腹腔镜治疗Mirizzi综合征35例临床分析

Clinical analysis of laparoscopy in the treatment of 35 cases of Mirizzi syndrome

目的探讨Mirizzi综合征的诊断方法选择及腹腔镜治疗的可行性。方法回顾同济大学附属上海市同济医院2010年1月至2015年12月收治的共35例Mirizzi综合征的临床资料,对其诊断方法、手术方式以及治疗结果进行分析。结果实施腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)4 352例,其中确诊为Mirizzi综合征共35例,占0.8%。术前诊断率为60.0%。根据Csendes’s分型:Ⅰ型21例,LC共17例,腹腔镜胆囊大部切除术(laparoscopic subtotal cholecystectomy,LSC)+胆总管切开术+T管支撑引流术4例;Ⅱ型10例,LSC+瘘口直接修补术+胆总管切开术+T管支撑引流术4例,LSC+胆囊壁组织修补瘘口术+胆总管切开术+T管支撑引流术3例,中转开腹行胆囊大部切除术+胆总管空肠Roux-en-Y吻合术3例;Ⅲ型4例,LSC+胆囊壁组织修补瘘口术+胆总管切开术+T管支撑引流术1例,中转开腹行胆囊大部切除术+部分胆管切除术+胆管端端吻合术+胆总管切开术+T管支撑引流术1例,中转开腹行胆囊大部切除术+胆总管空肠Roux-en-Y吻合术2例。结论 Mirizzi综合征术前诊断困难,磁共振胆胰管成像(MRCP)能够作为提高诊断准确率的一种无创手段;腹腔镜可以安全处理大部分Ⅰ型、Ⅱ型及小部分Ⅲ型Mirizzi综合征,对大部分Ⅲ型Mirizzi综合征腹腔镜处理困难,应及时开腹处理。

Objective To investigate the diagnostic method and feasibility of laparoscopy in the treatment of Mirizzi syndrome. Methods The clinical data of 35 cases of Mirizzi syndrome from Janu- ary 2010 to December 2015 in Shanghai Tongji Hospital were analyzed retrospectively. Results Thir- ty-five cases accounting for 0. 8% of 4 352 patients who underwent laparoscopic cholecystectomy （LC） were diagnosed as having Mirizzi syndrome. The preoperative diagnostic rate was 60. 0%. According to the Csende＇s classification, there were 21 cases of type Ⅰ. 17 cases were given LC,and the rest 4 cases underwent laparoseopic subtotal eholeeysteetomy （LSC） ＋ common bile duct exploration （CBDE） ＋ T tube drainage. Ten cases were diagnosed as having type Ⅱ, given LSC ＋ simple fistular repair for bile duct ＋ CBDE ＋ T tube drainage in 4 cases,LSC ＋ closure of fistulae with padiele gallbladder flap ＋ CBDE ＋ T tube drainage in 3 cases,and conversion to open subtotal choleeystectomy （OSC） ＋ Roux-en-Y choledochojejunostomy in 3 cases. Four cases were diagnosed as having type Ⅲ, given LSC ＋ closure of fistulae with padicle gallbladder flap ＋ CBDE ＋ T tube drainage in one case,con- version to OSC ＋ partial common bile duct resection ＋ common bile duct reconstruction by end-to- end anastomosis ＋ CBDE ＋ T tube drainage in one case,and conversion to OSC ＋ Roux-en-Y chole- dochojejunostomy in 2 cases. Conclusions It is hard to diagnose Mirizzi syndrome preoperatively, and accurate intraoperative diagnosis can decrease the occurrence of bile duct injuries. Magnetic resonance cholangiopancreatography is an ideal imaging diagnostic strategy. Type Ⅰ , most of type Ⅱ and a small part of type Ⅲ Mirizzi syndrome can be treated with laparoscopy safely, while most of type Ⅲ Mirizzi syndrome should undergo laparotomy in case of bile duct injury.