Vracko J, Wiechel K L
Department of Gastroenterological Surgery, University Medical Center of Ljubljana, Slovenia.
Hepatogastroenterology. 2000 Jan-Feb;47(31):115-20.
BACKGROUND/AIMS: The change from laparotomy to laparoscopy for cholecystectomy has raised the question of how to manage concomitant bile duct stones. The present-day interest--and controversy--has focused on a transcystic approach reported to be feasible in 66-96% of cases, but without explaining the necessary prerequisite: the widening of the cystic duct. The cystic duct, wide mainly in patients with bile duct stones, has been reported to be highly variable: from strictured to very wide. The present study aims at comparing the trypsin level in the gallbladder bile and the cystic duct morphology and width in patients with and without bile duct stones.
A prospective series of 63 gallstone patients, 30 with and 33 without bile duct stones (controls), underwent cholecystectomy and bile duct clearance. The study includes the trypsin level in the gallbladder bile, the width and morphology of the cystic duct, and the size of the gallstones.
The patients with bile duct stones had, in contrast to the controls, higher trypsin levels in the gallbladder bile (P < 0.001) and wider cystic ducts (P < 0.001) with more pronounced signs of chronic ductitis.
The obtained results strongly suggest that the increased trypsin level, a sign of reflux of pancreatic juice, caused changes in the cystic duct that facilitate gallstone migration, which also ought to render a transcystic stone extraction feasible.
背景/目的：胆囊切除术从开腹手术转变为腹腔镜手术引发了如何处理合并胆管结石的问题。目前的关注点及争议集中在经胆囊管途径，据报道该方法在66% - 96%的病例中可行，但未解释其必要前提条件：胆囊管扩张。胆囊管主要在胆管结石患者中较宽，据报道其变化很大：从狭窄到非常宽。本研究旨在比较有胆管结石和无胆管结石患者胆囊胆汁中的胰蛋白酶水平以及胆囊管的形态和宽度。
对63例胆结石患者进行前瞻性研究，其中30例有胆管结石，33例无胆管结石（对照组），均接受胆囊切除术和胆管清理。研究包括胆囊胆汁中的胰蛋白酶水平、胆囊管的宽度和形态以及胆结石的大小。
与对照组相比，有胆管结石的患者胆囊胆汁中的胰蛋白酶水平更高（P < 0.001），胆囊管更宽（P < 0.001），慢性胆管炎的体征更明显。
所得结果强烈表明，胰蛋白酶水平升高是胰液反流的标志，它导致胆囊管发生变化，有利于胆结石迁移，这也应该使经胆囊管取石可行。
