腹腔镜下经胆囊管胆管引流联合胆总管探查取石术治疗复杂胆管结石的临床效果

目的:探讨腹腔镜下经胆囊管胆管引流联合胆总管探查取石术治疗复杂胆管结石的可行性及效果。方法:回顾性分析2020年4月至2021年12月因复杂胆管结石采用腹腔镜下经胆囊管胆管引流(C管技术)联合胆总管探查取石术治疗的18例患者的临床资料,分析此种治疗方式的安全性及有效性。结果:18例患者中,13例采用传统C管技术,5例采用改良C管技术,手术时间(161±59)min(82~279 min),术后经C管造影均无结石残留及胆道狭窄,C管最大引流量为(500±163)mL/d(180~820 mL/d),3例C管脱落患者早期拔除C管,其余15例患者拔除C管的中位时间为8 d(5~12 d),18例患者术后住院时间为(12±3)d(7~21 d)。5例患者出现C管相关不良事件,均发生在采用传统C管技术的患者中,包括C管位置异常2例、早期脱落3例,均未出现并发症。1例患者出现1级并发症,该例患者采用的是改良C管技术,患者拔管后出现一过性发热,拔管后保留的腹腔引流管无胆汁,进一步行CT检查亦无明显胆漏,保守观察后第2天平稳出院。患者的术后中位随访时间为9个月(1~20个月),所有患者的肝功能均于术后1个月恢复正常,彩超或磁共振胰胆管造影(magnetic resonance cholangiopan-creatography,MRCP)检查未见结石复发征象。结论:腹腔镜下C管引流联合胆总管探查取石术在复杂胆总管结石患者的治疗上安全可行,近期效果良好,改良C管技术可能会减少C管脱落及胆漏的风险。

胃空肠吻合术后胆总管结石腹腔镜手术取石和内镜取石的比较

目的:探讨胃空肠吻合术后胆总管结石腹腔镜手术取石或内镜取石的疗效及优劣。方法:回顾性分析2012年1月至2016年12月的25例既往有胃空肠吻合手术史的胆总管结石患者的临床资料。按胆总管结石的处理方法分为腹腔镜手术组和内镜取石组,其中腹腔镜手术组15例,内镜取石组10例,比较两种方法的一般资料及治疗情况。结果:25例胃切除术后胆总管结石患者,毕Ⅱ式(BillrothⅡ)吻合术21例,Roux-en-Y吻合术4例,其中6例患者在急性胆管炎状态下行手术或内镜取石。腹腔镜手术组15例患者中5例有大于1 cm的胆总管结石,7例有多发胆总管结石;内镜取石组10例患者中3例有大于1 cm的胆总管结石,4例有多发胆总管结石。腹腔镜手术组更多患者合并胆囊结石,其中6例经胆囊管取石成功,未放置T管,内镜取石组患者中4例内镜单次取石成功,其中3例为单发小结石,另1例为多发小结石。有2例患者因粘连严重腹腔镜手术失败中转开腹,1例Roux-en-Y吻合术患者内镜取石失败,转行腹腔镜手术取石。腹腔镜手术组和内镜取石组的中位住院时间分别为12 d和10d。共有3例患者术后出现并发症,均经保守治疗后好转。结论:腹腔镜手术及内镜取石在胃空肠吻合术后的胆总管结石治疗中均可行,各有优势,相互补充,两种方法均有较高难度,需结合具体技术能力合理选择。

Strategies for diagnosis of xanthogranulomatous cholecystitis masquerading as gallbladder cancer

Background Patients with xanthogranulomatous cholecystitis sometimes exhibit imaging and intraoperative findings that are similar to those of advanced gallbladder cancer,thus these patients are easily misdiagnosed.The present study aimed to investigate the characteristics of xanthogranulomatous cholecystitis masquerading as gallbladder cancer that could potentially aid in the correct diagnosis of this condition.Methods The clinical,serological,radiological and operative features of twelve patients with obviously wall-thickening or mass-forming xanthogranulomatous cholecystitis were retrospectively analyzed.Additionally,the patient preoperative features were compared to those of 36 patients with advanced gallbladder cancers.Results Twelve patients with xanthogranulomatous cholecystitis exhibited one to three episodes of acute cholecystitis within 0.5 to 7 months prior to admission to the hospital.Five of these patients exhibited concomitant choledocholithiasis,whereas no concomitant choledocholithiasis was identified in patients with advanced gallbladder cancer.The incidence of abdominal pain （x2=6.588,P=0.010）,acute cholecystitis （x2=29.176,P=0.000）,acute cholangitis （x2=6.349,P=0.012）,choledocholithiasis （x2=16.744,P=0.000）,carcinoembryonic antigen test （P=0.007）,CA125 （P=0.001）,and diffuse gallbladder wall thickening （x2=6.031,P=0.014）,continued mucosal line （x2=15.745,P=0.000）,homogeneous enhancement of mucosal line （x2=19.947,P=0.000）,submucosal hypoattenuated nodules or band （x2=18.607,P=0.000） in computed tomography demonstrated statistically significant differences between cases of xanthogranulomatous cholecystitis and gallbladder cancer.Furthermore,all the twelve patients with xanthogranulomatous cholecystitis exhibited at least one positive computed tomography imaging feature aside from past acute cholecystitis episode,and no patient with advanced gallbladder cancer simultaneously exhibited past acute cholecystitis episode and at least one positive computed tomography imaging feature.Conclusions The accurate preoperative diagnosis of xanthogranulomatous cholecystitis includes an integrated review of past acute cholecystitis episode,choledocholithiasis,and positive computed tomography imaging features.Besides,we present an algorithm for intraoperative diagnosis.