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经皮经肝胆道镜碎石取石术治疗胆肠吻合术后肝胆管结石病

目的探讨经皮经肝胆道镜碎石取石术（PTCSL）必要时联合球囊扩张治疗胆肠吻合术后肝胆管结石病的可行性及安全性。方法重庆医科大学附属第二医院 2015 年 12 月至 2020 年 12 月期间共有 54 例胆肠吻合术后肝胆管结石病患者接受 PTCSL 必要时联合球囊扩张治疗（符合纳入标准）。回顾性收集患者的一般资料、手术情况、术后情况以及术后随访资料。结果54 例患者中有 52 例（96.3%）行 PTCSL 治疗成功，2 例因为胆肠吻合口完全闭塞而失败。术中出血量的中位数为 55 mL（15～520 mL）；取净结石 48 例（88.9%），结石残留 6 例（11.1%）。术后并发症发生率为 27.8%（15/54），无围手术期死亡患者。取净结石的 48 例患者获随访，中位随访时间 33 个月（2～60 个月），有 10 例结石复发，复发率为 20.8%（10/48）。结论PTCSL 必要时联合球囊扩张治疗胆肠吻合术后肝胆管结石病具有良好的安全性和可行性，但是术后需要注意预防结石复发。

Clinical Exploration of Shockwave Lithotripsy under Laparoscope Combined with Choledochoscope for the Treatment of Hepatobiliary Calculi

目的　探讨腹腔镜下胆道镜联合微爆破碎石术仪治疗肝胆管结石的安全性及治疗效果。 方法　回顾分析2008年7月－2012年6月183例胆道结石患者，行腹腔镜下胆道镜联合微爆破碎石仪治疗或单纯经内镜Oddi括约肌切开取石治疗的临床资料。87例患者在术中均应用微爆破碎石仪碎石（微爆破组），96例患者行单纯经内镜Oddi括约肌切开术或经内镜乳头切开术碎石（对照组）。 结果　微爆破组碎石成功率100%，结石取净率85.06%（74/87），微爆破组的碎石时间、平均住院时间、平均住院总费用、并发症发生率均明显低于对照组（P＜0.05）。 结论　腹腔镜下胆道镜联合微爆破碎石术在治疗肝胆管结石病方面，具有微创、安全、经济有效的优点，能降低结石残留率及取石次数，值得临床推广。

Treatment of Renal Pelvic Calculi by Transurethral Ureteroscopic Pneumatic Lithotripsy

目的:探讨经尿道输尿管镜腔内气压弹道碎石治疗肾盂结石的疗效。方法:回顾分析7例肾盂结石经尿道输尿管镜腔内气压弹道碎石术式治疗的临床资料。结果:5例术后复查出现大小不等上尿路残余结石,分别予经皮肾镜碎石,经尿道输尿管镜碎石,体外振波碎石治疗后复查无残余结石。结论:肾盂结石经尿道输尿管镜腔内气压弹道碎石治疗需要根据结石的大小、形态及位置严格掌握适应症。

Value of percutaneous transhepatic choledochoscopic lithotripsy in treatment of recurrent type Ⅱa hepatolithiasis

ObjectiveTo investigate the feasibility and safety of percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) in the treatment of recurrent type Ⅱa hepatolithiasis.MethodsAll of 293 patients with recurrent type Ⅱa hepatolithiasis admitted to the Second Affiliated Hospital of Chongqing Medical University from December 2010 to December 2017 were collected retrospectively, 82 of whom were treated with the PTCSL (PTCSL group), 211 of whom were treated with traditional open surgery (open group). The patients were matched according to the ratio of 1∶1 by using the method of propensity score matching, then the patients were compared after matching.ResultsA total of 59 pairs were successfully matched, that was, there were 59 patients in the PTCSL group and open group, respectively. Compared with the open group, the PTCSL group had the similar conditions such as the gender, age, preoperative Child-Pugh classification, and times of previous biliary operations, etc. (P>0.050). There was no perioperative death in both groups. There were no significant differences between the two groups in the success rate, operation time, times of operations, time of T tube removal after operation, stone residual rate, and stone recurrence rate (P>0.050). Although the hospital costs of the PTCSL group was higher than that of the open group (P<0.050), the PTCSL group had various advantages, such as less intraoperative bleeding, smaller incisional scar, shorter hospital stay and postoperative ventilation time, and lower rate of total postoperative complications (P<0.050).ConclusionsAfter learning curve, PTCSL has many advantages over traditional open surgery in treatment of recurrent type Ⅱa hepatolithiasis. PTCSL is a minimally invasive surgery, which is safe and effective.

