Step by Step Catheter Papillary Dilatation and Realignment of Three Endoscopes at the Same Time by Abdominal Consequent Propulsive Guidance Technology: A Report of 205 Cases

Abstract

目的：探讨在同期三镜下，经胆总管至十二指肠顺行推进法逐级导管乳头扩张会师术(LPSCD)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2008年7月至2019年4月期间，符合入选标准的205例患者的临床资料。结果：本组205例行腹腔镜胆囊切除术、胆总管探查胆管镜取石术，必要时行冲击波或液电碎石术。十二指肠镜窥视、逐级导管扩张乳头行鼻胆管引流50.2% (103/205)，行T管双导管引流19.0% (39/205)；十二指肠镜乳头微切开、逐级导管扩张乳头行鼻胆管引流5.9% (12/205)，行T管双导管引流0.5% (1/205)；十二指肠镜乳头小切开、逐级导管扩张乳头行鼻胆管引流8.8% (18/205)，行T管双导管引流2.4% (5/205)；十二指肠镜乳头中切开、逐级导管扩张乳头行鼻胆管引流3.4% (7/205)，行T管双导管引流3.4% (7/205)；因胆总管残石放弃鼻胆管引流和T管双导管引流各1例，于腹腔镜下留置T形管1.0% (2/205)；因胆总管末端狭窄未解除放弃鼻胆管引流4例和T管双导管引流3例，于腹腔镜下留置T形管3.4% (7/205)；因腹腔镜下取石失败放弃鼻胆管引流3例和T管双导管引流1例，中转为开腹胆总管探查取石T管引流术2.0% (4/205)。鼻胆管引流术后残石1例(0.5%)，胆汁漏8例(3.9%)，轻型胰腺炎2例(1.0%)；T管双导管引流术后胆汁漏1例(0.5%)，轻症胰腺炎2例(1.0%)，经T管瘘道拔除T管双导管无失败病例。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。术后总并发症发生率为6.8% (14/205)。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，在同期三镜下，采用LPSCD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；此方法可以尽量保护十二指肠乳头的解剖完整性或生理功能。 Objective: To explore the experiment of clinical application of laparoscopic duodenal papilla step by step dilatable catheter dilatation and realignment of three endoscopes at the same time through common bile duct to duodenal lumen of transabdominal consequent propulsive guidance technology (LPSCD) for the treatment of the gall bladder stones, common bile duct stones, and combination of duodenal papilla obstruction or stenosis during the course of laparoscopic common bile duct exploration (LCBDE). Methods: The clinical data of 205 patients who met the inclusion criteria of extrahepatic bile duct stones with obstruction and stenosis of papillary undergoing LPSCD were retrospectively analyzed from July 2008 to April 2019 in the Second Hospital of Chengdu City. Results: In this group, 205 patients underwent laparoscopic cholecystectomy and choledocholithotomy for common bile duct exploration, and shock wave or electrohydraulic lith-otripsy was performed when necessary. Take a peek at the duodenoscopy, stepwise catheter dila-tion of the duodenal papilla, nasobiliary drainage 50.2% (103/205), and T tube + double biliary catheter drainage 19.0% (39/205); duodenoscopic papillotomy of micro dissection, stepwise ductal expansion of the papilla, nasobiliary drainage 5.9% (12/205), and T tube + double biliary catheter drainage 0.5% (1/205); duodenoscopic papillotomy of small incision, stepwise ductal dilatation of the papilla, nasobiliary drainage 8.8% (18/205), and T tube + double biliary catheter drainage 2.4% (5/205); duodenoscopic papillotomy of median incision, stepwise ductal dilatation of the papilla, nasobiliary drainage 3.4% (7/205), and T tube + double biliary catheter drainage 3.4% (7/205); one case was given up for nasobiliary drainage and one case for double-catheter T tube drainage due to common bile duct residual stone, and the t-tube was placed under laparoscope 1.0% (2/205); four cases of nasobiliary drainage and three cases of double t-tube drainage were abandoned due to terminal bile duct stenosis; the t-tube was indurated under laparoscope with 3.4% (7/205); due to the failure of laparoscopic lithotomy, three cases of nasobiliary drainage and one case of T tube double catheter drainage were abandoned, and all of them were converted to laparotomy for common bile duct exploration and lithotomy with T tube drainage of 2.0% (4/205). It is found the residual stone after nasobiliary drainage in one case (0.5%), bile leakage in eight cases (3.9%), and slight pancreatitis in two cases (1.0%). It is found the bile leakage after T tube + double biliary catheter drainage in one case (0.5%), and slight pancreatitis in two cases (1.0%). There were no failed cases through the T tube fistula pull T tube + double biliary catheter drainage. None of the cases had a perforation of intestine and bile duct, bleeding, severe pancreatitis, perioperative reoperation or death. The total postoperative complication rate was 6.8% (14/205). Conclusion: Based on the limited number of cases in our hospital the preliminary research result is, if suitable patients are selected, LPSCD of three endoscopes at the same time for treatment of gall bladder stones, common bile duct stones, and combination of duodenal papilla obstruction or stenosis is feasible, effective and safe. This method can protect the anatomical integrity or physiological function of duodenal papilla as much as possible.