最佳手术技术、术中胆管造影（IOC）的应用以及急性胆囊疾病的管理：英国和爱尔兰全国性调查结果
Optimal surgical technique, use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland.
作者信息
Sanjay P, Kulli C, Polignano F M, Tait I S
机构信息
Department of Surgery, Ninewells Hospital and Medical School, Dundee, UK.
出版信息
Ann R Coll Surg Engl. 2010 May;92(4):302-6. doi: 10.1308/003588410X12628812458617.
INTRODUCTION
There is debate on optimal techniques that reduce bile duct injury during laparoscopic cholecystectomy (LC). A national survey of Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) members was carried out to determine current surgical practice for gallstones, including the use of intra-operative cholangiography (IOC) or critical view of safety to reduce the risk of bile duct injury.
SUBJECTS AND METHODS
An anonymous postal survey was sent to all 417 AUGIS members. Data on grade of surgeon, place of work (district general hospital, teaching), subspecialty, number LC per year, use of IOC, critical view of safety, and management of stones detected during surgery were collated.
RESULTS
There was a 36% (152/417) response - 134 (88%) from consultant surgeons (36, HPB; 106,OG; 64, DGH; 88, teaching hospital). Of these, 38% performed > 100 LC per year, 36% 50-100 LC per year, and 22% 25-50 LC per year. IOC was routine for 24%; and selective for 72%. Critical view of Calot's triangle was advocated by 82%. Overall, 55% first clip and divide the cystic artery, whereas 41% first clip and divide the cystic duct. Some 39% recommend IOC and 23% pre-operative MRCP if dilated common bile duct (CBD) is noted on pre-operative ultrasound. When bile duct stones are identified on IOC, 61% perform laparoscopic CBD exploration (LCBDE), 25% advise postoperative ERCP, and 13% perform either LCBDE or ERCP. Overall, 88% (n = 134) recommend index cholecystectomy for acute pathology, and this is more likely in a teaching hospital setting (P = 0.003). Laparoscopic CBD exploration was more likely to be performed in university hospitals (P < 0.05).
CONCLUSIONS
A wide dissection of Calot's triangle to provide a critical view of safety is the technique most commonly recommended by AUGIS surgeons (83%) to minimise risk of bile duct injury, in contrast to 24% that recommend routine IOC. The majority (88%) of AUGIS surgeons advise index admission cholecystectomy for acute gallbladder disease.
引言
关于在腹腔镜胆囊切除术（LC）中降低胆管损伤的最佳技术存在争议。对大不列颠及爱尔兰上消化道外科医生协会（AUGIS）成员进行了一项全国性调查，以确定当前胆结石的手术操作情况，包括术中胆管造影（IOC）的使用或安全关键视野的运用，以降低胆管损伤风险。
研究对象与方法
向所有417名AUGIS成员发送了一份匿名邮寄调查问卷。整理了有关外科医生级别、工作地点（地区综合医院、教学医院）、亚专业、每年LC手术数量、IOC的使用、安全关键视野以及手术中发现结石的处理等数据。
结果
有36%（152/417）的回复率——来自顾问外科医生的回复有134份（88%）（36名肝脏胰胆外科医生；106名普通外科医生；64名地区综合医院医生；88名教学医院医生）。其中，38%的医生每年进行超过100例LC手术，36%的医生每年进行50 - 100例LC手术，22%的医生每年进行25 - 50例LC手术。24%的医生将IOC作为常规操作；72%的医生选择性使用。82%的医生提倡对胆囊三角进行安全关键视野的观察。总体而言，55%的医生先夹闭并离断胆囊动脉，而41%的医生先夹闭并离断胆囊管。约39%的医生建议进行IOC检查，23%的医生建议在术前超声检查发现胆总管（CBD）扩张时进行术前磁共振胰胆管造影（MRCP）检查。当在IOC检查中发现胆管结石时，61%的医生进行腹腔镜胆总管探查术（LCBDE），25%的医生建议术后进行内镜逆行胰胆管造影（ERCP），13%的医生进行LCBDE或ERCP。总体而言，88%（n = 134）的医生建议对急性病变进行初次胆囊切除术，在教学医院环境中更有可能如此（P = 0.003）。腹腔镜胆总管探查术在大学医院中更有可能进行（P < 0.05）。
结论
AUGIS外科医生最常推荐的技术（83%）是广泛解剖胆囊三角以提供安全关键视野，以将胆管损伤风险降至最低，相比之下，24%的医生推荐常规IOC。大多数（88%）AUGIS外科医生建议对急性胆囊疾病进行初次入院胆囊切除术。
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