Ng T, Amaral J F
Department of Surgery, Brown University, Rhode Island Hospital, Providence, USA.
J Laparoendosc Adv Surg Tech A. 1999 Feb;9(1):31-7. doi: 10.1089/lap.1999.9.31.
Although experience with laparoscopic approaches to common duct stones is increasing, endoscopic retrograde cholangiopancreatography (ERCP) performed either before or after laparoscopic cholecystectomy (LC) remains the most common approach. Debate remains as to the best timing for ERCP in patients with suspected choledocholithiasis. Because clinical, laboratory, and radiological data are poor predictors of choledocholithiasis, many ERCPs done before LC give negative results. ERCP performed after LC with a positive intraoperative cholangiogram (i.o.p.) would eliminate many unnecessary preoperative endoscopic studies. This is a retrospective analysis of the treatment of choledocholithiasis with the combination of LC and ERCP. All patients included could have had ERCP preoperatively or postoperatively; therefore, those with cholangitis requiring emergent preoperative ERCP were excluded. Two groups of patients were compared: those who underwent ERCP followed by LC and those who underwent LC and IOC followed by ERCP. No significant differences were found with respect to age, gender, health status, clinical presentation, laboratory values (most liver functions, white blood cell count, hemoglobin, and serum amylase), surgery time, blood loss, ERCP time, time between treatment modalities, and days to regular diet. However, the preoperative ERCP group was found to have a longer hospital stay (6.7 days vs. 3.5 days, p = 0.003) and higher hospital cost ($9,406.39 vs. $12,816.23, p = 0.05). The preoperative ERCP group had two patients requiring two ERCPs to clear the common duct, one patient requiring conversion to open procedure because of failed LC, and four minor complications. The postoperative ERCP group had no failed LC, IOC, or postoperative ERCPs and one minor complication. The rate of false positive IOC was 6.7% and of negative preoperative ERCP, 43%. We conclude that in the absence of cholangitis requiring emergent endoscopic decompression, suspected choledocholithiasis can be successfully managed first with LC, ERCP being reserved for patients with a positive IOC. This eliminates many negative preoperative ERCPs.
尽管腹腔镜治疗胆总管结石的经验日益丰富，但在腹腔镜胆囊切除术（LC）之前或之后进行的内镜逆行胰胆管造影术（ERCP）仍是最常用的方法。对于疑似胆总管结石患者，ERCP的最佳时机仍存在争议。由于临床、实验室和影像学数据对胆总管结石的预测性较差，许多在LC之前进行的ERCP结果为阴性。在LC术后进行且术中胆管造影（i.o.p.）为阳性的ERCP可避免许多不必要的术前内镜检查。这是一项对LC联合ERCP治疗胆总管结石的回顾性分析。纳入的所有患者均可在术前或术后进行ERCP；因此，排除了因胆管炎需要紧急术前ERCP的患者。比较了两组患者：接受ERCP后再行LC的患者和接受LC及术中胆管造影（IOC）后再行ERCP的患者。在年龄、性别、健康状况、临床表现实验室值（大多数肝功能指标、白细胞计数、血红蛋白和血清淀粉酶）、手术时间、失血量、ERCP时间、治疗方式间隔时间以及恢复正常饮食天数方面，未发现显著差异。然而，术前ERCP组的住院时间更长（6.7天对3.5天，p = 0.003），住院费用更高（9406.39美元对12816.23美元，p = 0.05）。术前ERCP组有2例患者需要进行两次ERCP以清理胆总管，1例患者因LC失败而需要转为开放手术，还有4例轻微并发症。术后ERCP组没有LC、IOC或术后ERCP失败的情况，只有1例轻微并发症。术中胆管造影假阳性率为6.7%，术前ERCP阴性率为43%。我们得出结论，在不存在需要紧急内镜减压的胆管炎的情况下，对于疑似胆总管结石，可首先成功采用LC治疗，ERCP仅用于术中胆管造影阳性的患者。这避免了许多术前ERCP阴性的情况。
