胃大部切除术后患者实施腹腔镜胆囊切除和胆总管探查术的体会

Laparoscopic cholecystectomy and common bile duct exploration in patients with previous subtotal gastrec- tomy

目的探讨对有胃大部切除手术史者行腹腔镜联合纤维胆道镜行胆囊切除、胆总管探查的可行性及手术技巧。方法2001年1月至2010年12月对22例有胃大部切除史的胆囊结石合并胆总管结石患者采用腹腔镜胆囊切除、胆总管切开探查取石、术中胆道镜取石、T管引流术或胆总管一期缝合术。结果手术成功18例；中转开腹4例：1例为术中胆道造影见胆总管下端有多枚充盈缺损，但胆总管直径仅约6mm，胆道镜进入胆总管较困难，并且放置T管也较困难；1例胆总管壁水肿，达2mm厚，切开胆总管壁出血多，而管径较细；1例为术中胆道镜活检证实为胆总管下段癌伴结石嵌顿；1例为Mirizzi综合征。16例胆囊切除、胆总管探查术后T管引流，2例胆总管取石后一期缝合胆总管，无出血、胆漏、腹腔感染等并发症。13例随访3～60个月，平均19个月，无结石残留、胆管狭窄及胆管炎发生，3例胆管结石复发。3例失访。结论对有胃大部切除手术史者施行腹腔镜联合纤维胆道镜行胆囊切除、胆总管探查安全、可行。胃大部切除手术史不是腹腔镜胆囊切除、胆总管探查手术的绝对禁忌证。

Objective To investigate the feasibility and technique in laparoscopic cholecystecto- my and exploration of common bile duct （CBD） in patients who have previous subtotal gastrectomy. Methods From January 2001 to October 2010, 22 patients who had a history of subtotal gastrectomy received laparoscopic cholecystectomy and CBD exploration in our hospital. In addition, these patients received cholangioscopic lithotomy, electrohydraulic lithotripsy, T-tube drainage, or primary suturing of the CBD wound. Results The procedures were completed successfully in 18 patients. In 4 patients, conversion to laparotomy was necessary because of multiple stones in a stenosed CBD （n= 1）, severely congested CBD wall with edema （n= 1）, CBD carcinoma associated with impacted stones （n= 1） or Mirzzi syndrome （n= 1）. T-tube drainage was employed in 16 patients, and primary suturing in 2 pa- tients at the end of the operation. There was no hemorrhage, biliary leakage or abdominal infection. At a mean follow-up of 13 （range 3 to 60） months there was no residual stone, biliary stenosis or cholangitis. In 3 patients stone recurred, and another 3 patients were lost to follow-up. Conclusions A history of subtotal gastrectomy is not a contradiction to laparoscopic cholecystectomy and CBD ex- ploration. With choledocoscopy, surgery can be safe and feasible even for patients with previous gastectomy.