Predictive value and main determinants of abnormal features of intraoperative cholangiography during cholecystectomy

BACKGROUND:The major issue with intraoperative cholangiography (IOC) is whether its diagnostic accuracy for common bile duct (CBD) stones matches that of other diagnostic procedures,and thus,whether it will become a routine diagnostic procedure.The current study aimed to address the main determinants of CBD stone diagnosis in IOC among an Iranian population.METHODS:In a retrospective review database-based study conducted in Taleghani Hospital in Tehran between 2006 and 2008,baseline data and perioperative information of 2060 patients (male to female ratio 542:1518,mean age 53.7 years) who were candidates for cholecystectomy and underwent concomitant IOC for confirming CBD stones were reviewed.The predictive power of this procedure for diagnosis of abnormal biliary ducts with the focus on biliary stones was determined.RESULTS:Overall mortality and morbidity following cholecystectomy in the study population were 0.6% and 2.6%,respectively.Both early mortality and morbidity due to cholecystectomy were higher in male than female.The prevalence of CBD stones in IOC was 3.4% (5.2% in male and 2.8% in female,P=0.008).Among those without gallstones,8.7% had CBD stones and only 3.1% had concomitant gallstones and CBD stones.The main predictors of stone appearance as an abnormal feature of IOC during cholecystectomy were:advanced age (OR=1.022,P=0.001),male gender (OR=1.498,P=0.050),history of abdominal surgery (OR=1.543,P=0.040) and preoperative endoscopic retrograde cholangiopancreatography (OR=5.400,P<0.001).CONCLUSIONS:IOC is a safe and accurate method for the assessment of bile duct anatomy and stones.Therefore,the routine use of IOC within cholecystectomy seems reasonable and is recommended.

Current use of intraoperative ultrasound in modern liver surgery

Ultrasound plays an important role not only in preoperative diagnosis but also in intraoperative guidance for liver surgery.Intraoperative ultrasound(IOUS)has become an indispensable tool for modern liver surgeons,especially for minimally invasive surgeries,partially substituting for the surgeon’s hands.In fundamental mode,Doppler mode,contrast enhancement,elastography,and real-time virtual sonography,IOUS can provide additional real-time information regarding the intrahepatic anatomy,tumor site and characteristics,macrovascular invasion,resection margin,transection plane,perfusion and outflow of the remnant liver,and local ablation efficacy for both open and minimally invasive liver resections.Identification and localization of intrahepatic lesions and surrounding structures are crucial for performing liver resection,preserving the adjacent vital vascular and bile ducts,and sparing the functional liver parenchyma.Intraoperative ultrasound can provide critical information for intraoperative decision-making and navigation.Therefore,all liver surgeons must master IOUS techniques,and IOUS should be included in the training of modern liver surgeons.Further investigation of the potential benefits and advances in these techniques will increase the use of IOUS in modern liver surgeries worldwide.This study comprehensively reviews the current use of IOUS in modern liver surgeries.

回收式自体输血在前置胎盘剖宫产术中应用价值的Meta分析

目的荟萃分析回收式自体输血(IOCS)在前置胎盘剖宫产术中的安全性和有效性。方法计算机检索PubMed、Web of Science、Embase、the Cochrane Library of clinical trials、中国知网(CNKI)及万方数据知识服务平台。检索时限设定为建库至2022年12月。采用R 4.1.2与Stata 12.0软件计算IOCS组和异体输血(ABT)组之间的标准化均数差(SMD)或相对危险度(RR)及95%置信区间(CI)和预测区间(PI)。结果本次Meta分析共纳入5项随机对照试验和10项回顾性队列研究。队列研究的合并结果显示,与ABT组相比,接受IOCS的前置胎盘孕产妇术后血红蛋白(Hb)浓度(SMD=0.626,95%CI:0.103~1.149;95%PI:-1.320~2.572)与红细胞压积较高(SMD=0.617,95%CI:0.130~1.104;95%PI:-1.084~2.317)。在随机对照试验中,接受IOCS的前置胎盘孕产妇发生不良事件的风险比ABT组低72.7%(RR=0.273,95%CI:0.082~0.904)。IOCS组和ABT组术后凝血酶原时间(PT)、活化凝血酶原时间(APTT)、纤维蛋白原(Fib)浓度、血尿素氮(BUN)和肌酐(Cr)差异均无无统计学意义。结论接受IOCS的前置胎盘孕产妇术后Hb浓度和Hct均高于接受ABT的妇女。IOCS对术后凝血参数和肾功能参数无显著影响。在接受剖宫产术的前置胎盘孕产妇中,IOCS与较低的输血相关不良事件发生风险有关。

