梁 剛， 馬富平， 何盟國(guó)

(1 陜西省核工業(yè)二一五醫(yī)院 肝膽外科， 陜西 咸陽 712000； 2 咸陽市中心醫(yī)院， 陜西 咸陽 712000)

腹腔鏡聯(lián)合膽道鏡經(jīng)膽囊管治療膽囊結(jié)石合并膽總管結(jié)石的臨床分析

梁 剛1， 馬富平2， 何盟國(guó)1

(1 陜西省核工業(yè)二一五醫(yī)院 肝膽外科， 陜西 咸陽 712000； 2 咸陽市中心醫(yī)院， 陜西 咸陽 712000)

目的探討應(yīng)用腹腔鏡聯(lián)合膽道鏡經(jīng)膽囊管行膽道探查治療膽囊結(jié)石合并膽總管結(jié)石的臨床效果。方法對(duì)2014年1月-2015年12月陜西省核工業(yè)二一五醫(yī)院收治的52例膽囊結(jié)石合并膽總管結(jié)石患者行腹腔鏡聯(lián)合膽道鏡經(jīng)膽囊管膽道探查取石術(shù)，觀察其臨床效果。結(jié)果52例患者中40例順利完成手術(shù)，手術(shù)成功率為76.92%。7例改為腹腔鏡下膽總管切開取石、T管引流術(shù)，5例中轉(zhuǎn)開腹行膽總管切開取石、T管引流術(shù)，中轉(zhuǎn)開腹率9.62%。43例患者一次取石成功，占82.69%；剩余9例患者行二次取石，其中行經(jīng)膽囊管膽道探查取石術(shù)者8例，行腹腔鏡下膽總管切開取石術(shù)者1例。所有患者術(shù)后留置網(wǎng)膜孔引流管，術(shù)后3～10 d拔除，1例行腹腔鏡下膽總管切開取石患者術(shù)后出現(xiàn)膽漏，經(jīng)保守治療后康復(fù)。無膽道出血、膽道感染等發(fā)生，平均住院時(shí)間(8.24±2.52)d，所有患者均得到隨訪1年，B超及磁共振胰膽管造影檢查肝內(nèi)外未見結(jié)石殘留，肝功能膽紅素指標(biāo)正常。結(jié)論腹腔鏡聯(lián)合膽道鏡經(jīng)膽囊管進(jìn)行膽道探查取石術(shù)具有創(chuàng)傷小、患者恢復(fù)快、并發(fā)癥少、安全等優(yōu)點(diǎn)，臨床應(yīng)用需嚴(yán)格掌握其適應(yīng)證。

膽囊結(jié)石??； 膽總管結(jié)石； 腹腔鏡檢查； 膽道鏡； 治療

隨著微創(chuàng)技術(shù)在膽道外科中的應(yīng)用，采用腹腔鏡聯(lián)合膽道鏡進(jìn)行膽囊切除、膽總管探查、T管引流術(shù)治療膽囊結(jié)石合并膽總管結(jié)石，已經(jīng)逐漸在臨床中開展，并取得了較好的效果[1-2]。但是，膽道探查術(shù)后長(zhǎng)時(shí)間留置T管具有誘發(fā)膽總管結(jié)石形成、膽汁丟失導(dǎo)致內(nèi)環(huán)境失衡、護(hù)理不便等缺點(diǎn)。近年來，腹腔鏡下膽道鏡經(jīng)膽囊管膽總管探查取石術(shù)(laparoscopic transcystic common bile duct exploration，LTCBDE)，逐步開展通過機(jī)體生理管道(膽囊管)行膽總管探查取石，不必切開膽總管，減少了膽管損傷風(fēng)險(xiǎn)，且術(shù)后無需留置T管[3]。本研究回顧性分析了LTCBDE治療膽囊結(jié)石合并膽總管結(jié)石患者的臨床資料，報(bào)告如下。

