Nassar Ahmad H M, Ng Hwei J, Katbeh Tarek, Cannings Elizabeth
Laparoscopic Biliary Surgery Service, University Hospital Monklands, Lanarkshire, Scotland, United Kingdom.
Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, United Kingdom.
Ann Surg. 2022 Nov 1;276(5):e493-e501. doi: 10.1097/SLA.0000000000004680. Epub 2020 Dec 18.
The primary aim of this study was to describe the service model of one-session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to available studies on LCBDE.
The laparoscopic era brought about a decline in the conventional surgical management of common bile duct stones. Preoperative endoscopic removal became the primary method of managing choledocholithiasis. Although LCBDE deals with gallstones and ductal stones in onw session, the limited availability of such an advanced procedure perpetuated the reliance on the endoscopic approach.
Prospective data was entered into a single surgeon's database containing 5739 laparoscopic cholecystectomy over 28 years and analyzed.
One thousand eighteen consecutive LCBDE were included (23% of the series). Intraoperative cholangiography was performed in 1292 (98.0%). The median age was 60 years, male to female ratio 1:2 and 75% were emergency admissions. Most patients (43.4%) presented with jaundice. 66% had transcystic explorations and one third through a choledochotomy with 2.1% retained stones, 1.2% conversion, 18.7% morbidity, and 0.2% mortality. Postoperative ERCPs were needed in 3.1%. Recurrent stones occurred in 3%.
One stage LCBDE is a safe and cost-effective treatment where the expertise and equipment are available. Endoscopic treatment has a role for specific indications but remains the first-line treatment in most units. This study demonstrates that establishing specialist services through training and logistic support can optimize the outcomes of managing common bile duct stones.
本研究的主要目的是描述一期手术管理的服务模式，术前内镜清除的作用有限。次要目的是与现有的关于腹腔镜胆总管探查术（LCBDE）的研究相比，回顾其结果和长期随访情况。
腹腔镜时代使胆总管结石的传统手术管理有所减少。术前内镜下取出成为治疗胆总管结石的主要方法。尽管LCBDE可在一次手术中处理胆囊结石和胆管结石，但这种先进手术的可及性有限，使得对内镜方法的依赖一直存在。
前瞻性数据录入一位外科医生的数据库，该数据库包含28年间的5739例腹腔镜胆囊切除术，并进行分析。
纳入连续1018例LCBDE（占该系列的23%）。1292例（98.0%）进行了术中胆管造影。中位年龄为60岁，男女比例为1:2，75%为急诊入院。大多数患者（43.4%）出现黄疸。66%进行了经胆囊管探查，三分之一通过胆总管切开术，结石残留率为2.1%，中转率为1.2%，发病率为18.7%，死亡率为0.2%。3.1%的患者术后需要进行内镜逆行胰胆管造影（ERCP）。复发性结石发生率为3%。
在具备专业知识和设备的情况下，一期LCBDE是一种安全且具有成本效益的治疗方法。内镜治疗在特定适应证中有作用，但在大多数单位仍是一线治疗方法。本研究表明，通过培训和后勤支持建立专科服务可以优化胆总管结石的管理结果。