Analysis on Fiber Cholangioscopy and Micro-Blasting Lithotripsy for 58 Patients with Refractory Biliary Passage Lithiasis

目的　探讨纤维胆道镜下微爆破碎石治疗肝内外胆管难取性结石的疗效和安全性。方法　对笔者所在医院2007年4月至2011年12月期间收治的58例肝内外胆管难取性结石患者，行纤维胆道镜下体内微爆破碎石治疗，对其治疗效果进行回顾性分析。结果　58例肝内外胆管难取性结石患者的碎石成功率为100%（58/58）。27例胆总管结石患者的取石成功率为100%（27/27），31例肝内胆管结石患者的取石成功率为93.5%（29/31）。术后均无窦道穿孔、胆道大出血及胆瘘发生，术后出现胆管黏膜渗血6例，出现畏寒、发热3例，出现一过性腹泻2例。42例患者获访，随访时间3～38个月，平均21个月。2例患者分别于术后6个月和9个月出现胆管炎，行B超及磁共振胰胆管成像（MRCP）检查，均未发现肝内外胆管结石及胆管狭窄；1例患者于术后3年行B超检查，发现胆总管下端有1枚直径为0.5cm的结石；其余患者均无腹痛、发热、黄疸等症状，均未发生结石复发及胆管狭窄。结论　纤维胆道镜下微爆破碎石可有效治疗术中及术后胆管难取性结石，安全性好。

微通道经皮肾镜激光碎石术后全身炎症反应综合征致弥散性血管内凝血一例

Ureteroscope Pneumatic Lithotripsy for Calculi in Distal Common Bile Duct (Report of 19 Cases)

目的　探讨输尿管镜气压弹道碎石治疗胆总管下段嵌顿性结石的方法及疗效。方法　传统方法取石失败病例改用输尿管镜置入胆总管直视见到胆总管下段嵌顿性结石，气压弹道碎石，盐水冲洗出或钳夹出结石，并探查下段是否通畅。结果　清除结石时间5~10 min，成功率100%（19/19），术后2~4周拔T管，无切口感染、无胆道感染、无残留结石。结论　输尿管镜气压弹道碎石治疗胆总管下段嵌顿性结石，高效、安全，值得临床推广应用。

微通道经皮肾输尿管镜联合气压弹道碎石术在基层医院的应用分析

目的探讨微通道经皮肾输尿管镜联合气压弹道碎石取石术（mini-PCNL）在基层医院的应用疗效和安全性。 方法对2010年3月－2013年3月收治的108例上尿路结石患者采用mini-PCNL予以治疗，并就手术方式、手术时间、结石清除率等情况进行分析表述。 结果107例患者成功在B型超声引导下建立经皮肾穿刺通道，1例肾下盏结石因肾脏大出血改开放手术行肾部分切除术，3例患者术中建立通道后出血较多安置肾造瘘管后行二期手术。手术时间为20～190 min，平均（78.0±40.1）min，结石总清除率78.5%，其中输尿管上段结石单次清除率100.0%、肾结石单次清除率70.1%。术中平均出血量（105.0±45.6）mL，无胸膜、腹腔脏器、结肠损伤；平均住院7～14 d。 结论mini-PCNL治疗上尿路结石具有较高的结石清除率、良好的安全性，同时具有术后恢复快、费用适中等优点，值得在基层医院推广应用。

The Value of Ureteral Stent Placement before Extracorporeal Shock Wave Lithotripsy: A Meta-analysis

Objective　To evaluate the value of Ureteral Stent Placement before Extracorporeal Shock Wave Lithotripsy (ESWL). Methods　We searched the Cochrane Central Register of Controlled Trials (Issue 4, 2010), MEDLINE (OVID 1950 to April 2010), EMbase (1979 to April 2010), CBM (1978 to April 2010), CNKI (1979 to April 2010), and VIP (1989 to April 2010), and manually searched journals as well. All the randomized controlled trials (RCTs) of treating ureteral stone with ESWL after stent placement were included. We evaluated the risk of the bias of the included RCTs according to the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1. The Cochrane Collaboration’s software RevMan 5.0 was used for meta-analysis. Results　Three RCTs with C-level evidence involving 319 ureteral stone patients were identified. The results of meta-analyses showed that: a) Effect of treatment: The ureteral stent placement before ESWL did not take better effects in aspects of the complete clearance rate (WMD= 1.10, 95%CI 0.87 to 1.38), the quantity of lithotripsy (WMD= 0.43, 95%CI – 1.05 to 0.19), the frequency of shock wave (WMD= 0.00, 95%CI – 0.25 to 0.25), and the power of shock wave (WMD= 0.20, 95%CI – 0.05 to 0.46); and b) Postoperative complications: The ureteral stent placement were prone to cause dysuria (RR= 2.30, 95%CI 1.62 to 3.26), microscopic hematuria (RR= 2.66, 95%CI 1.97 to 3.58), gross hematuria (RR= 6.50, 95%CI 1.50 to 28.15), pyuria (RR= 1.78, 95%CI 1.44 to 2.21), positive urine culture (RR= 2.13, 95%CI 1.71 to 2.64), and suprapubic pain (RR= 3.10, 95%CI 1.59 to 6.04). Conclusions　Ureteral stent placement before ESWL is inadvisable. Multi-factors which lead to bias affected the authenticity of our review, such as low-quality and small amount of RCTs. Further large-scale trials are required.

小儿体外冲击波碎石的护理

目的　总结小儿体外冲击波碎石围手术期护理方法。 方法　2009年3月－2011年6月对56例行体外冲击波碎石的泌尿结石患儿，术前完善各项筛查、抗感染工作，术后严密监测生命体征，予促石排泄指导，对相关并发症及时处置，并做好出院指导等护理工作。 结果　56例患儿均顺利完成体外冲击波碎石手术。其中1例排石效果不理想于次日行手术切开取石，1例术后14 d复查结石仍未排净行第2次排石术，其余54例患儿均一次性碎石成功。术后3个月门诊随访，56例均无结石形成。 结论　术前完善的检查及抗感染处置，术后排石的观察与指导，及并发症的预防护理是结石患儿体外碎石治愈成功的关键。