Curet M J, Pitcher D E, Martin D T, Zucker K A
Department of Surgery, University of New Mexico School of Medicine, Albuquerque.
Ann Surg. 1995 Feb;221(2):149-55. doi: 10.1097/00000658-199502000-00004.
Laparoscopic antegrade sphincterotomy represents a new technique that expands the ability of the surgeon to manage complex choledocholithiasis at the time of laparoscopic cholecystectomy. The authors describe their experience with six patients with cholelithiasis and complex common bile duct stone disease who underwent successful laparoscopic cholecystectomy and antegrade sphincterotomies.
Patients with complex choledocholithiasis have represented a technical challenge to the minimally invasive surgeon. Recently, a laparoscopic technique of antegrade biliary sphincterotomy has been reported by DePaulo in Brazil. This technique has been successful at clearing the common bile duct at the time of laparoscopic cholecystectomy.
Laparoscopic antegrade sphincterotomy was performed in six patients with multiple common bile duct stones. A standard endoscopic sphincterotome was introduced antegrade via the cystic duct or common bile duct and guided through the ampulla. A side-viewing duodenoscope was used to confirm proper positioning of the sphincterotome. Then a blended current was applied until the sphincterotomy was complete.
There was no mortality or morbidity associated with laparoscopic antegrade sphincterotomy. The mean additional operative time to complete laparoscopic antegrade sphincterotomy was 19 minutes. Three of the six patients were noted to have transient, asymptomatic elevation in serum amylase levels immediately after surgery (average 252 international units/L; normal < 115), which normalized within 72 hours. The mean postoperative hospital stay was 2.9 days. At a mean follow-up of 5 months (range 1 to 10 months), five patients remain asymptomatic. One individual with acquired immune deficiency syndrome had persistent symptoms, and a diagnosis of cytomegalovirus pancreatitis was eventually made.
Laparoscopic antegrade sphincterotomy appears to be a safe and effective technique for the management of complex biliary tract disease.
腹腔镜顺行括约肌切开术是一种新技术，它拓展了外科医生在腹腔镜胆囊切除术时处理复杂胆总管结石的能力。作者描述了他们对6例胆石症合并复杂胆总管结石疾病患者的治疗经验，这些患者均成功接受了腹腔镜胆囊切除术和顺行括约肌切开术。
复杂胆总管结石患者一直是微创外科医生面临的技术挑战。最近，巴西的德保罗报道了一种腹腔镜顺行胆管括约肌切开术。该技术在腹腔镜胆囊切除术时成功清除了胆总管结石。
对6例患有多发胆总管结石的患者实施腹腔镜顺行括约肌切开术。通过胆囊管或胆总管将标准的内镜括约肌切开刀顺行插入，经壶腹穿出。使用侧视十二指肠镜确认括约肌切开刀的正确位置。然后施加混合电流，直至括约肌切开术完成。
腹腔镜顺行括约肌切开术未导致死亡或并发症。完成腹腔镜顺行括约肌切开术的平均额外手术时间为19分钟。6例患者中有3例在术后立即出现血清淀粉酶水平短暂、无症状性升高（平均252国际单位/升；正常<115），72小时内恢复正常。术后平均住院时间为2.9天。平均随访5个月（范围1至10个月），5例患者无症状。1例获得性免疫缺陷综合征患者症状持续存在，最终诊断为巨细胞病毒胰腺炎。
腹腔镜顺行括约肌切开术似乎是治疗复杂胆道疾病的一种安全有效的技术。
