Hamouda A H, Goh W, Mahmud S, Khan M, Nassar A H M
Laparoscopic and Upper GI Service, Monklands Hospital, Airdrie, Lanarkshire, Scotland, UK.
Surg Endosc. 2007 Jun;21(6):955-9. doi: 10.1007/s00464-006-9127-2. Epub 2007 Feb 7.
In the absence of facilities and expertise for laparoscopic bile duct exploration (LBDE), most patients with suspected ductal calculi undergo preoperative endoscopic duct clearance. Intraoperative cholangiography (IOC) is not performed at the subsequent laparoscopic cholecystectomy. This study aimed to investigate the rate of successful duct clearance after simple transcystic manipulations.
This prospective study investigated 1,408 patients over 13 years in a unit practicing single-session management of biliary calculi. For the great majority, IOC was attempted. Abnormalities were dealt with by flushing of the duct, glucagon injection, Dormia basket trawling, choledochoscopic transcystic exploration, or choledochotomy.
Of 1,056 cholangiograms performed (75%), 287 were abnormal (27.2%). Surgical trainees, operating under supervision, successfully performed 24% of all cholangiograms. Of 396 patients admitted with biliary emergencies, 94.1% had abnormal cholangiograms. Of the 287 patients with abnormal IOCs, 9.4% required no intervention, 18% were clear after glucagon and flushing, and 13% were cleared using Dormia basket trawling under fluoroscopy. A total of 95 patients required formal LBDE, and 2 required postoperative endoscopic retrograde cholangiopancreatography (ERCP). No postoperative ERCP for retained stones was required after simple transcystic manipulation. Eight conversions occurred, one during a transcystic exploration. Follow-up evaluation continued for as long as 6 years in some cases. Two patients had recurrent stones after LBDE and a clear postoperative tube cholangiogram.
In this series, 10% of the abnormal cholangiograms occurred in patients without preoperative risk factors for bile duct stones. Altogether, 88 IOCs (31%) were cleared after either simple flushing or trawling with a Dormia basket. Formal LBDE was not required for 40% of abnormal cholangiograms. Simple transcystic manipulations to clear the bile ducts justify the use of routine IOC in units without laparoscopic biliary expertise.
在缺乏腹腔镜胆管探查（LBDE）设备和专业技术的情况下，大多数疑似胆管结石的患者会接受术前内镜下胆管清理。在随后的腹腔镜胆囊切除术中不进行术中胆管造影（IOC）。本研究旨在调查单纯经胆囊操作后胆管清理成功的比例。
这项前瞻性研究在一个采用单阶段处理胆石症的科室对1408例患者进行了为期13年的调查。绝大多数患者尝试进行了IOC。异常情况通过胆管冲洗、注射胰高血糖素、使用多尔米亚网篮打捞、经胆囊胆管镜探查或胆管切开术来处理。
在1056例进行了胆管造影的患者中（75%），287例异常（27.2%）。在监督下操作的外科实习生成功完成了所有胆管造影的24%。在396例因胆道急症入院的患者中，94.1%的胆管造影异常。在287例IOC异常的患者中，9.4%无需干预，18%在注射胰高血糖素和冲洗后胆管通畅，13%在荧光透视下使用多尔米亚网篮打捞后胆管通畅。共有95例患者需要进行正式的LBDE，2例需要术后内镜逆行胰胆管造影（ERCP）。单纯经胆囊操作后无需因残留结石进行术后ERCP。发生了8例中转，其中1例在经胆囊探查时发生。在某些情况下，随访评估持续长达6年。2例患者在LBDE后出现复发性结石，术后胆管造影显示胆管通畅。
在本系列研究中，10%的异常胆管造影发生在无胆管结石术前危险因素的患者中。总体而言，88例IOC（31%）在单纯冲洗或用多尔米亚网篮打捞后胆管通畅。40%的异常胆管造影无需进行正式的LBDE。在没有腹腔镜胆道专业技术的科室，单纯经胆囊操作清理胆管证明了常规IOC的应用价值。
