Is there a place for endoscopic management in postcholecystectomy iatrogenic bile duct injuries?

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery.Previously,surgery was the primary treatment for bile duct injuries(BDI).The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures.Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years.Patient management,including the specific technique,is typically impacted by local knowledge and the kind and severity of the injury.Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction.Based on the damage features of BDI,therapeutic options include endoscopic duodenal papillary sphincterotomy,endoscopic nasobiliary drainage,and endoscopic biliary stent implantation.

Chronic pancreatitis-induced compressed relative stenosis of the distal Common bile duct

BACKGROUND: Fibrosis and enlargement of chronic pancreatitis (CP) can cause biliary stenosis, in which fixed circular stenosis is the common type, by compressing the intrapancreatic portion of the common bile duct. Another type of distal bile duct stenosis is compressed relative stenosis, in which the common bile duct walks along the back of the pancreas partially. METHODS: Thirty patients with dilation of the proximal common bile duct (diameter≥15mm) caused by CP underwent overall and systemic exploratory operation at our hospital. All of the patients were followed up for 3.5 to 15 years, averaging 8.5 years. RESULTS: The intrapancreatic portion of the common bile duct was found to walk along the back of the pancreas, and its anterior wall was compressed flat by enlarged pancreas, but the posterior wall showed a good flexibility because there was no pancreas covering. Bake’s dilators bigger than No. 6 (diameter≥4mm) and No. 14 urinary catheter could pass through the distal common bile duct after the posterior wall was separated. Roux-en-Y choledochojejunostomy was performed for 4 patients, and T-tube drainage was carried out for the remaining 26 patients. All of the patients were followed up but 2 were lost. Only 2 patients underwent choledochojejunostomy 3 years after T-tube drainage because of repeated acute pancreatitis attack, and others were normal. CONCLUSIONS: Compressed relative stenosis of the distal common bile caused by CP is a clinical sign, and its diagnosis mainly depends on surgical findings. Most patients can be treated by separating the posterior wall of the pancreas and T-tube drainage as well, but to patients with recurrent CP, choledochojejunostomy may be a feasible alternative.

Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUND Laparoscopic cholecystectomy(LC)combined with laparoscopic common bile duct(CBD)exploration(LCBDE)is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm.However,for patients with small CBD(CBD diameter≤8 mm),endoscopic sphincterotomy remains the preferred treatment at present,but it also has some drawbacks associated with a series of complications,such as pancreatitis,hemorrhage,cholangitis,and duodenal perforation.To date,few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIM To investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODS A total of 257 patients without acute cholangitis who underwent LC+LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed.The clinical data were retrospectively collected and analyzed.According to whether the diameter of CBD was larger than 8 mm,257 patients were divided into large CBD group(n=146)and small CBD group(n=111).Propensity score matching(1:1)was performed to adjust for clinical differences.The demographics,intraoperative data,short-term outcomes,and long-term follow-up outcomes for the patients were recorded and compared.RESULTS In total,257 patients who underwent successful LC+LCBDE were enrolled in the study,146 had large CBD and 111 had small CBD.The median follow-up period was 39(14-86)mo.For small CBD patients,the median CBD diameter was 0.6 cm(0.2-2.0 cm),the mean operating time was 107.2±28.3 min,and the postoperative bile leak rate,rate of residual CBD stones(CBDS),CBDS recurrence rate,and CBD stenosis rate were 5.41%(6/111),3.60%(4/111),1.80%(2/111),and 0%(0/111),respectively;the mean postoperative hospital stay was 7.4±3.6 d.For large CBD patients,the median common bile duct diameter was 1.0 cm(0.3-3.0 cm),the mean operating time was 115.7±32.0 min,and the postoperative bile leak rate,rate of residual CBDS,CBDS recurrence rate,and CBD stenosis rate were 5.41%(9/146),1.37%(2/146),6.85%(10/146),and 0%(0/146),respectively;the mean postoperative hospital stay was 7.7±2.7 d.After propensity score matching,184 patients remained,and all preoperative covariates except diameter of CBD stones were balanced.Postoperative bile leak occurred in 11 patients overall(5.98%),and no difference was found between the small CBD group(4.35%,4/92)and the large CBD group(7.61%,7/92).The incidence of CBDS recurrence did not differ significantly between the small CBD group(2.17%,2/92)and the large CBD group(6.52%,6/92).CONCLUSION LC+LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with choledocholithiasis patients with large CBD.

