Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred t...Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.展开更多
Extraction of large pancreatic and common bile duct(CBD)calculi has always challenged the therapeutic endoscopist.Extracorporeal shockwave lithotripsy(ESWL)is an excellent tool for patients with large pancreatic and C...Extraction of large pancreatic and common bile duct(CBD)calculi has always challenged the therapeutic endoscopist.Extracorporeal shockwave lithotripsy(ESWL)is an excellent tool for patients with large pancreatic and CBD calculi that are not amenable to routine endotherapy.Pancreatic calculi in the head and body are targeted by ESWL,with an aim to fragment them to<3 mm diameter so that they can be extracted by subsequent endoscopic retrograde cholangio-pancreatography(ERCP).In our experience,complete clearance of the pancreatic duct was achieved in 76% and partial clearance in 17%of 1006 patients.Short-term pain relief with reduction in the number of analgesics ingested was seen in 84%of these patients.For large CBD calculi,a nasobiliary tube is placed to help target the calculi,as well as bathe the calculi in salinea simple maneuver which helps to facilitate fragmenta-tion.The aim is to fragment calculi to<5 mm size and clear the same during ERCP.Complete clearance of the CBD was achieved in 84.4%of and partial clearance in 12.3%of 283 patients.More than 90%of the patients with pancreatic and biliary calculi needed three or fewer sessions of ESWL with 5000 shocks being de-livered at each session.The use of epidural anesthesia helped in reducing patient movement.This,together with the better focus achieved with newer third-gen-eration lithotripters,prevents collateral tissue damage and minimizes the complications.Complications in our experience with nearly 1300 patients were minimal,and no extension of hospital stay was required.Similar rates of clearance of pancreatic and biliary calculi with minimal adverse effects have been reported from the centers where ESWL is performed regularly.In view of its high efficiency,non-invasive nature and low complication rates,ESWL can be offered as the first-line therapy for selected patients with large pancreatic and CBD calculi.展开更多
BACKGROUND Ectopic opening of the common bile duct is a condition with low incidence.Patients with an ectopic common bile duct opening have a high incidence of common bile duct stones and acute cholangitis.Patients wi...BACKGROUND Ectopic opening of the common bile duct is a condition with low incidence.Patients with an ectopic common bile duct opening have a high incidence of common bile duct stones and acute cholangitis.Patients with atypical symptoms and imaging findings are easily misdiagnosed;moreover,it is difficult to retrieve stones by endoscopic retrograde cholangiopancreatography,and common bile duct stones are prone to postsurgical recurrence.CASE SUMMARY A 45-year-old male patient presented with“intermittent upper abdominal pain and elevated liver enzymes for 1 wk”.Transabdominal ultrasound indicated dilation of the common bile duct and the presence of stones.Magnetic resonance imaging showed that the common bile duct was dilated with stones and that its opening was ectopic.Endoscopic retrograde cholangiopancreatography revealed an abnormal opening of the common bile duct into the duodenal bulb and the presence of common bile duct stones.Laparoscopic extrahepatic choledochectomy and hepatoenteric anastomosis were performed.After surgery,the patient recovered well and was discharged.The patient has been followed up for 2 years since the operation.He has not experienced stone recurrence,and his liver function and quality of life are good.CONCLUSION Improved understanding of ectopic opening of the common bile duct is needed for clinicians to provide patients with appropriate treatment.展开更多
BACKGROUND: Despite its rare incidence, few cases of left-side gallbladder have been already published. METHODS: We reported herein the case of a 29-year-old man with a left liver tumor in whom left lateral bisegmen- ...BACKGROUND: Despite its rare incidence, few cases of left-side gallbladder have been already published. METHODS: We reported herein the case of a 29-year-old man with a left liver tumor in whom left lateral bisegmen- tectomy was mandatory. It represents the first description of a sinistroposition of both gallbladder and common bile duct. RESULTS: Surgical exploration revealed a left-side gall- bladder , located under the left lobe of the liver. During he- patic parenchyma dissection at the left side of the round liga- ment and the Rex recessus, the common bile duct was in- jured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the Rex recessus before reaching the hepatoduo- denal ligament. CONCLUSION: Only careful dissection of the hepatoduo- denal ligament up to Rex recessus level prior to liver paren- chyma resection could avoid biliary tract injury during left lobectomy.展开更多
AIM To summarize the experience in the clinical treatment of the biliary ductal strictures complicating localized left hepatolithiasis in recent two decades.