Is intra-operative cholangiography necessary during laparoscopic cholecystectomy? A multicentre rural experience from a developing world country

AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in nonteaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC.METHODS: A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay.RESULTS: Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now.CONCLUSION: LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.

Mechanism of Dynamic Near-infrared Fluorescence Cholangiography of Extrahepatic Bile Ducts and Applications in Detecting Bile Duct Injuries Using Indocyanine Green in Animal Models

Fluorescence intraoperative cholangiography（IOC） is a potential alternative for identifying anatomical variation and preventing iatrogenic bile duct injuries by using the near-infrared probe indocyanine green（ICG）. However, the dynamic process and mechanism of fluorescence IOC have not been elucidated in previous publications. Herein, the optical properties of the complex of ICG and bile, dynamic fluorescence cholangiography and iatrogenic bile duct injuries were investigated. The emission spectrum of ICG in bile peaked at 844 nm and ICG had higher tissue penetration. Extrahepatic bile ducts could fluoresce 2 min after intravenous injection, and the fluorescence intensity reached a peak at 8 min. In addition, biliary dynamics were observed owing to ICG excretion from the bile ducts into the duodenum. Quantitative analysis indicated that ICG-guided fluorescence IOC possessed a high signal to noise ratio compared to the surrounding peripheral tissue and the portal vein. Fluorescence IOC was based on rapid uptake of circulating ICG in plasma by hepatic cells, excretion of ICG into the bile and then its interaction with protein molecules in the bile. Moreover, fluorescence IOC was sensitive to detect bile duct ligation and acute bile duct perforation using ICG in rat models. All of the results indicated that fluorescence IOC using ICG is a valid alternative for the cholangiography of extrahepatic bile ducts and has potential for measurement of biliary dynamics.

中央型前置胎盘剖宫产术中ANH与IOCS的应用比较

目的探讨急性等容血液稀释(ANH)与术中回收式自体输血(IOCS)2种自体输血方式在中央型前置胎盘剖宫产术中的应用的有效性与适宜性。方法选取2016年8月至2019年3月廊坊市第四人民医院产科诊治的92例中央型前置胎盘剖宫产产妇作为研究对象。随机分为回收组(n=46)和稀释组(n=46)。两组手术方式均为子宫下段剖宫产术,回收组实施IOCS,稀释组实施ANH。记录两组术中出血量、血液输注量,观察比较两组自体血采集前(回收组为手术前5min,T0)、自体血回输后(T1)、关腹时(T2)、术后24 h(T3)平均动脉压(MAP)、心率(HR)、血氧饱和度(SpO2)、血红蛋白(Hb)、红细胞比容(Hct)、血小板计数(PLT)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(Fib)。记录两组新生儿Apgar评分、脐动脉血pH及产妇输血后并发症。结果两组术中出血量、自体血输注量、异体血输注量及异体血输注例数比较,差异无统计学意义(P>0.05)。两组不同时点MAP、HR、SpO2无明显变化,组间各时点MAP、HR、SpO2比较差异无统计学意义(P>0. 05)。与T0 比较,两组T2、T3、T4的Hb、Hct、PLT、Fib有所下降,PT、APTT有所延长,但均在正常参考值范围,组内组间比较差异无统计学意义(P>0. 05)。两组新生儿脐动脉血pH值、5分钟Apgar评分正常,差异无统计学意义(P>0. 05)。两组产妇自体血回输后均未出现溶血、感染、羊水栓塞等不良反应。结论 ANH与IOCS均是中央型前置胎盘剖宫产术中安全有效的输血方式。对于出血量较少的剖宫产手术,ANH应用的可行性更高,估计出血量较多时,可考虑与IOCS联合应用。