Microstructural and ultrastructural changes in the healing process of bile duct trauma

OBJECTIVE: To explore the mechanism of benign biliary stricture caused by bile duct trauma. METHODS: A model of trauma of the common bile duct was established in 28 dogs and then repaired. The anastomotic tissues were taken on 3 days, 1 week, 3 weeks, 3 months, and 6 months respectively after operation and examined by using light microscopy and electromicroscopy. Macrophage. transforming growth factor beta I (TGF-β1) and α-smooth muscle actin (α-SMA) were studied immunohistochemically. RESULTS: The mucosal epithelium of the common bile duct restored poorly, chronic inflammation lasted for a long time, fibroblasts proliferated actively, extracellular matrix overdeposited, and myofibroblasts functioned actively during the whole healing process. Immunohistochemical test showed a high expression of macrophage, TGF-β1 and α-SMA during the healing process lasting a long duration. Macrophages were found in the lamina propria under mucosa, TGF-β1 in the granular tissue, fibroblasts and endothelial cells of blood vessels, while α-SMA in the myofibroblasts and smooth muscle tissue. CONCLUSIONS: The healing of the bile duct is in the mode of overhealing. Myofibroblast is the main cause for contracture of scar and stricture of the bile duct. The high expression of macrophage, TGF-β1 and α-SMA is closely related to active proliferation of fibroblasts, extracellular matrix overdeposition and scar contracture of the bile duct.

Pathologico-Anatomic Categories of Choledochal End-Piece Stenosis Due to Chronic Pancreatitis and Clinical Significance

Background: Chronic pancreatitis caused by common bile duct segment stenosis is a common complication. It often results in near side bile duct expansion, bile drain disorder, appearing serious obstructive jaundice, biliary cirrhosis, lifethreatening. However, chronic pancreatitis causes not bravery manager narrow some light, some heavy, and the clinical manifestation is different too. We think there may be different kinds of pathological anatomy. As a result, we carried out the research of this subject. Objective: To investigate the anatomicopathological classification of terminal stenosis of the common bile duct (CBD) caused by chronic pancreatitis (CP) and the treatment. Method: A retrospective analysis was made for the management of sympatomatic stenosis of the terminal end of CBD 47 CP cases. Autopsy was performed in 25 bodies to verify our classification. Result: By analyzing operation and postoperative follow-ups to 47 patients with obvious choledochal dilatations (diameter ≥ 15 mm) due to chronic pancreatitis, the authors have found that there exist three pathologico-anatomic categories of choledochal end-piece stenosis due to chronic pancreatitis. The stenosis of type I is the external-pressing annular stricture (59.6%);type II is front wall of choledochus being compressed one (31.9%);and type III is the pseudocystic oppression one (8.5%). Conclusion: The treatment of CP patients complicated with terminal stenosis of CBD need individual consideration. Clinical Significance: Type I should be treated with biliary-enterostomy owing to more serious stricture (only No.3 the Bake’s dilstors and smaller ones can be passed through its stenotic segment). Type II Could be managed with T-tube drainage because of its slighter stricture (Bake’s dilators bigger than No.6 and No.12 French urinary catheter can get through the Choledochal terminal). If there aren’t biliary and pancreatic complicated diseases, non-operative treatment can be carried out. Type III can undergo with the T-tube replacement between biliary tract and pseudocyst if pseudocystic decompression doesn’t lead to obvious stenosis (type IIIo and IIIb). If type III combines type I, the internal drainage should be performed in both ectatic bile duct and cyst.