目的分析基于加速康复外科(ERAS)理念下的医护一体化护理对腹腔镜胆总管切开取石术后患者心理应激及术后恢复应用效果。方法选择2022年1月至2023年7月于萍乡赣西医院普通外科就诊实行腹腔镜胆总管切开取石术的120例患者作为研究对象,根...目的分析基于加速康复外科(ERAS)理念下的医护一体化护理对腹腔镜胆总管切开取石术后患者心理应激及术后恢复应用效果。方法选择2022年1月至2023年7月于萍乡赣西医院普通外科就诊实行腹腔镜胆总管切开取石术的120例患者作为研究对象,根据护理方法将患者分为ERAS组(n=60)和对照组(n=60),对照组采取常规围手术期护理,ERAS组采用基于ERAS理念下的医护一体化护理。比较两组术后住院及康复基本情况、临床疗效、焦虑自评量表(SAS)、抑郁自评量表(SDS)、应激反应相关指标[皮质醇(Cor)、去甲肾上腺素(NE)、游离三碘甲状腺原氨酸(FT3)]水平变化,比较两组的护理满意度和并发症发生率。结果ERAS组患者下床活动时间、拔除腹腔引流管时间及肛门首次排气、排便时间、住院时间均短于对照组,住院费用少于对照组,差异有统计学意义(P<0.05)。ERAS组患者总有效率高于对照组,差异有统计学意义(P<0.05)。ERAS组术后3 d SAS、SDS评分、Cor、NE、FT3水平均低于对照组,差异有统计学意义(P<0.05)。ERAS组患者护理总满意率高于对照组,并发症总发生率低于对照组,差异有统计学意义(P<0.05)。结论在腹腔镜下胆总管切开取石手术中患者中开展基于ERAS理念下的医护一体化护理是安全有效的,有利于缓解患者抑郁、焦虑等不良情绪,加快术后康复,降低应激反应并减少术后并发症发生,提高护理满意度,值得临床推广。展开更多
Single-incision laparoscopic surgery(SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecyste...Single-incision laparoscopic surgery(SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy(SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials(RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration(CBDE) methods have been used for more than one hundred years, laparoscopic CBDE(LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and singleincision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.展开更多
目的探究磁共振胰胆管造影(MRCP)诊断不同直径、不同部位胆总管结石(CBDS)的价值。方法选取2019年9月至2022年9月我院175例疑似CBDS患者,均行术前超声、CT及MRCP,以内镜下逆行胰胆管造影术(ERCP)检查结果为“金标准”,统计术前超声、CT...目的探究磁共振胰胆管造影(MRCP)诊断不同直径、不同部位胆总管结石(CBDS)的价值。方法选取2019年9月至2022年9月我院175例疑似CBDS患者,均行术前超声、CT及MRCP,以内镜下逆行胰胆管造影术(ERCP)检查结果为“金标准”,统计术前超声、CT及MRCP诊断CBDS的结果,比较3种方法诊断CBDS的价值,并比较超声、CT、MRCP诊断不同直径、不同部位CBDS的准确度,根据术前MRCP诊断结果选择手术方案,统计一次取石成功率。结果基于ERCP检查结果的“金标准”,术前MRCP诊断CBDS的敏感度(95.83%)、准确度(95.43%)均高于超声、CT诊断(P<0.05);MRCP诊断结石直径<5 mm CBDS的准确度(88.00%)均高于超声、CT诊断,诊断直径5~10 mm CBDS的准确度(96.83%)高于超声诊断(P<0.05),诊断直径>10 mm CBDS的准确度为100.00%;MRCP诊断上段CBDS的准确度(96.88%)均高于超声、CT诊断,诊断胰腺段CBDS的准确度(92.68%)高于超声诊断(P<0.05),诊断壶腹段CBDS的准确度为100.00%。结论MRCP诊断CBDS的敏感度、准确度较高,在不同直径、不同部位CBDS诊断方面均具有很高准确度,可为手术取石提供可靠术前参考依据。展开更多
文摘Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.