肝外胆道腔镜手术中胆道造影术的临床意义

通过腹腔镜微创技术不断的发展及完善,腹腔镜胆道外科技术体系已进入精准时代,朝着更安全、高效、微创的方向发展。随着腹腔镜技术的推广,胆道术后并发症发生率有所上升,如何预防其发生是关键所在。目前,常应用术中胆道造影及吲哚菁绿荧光胆道造影技术于腹腔镜胆道术中以预防胆管损伤,明确术中有无结石遗漏及胰胆管变异,了解术中胆总管通畅程度及Oddis括约肌的功能状态。

吲哚菁绿荧光胆道造影在腹腔镜胆囊切除术中的应用效果

目的:观察吲哚菁绿荧光胆道造影在腹腔镜胆囊切除术中的应用效果。方法:选取2018年10月至2021年10月在该院行腹腔镜胆囊切除术的80例患者进行前瞻性研究,按照随机数字表法将其分为对照组和观察组各40例。对照组采用常规腹腔镜胆囊切除术,观察组在吲哚菁绿荧光胆道造影下行腹腔镜胆囊切除术。比较两组围术期相关指标(胆囊三角暴露时间、手术时间、术中出血量、住院时间)水平和术后并发症发生率。结果:观察组术中出血量少于对照组,胆囊三角暴露时间、手术时间和住院时间均短于对照组,差异有统计学意义(P<0.05);观察组术后并发症发生率为5.00%(2/40),低于对照组的22.50%(9/40),差异有统计学意义(P<0.05)。结论:吲哚菁绿荧光胆道造影下腹腔镜胆囊切除术可减少术中出血量,缩短胆囊三角暴露时间、手术时间和住院时间,降低并发症发生率,效果优于常规腹腔镜胆囊切除术。

选择性应用术中胆道造影在腹腔镜胆囊切除术中的价值

目的:探讨在腹腔镜胆囊切除术中经胆囊管胆道造影的价值。方法:分析56例因慢性结石性胆囊炎、急性结石性胆囊炎、胆源性胰腺炎行LC患者,在术中经胆囊管插管行胆道造影的结果。结果:56例LC术中胆道造影,插管成功54例,成功率为96.4%,54例均显影满意,显影率100%。术中造影发现胆总管结石5例,2例经中转开腹胆总管切开探查证实,3例行腹腔镜胆总管切开探查、胆道镜检查证实;发现胆道变异2例。4例因术中胆囊三角解剖结构不清楚,无法分清胆囊管和胆总管而行术中胆道造影。造影平均时间为(15.5±3.7)min。无并发症发生。结论:LC术中胆道造影操作简便安全,显影清晰,成功率高,能发现术前未能发现的胆总管结石、胆囊管结石及胆道解剖变异,能有效地降低胆道残余结石和胆管损伤的发生率,及时发现胆道损伤,提高LC手术的质量和安全性。

腹腔镜术中联合胰胆镜治疗胆石症疗效评价

目的 评价腹腔镜胆囊切除术 (laparoscopiccholecystectomy,LC)术中联合应用内镜括约肌切开术 (intraoperativeendoscopicsphincterotomy,IOEST)治疗胆石症的疗效。 方法 回顾性分析LC联合IOEST治疗LC术前诊断和术中常规胆道造影确诊的 6 8例胆囊合并胆总管结石患者的临床效果。 结果 联合手术成功率为 97.1% (6 6 6 8) ;IOEST成功率 98.5 % (6 7 6 8) ,取净结石率 10 0 % (6 7 6 7)。IOEST后并发轻度急性胰腺腺炎 3例 ,并发胃潴留 2例。术后平均住院时间 2 .8天。 结论 LC联合IOEST能一次性有效治疗胆囊结石合并胆总管结石 ,优于术前或术后联合EST。

