March Brayden, Burnett David, Gani Jon
Division of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia.
School of Medicine, University of Newcastle, Newcastle, New South Wales, Australia.
ANZ J Surg. 2016 Nov;86(11):874-877. doi: 10.1111/ans.13676. Epub 2016 Jul 21.
Currently in Australasia, concomitant cholecystolithiasis and choledocholithiasis are usually managed with two procedures: laparoscopic cholecystectomy (LC) and pre or postoperative endoscopic retrograde cholangiopancreatography (ERCP). This approach exposes the patient to the risk of complications from the common bile duct stone(s) while awaiting ERCP, the risks of the ERCP itself (particularly pancreatitis) and the need for a second anaesthetic. This article explores the evidence for a newer hybrid approach, single stage LC and intraoperative ERCP (SSLCE) and compares this approach with the commonly used alternatives. SSLCE offers reduced rates of pancreatitis, reduced length of hospital stay and reduced cost compared with the two-stage approach and requires only one anaesthetic. There is a reduced risk of bile leak compared with procedures that involve a choledochotomy, and ductal clearance rates are superior to trans-cystic exploration and equivalent to the standard two-stage approach. Barriers to widespread implementation relate largely to operating theatre logistics and availability of appropriate endoscopic expertise, although when bile duct stones are anticipated these issues are manageable. There is compelling justification in the literature to gather prospective evidence surrounding SSLCE in the Australian Healthcare system.
目前在澳大拉西亚地区，胆囊结石合并胆总管结石通常采用两种手术方式进行治疗：腹腔镜胆囊切除术（LC）以及术前或术后内镜逆行胰胆管造影术（ERCP）。这种方法会使患者在等待ERCP期间面临胆总管结石相关并发症的风险、ERCP本身的风险（尤其是胰腺炎）以及需要进行第二次麻醉。本文探讨了一种更新的联合手术方法——单阶段LC及术中ERCP（SSLCE）的证据，并将这种方法与常用的替代方法进行比较。与两阶段手术方法相比，SSLCE可降低胰腺炎发生率、缩短住院时间并降低成本，且仅需一次麻醉。与涉及胆总管切开术的手术相比，胆漏风险降低，胆管清除率优于经胆囊探查术，且与标准两阶段手术方法相当。尽管在预计存在胆管结石时这些问题是可控的，但广泛实施SSLCE的障碍主要与手术室后勤保障及合适的内镜专业技术人员的可获得性有关。在澳大利亚医疗保健系统中，有充分的理由收集围绕SSLCE的前瞻性证据。
