy. The stones were removed through a choledochoscope, and the bile duct was drained by a T-tube (LCTD). 18 patients were treated by endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (LC). The choledocholiths were removed by a choledochoscope through the cystic duct. 22 patients were treated by choledochotomy, and the calculus was removed through a choledochoscope and the bile duct was primarily sutured. 46 patients were treated by endoscopic nasobiliary drainage (ENBD) plus LC, choledochotomy. The calculi were through a choledochoscope and followed by primary suture of the bile duct. The mean time of endoscopic treatment, LC and postoperative hospital day were 35 min, 110 min and 6.5 d respectively. None of the 102 patients died after operation. 9 patients developed complications of ERCP or EST including acute pancreatitis (n=6), hemorrhage of papilla duodeni (n=2) and duodenal perforation (n= 1). 11 patients developed biliary fistula after primary suturing of the choledochus and they recovered with drainage; 2 patients developed residual or recurrent biliary fistula after the T tube was removed and they recovered after drainage via a [aparoscope. During follow-up for 1 to 3 years using ultrasonic or MRCP examinations, 3 cases of stones were found and they were removed by EST. There was no stenosis of common bile duct. Conclusions Our results suggested that the three-endoscope-combination in one anesthetic session for the treatment of extrahepatic bile duct calculi and acute gallstone pancreatitis was safe and efficacious. Moreover, this technique reduced the complications of EST. This technique increased the success rate using minimal invasive surgery.