Operative choledochoscopic laser lithotripsy for impacted intrahepatic gallstones: a novel surgical approach.
Operative choledochoscopic laser lithotripsy for impacted intrahepatic gallstones: a novel surgical approach.
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手术胆道镜激光碎石术治疗受影响的肝内胆结石：一种新颖的手术方法。
DOI：
10.1007/s00464-008-9953-5
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发表时间：
2009
期刊：
影响因子：
--
通讯作者：
Geller,DavidA
中科院分区：
文献类型：
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作者：
Bark,Kenneth;Gamblin,TClark;Zuckerman,Randall;Geller,DavidA
简介偶尔，患有肝管结石或受影响的胆总管结石的患者无法或不适合内镜逆行胰胆管造影（ERCP）取出。更麻烦的是之前接受过手术导致解剖结构改变的患者，这使得传统的内窥镜取出导管结石变得非常困难。我们提出了一种结合手术、胆道内窥镜检查和激光碎石术来治疗这些导管结石的新方法。方法我们报告了 5 名患有导管结石的患者，这些患者要么 ERCP 失败，要么不适合 ERCP 取出。数据是通过机构审查委员会批准的图表审查收集的。结果患者的平均年龄为 70.1 岁。所有患者均出现肝胆管结石和胆管炎症状，包括肝功能检查升高以及反复发烧和寒战。患者平均有 2.8 次 ERCP 或经皮结石清除尝试失败（范围 2-4）。所有患者均结合手术、术中胆道内窥镜检查和激光碎石术（钬激光）进行治疗。在四名患者中，通过胆总管切开术或肝总管切开术引入碎石器。一名患者此前曾接受过 Roux-en-Y 肝空肠吻合术，发现狭窄吻合口上方有一颗大肝管结石。通过对 Roux 肢体进行肠切开术获得通路。所有患者均获得完全结石清除。平均手术时间为 349 分钟。所有患者的肝功能检查均正常（随访 27-36 个月）。 结论 过去，激光碎石术被描述为 ERCP 的辅助手段，用于治疗球囊或篮取回难治的结石。外科肠切开术、胆道内窥镜检查和激光碎石术的结合为治疗不适合接受 ERCP 或失败的肝内大结石患者提供了一种新方法。
IntroductionOccasionally patients present with hepatic duct stones or impacted common bile duct stones that either fail or are not amenable to endoscopic retrograde cholangiopancreatography (ERCP) extraction. More troublesome are patients with prior surgeries resulting in altered anatomy that makes traditional endoscopic extraction of ductal stones very difficult. We present a novel approach to these ductal stones using a combination of surgery, biliary endoscopy, and laser lithotripsy.MethodsWe report on five patients with ductal stones that either failed ERCP or were not candidates for ERCP extraction. Data was collected via chart review with Institutional Review Board approval.ResultsThe average age of patients was 70.1 years. All patients presented with hepaticolithiasis and symptoms of cholangitis including elevated liver function tests and recurrent fever and chills. Patients had a mean of 2.8 failed ERCP or percutaneous attempts at stone clearance (range 2–4). A combination of surgery and intraoperative biliary endoscopy with laser lithotripsy (holmium laser) was used in all patients. In four patients the lithotripter was introduced via a choledochotomy or hepaticodochotomy. One patient had previously undergone a Roux-en-Y hepaticojejunostomy and was found to have a large hepatic duct stone sitting above a strictured anastomosis. Access was gained via an enterotomy in the Roux limb. Complete stone clearance was obtained in all patients. Average operative time was 349 min. All patients have normal liver function tests (27–36 month follow-up).ConclusionLaser lithotripsy has been described as an adjunct to ERCP in the past for stones refractory to balloon or basket retrieval. The combination of a surgical enterotomy, biliary endoscopy, and laser lithotripsy provides a novel approach to treat patients with large intrahepatic stones who are not candidates for or have failed ERCP.