内镜乳头气囊扩张联合腹腔镜胆囊切除术治疗肝外胆管结石158例报告
张成 安东均 王羊
摘 要
目的：探讨内镜乳头气囊扩张（EPBD）联合腹腔镜胆囊切除术（LC）治疗胆囊结石合并胆总管结石经验。
方法：2005年2月～2009年8月采用EPBD联合LC治疗胆囊结石合并胆总管结石。采用十二指肠镜，常规逆行胰胆管造影（ERCP），留置导丝，行EPBD，取石完毕常规放置鼻胆管引流（ENBD），观察1～3d，无并发十二指肠乳头出血、十二指肠漏、胆管炎及胰腺炎者，在全身麻醉下行LC。
结果：158例患者成功行EPBD、ENBD 154例，手术时间32～56min，平均41min。1例取石时取石网篮将结石挤入左肝管并嵌顿，留置鼻胆管，放弃改开腹手术。1例因乳头纵轴较长，开口下移，且开口狭窄，呈“针尖状”，造影导管及导丝不能顺利插入乳头，改用针刀开窗。1例气囊扩张乳头3次后，取石时网篮嵌顿于乳头部，努力使结石脱出网篮，切开乳头，取出结石。1例取石网篮成功取出2枚结石，再次检查取石时，乳头开口充血、水肿，反复努力，仍不能完成，改针刀开窗。术后并发症5例，4例急性轻型胰腺炎，经保守治疗后于术后1～2周痊愈，1例并发急性化脓性胆囊炎，经抗感染等治疗后于术后7d痊愈。154例EPBD、ENBD成功者中，成功行LC 154例，手术时间26～85min，平均39min。1例LC术后4d出现胆漏，急行剖腹探查证实肝床有直径约0.2cm迷走胆管，缝合结扎胆管，行T管引流，术后10d痊愈。本组成功施行EPBD、ENBD及LC共154例，成功率97.4%。总住院时间7～19d，平均10d。ERCP术后住院时间1～14d，平均2.5d。LC术后住院时间3～22d，平均8d。无十二指肠漏、十二指肠乳头出血、急性胆管炎等严重并发症出现。143例随访8～24个月，平均15个月，其中112例＞12个月，无胆管结石复发及其他并发症出现。
结论：选择合适的病例，掌握操作技巧，EPBD联合LC可作为治疗部分胆囊结石合并胆总管结石的首选方法。
关键词
内镜乳头气囊扩张；腹腔镜胆囊切除术；胆囊结石；胆总管结石
Experience of treating 158 patients with extrahepatic bile duct stone by LC and EPBD
ZHANG Cheng，AN Dongjun，WANG Yang
（General Surgery of Central Hospital，Xianyang，Shanxi 712000，P.R.China）
ABSTRACT
Objective:To assess the clinical effectiveness of laparoscopic cholecystectomy（LC）combined with endoscopic papillary balloon dilation（EPBD）for holecystocholedochohthiasi.
Methods:All the cases were treated with LC and EPBD from Feb.2005 to Aug.2008，EPBD was carried out after endoscopic retrograde cholangiopancreatography（ERCP）ended，and endoscopic nasobiliary drainage（ENBD）was placed after bile duct stones were removed.After 1～3 days observation，there were no duodenal hemorrhage，duodenal leakage，cholangiolitis and pancreatitis before LC，if combined with pancreatitis，treated chiefly.
Results:158 succeeded with EPBD and 154 succeeded with ENBD，operation time 32～56 min，average 41 min，1 case failed because of calculi falling to the left hepatic duct；The opacification pipe and guidewire were not interposed into the stenosis duodenum nipples in 1 case；another failed in the case of bleeding and edema in the duodenum nipples.4 patients had acute pancreatitis，recovered after 1～2 weeks treatment；1 developed acute suppurative cholecystitis，healed from 7 days of anti-infection.All the cases succeeded with LC after EPBD and ENBD，operation time 26～85 min，average39 min，1 case developed bile leakage after 4 days of LC，0.2 cm aberrant bile-duct was certified from exploratory laparotomy，and cured 10 days of treatment via transfixion and T pipe drainage.154 cases succeeded with EPBD，ENBD and LC，the achievement ratio was 97.4%.The general length of stay was 7～19 days，average 10 days，ERCP patients was 1～14 days，average 2.5 days，and LC patients was 3～22 days，average 8 days.There are no serious complications like duodenum leakage，duodenum hemorrhage and acute cholangitis；there were no cholangiolithiasis and other complications after 8～24 months follow up，average 15 months in all the 154 patients，and the follow up days exceeded 12 months in 112 patients.
Conclusion:The combination of EPBD and LC can be used first in cholecystocholedocholithiasis partially，if patients is suitable and technique is proficient.
KEY WORDS
endoscopic papillary balloon dilation；laparoscopic cholecystectomy；cholecystolithiasis；common bile duct calculi
我院在内镜下十二指肠乳头括约肌切除术（endoscopic sphincterotomy，EST）联合腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）的基础上，于2005年2月～2009年8月采用内镜乳头气囊扩张术（endoscopic papillary balloon dilation，EPBD）联合LC治疗胆囊结石合并胆总管结石158例，取得了满意效果，本文对手术适应证、手术技巧及经验教训进行探讨。现报道如下：