腹腔镜手术治疗急性胆管炎合理选择及争议

Reasonable options and controversies of laparoscopic treatment for acute cholangitis

急性胆管炎治疗选择与诊断、分级密切相关。中、重度急性胆管炎须立即行胆道引流,国内外指南均推荐首选内镜下鼻胆管引流术(ENBD),经皮经肝胆道引流术(PTCD)与外科手术为备选治疗方案。在对急性胆管炎准确分级前提下,行急诊腹腔镜胆总管探查术(LCBDE)治疗胆总管结石引起的轻、中度急性胆管炎安全可靠。急诊行LCBDE时,轻度胆管炎病人的术中情况与择期手术基本相同,特殊情况少见;中度胆管炎病人可能发生出血量偏大、胆管壁菲薄或偏厚缝合困难等情况,须酌情处理,必要时中转开腹手术。对于重度胆管炎病人,应尽可能避免手术引流,如果ENBD和PTCD失败或存在禁忌证时,可考虑行开腹胆道引流术。

Treatment option of acute cholangitis is closely related to diagnosis and severity assessment. For moderate and severe acute cholangitis, early biliary drainage should be performed. Both of China and aboard guidelines recommend endoscopic naso-biliary drainage （ENBD） as the first choice, and suggest that percutaneous transhepatic cholangial drainage （PTCD） and surgical operationmay be considered as alternative methods. With the current technology and accurate severity assessment in acute cholangitis, emergency laparoscopic common bile duct exploration （LCBDE） can be performed safely and effectively for patients with moderate acute cholangitis caused by common stones. For mild acute cholangitis, emergency operation is the same as elective operation. For modera!e acute cholangitis, massive bleeding and difficult suture due to thin / or thick biliary wall may occur, which need spe^ial management even conversion to open operation when necessary. Surgical biliary drainage should be avoided in severe cholangitis. When ENBD and PTCD failed, or contraindications occurred, open surgical biliary drainage should be performed.