Taylor Craig J, Kong Justin, Ghusn Michael, White Stephen, Crampton Nick, Layani Laurent
Department of General Surgery, The Tweed Hospital, Northern Rivers, New South Wales, Australia.
ANZ J Surg. 2007 Jun;77(6):440-5. doi: 10.1111/j.1445-2197.2007.04091.x.
Despite numerous reports showing the advantages of laparoscopic common bile duct exploration (LCBDE), many general surgeons, particularly those working outside of nonspecialist units, continue to rely heavily on endoscopic retrograde cholangiography with sphincterotomy (ERCP) to manage bile duct stones (BDS). This article investigates the performance of LCBDE when adopted as the preferred first-line management of both suspected and incidental BDS by general surgeons in a regional setting.
A retrospective review was conducted of all patients in whom LCBDE was attempted by a regional general surgical unit. The unit policy was to preferentially treat all incidental and suspected BDS (except in ascending cholangitis or severe pancreatitis) by LCBDE, with ERCP used only if unsuccessful. In addition to chart review, formal prospective follow up by telephone interview was carried out.
A total of 160 consecutive patients with BDS (mean age 66.9 years, 65% suspected and 35% incidental) underwent attempted LCBDE between January 2000 and July 2005. Successful clearance was achieved in 84.3% according to chart review. However, four additional cases of retained choledocholithiasis shown by late telephone interview (median interval 2.5 years) yielded a more accurate clearance rate of 81.8%. Major morbidity occurred in 13.8%, including biliary leak in 7.5% and one late biliary stricture (0.6%). Median length of hospital stay was 4.8 days. In-hospital mortality was 0.6%.
Laparoscopic common bile duct exploration remains an effective, efficient and safe first-line treatment of BDS even when carried out in regional nonspecialist units. In spite of the wide availability of ERCP, general surgeons should be encouraged to continue performing LCBDE in order to optimise patient care and maintain important surgical skills.
尽管有大量报告显示腹腔镜胆总管探查术（LCBDE）具有诸多优势，但许多普通外科医生，尤其是那些在非专科单位工作的医生，在处理胆管结石（BDS）时仍严重依赖内镜逆行胰胆管造影术及括约肌切开术（ERCP）。本文探讨了在区域环境中，普通外科医生将LCBDE作为疑似和偶然发现的BDS的首选一线治疗方法时的表现。
对一个区域普通外科单位尝试进行LCBDE的所有患者进行回顾性研究。该单位的政策是优先通过LCBDE治疗所有偶然发现和疑似的BDS（急性胆管炎或严重胰腺炎除外），仅在不成功时使用ERCP。除了查阅病历外，还通过电话访谈进行了正式的前瞻性随访。
2000年1月至2005年7月期间，共有160例连续的BDS患者（平均年龄66.9岁，65%为疑似病例，35%为偶然发现病例）接受了LCBDE尝试。根据病历审查，成功清除结石的比例为84.3%。然而，通过后期电话访谈（中位间隔时间2.5年）发现另外4例残留胆总管结石病例，得出更准确的清除率为81.8%。主要并发症发生率为13.8%，包括胆漏7.5%和1例晚期胆管狭窄（0.6%）。中位住院时间为4.8天。住院死亡率为0.6%。
即使在区域非专科单位进行，腹腔镜胆总管探查术仍然是BDS有效、高效且安全的一线治疗方法。尽管ERCP广泛可用，但应鼓励普通外科医生继续进行LCBDE，以优化患者护理并保持重要的手术技能。
