Kent A L, Cox M R, Wilson T G, Padbury R T, Toouli J
Department of Surgery, Flinders Medical Centre, Bedford Park, Australia.
Aust N Z J Surg. 1994 Jun;64(6):407-12. doi: 10.1111/j.1445-2197.1994.tb02240.x.
Laparoscopic cholecystectomy is the preferred method of treatment for symptomatic choledocholithiasis. Since its introduction there has been an increase in postoperative diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to assess the indications and results of ERCP following laparoscopic cholecystectomy. Sixty-one patients had an ERCP following laparoscopic cholecystectomy. Two broad groups were identified: Group 1 (35 patients) had filling defects (consistent with stones) noted on operative cholangiography, which were not successfully flushed or extracted at the time of laparoscopic cholecystectomy; Group 2 consisted of patients who developed problems following laparoscopic cholecystectomy. Nine patients had post-laparoscopic cholecystectomy pain with abnormal liver function tests (LFT), four of whom had common bile duct (CBD) injuries and three had CBD stones. Eleven patients had post-laparoscopic cholecystectomy pain with a normal diameter common bile duct on ultrasound and normal LFT; only one had a CBD stone. Five patients with a persisting bile leak following laparoscopic cholecystectomy had an ERCP and endoscopic sphincterotomy. In three the leak ceased, while two required subsequent open surgery to drain bile collections and ligate the cystic duct. One patient presented with an episode of transient jaundice but had a normal ERCP. There were six post-ERCP complications; three patients had mild pancreatitis, two had a minor haemorrhage and one an asymptomatic duodenal perforation. Endoscopic retrograde cholangiopancreatography post-laparoscopic cholecystectomy was most valuable for the management of retained stones and the diagnosis and management of post-laparoscopic cholecystectomy pain in association with abnormal LFT. The diagnostic yield was low (9%) when the LFT were normal.
腹腔镜胆囊切除术是有症状胆总管结石的首选治疗方法。自其应用以来，术后诊断性和治疗性内镜逆行胰胆管造影（ERCP）的使用有所增加。本研究的目的是评估腹腔镜胆囊切除术后ERCP的适应证和结果。61例患者在腹腔镜胆囊切除术后接受了ERCP。分为两大组：第1组（35例患者）在术中胆管造影时发现充盈缺损（符合结石表现），在腹腔镜胆囊切除术时未成功冲洗或取出；第2组由腹腔镜胆囊切除术后出现问题的患者组成。9例患者腹腔镜胆囊切除术后出现疼痛且肝功能检查（LFT）异常，其中4例有胆总管（CBD）损伤，3例有CBD结石。11例患者腹腔镜胆囊切除术后出现疼痛，超声显示胆总管直径正常且LFT正常；仅1例有CBD结石。5例腹腔镜胆囊切除术后持续胆漏的患者接受了ERCP和内镜括约肌切开术。3例漏液停止，而另外2例需要随后进行开放手术以引流胆汁积聚并结扎胆囊管。1例患者出现一过性黄疸，但ERCP正常。ERCP术后有6例并发症；3例患者发生轻度胰腺炎，2例有少量出血，1例有无症状十二指肠穿孔。腹腔镜胆囊切除术后的内镜逆行胰胆管造影对于残留结石的处理以及与LFT异常相关的腹腔镜胆囊切除术后疼痛的诊断和处理最有价值。当LFT正常时，诊断率较低（9%）。
