微创治疗胆囊结石合并胆管结石57例报告

Minimally invasive treatment of gallbladder calculi combined with bile duct calculi:a report of 57 cases

目的：探讨胆囊结石合并胆管结石的微创治疗方式及如何选择最佳的治疗方案。方法：回顾分析2010年1月至2013年6月57例胆囊结石合并胆管结石患者的临床资料。结果：本组57例均顺利完成手术。49例行腹腔镜胆囊切除（laparoscopic cholecystectomy，LC）4-腹腔镜胆总管探查术（laparoscopi ccommonbileduct exploration，LCBDE），其中3例术后发生胆漏，1例为胆总管T管引流，经保守治疗后治愈；2例行胆总管一期缝合，于术后2—3d急诊开腹手术探查，术后恢复良好；术后经T管造影发现胆管残余结石2例，于术后8—9周经T管窦道取石成功。术前影像学检查发现2例患者胆总管直径〈0．8cm，行内镜十二指肠乳头括约肌切开取石术（endoscopicsphincterotomyforlithotomy，EST-L）＋LC，术后恢复良好。3例LC术中经扩张的胆囊管置入胆道镜取石后直接结扎。LC术后确诊继发胆总管结石3例，均行EST—L，患者恢复良好。结论：胆囊结石合并胆总管结石的微创治疗。应根据患者病情、术者所掌握的技能及设备条件等个体化选择具体术式，一般术前及术中确诊的患者应以“LC＋LCBDE”为首选，而LC术后确诊的继发胆总管结石应首选EST-L。由于Oddi括约肌结构的复杂性、功能的特殊性及不可复制性，术者在选择具体手术方式时，应注意保护Oddi括约肌的结构与功能，尽量避免行EST-L。

Objective：To explore the methods and option of minimally invasive treatment for gallbladder calculi combined with bile duct calculi. Methods： Clinical data of 57 patients with gallbladder calculi combined with bile duct calculi from Jan. 2010 to Jun. 2013 were analyzed retrospectively. Results： All the 57 operations were successful. 49 cases underwent laparoscopic cholecystectomy （LC） plus laparoscopic common bile duct exploration （LCBDE）, in which there were 3 cases of bile leakage, 1 case had T tube drain- age of common bile duct and was cured conservatively ;2 cases who underwent primary suture of common bile duct underwent emergency open exploration 2-3 d postoperatively, and recovered well. Remnant bile duct calculi was found by T-tube cholangiography postopera- tively in 2 cases, and was removed successfully by trans- sinus lithotomy 8-9 weeks postoperatively. 2 cases who had been found that the diameter of the common bile duct was less than 0.8 cm by preoperative imaging examination underwent endoscopic sphineterotomy for lithotomy （EST-L） plus LC, and recovered well. 3 cases received choledochoscopic lithotomy via dilated cystic duct during LC ,and the cystic duct was ligated directly. 3 patients who were diagnosed secondary common bile duct calculi after LC underwent EST-L, and re- covered well. Conclusions：The option of minimally invasive treatment for gallbladder calculi combined with bile duct calculi should de- pend on patients＇ condition,performer＇ s skills and equipment conditions. LC ＋ LCBDE is the first choice of patient diagnosed preopera- tively or intraoperatively, while EST-L is the first choice for secondary common bile duct calculi confirmed after LC. On account of its complex structure, special function and non-repeatability, surgeons should pay attention to protection of the structure and function of Oddi sphincter and avoid EST-L to the greatest extent when choosing operative method.