胆囊结石伴急性胆源性胰腺炎的微创治疗

Mini-invasive Therapy for Acute Biliary Pancreatitis Accompanying Gallstones

目的 探讨胆囊结石伴急性胆源性胰腺炎（acute biliary pancreatitis，ABP）的微创治疗方法及手术时机。方法 回顾分析我院2008年5月～2013年5月胆囊结石伴ABP122例的临床资料。先保守治疗，磁共振胰胆管成像（MRCP）明确胆总管有无结石梗阻，104例未发现结石者急性胰腺炎恢复后行腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）。18例MRCP发现胆总管下段结石，行内镜逆行胆胰管造影（ERCP）＋十二指肠乳头括约肌切开（EST）取石＋鼻胆管引流（ENBD）治疗成功，再行LC。结果轻型106例，手术时间为发病后7～14天；重型16例，手术时间为发病后15～30天。无中转开腹、胆管损伤及死亡。其中107例随访5～8个月，无胰腺炎复发。结论对胆囊结石伴ABP应常规MRCP检查。未发现胆总管结石者待胰腺炎恢复后行LC；有胆总管结石伴梗阻者72小时内用十二指肠镜取出胆管下端嵌顿结石并ENBD，待胰腺炎恢复后再行LC；无梗阻者保守治疗胰腺炎恢复后，先行ERcP并取石，再行LC。手术时机应遵循“个体化”原则，一般轻型胰腺炎可在发病1～2周内手术。采用上述方法治疗胆囊结石伴ABP安全、有效、微创、可行。

Objective To explore the mini-invasive therapy and the operation opportunity for the treatment of gallstone with acute biliary pancreatitis （ABP）. Methods The data of 122 cases of gallstone with ABP in our hospital between May 2008 and May 2013 were retrospectively reviewed. All patients underwent conventional treatment first and magnetic resonance cholangiopancreatography （MRCP） was used to confirm whether there was stone obstruction in the common bile duct. The 104 patients without choledocholithiasis underwent laparoscopic cholecystectomy （LC） after their recovery from pancreatitis. Eighteen patients diagnosed as choledocholithiasis by MRCP received endoscopic therapy （endoscopic retrograde cholangiopancreatography ＋ endoscopic sphineterotomy ＋ endoscopic nasobiliary drainage） and the stones were removed successfully, then LC was performed. Results The 106 cases of mild acute pancreatitis underwent LC within 7 - 14 days following the attack. The 16 cases of severe acute pancreatitis underwent LC within 15 -30 days following the attack. Cases in this group had no conversion to open surgery, bile duct injury or death. Among the 122 patients, 107 were followed up for 5 - 8 months, and no acute pancreatitis recurrence was found. Conclusions For patients of gallstone with ABP, MRCP is a routine test before the surgery. For patients with gallstone alone, LC should be performed after their recovery from pancreatitis. The patients with choledocholithiasis and bile duct obstruction should receive emergency endoscopic therapy within 72 hours, and LC should be performed after their recovery from pancreatitis; the patients with choledocholi[hiasis but without bile duct obstruction should receive ERCP first and then LC after their recovery from pancreatitis. The operation opportunity should be individualized. Most of the patients with mild acute pancreatitis should undergo LC within 1 - 2 weeks of the attack. The above treatment is safe, effective and minimally invasive for patients of gallstone with ABP.