Brady P G, Pinkas H, Pencev D
Department of Medicine, University of South Florida, College of Medicine, Tampa, USA.
Dig Dis. 1996 Nov-Dec;14(6):371-81. doi: 10.1159/000171571.
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful adjunct to laparoscopic cholecystectomy. Preoperative ERCP is indicated if there is a high degree of suspicion for common duct stones, when severe gallstone-induced pancreatitis is present, or when there is uncertainty regarding the diagnosis. The best indicators of common duct stones preoperatively are an elevated bilirubin, a dilated common bile duct (CBD) on sonography, or stones visualized in the CBD on sonography. Mild gallstone pancreatitis and transient mild elevations in liver enzymes are not predictive of CBD stones and are not indications for ERCP. Postoperative ERCP is highly effective in clearing CBD stones. It has the advantage of being more readily available as compared to laparoscopic CBD exploration, and preserves all the advantages of the laparoscopic approach. Post-operative ERCP is indicated for retained CBD stones, evaluation and therapy of biliary injuries, and persistent biliary symptoms or abnormal liver enzymes and bilirubin. ERCP is the procedure of choice for the evaluation of laparoscopic biliary injuries. Major biliary injuries will generally require surgical therapy. Bile duct strictures are sometimes amenable to endoscopic therapy with dilation and stents. Biliary leaks are readily treatable with endoscopic therapy. Small cystic duct stump leaks and leaks from a duct of Lushka close within a few days with nasobiliary drainage. Larger leaks may require more prolonged drainage with stents and early supplemental percutaneous drainage of an accompanying biloma. Bilious ascites should be treated with nasobiliary drainage using low suction to be prevent contamination of the peritoneal cavity with intestinal flora, and simultaneous percutaneous ascites drainage. Biliary leaks, unless associated with major bile duct injuries, rarely require surgical therapy.
内镜逆行胰胆管造影术（ERCP）是腹腔镜胆囊切除术的一种有用辅助手段。如果高度怀疑存在胆总管结石、出现严重胆石性胰腺炎或诊断存在不确定性，则需进行术前ERCP。术前胆总管结石的最佳指标是胆红素升高、超声显示胆总管（CBD）扩张或超声在CBD中发现结石。轻度胆石性胰腺炎和肝酶短暂轻度升高不能预测CBD结石，也不是ERCP的指征。术后ERCP在清除CBD结石方面非常有效。与腹腔镜胆总管探查相比，它具有更易于实施的优势，并保留了腹腔镜手术的所有优点。术后ERCP适用于残留的CBD结石、胆管损伤的评估和治疗以及持续的胆道症状或异常的肝酶和胆红素。ERCP是评估腹腔镜胆道损伤的首选方法。严重的胆道损伤通常需要手术治疗。胆管狭窄有时可通过内镜扩张和置入支架进行治疗。胆漏很容易通过内镜治疗。小的胆囊管残端漏和卢氏管漏在进行鼻胆管引流后几天内即可闭合。较大的漏可能需要通过支架进行更长时间的引流，并早期对伴随的胆汁瘤进行经皮引流。胆汁性腹水应采用低负压鼻胆管引流治疗，以防止肠道菌群污染腹腔，并同时进行经皮腹水引流。胆漏，除非与主要胆管损伤相关，很少需要手术治疗。
