摘要:目的:探討腹腔鏡膽囊切除術(laparoscopic cholecystectomy, LC)后發(fā)生嚴重并發(fā)癥的原因、治療措施和經(jīng)驗教訓。方法:分析 2007 年 8 月至2009 年 4月期間華西醫(yī)院膽道外科收治的LC術后發(fā)生嚴重并發(fā)癥的7例患者的臨床資料。結果:2例繼發(fā)性膽總管結石合并化膿性膽管炎患者,采用內(nèi)鏡下十二指腸乳頭切開(endoscopic sphincterotomy, EST)取出結石;3例膽道損傷患者,均進行肝門膽管成形和肝總管空腸吻合術;1例絞窄性腸梗阻患者,切除壞死空腸管后,行空腸對端吻合術;以上6例患者均順利出院,隨訪8～20個月,均生活良好。1例患者LC術后發(fā)生肺動脈栓塞,積極搶救后因呼吸衰竭而死亡。結論:術中仔細輕柔的操作以及辯清肝總管、膽總管與膽囊管的三者關系是預防LC術后發(fā)生嚴重并發(fā)癥的關鍵。合理可行的治療措施是提高發(fā)生并發(fā)癥的患者生活質(zhì)量的保障。LC術時,膽道外科醫(yī)生思想上要高度重視,不可盲目追求速度,必要時及時中轉(zhuǎn)開腹。Abstract: Objective: To investigate the causes and therapeutic measures and the experience and lesson of sever complications after laparoscopic cholecystectomy (LC). Methods:Clinical data of 7 patients with severe complications after LC from August 2007 to April 2009 were analyzed retrospectively. The clinical data was got from biliary department of West China Hospital. Results: Two cases of secondary common bile duct stone with acute suppurative cholangitis got cured by endoscopic sphincterotomy. Three cases of severe bile duct injury after LC had stricture of the hilar bile duct, and all of the cases were performed RouxenY hepaticojejunostomy with the diameter of stoma 2.03.0 centimeters. One case of strangulating intestinal obstruction was cured through jejunum endtoend anastomosis after cutting off the necrotic jejunum. All of the above 6 patients recovered well. Following up for 820 months, all lived well. One patient got pulmonary embolism after LC and dead of respiratory failure after active rescue. Conclusion: Carefully making operation and distinguishing the relationship of hepatic bile duct and common bile duct and the duct of gallbladder are the key points to prevent sever complications during LC. Reasonable and feasible treatment is the ensurement of increasing the living quality of the patients with sever complications after LC. And the surgeons of biliary department must have a correct attitude toward LC and should concern think highly during LC and should not pursue speed blindly. In necessary, the operation of LC should be turned into open cholecystectomy.
目的探討經(jīng)膽囊管路徑兩鏡（腹腔鏡+膽道鏡）或三鏡（腹腔鏡+膽道鏡+十二指腸鏡）聯(lián)合并一期縫合治療膽囊結石并繼發(fā)性膽總管結石的臨床療效及兩種術式的優(yōu)缺點。方法回顧性收集 2017 年 1 月至 2018 年 12 月期間成都市第二人民醫(yī)院肝膽外科收治并行經(jīng)膽囊管路徑兩鏡或三鏡聯(lián)合膽總管探查取石術+一期縫合術的 83 例膽囊結石并繼發(fā)性膽總管結石患者的臨床資料，其中 41 例行經(jīng)膽囊管路徑兩鏡聯(lián)合膽總管探查取石術+一期縫合術（兩鏡組），42 例行經(jīng)膽囊管路徑三鏡聯(lián)合膽總管探查取石術+經(jīng)腹置入鼻膽管引流術+一期縫合術（三鏡組）。結果兩鏡組和三鏡組的性別、年齡及術前膽總管直徑、術前基礎疾病等比較差異無統(tǒng)計學意義（P>0.05）。83 例患者的手術均成功且術后恢復情況良好，2 組患者的手術成功率、結石清除率、術后 1 d 腹腔引流量、拔除引流管時間和住院時間比較差異均無統(tǒng)計學意義（P>0.05），三鏡組的手術時間、術中出血量和術后輕型胰腺炎發(fā)生率明顯高于兩鏡組（P<0.05），但術后肝功能恢復情況優(yōu)于兩鏡組（P<0.05）。結論對于膽囊結石合并繼發(fā)性膽總管結石患者，在嚴格掌握手術適應證情況下，經(jīng)膽囊管路徑兩鏡或三鏡聯(lián)合膽總管探查取石+一期縫合術均安全、可行，但在具體選擇兩鏡還是三鏡聯(lián)合應根據(jù)患者術前一般情況和術中探查情況來決定。