术中胆道造影在小切口胆囊切除术中的应用价值(附1042例报告)

目的 探讨术中胆道造影在小切口胆囊切除术中的应用价值。方法 共施行小切口胆囊切除术 10 0 2 0例 ,按相对胆管探查指征标准 ,施行 10 42例术中胆道造影 :胆囊切除前经胆囊管造影、胆囊切除后经胆囊管造影及穿刺胆 (肝 )总管造影等三种。结果 发现病变 119例 ,其中胆管结石 113例 ,胆管变异 4例 ,肝门部肿瘤 2例。造影阳性率 11.4%。结论 术中胆道造影能降低胆道阴性探查率、提供胆道解剖学依据、预防并及时发现胆道损伤 。

腹腔镜治疗胆囊-十二指肠瘘6例报告

目的 探讨腹腔镜治疗胆囊-十二指肠瘘的疗效。 方法 腔镜下分离胆囊底部,经胆囊穿刺胆系造影,观察解剖路线和胆囊与临近器官的关系,发现内瘘,镜下关闭瘘口,腹腔引流、胃肠减压、应用生长抑素。 结果 连续 327例腹腔镜胆囊切除术中胆道造影,发现胆囊-十二指肠内瘘 6例,全部镜下解剖、关闭瘘口成功,无术后出血和十二指肠胆汁漏。 结论 腔镜术中常规胆系造影,有助于发现胆囊-十二指肠瘘,熟练的镜下解剖、关闭瘘管技术加辅助治疗,疗效可靠。

急性胆囊炎腹腔镜胆囊切除术79例临床分析

目的 总结腹腔镜下处理急性胆囊炎的临床经验。 方法 回顾性分析 2 0 0 2年 9月～ 2 0 0 3年 8月 79例腹腔镜胆囊切除术 (laparoscopiccholecystectomy ,LC)治疗急性胆囊炎 (acutecholecystitis,AC)的临床资料。 结果 75例术中胆道造影成功 ,显示胆总管结石 6例 ,其中 4例行LC联合术中内镜括约肌切开取石 ,2例中转开腹行胆总管切开取石T管引流。单纯胆囊结石 73例 ,70例LC成功 ,3例因炎症粘连明显而中转开腹。全组无严重并发症发生。 结论 绝大多数急性胆囊炎行腹腔镜胆囊切除术安全可行。

如何评价腹腔镜胆囊切除术中胆道造影技术的应用价值

目的 评价胆道造影技术在腹腔镜胆囊切除术中的应用价值。方法 腹腔镜胆囊切除术中经胆囊管插管行胆道造影共2503例。结果 2503例中 ,造影成功2419例 ,成功率为96.64 %。术中造影发现胆总管结石193例 ,胆管损伤12例 ,副肝管1例。结论术中造影操作迅速、安全 ,显影清晰 ,成功率高 ,能降低胆管损伤发生率 ;提高腹腔镜胆囊切除术的质量 。

腹腔镜胆囊切除术中胆道造影的临床意义

目的:探讨术中胆道造影对行腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)患者的临床意义。方法:回顾性分析113例因胆囊结石行LC加术中胆道造影患者的情况。结果:113例患者中造影成功110例(成功率97%),发现胆总管结石5例,占4.5%(5/110)。结论:LC加术中胆道造影有利于防止胆道残余结石,对正确判断胆道解剖关系,减少胆道损伤有重要的临床意义。LC加术中胆道造影可常规使用。

术中胆道造影在腹腔镜手术治疗胆囊管结石中的应用

目的探讨术中胆道造影在腹腔镜手术治疗胆囊管结石中的应用。方法对74例胆囊管结石行腹腔镜胆囊切除同时术中胆道造影的临床资料进行回顾性分析。结果 68例完成腹腔镜手术,6例中转开腹;72例造影成功,成功率为97.3%;造影前行胆道冲洗14例,造影发现胆囊管残石2例,Mirizzi综合征5例,胆总管结石6例,造影后留置造影管减压4例。术中发现胆总管侧壁撕裂伤1例,造影提示胆总管-门静脉瘘1例。并发胆总管撕裂伤和胆总管-门静脉瘘各1例。结论腹腔镜手术治疗胆囊管结石过程中,胆道造影有助于了解胆囊管的走向和残端长度,明确Mirizzi综合征或胆总管结石的诊断,术中可经造影管冲洗胆道,术后留置造影管行胆道减压或为二期取石ERCP插管提供引导。

