Rojas-Ortega Sergio, Arizpe-Bravo Daniel, Marín López Eduardo R, Cesin-Sánchez Rachid, Roman Gerardo Reed-San, Gómez Crispina
Department of Surgery and Gastroenterology, Hospital de la Sociedad Espai;ola de Beneficencia de Puebla, Mexico.
J Gastrointest Surg. 2003 May-Jun;7(4):492-6. doi: 10.1016/s1091-255x(03)00026-x.
Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis of choledocholithiasis is made at the preoperative workup, it is common practice to refer the patient for endoscopic retrograde cholangiography and endoscopic sphincterotomy. However, if the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma-that is, the choice between laparoscopic common bile duct exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. We have opted to treat patients with choledocholithiasis in only one session during the laparoscopic cholecystectomy; we use the transcystic common bile duct exploration technique employing the choledochoscope. We report our early experience in terms of success of stone removal, operative time, morbidity and mortality, and length of hospital stay. From 1992 to 2002, we performed 350 laparoscopic cholecystectomies. Selective cholangiography was used in 105 patients (30%); 40 of them were found to have common bile duct stones, for an incidence of 11.4%. Among this group, we performed laparoscopic transcystic common bile duct exploration in all but six patients. Our success rate for stone removal was 94.1% (32 of 34 patients), with only two failures related to multiple stones and impaction at the ampulla, for a conversion rate of 5.8%. The mean operative time was 120+/-40 minutes. The morbidity rate was 8.8%, and there were no deaths. Length of hospital stay was 24 to 48 hours. Mean recovery time was 7 days, and time to return to work was 15+/-3 days. We concluded that most of the patients with common bile duct stones found during laparoscopic cholecystectomy could be treated successfully by means of the transcystic technique with choledochoscopy, with no increase in morbidity or mortality and a shortened hospital stay and recovery time, similar to patients who undergo only laparoscopic cholecystectomy. On the basis of our results, we recommend that this method become the primary strategy in the great majority of patients with common bile duct stones found during intraoperative cholangiography.
在接受腹腔镜胆囊切除术的患者中，约16%会发现胆总管结石。如果在术前检查时确诊为胆总管结石，通常的做法是将患者转诊进行内镜逆行胆管造影和内镜括约肌切开术。然而，如果在术中胆管造影时确诊，外科医生就会面临治疗困境，即在腹腔镜胆总管探查、转为开放手术或术后内镜括约肌切开术之间做出选择。我们选择在腹腔镜胆囊切除术期间仅通过一个阶段来治疗胆总管结石患者；我们采用经胆囊胆总管探查技术并使用胆管镜。我们报告了我们在结石清除成功率、手术时间、发病率和死亡率以及住院时间方面的早期经验。1992年至2002年，我们共进行了350例腹腔镜胆囊切除术。105例患者（30%）进行了选择性胆管造影；其中40例被发现有胆总管结石，发病率为11.4%。在这组患者中，除6例患者外，其余均进行了腹腔镜经胆囊胆总管探查。我们的结石清除成功率为94.1%（34例患者中的32例），仅有两例失败与多发结石及壶腹部嵌顿有关，转换率为5.8%。平均手术时间为120±40分钟。发病率为8.8%，无死亡病例。住院时间为24至48小时。平均恢复时间为7天，恢复工作时间为15±3天。我们得出结论，大多数在腹腔镜胆囊切除术期间发现胆总管结石的患者可通过经胆囊胆管镜技术成功治疗，发病率和死亡率无增加，住院时间和恢复时间缩短，与仅接受腹腔镜胆囊切除术的患者相似。基于我们的结果，我们建议该方法成为大多数在术中胆管造影时发现胆总管结石患者的主要治疗策略。
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