同期三镜、逐级扩张导管、乳头小切开、防滑脱鼻胆管治疗胆结石、乳头部梗阻105例

Laparoscopy, Choledochoscopy, Duodenoscopy, Step by Step Dilatable Catheter, the Small Incision of Papillary Sphincterotomy and Antislip Nasobiliary Drainage of the Same Period in Treatment of Extrahepatic Bile Duct Stones with Obstruction of Papillary: A Report of 105 Cases

摘要: 目的：探讨同期三镜(腹腔镜、胆管镜、十二指肠镜)、逐级扩张导管、乳头小切开、防滑脱鼻胆管(LCPND)治疗胆囊结石、胆总管结石、合并十二指肠乳头部梗阻或狭窄的临床应用体会。方法：回顾性分析成都市第二人民医院2010年12月至2018年12月期间，符合入选标准的105例患者的临床资料。结果：105例在腹腔镜下行胆囊切除术、胆总管探查胆管镜下取石术，必要时，在胆管镜下行冲击波或液电碎石术。采用逐级导管扩张乳头、十二指肠镜下乳头小切开并留置鼻胆管72.4% (76/105)，逐级导管扩张乳头、十二指肠镜下乳头切开和取石并留置鼻胆管13.3% (14/105)，逐级导管扩张乳头失败而改为十二指肠镜下乳头切开或取石并留置鼻胆管7.6% (8/105)，因逐级导管扩张乳头和十二指肠镜下切开乳头均失败而中转为腹腔镜胆总管探查取石并留置T形管1.0% (1/105)，因腹腔镜下取石失败而中转为开腹胆总管探查取石、逐级导管扩张乳头、十二指肠镜下乳头切开并留置鼻胆管1.9% (2/105)，因腹腔镜下取石失败而中转为开腹胆总管探查取石并留置T形管3.8% (4/105)。一期缝合术后无残石，胆汁漏5例(4.8%)，轻症胰腺炎2例(1.9%)。无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症，无围手术期再手术和死亡病例。术后总并发症发生率为6.7%(7/105)。结论：对本医院有限病例进行初步研究发现，只要病例选择合适，LCPND治疗胆囊结石、胆总管结石、合并十二指肠乳头部梗阻或狭窄是可行、有效和安全的。

Abstract: Objective: To explore the surgical technique and clinical effect of laparoscopy, choledochoscopy, duodenoscopy, step by step dilatable catheter, the small incision of papillary sphincterotomy and antislip nasobiliary drainage (LCPND) of the corresponding period in treatment of extrahepatic bile duct stones with obstruction and stenosis of papillary during the course of therapeutic laparoscopy. Methods: The clinical data of 105 cases of extrahepatic bile duct stones with obstruction and steno-sis of papillary undergoing LCPND were analyzed retrospectively from December 2010 to December 2018 in the Second People’s Hospital of Chengdu. Results: It was in 105 cases removed the gallbladder and exploration of common bile duct by laparoscopy, to remove gallstones through the duct incision with choledochoscopy and shockwave lithotripsy. Step by step dilatable catheter ex-panded duodenal papilla, the small incision of papillary sphincterotomy and indwelling nasobiliary was in 72.4% (76/105); step by step dilatable catheter expanded duodenal papilla, through papil-lary sphincterotomy to remove gallstones and indwelling nasobiliary in 13.3% (14/105); the ex-panded papillary failed and was replaced by endoscopic papillotomy or lithotomy and indwelling nasobiliary in 7.6% (8/105); due to the failure of dilating papillary and endoscopic papillotomy, it was transferred to laparoscopic choledocholithiasis and retained T shape tube drainage in 1.0% (1/105); it was shifted to open CBD exploration for the stone removal, step by step dilatable cathe-ter expanded duodenal papilla, the papillary sphincterotomy and indwelling nasobiliary in 1.9% (2/105); it was shifted to open CBD exploration for the stone removal and indwelling T shape tube drainage in 3.8% (4/105). It had not residual stones after the balloon nasobiliary drainage, bile leakage in five cases (4.8%), and two patients (1.9%) had a slight pancreatitis. No cases had perfo-ration of intestine and bile duct, bleeding, severe pancreatitis. No perioperative reoperation and death. Total postoperative complication formation rate was 6.7% (7/105). Conclusion: From pre-liminary results of limited cases in our hospital, if patients are suitable, LCPND in treatment of ex-trahepatic bile duct stones with obstruction and stenosis of papillary is safe and effective.