内镜下逆行胰胆管造影及鼻胆管引流联合腹腔镜手术治疗Mirizzi综合征
安东均 张成 韩立 晁延军 周党军
摘 要
目的：探讨微创理念下ERCP放置鼻胆管引流（ENBD），联合腹腔镜手术治疗Mirizzi综合征（MS）患者的新方法和预防胆管损伤的对策。
方法：回顾性分析2011年3月～2016年2月于南方医科大学附属咸阳市中心医院接受ERCP联合腹腔镜手术治疗的56例MS患者资料。
结果：结果在1762例ERCP术前患者中，56例拟诊为MS并经手术确诊，占同期施行ERCP患者的3.2%。其中36例Ⅰ型 MS患者放置ENBD后顺利完成LC，12例Ⅱ型及4例Ⅲ型患者LC中采用组织修补横向一期缝合总管缺损，未放置T型管，用ENBD管引流胆汁。Ⅲ型、Ⅳ型各2例完成LC后，在腹腔镜下成功实施肝总管空肠Roux-en-Y型吻合。全组无围手术期死亡。其中行胆肠吻合的2例患者术后多次胆管炎症状发作，经内科治疗后病情稳定。其余患者随访2年以上，预后良好。
结论：术前ERCP可明确MS的诊断和Csendes分型。ENBD在腹腔镜术中可指示肝总管的走行，避免胆道损伤，术后可代替T管引流，减少创伤。ERCP联合腹腔镜手术治疗Mirizzi综合征具有创伤小、痛苦少、恢复快的特点，是一种安全有效的治疗方法。
关键词
Mirizzi综合征（MS）；内镜下逆行胰胆管造影（ERCP）；鼻胆管引流（ENBD）；腹腔镜手术；胆囊切除术；胆管损伤
Treatment of Mirizzi syndrome using ERCP and ENBD combined with laparoscopic surgery
AN Dongjun，ZHANG Cheng，HAN Li，CHAO Yanjun，ZHOU Dangjun.Department of Hepatobiliary Surgery，the Center Hospital of Xianyang City，Southern Medical University，Xianyang Shaanxi 712000，China Corresponding author:An Dongjun，Email:1158011981@qq.con
ABSTRACT
Objective:To study the combined used of endoscopic retrograde cholangiopancreatography（ERCP）and laparoscopic surgery in the treatment of Mirizzi syndrome and in the prevention of bile duct injury in minimally invasive surgery.
Methods:Methods A retrospective analysis was conducted on patients who suffered from Mirizzi syndrome treated with ERCP and laparoscopic surgery from March 2011 to February 2016 at the Center Hospital of Xianyang City.Southern Medical University.
Results:Of 1762 patients who underwent ERCP，56 patients were diagnosed to suffer from Mirizzi syndrome（3.2% ）.Thirty six patients with type I disease successfully completed LC.The adjacent tissues were used to repair the defects in the first stage for typeⅡ disease in 12 patients and for type Ⅲ disease in 4 patients.T tube was not used.The bile was drained with a ENBD drainage tube.After LC，a bile duct to jejunum Roux-en-Y anastomosis was carried out for the type Ⅱ disease in 2 patients and for the type Ⅲ disease in 2 patients.There was no perioperative death for the whole group of patients.Two patients developed symptoms of cholangitis，and the disease was stable after nonoperative treatment.For the other patients，follow up for more than 2 years showed good results.
Conclusion:ERCP was useful in the diagnosis of Mirizzi syndrome and in the Csendes typing before operation.ENBD could be used as a guide to find the hepatic duct.thus avoiding bile duct iniury dur.ing laparoscopic surgery and for the placement of T tube drainage.ERCP combined with laparoscopic surgery in the treatment of Mirizzi syndrome was safe and effective.It is an operation which has the advantage of minimal trauma，less pain and rapid recovery.
KEY WORDS
Mirizzi syndrome（MS）；Endoscopic retrograde cholangiopancreatography（ERCP）；Endoscopic nasal biliary drainage（ENBD）；Laparoscope surgery；Cholecystectomy；Bile duct injury
胆囊管或胆囊颈部结石及炎症可导致肝总管狭窄，引起以阻塞性黄疸及胆管炎为临床特征的Mirizzi综合征（Mirizzi syndrome，MS）。因其胆道病理改变复杂，术前不易明确诊断，且往往是造成术中胆道损伤的陷阱，长期被列为腹腔镜手术治疗的禁忌证［1］。近年来，随着影像技术的发展，MS的术前诊断率不断提升，加之腹腔镜胆道手术经验的积累，MS已不再是腹腔镜外科的禁忌。南方医科大学附属咸阳市中心医院采用ERCP放置ENBD，联合腹腔镜手术治疗MS 56例，现报告如下。