Santo Marco Aurelio, Domene Carlos Eduardo, Riccioppo Daniel, Barreira Lian, Takeda Flavio Roberto, Pinotti Henrique Walter
Departmento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, Brasil.
Arq Gastroenterol. 2012 Jan-Mar;49(1):41-51. doi: 10.1590/s0004-28032012000100008.
About 9% of the Brazilian population has gallstones and the incidence increases significantly with aging. The choledocholithiasis is found around 15% of these patients, and a third to half of these cases presented as asymptomatic. Once the lithiasis in the common bile duct is characterized through intraoperative cholangiography, the laparoscopic surgical exploration can be done through the transcystic way or directly through choledochotomy.
To evaluate the results and outcomes of the laparoscopic treatment of common bile duct lithiasis.
Seventy consecutive patients were evaluated. They prospectively underwent the treatment of the lithiasis in the common bile duct and the exploration ways were compared according to the following parameters: criteria on their indication, success in the clearance, surgical complications. It was verified that about ½ of the choledocholithiasis carriers did not show any expression of predictive factors (clinical antecedents of jaundice and/or acute pancreatitis, compatible sonographic data and the pertaining lab tests). The laparoscopic exploration through the transcystic way is favored when there are no criteria for the practice of primary choledochotomy, which are: lithiasis in the proximal bile duct, large (over 8 mm) or numerous calculi (multiple calculosis).
The transcystic way was employed in about 50% of the casuistic and the choledochotomy in about 30%. A high success rate (around 80%) was achieved in the clearance of the common bile duct stones through laparoscopic exploration. The transcystic way, performed without fluoroscopy or choledochoscopy, attained a low rate of success (around 45%), being 10% of those by transpapilar pushing of calculi less than 3 mm. The exploration through choledochotomy, either primary or secondary, if the latter was performed after the transcystic route failure, showed high success rate (around 95%). When the indication to choledochotomy was primary, the necessity for choledochoscopy through choledochotomy to help in the removal of the calculi was 55%. However, when choledochotomy was performed secondarily, in situations where the common bile duct diameter was larger than 6 mm, the use of choledochoscopy with the same purpose involved about 20% of the cases. There was no mortality in this series.
The laparoscopic exploration of the common bile duct was related to a low rate of morbidity. Therefore, the use of laparoscopy for the treatment of the lithiasis in the common bile duct depends on the criteria for the choice of the best access, making it a safe procedure with very good results.
约9%的巴西人口患有胆结石，且发病率随年龄增长显著上升。在这些患者中，胆总管结石的发生率约为15%，其中三分之一至一半的病例为无症状性。一旦通过术中胆管造影确定胆总管结石的情况，腹腔镜手术探查可通过经胆囊途径或直接通过胆总管切开术进行。
评估腹腔镜治疗胆总管结石的结果和疗效。
对70例连续患者进行评估。他们前瞻性地接受了胆总管结石的治疗，并根据以下参数比较探查方式：适应证标准、结石清除成功率、手术并发症。结果发现，约一半的胆总管结石患者未表现出任何预测因素（黄疸和/或急性胰腺炎的临床病史、超声检查数据相符及相关实验室检查）。当不存在进行一期胆总管切开术的标准时，倾向于采用经胆囊途径进行腹腔镜探查，这些标准包括：胆总管近端结石、大结石（直径超过8mm）或多发结石（多发结石症）。
约50%的病例采用经胆囊途径，约30%采用胆总管切开术。通过腹腔镜探查清除胆总管结石取得了较高的成功率（约80%）。在无荧光透视或胆管镜检查的情况下进行的经胆囊途径成功率较低（约45%），经乳头推挤小于3mm结石的成功率为10%。无论是一期还是二期胆总管切开术（二期胆总管切开术在经胆囊途径失败后进行），其探查成功率都较高（约95%）。当胆总管切开术的适应证为一期时，通过胆总管切开术进行胆管镜检查以协助取出结石的必要性为55%。然而，当二期进行胆总管切开术时，在胆总管直径大于6mm的情况下，出于相同目的使用胆管镜检查的病例约占20%。本系列病例无死亡病例。
腹腔镜探查胆总管的发病率较低。因此，使用腹腔镜治疗胆总管结石取决于选择最佳入路的标准，使其成为一种安全且效果良好的手术。