A study on the expressions and the correlation of TGF-β1 and α-SMA in healing process of bile duct trauma

Objective: To explore the formation mechanism of benign biliary stricture. Methods: A model of trauma of common bile duct was established in 28 dogs and then repaired. The anasomosis tissues were taken on the 1st week, 3rd week and the 3rd month, 6th month respectively after operation and examined by using light microscopy and elec-tromicroscopy. Macrophage, TGF-p, and a-SMA were studied immunohistochemically. Results: The mucosal epithelium of common bile duct restored poorly, chronic inflammation lasted for a long time, fibroblasts proliferated actively, extracellular matrix overdeposited; and myofibroblasts functioned actively and existed during the whole healing process. Immunohistochemical test showed a high expression of macrophage, TGF-β1 and a-SMA during healing process lasting a long duration. Macrophages were found in the lamina propria under mucosa, TGF-β1 in the granulation tissue, fibroblasts and endothelial cells of blood vesssels, while a-SMA in the myofiroblasts and smooth muscle tissue. Conclusion: The healing of bile duct is in the mode of overhealing. Myofibroblast is the main cause for contracture of scar and stricture of bile duct. The high expression of macrophage, TGF-β1 and a-SMA is closely related to active proliferation of fibroblasts, extracelluar matrix overdeposition and scar contracture of bile duct.

LCBDE及一期缝合术后发生胆瘘及胆总管狭窄的影响因素分析

目的研究腹腔镜胆总管探查(LCBDE)及一期缝合术(PDC)后发生胆瘘及胆总管狭窄的影响因素。方法回顾性分析2021年2月至2024年2月于漳州市第二医院接受LCBDE及PDC治疗的82例患者的临床资料。采用单因素分析及多因素Logistic回归分析明确LCBDE及PDC后胆瘘及胆总管狭窄的危险因素。结果单因素分析发现,糖尿病、胆总管直径、手术时长及胆总管缝合方式与LCBDE及PDC后发生胆瘘和胆总管狭窄有关(均P<0.05)。多因素Logistic回归分析显示,糖尿病、胆总管直径<1 cm、手术时长≥120 min和胆总管连续缝合是LCBDE及PDC后胆瘘发生的危险因素(OR=2.385、6.106、5.409、4.130,P<0.05);糖尿病、胆总管直径<1 cm、手术时长≥120 min和胆总管连续缝合是LCBDE及PDC后胆总管狭窄的危险因素(OR=2.301、4.159、3.201、2.791,P<0.05)。结论糖尿病、胆总管直径<1 cm、手术时长≥120 min和胆总管连续缝合是LCBDE及PDC后胆瘘和胆总管狭窄的危险因素。临床工作中可针对上述危险因素开展干预,从而达到降低胆瘘及胆总管狭窄发生风险的目的。

胆管结石应用腹腔镜联合胆道镜取石术及利胆排石颗粒治疗的远期效果分析

目的分析胆管结石应用腹腔镜联合胆道镜取石术及利胆排石颗粒治疗的远期效果。方法72例胆管结石患者,随机分为对照组和观察组,各36例。对照组应用腹腔镜联合胆道镜取石术治疗,观察组在对照组基础上加用利胆排石颗粒治疗。对比两组治疗6和12个月后最大结石直径、胆结石残留率、胆管狭窄率、临床症状(上腹疼痛、黄疸及发热)发生率及治疗12个月后的效果。结果观察组治疗6、12个月后最大结石直径分别为(3.84±1.08)、(3.12±0.86)mm,均小于对照组的(4.52±1.25)、(4.56±1.27)mm,差异有统计学意义(P<0.05)。观察组治疗6、12个月后胆结石残留率和胆管狭窄率分别为16.67%、25.00%和11.11%、19.44%,均低于对照组的38.89%、50.00%和30.56%、44.44%,差异有统计学意义(P<0.05)。两组治疗6个月后黄疸、发热发生率对比,差异无统计学意义(P>0.05);观察组治疗6、12个月后上腹疼痛发生率分别为8.33%、13.89%,均低于对照组的27.78%、36.11%,差异有统计学意义(P<0.05);观察组治疗12个月后黄疸、发热发生率分别为2.78%、5.56%,均低于对照组的22.22%、27.78%,差异有统计学意义(P<0.05)。观察组治疗12个月后总有效率94.44%高于对照组的77.78%,差异有统计学意义(P<0.05)。结论胆管结石应用腹腔镜联合胆道镜取石术及利胆排石颗粒治疗能有效降低胆结石残留率及胆管狭窄率,缩小结石直径,进而改善患者临床症状,提升远期治疗效果。