1 資料與方法

1.1 研究對(duì)象 收集2014年1月-2015年12月陜西省核工業(yè)二一五醫(yī)院收治的行LTCBDE患者52例，其中男25例，女27例，年齡40～70歲，平均(65.32±8.24)歲。20例患者無上腹部癥狀，32例患者反復(fù)出現(xiàn)右上腹疼痛，所有患者均無發(fā)熱、寒戰(zhàn)癥狀。52例患者經(jīng)B超或磁共振胰膽管造影(MRCP)檢查診斷為膽囊結(jié)石合并膽總管結(jié)石，膽囊頸部無結(jié)石嵌頓，膽囊管直徑約0.4～0.5 cm。膽總管直徑最寬1.30 cm，最窄0.92 cm，平均(1.12±0.45)cm。膽總管結(jié)石最大1.10 cm，最小0.40 cm，平均(0.72±0.25)cm。膽總管單發(fā)結(jié)石32例，多發(fā)結(jié)石20例。不同程度血清TBil和DBil水平升高、轉(zhuǎn)氨酶升高者16例。所有患者排除急性膽囊炎、急性膽管炎、急性胰腺炎。

1.2 手術(shù)方法 麻醉成功后，常規(guī)三孔法建立氣腹，術(shù)中術(shù)野顯露不佳時(shí)改為四孔法。合并膽囊結(jié)石者，先于腹腔鏡下解剖出膽囊管和膽囊動(dòng)脈，仔細(xì)分離膽囊管和膽總管匯合處，辨清膽囊管、肝總管、膽總管的解剖關(guān)系。膽囊動(dòng)脈夾閉后電凝切斷，在膽囊管和膽總管匯合處遠(yuǎn)端約1 cm用鈦夾夾閉膽囊管，并于膽囊管和膽總管匯合處遠(yuǎn)端約0.6 cm斜形部分剪開膽囊頸部膽囊管。若膽囊管內(nèi)徑允許，直接插入膽道鏡(Olympus CHF P20Q，直徑5 mm)；若膽道鏡進(jìn)入困難，可采用球囊導(dǎo)管擴(kuò)張膽囊管或沿膽囊管長(zhǎng)軸剪開膽總管前壁0.2～0.5 cm，插入膽道鏡進(jìn)行膽總管探查，用取石網(wǎng)籃(Wilson WF-1810 GL520)取出結(jié)石。結(jié)石較大時(shí)，可碎石后取出。取凈結(jié)石后，若完整的膽囊管近端距膽總管>0.3 cm，可用生物夾夾閉膽囊管近端；如膽囊管殘留部分過短或沿著膽囊管剪開膽總管前壁的，可用4-0薇喬線縫合關(guān)閉膽囊管殘端或膽總管切口。切除并取出膽囊，于Winslow孔處放置橡膠引流管。

2 結(jié)果

52例患者中40例順利完成手術(shù)，手術(shù)成功率為76.92%。7例改為腹腔鏡下膽總管切開取石、T管引流術(shù)，5例中轉(zhuǎn)開腹行膽總管切開取石、T管引流術(shù)，中轉(zhuǎn)開腹率9.62%。43例患者一次取石成功，占82.69%；余9例患者行二次取石，其中行經(jīng)膽囊管膽道探查取石術(shù)者8例，行腹腔鏡下膽總管切開取石術(shù)者1例。平均手術(shù)時(shí)間(54.7±8.4)min，平均出血量(30±12)ml，術(shù)后腸功能平均恢復(fù)時(shí)間(1.2±0.4)d。所有患者術(shù)后留置網(wǎng)膜孔引流管，術(shù)后3～10 d拔除。1例行腹腔鏡下膽總管切開取石患者術(shù)后出現(xiàn)膽漏，經(jīng)保守治療后康復(fù)；無膽道出血、膽道感染等發(fā)生，平均住院時(shí)間(8.24±2.52)d，所有患者均隨訪1年，B超及MRCP檢查肝內(nèi)外未見結(jié)石殘留，肝功能膽紅素指標(biāo)正常。

