Nardi Mario, Perri Sergio G, Pietrangeli Francesco, Amendolara Mauro, Dalla Torre Andrea, Gabbrielli Francesco, Nicita Antonio, Lotti Roberto, Piacentini Francesca, Citone Giorgio
Cattedra e Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di L'Aquila.
Chir Ital. 2002 Nov-Dec;54(6):785-98.
Laparoscopic cholecystectomy has become the treatment of choice for patients with symptomatic cholelithiasis. About 10-20% of patients with gallbladder stones may also present associated common bile duct stones. The management of the latter remains controversial because many different surgical strategies are available: laparoscopic treatment (laparoscopic common bile duct exploration), sequential endoscopic and laparoscopic treatment (endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy [ERCP/ES] prior to laparoscopic cholecystectomy), inverted sequential endoscopic-laparoscopic treatment (laparoscopic cholecystectomy followed by ERCP/ES), and combined endoscopic-laparoscopic treatment (laparoscopic cholecystectomy with intraoperative ERCP/ES). The aim of this study was to evaluate the efficacy and safety of sequential endoscopic-laparoscopic treatment in patients with cholecystocholedocholithiasis. We retrospectively analyzed the clinical, biochemical and radiological features of 552 patients operated on for cholelithiasis from 1991 to 2001. Common bile duct stones were suspected on the basis of increased serum levels of bilirubin, GOT, GPT, GGT, alkaline phosphatase; presence of jaundice; history of pancreatitis or cholangitis; dilated common bile duct (diameter > 8 mm) or common bile duct stones at hepatobiliary ultrasonography; presence of common bile duct stones at MR-cholangiography or at i.v. cholangiography. In patients with suspected common bile duct stones, preoperative ERCP was performed; if common bile duct stones were confirmed, ES was performed. When common bile duct stones were not suspected preoperatively, laparoscopic cholecystectomy was performed directly. Overall morbidity, mortality and conversion rates in the two groups were evaluated. Of 552 patients admitted for cholelithiasis, 62 (11.3%) underwent preoperative ERCP for suspected common bile duct stones. In 41 patients (66.1%) common bile duct stones were identified and ES with common bile duct stone extraction was performed in 40 patients (clearance: 97.5%). The overall morbidity was 16% (10 cases of post-ERCP acute pancreatitis); no mortality occurred. The conversion rate during subsequent laparoscopic cholecystectomy was 4.8%. In the group of patients with no suspicion of common bile duct stones, the conversion rate was 4.9%. Sequential treatment cannot be considered the best approach for patients with cholecystocholedocholithiasis because of its morbidity rate and the high rate of negative preoperative ERCP findings. Combined endoscopic-laparoscopic treatment seems to present more advantages, especially in term of morbidity, hospital stay and patient compliance and may, in future, be considered the treatment of choice for patients with cholecystocholedocholithiasis.
腹腔镜胆囊切除术已成为有症状胆结石患者的首选治疗方法。约10%-20%的胆囊结石患者可能同时存在胆总管结石。后者的治疗仍存在争议，因为有许多不同的手术策略可供选择：腹腔镜治疗（腹腔镜胆总管探查）、序贯内镜和腹腔镜治疗（在腹腔镜胆囊切除术之前进行内镜逆行胰胆管造影/内镜括约肌切开术[ERCP/ES]）、倒置序贯内镜-腹腔镜治疗（腹腔镜胆囊切除术之后进行ERCP/ES）以及联合内镜-腹腔镜治疗（腹腔镜胆囊切除术联合术中ERCP/ES）。本研究的目的是评估序贯内镜-腹腔镜治疗在胆囊胆总管结石患者中的疗效和安全性。我们回顾性分析了1991年至2001年接受胆结石手术的552例患者的临床、生化和影像学特征。根据血清胆红素、谷草转氨酶、谷丙转氨酶、γ-谷氨酰转肽酶、碱性磷酸酶水平升高；黄疸的存在；胰腺炎或胆管炎病史；肝胆囊超声检查显示胆总管扩张（直径>8mm）或胆总管结石；磁共振胰胆管造影或静脉胆管造影显示胆总管结石，怀疑存在胆总管结石。对于怀疑有胆总管结石的患者，进行术前ERCP；如果证实有胆总管结石，则进行ES。术前未怀疑有胆总管结石的患者，直接进行腹腔镜胆囊切除术。评估两组的总体发病率、死亡率和中转率。在552例因胆结石入院的患者中，62例（11.3%）因怀疑有胆总管结石而接受了术前ERCP。41例患者（66.1%）发现有胆总管结石，40例患者进行了ES并取出胆总管结石（清除率：97.5%）。总体发病率为16%（10例ERCP后急性胰腺炎）；无死亡病例。后续腹腔镜胆囊切除术期间的中转率为4.8%。在未怀疑有胆总管结石的患者组中，中转率为4.9%。由于其发病率和术前ERCP阴性结果的高发生率，序贯治疗不能被认为是胆囊胆总管结石患者的最佳治疗方法。联合内镜-腹腔镜治疗似乎具有更多优势，特别是在发病率、住院时间和患者依从性方面，未来可能被认为是胆囊胆总管结石患者的首选治疗方法。
