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 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 探讨腹腔镜下联合胆道镜微创保胆取石术治疗胆囊结石的疗效。方法 解放军第452医院普外科2005年1月至2010年1月期间行腹腔镜保胆取石术治疗胆囊结石患者70例，与同期行腹腔镜胆囊切除术的患者对比，观察2组的手术时间、术中出血量、术后住院时间、住院费用及术后饮食恢复时间。结果 在术中出血量及术后饮食恢复时间上，保胆取石组明显少于或短于胆囊切除组（P＜0.05）；在手术时间、术后住院时间及住院费用上2组间差异无统计学意义（P＞0.05）。结论 相比胆囊切除术，腹腔镜联合胆道镜保胆取石术创伤较小且恢复较快，但是保胆取石术后结石的复发有待长期观察和研究。
ObjectiveTo explore the effect of the surgery with laparoscope combined with choledochoscope on plateau hepatic hydatid biliary fistulas. MethodsA total of 100 patients with liver hydatid disease diagnosed between January 2012 and June 2013 were divided into two groups according to the admitting time:laparoscope combined with choledochoscope group (combined group) and laparoscope group, with 50 patients in each group. The therapeutic results of the two groups were compared. ResultsA total of 186 biliary fistulas were found in the combined group during the operation, and there were 5 patients with biliary fistulas after the surgery; while 87 biliary fistulas were found in laparoscope group during the operation and there were 16 patients with biliary fistulas after the surgery. The difference in the occurrence rate of biliary fistulas after surgery between the two groups was significant (χ2=7.294, P=0.007). No infection of incisional wound was found in combined group but 5 infection was found in laparoscope group. The postoperative extubation time in the combined group and laparoscope group was (10.35±3.87) and (27.16±4.58) days, respectively, with a significant difference (t=12.538, P<0.001). ConclusionThe laparoscope combined with choledochoscope is a minimally invasive and safe therapeutic option for plateau hepatic hydatid biliary fistulas.
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 explore the effect of gallbladder preserving surgery with laparoscope and choledochoscope.Methods The data of 60 cases of gallbladder preserving surgery with laparoscope and choledochoscope （observation group） and carried out with the same period 61 cases of small incision gallbladder preserving surgery （control group） between June 2008 to January 2013 were retrospective analyzed. Results All patients were followed up for （18±2.4）months （6-36 months）. The intraoperative blood loss， postoperative gallbladder hemorrhage rate， gallbladder dysfunctionrate， postoperative hospitalization time， stone recurrence rate， and reoperation rate in observation group were less orlower or shorter than the control group （P＜0.05）. The operative time and hospital costs in observation group were longeror higher than that of the control group （P＜0.05）. The rest of the observation index of two groups were no significant differences （P＞0.05）. Conclusions The gallbladder preserving surgery with laparoscope and choledochoscope is safeand feasible in technique level， and the short-term effect after operation is better. But the operation indications must be controlled strictly. The long-term efficacy needs further accumulation of cases and collect enough evidence to verify.
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.