Bulkin A J, Tebyani N, Dorazio R A
Department of Surgery, Kaiser Permanente Medical Center, Los Angeles, California 90027, USA.
Am Surg. 1997 Oct;63(10):900-3.
This study focused on the management of all patients admitted with a diagnosis of gallstone pancreatitis (GP) since the advent of laparoscopic cholecystectomy in our institution. The inpatient and outpatient medical records of all 172 patients with GP admitted from November 1990 to June 1995 were retrospectively reviewed. The main outcome measures were the effectiveness of and complications associated with surgical and endoscopic treatment of GP, including the incidence and management of common bile duct stones. One hundred fifty-four patients underwent cholecystectomy (89 laparoscopic and 65 open), usually within 3 to 5 days after admission when the amylase had returned to normal or nearly normal. There was a progressive increase in the use of laparoscopy, with 6 per cent of cholecystectomies in 1991 performed laparoscopically and 88 per cent in the first half of 1995. Overall conversion rate was 16 per cent. A total of 33 patients (19.2%) underwent endoscopic retrograde cholangiopancreatography (ERCP): 9 preoperatively and 12 postoperatively, and in 12 patients it served as definitive treatment due to advanced age and/or serious associated medical problems. Of the 24 positive intraoperative cholangiograms, 14 had common bile duct (CBD) stones. CBD stones were found in a total of only 32 patients (18.6%). Laparoscopic CBD exploration was not performed during this time period. There were 16 (8.6%) complications and two deaths (1.2%). Six patients refused all treatment. There were no unsuccessful postoperative ERCPs, and no patient underwent reoperation. In conclusion, our approach to patients with GP is safe and effective, with a low rate of complications. Considering the relatively low incidence of CBD stones in GP (18.6% in this series), routine preoperative ERCP is not indicated, because it has some risk and the vast majority of studies would be negative. In certain highly selected patients with multiple medical problems and/or advanced age, endoscopic sphincterotomy may be considered the definitive treatment. The optimal management of GP and CBD stones, however, depends on the skills and resources available as well as patient preference.
本研究聚焦于自我院开展腹腔镜胆囊切除术以来，所有诊断为胆石性胰腺炎（GP）的住院患者的管理。回顾性分析了1990年11月至1995年6月期间收治的172例GP患者的住院和门诊病历。主要观察指标为GP手术及内镜治疗的有效性和相关并发症，包括胆总管结石的发生率及处理情况。154例患者接受了胆囊切除术（89例腹腔镜手术，65例开放手术），通常在入院后3至5天淀粉酶恢复正常或接近正常时进行。腹腔镜手术的应用呈逐渐增加趋势，1991年腹腔镜胆囊切除术占比6%，1995年上半年占比88%。总体中转率为16%。共有33例患者（19.2%）接受了内镜逆行胰胆管造影（ERCP）：9例术前进行，12例术后进行，12例因高龄和/或严重合并症而作为确定性治疗。在24例术中胆管造影阳性患者中，14例有胆总管（CBD）结石。总共仅32例患者（18.6%）发现有CBD结石。在此期间未进行腹腔镜胆总管探查。发生16例（8.6%）并发症，2例死亡（1.2%）。6例患者拒绝所有治疗。术后ERCP均未失败，也没有患者接受再次手术。总之，我们对GP患者的治疗方法安全有效，并发症发生率低。鉴于GP中CBD结石的发生率相对较低（本系列为18.6%），不建议常规进行术前ERCP，因为其有一定风险且绝大多数检查结果为阴性。对于某些经过严格筛选的有多种合并症和/或高龄患者，内镜括约肌切开术可考虑作为确定性治疗。然而，GP和CBD结石的最佳管理取决于可用的技术和资源以及患者的偏好。