腹腔镜联合内镜治疗胆管结石464例报告

目的 :探讨腹腔镜联合内镜治疗胆管结石和胆管狭窄的方法、适应证和禁忌证。方法 :采用腹腔镜胆总管切开胆道镜探查取石术 (LCDE)或腹腔镜胆道镜探查取石球囊导管扩张胆管切口即时即缝合术 (LPBD)治疗胆管结石和胆管狭窄 ,联合内镜处理并发症。结果 :LCDE 45 7例 (包括阴性探查 18例 ) ;术后残石 39例 ,7例未取净 ,内镜取净 32例 ,胆漏 13例 ,鼻胆管引流 (ENBD)解除 9例 ,腹腔引流管持续少量胆漏非手术综合处理4例自愈 ,脓性胆管炎败血症急诊LCDE死亡 1例。LPBD 2 5例 ,3例原发性肝胆管结石狭窄解除 ,其中 1例左肝内胆管残石未取净 ;2 2例继发性胆总管结石乳头狭窄解除 ,结石取净。结论 :腹腔镜联合内镜治疗胆管结石和胆管狭窄 ,具有创伤小、有效。

自膨胀式支架在梗阻性黄疸治疗中的应用

目的 评价自膨胀式支架在梗阻性黄疸姑息性治疗中的价值。方法 我们对 18例梗阻性黄疸患者 ,实施了经皮肝穿 ,胆道内自膨胀式支架植入术。对其中 17例患者进行了 2～ 44周随访。结果 18例内支架均成功植入 ,除 1例外 ,术后 2周内血清胆红素及碱性磷酸酶都显著降低 ,胆道梗阻引起的症状缓解。 3例 (17% )发生支架堵塞 ,平均支架通畅时间 18周。结论 自膨胀式内支架植入 ,是姑息性治疗梗阻性黄疸的安全有效手段。

内镜下乳头括约肌切开术的远期疗效观察及其并发症的相关危险因素分析

目的探讨内窥镜下十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)对胆总管结石、十二指肠乳头狭窄等疾病的治疗效果,并对术后出现的远期并发症的可能危险因素进行分析。方法收集我院2005年1月至2006年12月间行EST治疗的158例患者的临床病例资料,对其中资料完整的103例患者进行资料统计分析。结果出现远期(≥术后3月)并发症者13例,发生率为12.6%。其中,胆总管结石复发者8例,有6例伴随胆管炎反复发作;单纯胆管炎1例;出现结石性胆囊炎2例;胆管结石残留1例;慢性胰腺炎1例。结论EST是治疗胆道梗阻的安全、可靠的方法。术前患者黄疸可能是引起远期并发症的危险因素。

^(103)钯支架预防犬胆管损伤后狭窄的实验研究

目的 探讨1 0 3Pd(1 0 3钯 )支架及胆管内放射对胆管损伤后狭窄的预防作用。方法 健康犬 12只 ,随机分为 2组 :(1)实验组 (n =6) ,即1 0 3Pd支架组 ,实验术中经胆总管末端开口 ,将Forgort气囊导管插入胆总管内 ,进行球囊扩张术 ,然后用 11F医用推送器将1 0 3Pd支架送至目标的胆管段。 (2 )对照组(n =6) ,实验方法同实验 (1)组 ,但采用普通支架植入。术后 3 0d ,用γ计数器进行胆管及周围组织放射性测定、免疫组织化学测定、组织病理学和胆管造影检查。计算机图像分析胆管组织形态学的变化。结果 普通支架组术后 3 0d胆管损伤处 ,胆管黏膜断裂 ,内膜增生及管腔狭窄。1 0 3Pd支架组 :胆管内放射治疗后 3 0d与普通支架组比明显减少胆管内膜增生厚度 (P <0 .0 1)。胆管狭窄面积百分比 ,普通支架组为 (60± 2 1.6) % ,1 0 3Pd支架组为 (3 1.6± 9.5 ) % (P <0 .0 1) ,1 0 3Pd支架组胆管腔面积比普通支架组明显增加 (P <0 .0 1)。结论 在球囊扩张致胆管损伤术后即刻应用1 0 3Pd支架胆管腔内放射植入及行内照射治疗 ,可有效地预防犬的胆管损伤术后 3 0d胆管内膜增生和胆管狭窄。

