Thompson M H, Tranter S E
Department of Surgery, Southmead Hospital, Bristol BS10 5NB, UK.
Br J Surg. 2002 Dec;89(12):1608-12. doi: 10.1046/j.1365-2168.2002.02298.x.
Laparoscopic exploration of the common bile duct is associated with substantial variation in results suggesting that different patient populations are being reported. This report observes the results in a defined population and on an intention-to-treat basis.
All patients with suspected bile duct stones who were fit for surgery from April 1994 were offered laparoscopic bile duct exploration. There were 224 patients of mean age 56 years, of whom 174 were women. Endoscopic sphincterotomy was used in 149 patients deemed unfit for surgery. All data were recorded prospectively and checked at the time of discharge. Patients were followed up after 6 months and beyond after the operation.
Stones were removed transcystically in 56 patients, transductally in 158 and by flushing in nine. The duct clearance rate was 96 per cent overall, 98 per cent for transcystic and 94 per cent for transductal exploration. Intracorporeal lithotripsy safely reduced the failure rate of exploration from seven of the first 28 to four of the subsequent 196 procedures. Biliary complications occurred in 16 per cent of procedures in which a T tube was used but only 4 per cent if the duct was closed by suturing. Conversion to open operation for severe gallbladder inflammation was necessary in 6 per cent of patients. There were no deaths, bile duct injuries or pancreatitis but complications occurred in 19 per cent, associated with use of T tubes and advancing age. Laparoscopic duct exploration succeeded in seven patients after previous cholecystectomy.
Laparoscopic bile duct exploration is effective and safe when used for all patients. For young and fit patients it should replace endoscopic sphincterotomy.
腹腔镜胆总管探查术的结果存在显著差异，这表明所报道的患者群体有所不同。本报告观察了特定人群的结果，并基于意向性治疗原则进行分析。
自1994年4月起，所有适合手术的疑似胆管结石患者均接受腹腔镜胆管探查术。共有224例患者，平均年龄56岁，其中174例为女性。149例被认为不适合手术的患者接受了内镜括约肌切开术。所有数据均进行前瞻性记录，并在出院时进行核对。患者在术后6个月及以后进行随访。
56例患者经胆囊管取出结石，158例经胆管取出结石，9例通过冲洗取出结石。总体胆管清除率为96%，经胆囊管探查为98%，经胆管探查为94%。体内碎石术安全地将探查失败率从前28例中的7例降至随后196例中的4例。使用T管的手术中16%发生胆道并发症，而胆管缝合关闭时仅为4%。6%的患者因严重胆囊炎需要转为开腹手术。无死亡、胆管损伤或胰腺炎发生，但19%的患者出现并发症，与使用T管和年龄增长有关。7例曾行胆囊切除术的患者腹腔镜胆管探查成功。
腹腔镜胆管探查术应用于所有患者时有效且安全。对于年轻且健康的患者，应取代内镜括约肌切开术。
