Jones D B, Soper N J, Brewer J D, Quasebarth M A, Swanson P E, Strasberg S M, Brunt L M
Institute for Minimally Invasive Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
Surg Laparosc Endosc. 1996 Apr;6(2):114-22.
From 1990 through 1993, we treated 36 patients with recurrent typical biliary colic but who showed no ultrasonic evidence of cholelithiasis by laparoscopic cholecystectomy. Associated symptoms included nausea (75%), bloating (56%), fatty-food intolerance (53%), vomiting (17%), weight loss (31%), bowel irregularity (28%), reflux or dyspepsia (25%), and fever (17%). Diagnostic evaluation included ultrasound (100%), upper gastrointestinal series (36%), oral cholecystogram (14%), computed tomographic scan (39%), endoscopic retrograde cholangiopancreatography (17%), upper gastrointestinal endoscopy (14%), and hepatobiliary scan (92%). Quantitative hepatobiliary scans in 33 patients revealed a low gallbladder ejection fraction (EF) of less than 35% in 29 patients (88%; mean EF = 9%), and 13 patients experienced reproducible pain after cholecystokinin provocation. All patients underwent attempted laparoscopic cholecystectomy; one case of unsuspected acute acalculous cholecystitis was converted to open laparotomy because of unclear anatomy. Gross and histological examination of the gallbladders revealed chronic inflammation (83%), cholesterolosis (31%), cholesterol crystals or small stones (17%), acute inflammation (8%), polyps (6%), and normal histology (6%); however, blind retrospective scoring of gallbladders revealed significant chronic inflammation in only 38%. In the 2 to 40 months (mean, 14 months) since operation, there have been no deaths (97% follow-up). Laparoscopic cholecystectomy relieved pain in 93% of patients with a low preoperative EF compared with 75% of patients with a normal EF (nonsignificant p value). Persistent abdominal or gastrointestinal complaints included flatulence (31%), loose stools or fecal urgency (29%), belching (29%), indigestion (20%), nausea (11%), and "typical" gallbladder pain (9%). We conclude that many patients with symptoms of biliary colic and scintigraphic evidence of biliary dyskinesia have histologic findings of chronic cholecystitis. Although laparoscopic cholecystectomy usually eliminates biliary colic, persistent nonbiliary complaints are frequent.
1990年至1993年期间，我们对36例复发性典型胆绞痛但超声检查无胆结石证据的患者实施了腹腔镜胆囊切除术。相关症状包括恶心（75%）、腹胀（56%）、不耐油腻食物（53%）、呕吐（17%）、体重减轻（31%）、排便不规律（28%）、反流或消化不良（25%）以及发热（17%）。诊断性评估包括超声检查（100%）、上消化道造影（36%）、口服胆囊造影（14%）、计算机断层扫描（39%）、内镜逆行胰胆管造影（17%）、上消化道内镜检查（14%）以及肝胆扫描（92%）。对33例患者进行的定量肝胆扫描显示，29例患者（88%；平均排空分数=9%）的胆囊排空分数低于35%，且13例患者在注射胆囊收缩素后出现可重复性疼痛。所有患者均尝试进行腹腔镜胆囊切除术；1例未被怀疑的急性非结石性胆囊炎因解剖结构不清而转为开腹手术。胆囊的大体和组织学检查显示慢性炎症（83%）、胆固醇沉着症（31%）、胆固醇结晶或小结石（17%）、急性炎症（8%）、息肉（6%）以及正常组织学（6%）；然而，对胆囊进行盲目回顾性评分时，仅38%显示有明显的慢性炎症。术后2至40个月（平均14个月），无死亡病例（随访率97%）。与术前胆囊排空分数正常的患者中75%的缓解率相比，腹腔镜胆囊切除术使术前胆囊排空分数低的患者中93%的患者疼痛得到缓解（p值无统计学意义）。持续的腹部或胃肠道不适包括肠胃胀气（31%）、腹泻或便急（29%）、嗳气（29%）、消化不良（20%）、恶心（11%）以及“典型的”胆囊疼痛（9%）。我们得出结论，许多有胆绞痛症状且闪烁扫描显示有胆囊运动障碍证据的患者存在慢性胆囊炎的组织学表现。虽然腹腔镜胆囊切除术通常可消除胆绞痛，但持续性非胆源性不适却很常见。