医源性高位胆管损伤狭窄的处理

目的 探讨医源性高位胆管损伤后狭窄的处理方法 ,以期提高疗效、减少并发症。方法 对 2 3年中 183例医源性胆管损伤病例资料进行回顾性分析 ,以修复后再手术作为判断疗效标准。结果 183例中有 173例行不同方式修复术 ,有 14 4例因高位胆管狭窄再行 1～ 5次手术 ,再手术率 83 .2 4% ( 14 4/173 )。结论 采用狭窄以上正常胆管进行胆肠Roux Y吻合术 ,注意吻合方法和质量 ,可减少术后胆管再狭窄复发的发生率 。

先天性胆管扩张症合并肝内胆管扩张的手术治疗对策

目的探讨先天性胆管扩张症合并肝内胆管扩张的手术治疗对策,以提高手术的远期疗效。方法第1组不管是否提示合并肝内胆管扩张,均单纯行扩张胆总管、胆囊切除,肝总管空肠Roux-en-Y吻合。第2组在第1组手术术式基础上,对胆管狭窄者行胆管成形术和冲洗处理胰胆管共同通道。采用时序分组进行对比分析研究。结果第1组13例,6例合并肝内胆管扩张,4例为囊样扩张。第2组共46例,18例有肝内胆管扩张,其中11例为囊样扩张,同时存在胆管狭窄。第2组术后腹痛、胆道感染的发生率明显低于第1组。讨论在标准根治术(囊肿切除胆道重建)的基础上对近端肝内胆管狭窄矫治、可能存在的复杂胆道畸形的处理及远端胰胆管共同通道冲洗,可有效降低术后胆道胰管并发症的发生,提高手术远期疗效。

胰胆管磁共振水成像:快速自旋回波单激发与重T_2序列对照研究

目的 :探讨两种MRCP方法显示胰胆道解剖与病变的价值。材料与方法 :回顾性分析 39例明确诊断的胆道系统SS FSE和HT2 FSE资料。结果 :HT2 FSE图像为胰胆管多层冠状源影像 ,10 0 %病例获得了有诊断价值的MIP、SSD和VE等重建影像 ;厚层单层SS FSE序列图像为 1幅胰胆管容积投影像 ,无需重建。HT2 FSE和SS FSE对胆总管、左右肝管及主要属支显示率均达 10 0 % ,胆囊显示率分别为 10 0 %和 76 4% ,胰管显示率分别为 74 4%和 92 3 % ;其对病变总敏感性和准确性前者高于后者。结论 :磁共振水成像为无创性显示胆胰管系统解剖与病理改变的有效方法 ,常规应用HT2 FSE序列 ,患者难以配合时采用SS FSE序列。

肝内胆管结石并胆管狭窄的治疗

为探讨肝内胆管结石并胆管狭窄的外科治疗，对１０年来收治的１６８例肝内胆管结石并胆管狭窄的术前检查、结石及狭窄的部位和分布情况、手术方式、手术后并发症及残余结石的处理进行了分析。结果显示：１６８例中，左肝内胆管结石、全肝结石和右肝内胆管结石分别是８３，５９和２６例；左外叶及左半肝切除１１６例；右肝段切除２２例；高位胆管切开整形胆肠大口吻合９６例；残石率３％；１３例出现手术后并发症；随访１４２例，优良效果９６．５％。结果提示肝叶、肝段切除联合肝胆管空肠大口吻合是肝内胆管结石并胆管狭窄的最佳治疗选择。