3 討論

LTCBDE利用自然管道進(jìn)行膽總管結(jié)石治療，術(shù)中可避免損傷膽總管，相比腹腔鏡下膽總管切開取石、T管引流術(shù)，具有更加微創(chuàng)、安全的優(yōu)勢(shì)[4]。同時(shí)，也可避免術(shù)后長(zhǎng)期留置T管給患者帶來的痛苦及相關(guān)并發(fā)癥[5]。近年來，LTCBDE逐漸成為臨床上治療膽囊結(jié)石合并膽總管結(jié)石的一種重要的方法。從解剖上說，膽囊管一般長(zhǎng)度約2.5～4.0 cm，直徑0.20～0.35 cm，膽囊內(nèi)的小結(jié)石易通過較粗的膽囊管進(jìn)入膽總管。因此，理論上只要膽道鏡能夠通過膽囊管進(jìn)入膽總管，便可將膽總管結(jié)石取出。但腹腔鏡下膽道鏡操作較開腹手術(shù)經(jīng)竇道膽道鏡探查取石的難度大，操作困難，取石成功率與患者的自身狀況、膽道鏡的粗細(xì)質(zhì)地以及術(shù)者的經(jīng)驗(yàn)有很大關(guān)系。國(guó)內(nèi)外多項(xiàng)報(bào)道[6-9]顯示LTCBDE的成功率為70%～96%。由于LTCBDE治療膽囊結(jié)石合并膽總管結(jié)石的方法符合一次性完成、膽管Ⅰ期縫合、保留括約肌功能等的標(biāo)準(zhǔn)，被很多學(xué)者在腹腔鏡治療膽囊結(jié)石合并膽總管結(jié)石時(shí)推崇[8,10]。本研究52例患者中40例順利完成手術(shù)，其余患者因膽囊管過細(xì)無法進(jìn)膽道鏡而改為其他方式手術(shù)。43例患者一次取石成功，占82.69%。分析本研究取石成功率不高的原因，考慮和術(shù)前病例選擇、術(shù)中經(jīng)膽囊管進(jìn)入膽道鏡的技巧不高、膽道取石方法不熟練等有關(guān)，這也是日后需要認(rèn)真總結(jié)改進(jìn)之處。結(jié)合相關(guān)文獻(xiàn)報(bào)道[7，11]和手術(shù)經(jīng)驗(yàn)，筆者認(rèn)為對(duì)于結(jié)石少于3枚且直徑<0.5 cm的繼發(fā)性膽總管結(jié)石、膽囊管直徑>0.4 cm、MRCP檢查提示膽囊管無明顯狹窄及閉塞，無Mirizzi綜合征表現(xiàn)的膽囊結(jié)石合并膽總管結(jié)石的患者，行LTCBDE成功率較高。

筆者的手術(shù)經(jīng)驗(yàn)為：(1)盡量游離膽囊管至匯合部，可于膽囊管切開處縫合牽引線，配合術(shù)中牽拉膽囊協(xié)助膽道鏡經(jīng)膽囊管切開處進(jìn)入膽總管。(2)可采用球囊擴(kuò)張膽囊管松弛膽囊管壁，增加膽道鏡經(jīng)膽囊管進(jìn)鏡機(jī)會(huì)，尤其適用于炎癥增厚、管腔狹窄的膽囊管。(3)對(duì)于經(jīng)膽囊管進(jìn)膽道鏡困難的患者，可采用膽囊管匯入膽總管部微切開的途徑[12]，經(jīng)切開處置入膽道鏡取出膽總管結(jié)石。若患者術(shù)前無急性膽管炎、重度黃疸、膽總管下端水腫，也可考慮Ⅰ期縫合膽囊管匯入膽總管部切開處，最大限度為患者提供微創(chuàng)治療方法[13]。(4)對(duì)于膽總管內(nèi)較大的結(jié)石可以采用取石網(wǎng)籃將其夾碎后取出，或聯(lián)合碎石設(shè)備將其粉碎后取出。(5)盡量減少反復(fù)插管，輕柔操作，避免過度刺激膽總管壁及十二直腸乳頭導(dǎo)致Oddi括約肌水腫或痙攣，從而增加術(shù)后膽漏風(fēng)險(xiǎn)。(6)在對(duì)膽管壁進(jìn)行縫合時(shí)，避免針距過小，張力過大，導(dǎo)致膽管壁缺血壞死。手術(shù)結(jié)束前常規(guī)用白色紗條檢查有無漏膽，常規(guī)于Winslow孔放置腹腔引流管，以便觀察及治療患者術(shù)后可能出現(xiàn)的膽漏。本研究患者1例行腹腔鏡下膽總管切開取石術(shù)后出現(xiàn)膽漏，經(jīng)保守治療后康復(fù)，未導(dǎo)致嚴(yán)重后果。所有患者術(shù)后隨訪1年，均未見膽總管結(jié)石復(fù)發(fā)。

