Binmoeller K F, Schafer T W
Department of Medicine and Surgery, University of California, San Diego 92103-8413, USA.
J Clin Gastroenterol. 2001 Feb;32(2):106-18. doi: 10.1097/00004836-200102000-00004.
The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.
内镜逆行胰胆管造影术（ERCP）相较于开放手术的优势使其成为治疗胆总管结石的主要方法。如今，诸如磁共振胰胆管造影术和腹腔镜手术等技术进步正在挑战ERCP在胆总管（CBD）结石管理中的首要地位。本文回顾了胆石症内镜治疗的现状，并将其与腹腔镜管理进行了对比研究。文中回顾了内镜括约肌切开术和球囊括约肌成形术的技术及安全性。由于安全问题和固有局限性，球囊括约肌成形术应仅限于研究方案。括约肌切开术后，85%至90%的CBD结石可用多尔米亚篮或球囊导管取出。这些技术既有优点也有缺点。处理“困难结石”的方法包括机械碎石术、导管内冲击波碎石术、体外冲击波碎石术、化学溶解和胆管支架置入术。这些方法连同支持其在特定情况下使用的数据一并列出。腹腔镜胆囊切除术已成为开放胆囊切除术的首选替代方法。CBD结石内镜和腹腔镜管理的同步进展使得关于最佳治疗策略的问题变得复杂。腹腔镜时代胆总管结石管理的三种方法如下：严格治疗性分割、灵活治疗性分割和严格腹腔镜管理。最佳方法需要在前瞻性对比试验中确定。目前，对于根据临床、生化和影像学参数怀疑有CBD结石的患者，仍应推荐术前内镜下取石作为首选方法。对于CBD结石发生概率低至中等的患者，初次腹腔镜评估和管理是合理的。
