Pitt H A
Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.
Am J Surg. 1993 Apr;165(4):483-6. doi: 10.1016/s0002-9610(05)80946-8.
In recent years, several less invasive procedures have challenged the preeminence of open choledochotomy in the management of patients with choledocholithiasis. Alternatives now include endoscopic sphincterotomy, extracorporeal shock-wave lithotripsy, percutaneous transhepatic stone extraction, and laparoscopic common duct exploration. In deciding whether an alternative is appropriate for an individual patient, factors to consider include the following: (1) the presence or absence of the gallbladder; (2) the severity of the presenting symptoms; (3) the results of open choledochotomy; and (4) local endoscopic, radiologic, and laparoscopic expertise. Review of available data suggests that endoscopic sphincteroplasty is appropriate for older patients without a gallbladder and for those with severe toxic cholangitis. However, endoscopic sphincterotomy has not been proven to be worthwhile before open surgery. Open choledochotomy has been reported to have a mortality rate of less than 2%, leaving fewer than 5% of patients with retained stones. Since the introduction of laparoscopic cholecystectomy, treatment algorithms for patients with common duct stones have seldom included open choledochotomy. However, future prospective, randomized trials of the management of patients with choledocholithiasis should include open choledochotomy as the gold standard.
近年来，几种侵入性较小的手术对胆总管切开术在胆总管结石患者管理中的主导地位提出了挑战。现在的替代方法包括内镜括约肌切开术、体外冲击波碎石术、经皮经肝胆管取石术和腹腔镜胆总管探查术。在决定某种替代方法是否适合某一特定患者时，需要考虑的因素包括：（1）胆囊的有无；（2）当前症状的严重程度；（3）胆总管切开术的结果；（4）当地的内镜、放射学和腹腔镜专业技术水平。对现有数据的回顾表明，内镜括约肌成形术适用于无胆囊的老年患者和患有严重中毒性胆管炎的患者。然而，在内镜手术之前，内镜括约肌切开术尚未被证明是值得的。据报道，胆总管切开术的死亡率低于2%，结石残留患者不到5%。自腹腔镜胆囊切除术问世以来，胆总管结石患者的治疗方案很少包括胆总管切开术。然而，未来关于胆总管结石患者管理的前瞻性、随机试验应将胆总管切开术作为金标准。
