摘要:目的:探討腹腔鏡膽囊切除術(shù)(laparoscopic cholecystectomy, LC)后發(fā)生嚴(yán)重并發(fā)癥的原因、治療措施和經(jīng)驗(yàn)教訓(xùn)。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(shù)后發(fā)生嚴(yán)重并發(fā)癥的7例患者的臨床資料。結(jié)果:2例繼發(fā)性膽總管結(jié)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(jié)石;3例膽道損傷患者,均進(jìn)行肝門膽管成形和肝總管空腸吻合術(shù);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(shù);以上6例患者均順利出院,隨訪8～20個(gè)月,均生活良好。1例患者LC術(shù)后發(fā)生肺動(dòng)脈栓塞,積極搶救后因呼吸衰竭而死亡。結(jié)論:術(shù)中仔細(xì)輕柔的操作以及辯清肝總管、膽總管與膽囊管的三者關(guān)系是預(yù)防LC術(shù)后發(fā)生嚴(yán)重并發(fā)癥的關(guān)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(shù)時(shí),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(shí)及時(shí)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(jié)石并繼發(fā)性膽總管結(jié)石的臨床療效及兩種術(shù)式的優(yōu)缺點(diǎn)。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(shù)+一期縫合術(shù)的 83 例膽囊結(jié)石并繼發(fā)性膽總管結(jié)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(shù)+一期縫合術(shù)（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(shù)+經(jīng)腹置入鼻膽管引流術(shù)+一期縫合術(shù)（三鏡組）。結(jié)果兩鏡組和三鏡組的性別、年齡及術(shù)前膽總管直徑、術(shù)前基礎(chǔ)疾病等比較差異無統(tǒng)計(jì)學(xué)意義（P>0.05）。83 例患者的手術(shù)均成功且術(shù)后恢復(fù)情況良好，2 組患者的手術(shù)成功率、結(jié)石清除率、術(shù)后 1 d 腹腔引流量、拔除引流管時(shí)間和住院時(shí)間比較差異均無統(tǒng)計(jì)學(xué)意義（P>0.05），三鏡組的手術(shù)時(shí)間、術(shù)中出血量和術(shù)后輕型胰腺炎發(fā)生率明顯高于兩鏡組（P<0.05），但術(shù)后肝功能恢復(fù)情況優(yōu)于兩鏡組（P<0.05）。結(jié)論對于膽囊結(jié)石合并繼發(fā)性膽總管結(jié)石患者，在嚴(yán)格掌握手術(shù)適應(yīng)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(shù)均安全、可行，但在具體選擇兩鏡還是三鏡聯(lián)合應(yīng)根據(jù)患者術(shù)前一般情況和術(shù)中探查情況來決定。