Mohtashami Ali, Ziaziaris William A, Lim Chris S H, Bhimani Nazim, Leibman Steven, Hugh Thomas J
Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards.
Northern Clinical School, University of Sydney.
Surg Laparosc Endosc Percutan Tech. 2024 Dec 1;34(6):625-629. doi: 10.1097/SLE.0000000000001333.
Retained gallstones are the most common cause of postcholecystectomy pain. They may be in a long remnant cystic duct (CD), the common bile duct (CBD), or within a remnant gallbladder (GB) post subtotal cholecystectomy. Although endoscopic management is often attempted, occasionally surgical clearance is required. Rates of preoperative surgery to remove stones in a remnant GB are rising due to the increased practice of subtotal cholecystectomy during a problematic laparoscopic cholecystectomy. This study aims to review the surgical management of symptomatic retained stones at a tertiary hepatobiliary referral center in Sydney, Australia.
This retrospective analysis of prospectively collected data was performed on patients who underwent an operation for retained stones after a previous cholecystectomy over 18 years (2004-2022). All of the patients with residual CBD stones had failed endoscopic retrograde cholangiopancreatogram (ERCP) attempts or could not have an ERCP because of prior foregut surgery. All patients underwent a systematic preoperative workup confirming the biliary anatomy and pathology.
Fourteen patients had surgical intervention for retained stones. All cases were attempted laparoscopically and were successful in 11/14 patients (78%). Retained stones were found within a remnant GB (29%, n=4), a remnant CD (36%, n=5), or the CBD (36%, n=5). Conversion to an open procedure in 3 patients was for dense fibrosis associated with a long low-insertion of the CD, necessitating a hepatico-jejunostomy, failure to delineate the biliary anatomy, and inability to clear CBD stones, respectively. One patient developed a minor postoperative complication (superficial wound infection), and all patients were free of symptoms at a median follow-up of 33.5 months.
This study demonstrates favorable outcomes in patients undergoing laparoscopic intervention for retained gallstones. A systematic approach to the workup and surgical management of patients with retained stones is essential.
残留胆结石是胆囊切除术后疼痛最常见的原因。它们可能存在于较长的残余胆囊管（CD）、胆总管（CBD）或次全胆囊切除术后的残余胆囊（GB）内。尽管常常尝试内镜治疗，但偶尔仍需要手术清除。由于在有问题的腹腔镜胆囊切除术中次全胆囊切除术的应用增加，术前手术切除残余胆囊内结石的比例正在上升。本研究旨在回顾澳大利亚悉尼一家三级肝胆转诊中心对有症状残留结石的手术治疗情况。
对前瞻性收集的数据进行回顾性分析，研究对象为在过去18年（2004 - 2022年）接受过胆囊切除术后残留结石手术的患者。所有残留CBD结石的患者内镜逆行胰胆管造影（ERCP）尝试均失败，或因先前的前肠手术无法进行ERCP。所有患者均接受了系统的术前检查以确认胆道解剖结构和病理情况。
14例患者因残留结石接受了手术干预。所有病例均尝试腹腔镜手术，11/14例患者（78%）成功。残留结石见于残余胆囊（29%，n = 4）、残余胆囊管（36%，n = 5）或CBD（36%，n = 5）。3例患者中转开腹手术分别是因为CD低位插入处长段致密纤维化需要行肝空肠吻合术、无法清晰显示胆道解剖结构以及无法清除CBD结石。1例患者出现轻微术后并发症（浅表伤口感染），所有患者在中位随访33.5个月时均无症状。
本研究表明，接受腹腔镜干预治疗残留胆结石的患者预后良好。对残留结石患者进行系统的检查和手术管理至关重要。
