Objective To explore the clinical therapeutic value of pancreatoduodenectomy in patients with carcinoma of ampulla of Vater (AVC). Methods The clinical data of 195 patients with AVC between March 1995 and March 2009 in this hospital were analyzed retrospectively. All the patients were divided into non-surgery group (n＝51), palliative surgery group (n＝96), and resection group (n＝48) according to the treatment methods. Results The 1-year, 3-year, and 5-year survival rates in the resection group were higher than those in the non-surgery group and the palliative surgery group (Plt;0.01). However, the incidence of complications in the resection group was higher than that in the nonsurgery group or the palliative surgery group (Plt;0.05). The radical resection rates, 1-year, 3-year, and 5-year survival rates of carcinomas of head of pancreas were significantly lower than those of carcinomas of the terminal of common bile duct or carcinomas of duodenal papilla (Plt;0.05, Plt;0.01). There was no significant difference of the perioperative mortality, complications rate, 1-year, 3-year, or 5-year survival rate between preoperative drainage jaundice group and preoperative nondrainage jaundice group (Pgt;0.05). The perioperative mortality in the resection group above the age of 70 years old was higher than that of less than or equal to 70 years old （Plt;0.05）. Compared with the non-surgery group or palliative surgery group, there were significant increasement of the incidence of serious or deadly perioperative complications in the resection group (Plt;0.05). Conclusions Surgical resection remains one of the most important measures of the treatment of AVC, in particular, the radical pancreatoduodenectomy is the only effect way for AVC, thus significantly prolonging the patient’s postoperative survivals and significantly improving the qualities of life.
ObjectiveTo compare the effect of laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE) in the treatment of cholecystolithiasis combined with choledocholithiasis in elderly patients and non-elderly patients. MethodsThe clinical data of 185 cases of cholecystolithiasis combined with choledocholithiasis who treated in our hospital from September 2010 to November 2015 were analyzed retrospectively. Then the 185 cases of holecystolithiasis combined with choledocholithiasis were divided into elderly patients group (n=74) and the non-elderly patients group (n=111). The operative time, intraoperative blood loss, postoperative exhaust time, postoperative activity time, abdominal drainage time, postoperative hospital stay, total hospital stay, hospitalization cost, incidence of complications, unplanned analgesia, stone-free rate, rate of conversion to laparotomy, recurrence of stone, and mortality were compared between the two groups. Results① Intraoperative and postoperative indexes. No significant difference was noted in operative time and intraoperative blood loss (P > 0.050), but the postoperative exhaust time, postoperative activity time, abdominal drainage time, postoperative hospital stay, total hospital stay, hospitalization cost, and ratio of indwelling T tube of elderly patients group were all higher or longer than corresponding index of non-elderly patients group (P < 0.050). ② Postoperative complications and unplanned analgesia. There was no striking discrepancy in incidence of complications (including biliary leakage, peritonitis, haemorrhage, vomit, ectoralgia, and fever), and Clavien-Dindo grade (P > 0.050), except unplanned analgesia (P=0.007), the rate of unplanned analgesia in elderly patients group was higher than that of non-elderly patients group. ③Surgical effect. There was no significant difference in the stone-free rate, rate of conversion to laparotomy, and rate of recurrence of stone between the 2 groups (P > 0.050). ConclusionLC+LCBDE is also safe and effective in treatment of cholecystolithiasis combined with choledocholithiasis in elderly patients, it's worthy to be expanded and be used broadly.
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.
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.
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.
Objective To investigate the method of the treatment on cholecystolithiasis combined with calculus of common bile duct (CBD) by laparoscopy with combination of choledochoscope and duodenoscope and its significances. Methods Forty-two patients with cholecystolithiasis combined with calculus of CBD were treated by laparoscopy with combination of choledochoscope and duodenoscope from Jan. 2007 to Dec. 2008 in this hospital. Under general anesthesia, laparoscopic cholecystectomy was performed first, then the anterior wall of CBD was opened, calculus of CBD was treated by choledochoscope and duodenoscope intraoperatively. Then primary suture of the CBD was performed under laparoscope and nasobiliary drainage duct was placed. Results One case was converted to laparotomy, 41 cases succeeded and left hospital after being taken off the nasobiliary drainage duct in 5-7 d. No case died, no bile leakage, no bleeding or perforation of upper digestive tract, and no acute pancreatitis happened after operation. Conclusion Laparoscopy with combination of choledochoscope and duodenoscope treating cholecystolithiasis combined with calculus of CBD is a safe, effective and quickly recovering method with less sufferings and trauma.
【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.
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.
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.