文摘Extraction of large pancreatic and common bile duct(CBD)calculi has always challenged the therapeutic endoscopist.Extracorporeal shockwave lithotripsy(ESWL)is an excellent tool for patients with large pancreatic and CBD calculi that are not amenable to routine endotherapy.Pancreatic calculi in the head and body are targeted by ESWL,with an aim to fragment them to<3 mm diameter so that they can be extracted by subsequent endoscopic retrograde cholangio-pancreatography(ERCP).In our experience,complete clearance of the pancreatic duct was achieved in 76% and partial clearance in 17%of 1006 patients.Short-term pain relief with reduction in the number of analgesics ingested was seen in 84%of these patients.For large CBD calculi,a nasobiliary tube is placed to help target the calculi,as well as bathe the calculi in salinea simple maneuver which helps to facilitate fragmenta-tion.The aim is to fragment calculi to<5 mm size and clear the same during ERCP.Complete clearance of the CBD was achieved in 84.4%of and partial clearance in 12.3%of 283 patients.More than 90%of the patients with pancreatic and biliary calculi needed three or fewer sessions of ESWL with 5000 shocks being de-livered at each session.The use of epidural anesthesia helped in reducing patient movement.This,together with the better focus achieved with newer third-gen-eration lithotripters,prevents collateral tissue damage and minimizes the complications.Complications in our experience with nearly 1300 patients were minimal,and no extension of hospital stay was required.Similar rates of clearance of pancreatic and biliary calculi with minimal adverse effects have been reported from the centers where ESWL is performed regularly.In view of its high efficiency,non-invasive nature and low complication rates,ESWL can be offered as the first-line therapy for selected patients with large pancreatic and CBD calculi.
基金Supported by The Key Research and Development Program of Gansu,No. 17YF1FA128Lanzhou Science and Technology Bureau Innovation and Entrepreneurship Talent Program,No. 2017-RC-37.
文摘BACKGROUND Ectopic opening of the common bile duct is a condition with low incidence.Patients with an ectopic common bile duct opening have a high incidence of common bile duct stones and acute cholangitis.Patients with atypical symptoms and imaging findings are easily misdiagnosed;moreover,it is difficult to retrieve stones by endoscopic retrograde cholangiopancreatography,and common bile duct stones are prone to postsurgical recurrence.CASE SUMMARY A 45-year-old male patient presented with“intermittent upper abdominal pain and elevated liver enzymes for 1 wk”.Transabdominal ultrasound indicated dilation of the common bile duct and the presence of stones.Magnetic resonance imaging showed that the common bile duct was dilated with stones and that its opening was ectopic.Endoscopic retrograde cholangiopancreatography revealed an abnormal opening of the common bile duct into the duodenal bulb and the presence of common bile duct stones.Laparoscopic extrahepatic choledochectomy and hepatoenteric anastomosis were performed.After surgery,the patient recovered well and was discharged.The patient has been followed up for 2 years since the operation.He has not experienced stone recurrence,and his liver function and quality of life are good.CONCLUSION Improved understanding of ectopic opening of the common bile duct is needed for clinicians to provide patients with appropriate treatment.