选择性术中胆道造影在腹腔镜胆囊切除术中的价值

目的:探讨选择性术中胆道造影在腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中的应用价值。方法:回顾分析231例术前诊断为胆囊结石、胆囊息肉样病变的患者于LC术中经胆道造影发现胆道病变、变异的临床资料。结果:225例造影成功,成功率97.4%。术中胆道造影发现胆囊管残石3例,胆总管结石12例,胆管损伤4例,胰胆管汇合异常14例,胆囊管异常开口12例,右侧副肝管4例,胆总管憩室1例,十二指肠乳头旁憩室6例,Mirizzi综合征5例,右肝内钙化灶2例。结论:LC术中行胆道造影不仅能发现术前未确诊的胆总管结石、胆囊管结石,而且利于胆管变异、胰胆管汇合异常及乳头旁憩室的诊断。

术中胆道造影在急性胆囊炎腹腔镜胆囊切除术中的评估

目的探讨急性胆囊炎腹腔镜胆囊切除术中胆道造影的价值。方法回顾性分析该院2008年1月～2010年1月符合急性胆囊炎并具有急症手术指征共105例。造影组55人,对照组50人。结果造影组55人,术中造影证实有胆总管结石11人,手术证实为10人,假阳性1人,胆总管阴性探查率为9.0%。阴性术后残石率2.3%。对照组50人,其中15人具有相对探查指征,手术证实有胆总管结石8人,假阳性7人,胆总管阴性探查率46.7%。阴性术后残石率14.2%。经统计学处理,造影组和对照组的胆总管阴性探查率(χ2=4.20)及阴性术后残石率(χ2=3.89)差异均有显著性(P<0.05)。结论在急性胆囊炎腹腔镜胆囊切除术中,术中胆道造影可避免不必要的胆总管探查,降低胆道残余结石的发生率,避免胆道损伤。

术中经胆囊管胆道造影在腹腔镜胆囊切除术中的应用

目的探讨术中经胆囊管胆道造影在腹腔镜胆囊切除术中的临床应用价值。方法回顾性分析术中经胆囊管胆道造影94例腹腔镜胆囊切除患者的临床资料。结果 91(96.8%)胆道造影成功,造影结果示16例胆总管结石,3例胆囊管结石,3例副肝管,2例发现有胆管损伤。行中转开腹手术21例,腹腔镜下缝扎副肝管3例。未见造影相关的并发症。结论术中经胆囊管胆道造影在腹腔镜胆囊切除术中方法简单、安全,可以减少胆总管及胆囊管结石的残留,避免不必要的胆道阴性探查,预防胆管损伤。

腹腔镜胆囊切除术中经胆囊管胆道造影的价值

目的 探讨在腹腔镜胆囊切除术 (LC)中经胆囊管胆道造影的价值。方法 分析 5 1例因慢性胆囊炎胆囊结石、急性胆囊炎胆囊结石、胆囊息肉和胆源性胰腺炎行LC的患者 ,在术中经胆囊管插管行胆道造影的结果。结果 5 1例中 ,插管成功 4 7例 ,成功率为 92 .2 % ,其中 4 6例显影满意 ,显影率为 97.9%。术中造影发现胆总管结石 3例 ,中转开腹行胆总管切开取石、T管引流术 ,发现胆囊管走行异常 2例 ,插管造影过程中发现胆囊管结石 4例 ,造影平均时间为 (16 .7± 2 .7)min。结论 LC术中胆道造影操作简便安全 ,显影清晰 ,成功率高 ,能发现胆总管结石、胆囊管结石及胆道解剖变异 ,可降低胆道残留结石和胆管损伤的发生率 ,并能及时发现胆道损伤 。