Berci G, Morgenstern L
Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048.
Surg Endosc. 1994 Oct;8(10):1168-74; discussion 1174-5. doi: 10.1007/BF00591044.
Laparoscopic common bile duct exploration (CBDE) was the subject of a multi-institutional study on 226 patients from 19 major hospital centers. Female patients predominated (2.3:1); the average age was 54; 75% of cases were chronic, and the remainder were acute. Although 97% had preoperative ultrasonograms, only 12% showed a stone in the dilated common bile duct. The alkaline phosphatase was elevated in 41% and the serum bilirubin in 28% of cases. Preoperative endoscopic retrograde cholangiography with sphincterotomy (ERC-ES) was performed in 8.5%; there was a successful stone extraction in less than half the cases. Cholangiography was performed in 99.5%, and in 94% of those cases, stones were found. In 83% of cases, stones were removed through the transcystic approach, and in 17% removal was throughout the CBD. In the majority of cases, the choledochoscope and wire basket (34%), irrigation (33%), or a combination of both was employed. In the transcystic group, 5% were converted to open procedures due to technical difficulty, as contrasted with the trans-CBD route, where the conversion rate was 19%. There were two ductal injuries. Minor complications occurred in 5.7% within 24 h; there was one death (0.4%). Within 30 days, the morbidity rate was 7% and there were no deaths. Retained stones were discovered in 2.6% of cases. Laparoscopic CBDE is a feasible approach for CBD stones which permits a definitive procedure in one stage, without pre- or postoperative ES. It is a skill which should be mastered by the biliary surgeon. Further improvement in instrumentation and technique should make the laparoscopic approach not only comparable but preferable to the standard open choledocholithotomy.
腹腔镜胆总管探查术（CBDE）是一项针对来自19个主要医院中心的226例患者的多机构研究的主题。女性患者居多（比例为2.3:1）；平均年龄为54岁；75%的病例为慢性，其余为急性。尽管97%的患者术前进行了超声检查，但只有12%的检查显示扩张的胆总管中有结石。41%的病例碱性磷酸酶升高，28%的病例血清胆红素升高。8.5%的患者术前进行了内镜逆行胆管造影并括约肌切开术（ERC - ES）；不到一半的病例成功取出结石。99.5%的患者进行了胆管造影，其中94%的病例发现了结石。83%的病例通过经胆囊途径取出结石，17%的病例通过整个胆总管取出结石。在大多数病例中，使用了胆管镜和钢丝篮（34%）、冲洗（33%）或两者结合的方法。在经胆囊组中，5%因技术困难转为开放手术，而经胆总管途径的转换率为19%。发生了两例胆管损伤。24小时内轻微并发症发生率为5.7%；有1例死亡（0.4%）。30天内，发病率为7%，无死亡病例。2.6%的病例发现有残留结石。腹腔镜CBDE是治疗胆总管结石的一种可行方法，可在一个阶段完成确定性手术，无需术前或术后的内镜括约肌切开术。这是一项应由胆道外科医生掌握的技术。仪器设备和技术的进一步改进应使腹腔镜手术不仅能与标准的开放胆总管切开取石术相媲美，而且更具优势。