局部应用5-氟尿嘧啶预防胆管电凝损伤后瘢痕狭窄的实验研究

目的探讨早期局部应用5-氟尿嘧啶(5-FU)对预防电凝损伤后胆管瘢痕狭窄的疗效,为临床治疗胆管良性狭窄寻求新的途径。方法 40只SD大鼠,随机分成2组:实验组(5-FU组)与对照组(NS组),利用电凝损伤胆总管建立胆总管损伤狭窄模型,于胆总管损伤部位分别局部应用5-FU与生理盐水,于术后1周和2周观察肝功能变化、近端胆管扩张程度及胆管狭窄部位病理表现。结果 5-FU组肝功能损害明显低于同时期NS组,差异有统计学意义(P<0.05)。5-FU组近端胆管扩张程度明显轻于NS组。胆管狭窄病理结果提示:5-FU组损伤部位胆管壁增厚不明显,成纤维细胞散在分布,胶原蛋白分布均匀;NS组损伤部位胆管壁明显增厚,成纤维细胞增生活跃,部分可见肌纤维细胞,胶原蛋白多而不规则。结论局部应用5-FU对大鼠胆管电凝损伤所致胆管瘢痕狭窄有预防作用,可以为临床治疗胆管良性狭窄提供新的研究方向。

肝内胆管结石合并胆管狭窄的处理

肝内胆管结石是指肝总管分叉以上的胆管结石.在东亚及东南亚一些国家和地区发病率很高,而在欧美国家发病率低.肝内胆管结石合并胆管狭窄发病率高,据报道国内胆管狭窄的发生率为24.80%-41.94%,肝内胆管狭窄是肝内胆管结石的主要病理改变,两者互为因果.长期存在的结石,合并肝内胆管感染、狭窄及胆汁淤积,常导致胆石存在肝段实质萎缩,甚至恶变.结石、炎症及狭窄3者互为因果,由于其反复发作的炎症、胆管狭窄及手术后残留的结石,肝内胆管结石合并狭窄一直是临床治疗的难点之一.因病变部位不同,其临床表现也因人而异.一般而言,其临床表现往往不如肝外胆管结石那样严重,但治疗难度却明显高于肝外胆管结石.B超诊断肝内胆管结石的准确率很高,近年来随着经皮肝穿刺胆管造影(percutaneous transhepatic cholangiography,PTC)、经内镜逆行胰胆管造影(endoscopic retrograde cholangio-pancreatography,ERCP)、磁共振胰胆管造影(magnetic resonance cholan giopancreatography,MRCP)等先进诊断技术手段的应用,肝内胆管结石及狭窄得以更及时更清晰的诊断,其治疗方法也取得一定进展.术前进行详尽的影像学检查,明确结石及胆管狭窄所处的具体位置,针对不同患者的病情,制定恰当的个体化治疗方案尤为重要.本文结合我们的治疗体会探讨肝内胆管结石合并胆管狭窄的诊断和治疗问题.

肝胆管结石手术患者的护理

目的探讨肝胆管结石手术患者的护理方法。方法回顾性分析190例因肝胆管结石行手术治疗患者的治疗与护理措施。结果本组无手术死亡病例,住院死亡3例,36例出现术后并发症,37例术后有结石残留。经积极治疗与护理,除肝功能衰竭的3例患者外,其他患者的并发症均好转或治愈,37例残留结石患者中17例取尽结石。结论积极有效的手术治疗与围术期护理是肝胆管结石患者手术顺利进行和术后康复的保证。

胆管修复与重建材料的研究及其临床应用

目的 复习胆管修复与重建材料的实验研究和临床应用。方法 比较不同类型材料的特点以及优缺点。结果 合成材料如镍钼合金管、聚四氟乙烯操作方便 ,但缺乏柔顺性 ,且有异物反应 ;游离的自体组织如静脉材料容易获得 ,抗感染力强 ,因缺乏血供易导致胆管狭窄 ;带血管蒂的邻近组织转位修复效果较佳。结论 胆管缺损的修复宜采用灵活多样的措施 ,避免胆管狭窄的发生 ;胆管的大段丢失应行胆管的端端吻合或胆管空肠Roux -en