文摘BACKGROUND: Despite its rare incidence, few cases of left-side gallbladder have been already published. METHODS: We reported herein the case of a 29-year-old man with a left liver tumor in whom left lateral bisegmen- tectomy was mandatory. It represents the first description of a sinistroposition of both gallbladder and common bile duct. RESULTS: Surgical exploration revealed a left-side gall- bladder , located under the left lobe of the liver. During he- patic parenchyma dissection at the left side of the round liga- ment and the Rex recessus, the common bile duct was in- jured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the Rex recessus before reaching the hepatoduo- denal ligament. CONCLUSION: Only careful dissection of the hepatoduo- denal ligament up to Rex recessus level prior to liver paren- chyma resection could avoid biliary tract injury during left lobectomy.
文摘AIM To summarize the experience in the clinical treatment of the biliary ductal strictures complicating localized left hepatolithiasis in recent two decades.
文摘目的分析基于加速康复外科(ERAS)理念下的医护一体化护理对腹腔镜胆总管切开取石术后患者心理应激及术后恢复应用效果。方法选择2022年1月至2023年7月于萍乡赣西医院普通外科就诊实行腹腔镜胆总管切开取石术的120例患者作为研究对象,根据护理方法将患者分为ERAS组(n=60)和对照组(n=60),对照组采取常规围手术期护理,ERAS组采用基于ERAS理念下的医护一体化护理。比较两组术后住院及康复基本情况、临床疗效、焦虑自评量表(SAS)、抑郁自评量表(SDS)、应激反应相关指标[皮质醇(Cor)、去甲肾上腺素(NE)、游离三碘甲状腺原氨酸(FT3)]水平变化,比较两组的护理满意度和并发症发生率。结果ERAS组患者下床活动时间、拔除腹腔引流管时间及肛门首次排气、排便时间、住院时间均短于对照组,住院费用少于对照组,差异有统计学意义(P<0.05)。ERAS组患者总有效率高于对照组,差异有统计学意义(P<0.05)。ERAS组术后3 d SAS、SDS评分、Cor、NE、FT3水平均低于对照组,差异有统计学意义(P<0.05)。ERAS组患者护理总满意率高于对照组,并发症总发生率低于对照组,差异有统计学意义(P<0.05)。结论在腹腔镜下胆总管切开取石手术中患者中开展基于ERAS理念下的医护一体化护理是安全有效的,有利于缓解患者抑郁、焦虑等不良情绪,加快术后康复,降低应激反应并减少术后并发症发生,提高护理满意度,值得临床推广。
文摘Single-incision laparoscopic surgery(SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy(SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials(RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration(CBDE) methods have been used for more than one hundred years, laparoscopic CBDE(LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and singleincision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.
文摘目的探究磁共振胰胆管造影(MRCP)诊断不同直径、不同部位胆总管结石(CBDS)的价值。方法选取2019年9月至2022年9月我院175例疑似CBDS患者,均行术前超声、CT及MRCP,以内镜下逆行胰胆管造影术(ERCP)检查结果为“金标准”,统计术前超声、CT及MRCP诊断CBDS的结果,比较3种方法诊断CBDS的价值,并比较超声、CT、MRCP诊断不同直径、不同部位CBDS的准确度,根据术前MRCP诊断结果选择手术方案,统计一次取石成功率。结果基于ERCP检查结果的“金标准”,术前MRCP诊断CBDS的敏感度(95.83%)、准确度(95.43%)均高于超声、CT诊断(P<0.05);MRCP诊断结石直径<5 mm CBDS的准确度(88.00%)均高于超声、CT诊断,诊断直径5~10 mm CBDS的准确度(96.83%)高于超声诊断(P<0.05),诊断直径>10 mm CBDS的准确度为100.00%;MRCP诊断上段CBDS的准确度(96.88%)均高于超声、CT诊断,诊断胰腺段CBDS的准确度(92.68%)高于超声诊断(P<0.05),诊断壶腹段CBDS的准确度为100.00%。结论MRCP诊断CBDS的敏感度、准确度较高,在不同直径、不同部位CBDS诊断方面均具有很高准确度,可为手术取石提供可靠术前参考依据。
