Service de chirurgie digestive, groupe hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, Paris 75020, France.
J Visc Surg. 2011 Sep;148(4):e287-90. doi: 10.1016/j.jviscsurg.2011.06.001. Epub 2011 Aug 3.
Unrecognized lithiasis of the cystic duct (CDL) may be responsible for post cholecystectomy. This retrospective study looked at the incidence of CDL during cholecystectomy, as well as the context of its occurrence; recommendations for a practical surgical approach are offered.
Over a period of 30 months, 143 consecutive cholecystectomies (103 women, 40 men; mean age: 57 years) were performed by the same surgeon: 142 by laparoscopy, and one by laparotomy due to a history of previous gastrectomy. The cystic duct was always opened and milked upward in search of CDL before immediate clip occlusion or performance of cholangiography (106 times, 74.1%). In seven cases, cholangiography was impossible because the cystic duct was too narrow.
There was no mortality. CDL was found in 21 cases (14.7%) and removed. This had not been identified by preoperative imaging (ultrasound or CT). Pain in the month preceding cholecystectomy occurred more frequently in cases of CDL (19/21[90.4%] vs 36/122 [29.5%]; P<0.001). Similarly, liver function tests were more often abnormal with CDL (10/21 [47.6%] vs 30/122 [24.5%]; P<0.05). However, neither jaundice nor gallbladder inflammation was predictive of CDL in this study. Echoendoscopy (EUS) was performed more often for suspected common duct lithiasis migration (CBDL) in patients with CDL than for those without (9/21 [42.8%] vs 26/122 [21.3%]; P<0.05). CBDL was present in 12 of 143 patients (8.3%). This was treated by preoperative endoscopic sphincterotomy in 10 cases, and twice by trans-cystic stone extraction during the laparoscopic intervention. CBDL occurred more frequently in association with CDL (5/21 [23.8%] vs 7/122 [5.7%]; P<0.01). In addition, CDL was still present at cholecystectomy in the four patients who underwent preoperative endoscopic sphincterotomy.
Cystic duct lithiasis is found frequently during cholecystectomy; CDL is often associated with preoperative pain, abnormal liver function tests and choledocholithiasis. It can persist despite preoperative sphincterotomy. The search for and treatment of CDL should be routinely performed during cholecystectomy.
探讨胆囊切除术后胆管结石（CBDL）的发生率、发生情况以及推荐实用的手术方法。
对 30 个月内 143 例连续接受胆囊切除术的患者（103 例女性，40 例男性；平均年龄 57 岁）进行了回顾性研究，142 例为腹腔镜胆囊切除术，1 例因既往胃切除术而行剖腹胆囊切除术。所有患者均在同一外科医生主刀下完成手术。手术过程中，我们始终打开胆囊管并向上挤奶，寻找胆管结石。如果发现胆管结石，我们将在立即夹闭或行胆管造影（106 例，74.1%）前进行处理。但有 7 例患者因胆囊管太窄而无法进行胆管造影。
所有患者均未出现死亡病例。我们发现 21 例（14.7%）患者存在胆管结石，并对其进行了切除。这些胆管结石术前影像学检查（超声或 CT）均未能识别。在接受胆囊切除术的前 1 个月内出现疼痛的患者，胆管结石的发生率更高（19/21[90.4%]vs36/122[29.5%]；P<0.001）。同样，有胆管结石的患者肝功能检查异常的发生率也更高（10/21[47.6%]vs30/122[24.5%]；P<0.05）。然而，在本研究中，黄疸或胆囊炎症均不能预测胆管结石的存在。有胆管结石的患者更常因疑似胆总管结石迁移（CBDL）而行超声内镜（EUS）检查（9/21[42.8%]vs26/122[21.3%]；P<0.05）。143 例患者中有 12 例（8.3%）存在 CBDL。其中 10 例患者术前接受内镜括约肌切开术治疗，2 例患者在腹腔镜手术过程中经胆囊管碎石取石术治疗。CBDL 更常与胆管结石同时存在（5/21[23.8%]vs7/122[5.7%]；P<0.01）。此外，术前接受内镜括约肌切开术的 4 例患者，术后胆囊切除术中仍存在胆管结石。
在胆囊切除术中经常发现胆管结石；胆管结石常伴有术前疼痛、肝功能异常和胆总管结石。尽管术前已行括约肌切开术，但仍可能存在胆管结石。在胆囊切除术中，应常规寻找并处理胆管结石。