綜上所述，經(jīng)膽囊管途徑行膽道探查微創(chuàng)優(yōu)勢(shì)明顯，手術(shù)創(chuàng)傷小、安全、有效，患者恢復(fù)快，是治療膽囊結(jié)石合并膽總管結(jié)石的一種重要手術(shù)方式。在經(jīng)膽囊管進(jìn)行膽道探查取石時(shí)，應(yīng)綜合考慮患者膽囊管直徑、膽總管結(jié)石大小及數(shù)目、膽道鏡直徑等條件，嚴(yán)格掌握其適應(yīng)證，提高手術(shù)成功率。

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引證本文：LIANG G, MA FP, HE MG. Clinical analysis of laparoscopic combined with choledochoscope via the cystic duct for choledocholithiasis[J]. J Clin Hepatol, 2017, 33(11): 2170-2172. (in Chinese)

梁剛， 馬富平， 何盟國(guó). 腹腔鏡聯(lián)合膽道鏡經(jīng)膽囊管治療膽囊結(jié)石合并膽總管結(jié)石的臨床分析[J]. 臨床肝膽病雜志, 2017, 33(11): 2170-2172.

(本文編輯：葛 俊)

Clinicalanalysisoflaparoscopiccombinedwithcholedochoscopeviathecysticductforcholedocholithiasis

LIANGGang,MAfuping,HEmengguo.

(1.DepartmentofHepatobiliarySurgery,Xianyang215HospitaloftheNuclearIndustryinShaanxiProvince,Xianyang,Shaanxi712000,China)

ObjectiveTo explore the clinical application of laparoscopic transcystic common bile duct exploration.MethodsFrom Jan 2014 to Dec 2015, laparoscopic transcystic common bile duct exploration was performed in 52 cases of cholecystolithiasis. The therapeutic effects of cases were studied.ResultsAmong them, 40 cases were performed operation successfully.The success rate of operation was 76.92%. 7 cases were changed to laparoscopic common bile duct incision exploratory stone operation. 5 cases were performed common bile duct incision nephrolithotomy,and the transfer rate was 9.62%. 43 cases were toke stone success at a time in all of patients. The success removed rate was 82.69%. The last 9 patients included 8 cases performed laparoscopic transcystic common bile duct exploration and 1 case performed laparoscopic common bile duct incision exploratory stone operation. All cases were placed abdominal cavity drainage tube pulled out after 3-10 days. Biliary leakage occurred in 1 patients performed laparoscopic common bile duct incision exploratory stone operation, and it was cured after conservative treatment. No biliary tract infection, biliary tract bleeding complications occurred. The average hospitalization time was (8.24±2.52) days. All patients were followed up 1 year. No extrahepatic bile duct stones were found by B-ultrasonic and MRCP, and bilirubin were normal.ConclusionLaparoscopic transcystic common bile duct exploration has positive clinical efficacy with small trauma, quick rever , less complications, safety and effective.etc. But its indications must be grasped strictly in clinical promotion.

cholecystolithiasis; choledocholithiasis; laparoscopy; choledochoscope; therapy

R657.42

A

1001-5256(2017)11-2170-03

10.3969/j.issn.1001-5256.2017.11.024

2017-05-12；

2017-07-13。

梁剛(1985-)，男，主治醫(yī)師，主要從事肝膽外科疾病治療方面的研究。

馬富平，電子信箱: mfp71@sina.com。