经皮经肝胆胆镜截石术的两步法
Summary
这种“两步法”显著提高了经皮经肝胆总管镜检查的成功率，使肝内和肝外胆总管结石的预后更好。
Abstract
肝内和肝外胆总管结石是胆道外科领域的一个挑战。我们介绍了使用两步经皮经肝胆总管镜截石术（PTCSL）手术治疗具有挑战性的胆结石的经验。我们回顾性评价了2013年1月至2020年1月使用这种两步PTCSL治疗的81例肝内和肝外胆总管结石患者，包括40名男性和41名女性，平均年龄为66岁。与传统的经皮经肝胆管镜检查（PTCS）相比，直接通过16F Amplatz鞘建立通道，并借助肾镜去除通道中的结石。分析所有患者的临床疗效及并发症。81例患者（81/81，100%）胆结石成功切除;62/81患者（76.5%）在首次手术后完全切除了胆结石;17/81患者（21%）接受了第二次手术;2/81患者（2.5%）需要第三次手术才能完全去除结石。手术期间严重出血发生率为0%，无死亡病例。使用两步PTCSL方法安全有效，有助于改善肝内和肝外胆总管结石的预后。
Introduction
肝内和肝外胆总管结石是外科医生面临的一个复杂的医学问题，在东亚国家非常普遍1。目前，大多数胆总管结石需要手术干预，而胆管结石的主要治疗方法包括开放手术、经皮经肝胆总管镜截石术（PTCSL）、腹腔镜截石术2、经皮内镜胆道探查术3，4和内镜逆行胰胆管造影术。然而，胆肠吻合术或Billroth II重建的患者，解剖结构异常，例如十二指肠壶腹周围憩室，这使得胆管难以通过内窥镜方法进入5，6，7，8，或者以前做过复杂的腹部手术，包括部分胃切除术，不能接受内窥镜治疗或腹腔镜截石术。内镜治疗也可能不适用于大结石和嵌塞结石的肝结石。因此，一般来说，PTCSL可能是更好的选择9。
传统的PTCS方法遵循这样的程序，逐渐扩张鼻窦并进行经皮经肝胆道引流10，11，这需要相对较长的住院周期，通常在2-3周之间，导致胆瘘，胆道感染，出血和腹膜炎的可能性，并具有多种扩张的鞘大小。该程序由两部分组成。第一步，刺穿目标胆管，在观察胆汁流出的同时插入导丝。然后，使用扩张器沿导丝缓慢扩展通道。通道建立成功后，拔出扩张器，将引流管放入目标胆管，然后拉出导丝。
如果胆汁引流畅通且引流固定且无血液流出，则经皮肝穿刺引流 （PTCD） 完成。PTCD 后 1 周窦道变得稳定，然后可以扩张。将导丝放入引流管中，并用10F扩张器沿导丝通过窦道膨胀，最后放入10F引流管中。手术后窦道每周扩张一次，每次增加2F尺寸，以便在PTCD后4周将窦道扩张到16F。在第二步中，将窦道扩张到16F后，使用胆道纤维镜片进行去除结石的手术。因此，上述传统的PTCSL需要一个治疗周期，并给患者带来很高的经济压力。而且，取石效率低，复方多次手术去除结石也是传统PTCS不可避免的缺点，限制了该技术的使用。
从2013年1月开始，我们开始将PTCS应用于我院复杂肝内和肝外胆总管结石患者的微创治疗，但修改了传统PTCS的一些关键步骤。第一步，在PTCD后1周进行手术，正好在窦道稳定时，使用16F扩张器将鼻窦直接扩张到16F，大大减少了术前准备时间。第二步，与传统技术不同，使用沃尔夫肾镜代替传统的胆总管镜进行手术，我们称之为“两步PTCSL法”。为了确定PTCSL手术是否安全、微创和高效，本研究回顾性回顾了2013年1月至2020年1月接受两步PTCSL方法治疗的81例肝内和肝外胆总管结石患者。
Protocol
Representative Results
Discussion
肝内和肝外胆总管结石会导致胆道梗阻，相关的胆管炎可导致革兰阴性内毒素血症，伴有脓毒性休克或多器官功能障碍的临床表现。因此，胆结石代表了一种复杂的疾病，对外科医生来说可能具有挑战性，特别是对于以前做过复杂腹部手术的患者或解剖结构异常的患者。PTCSL在世界各地被广泛使用，但仍需要创新的，侵入性较小的程序来根除结石并恢复畅通无阻的胆道引流14。</p…
Declarações
The authors have nothing to disclose.
Acknowledgements
没有。
Materials
| 0.9% Normal saline solution | – | ||
| 16-F series fascia dilator | type PLVW, Cook Medical | ||
| adjustable pressure pump | type APL; Guangzhou Jielun Medical Equipment Co. , Ltd, Guangdong Province, China | ||
| biliary balloon dilator | ATB advance; Cook Medical | ||
| blade | – | ||
| camera system | 1088i HD Camera Control Unit, PAL 220 V; Stryker Corporation | ||
| Cavity mirror protective sleeve | – | ||
| clamp | 5Fr, Richard Wolf GmbH, Germany | ||
| color ultrasound machine | DC-N2S, Mindray | ||
| Cook net basket | NGE-017115-MB, COOK Medical Inc. , Bloomington, USA | ||
| drainage pack | – | ||
| expander | – | ||
| guide wire | – | ||
| hydroelectric lithotripter | Aymed Medical,  stanbul, Turkey |
||
| Iodophor | – | ||
| Kidney basin | – | ||
| light source | Voice-control compatible X8000 Xenon Light Source of 300 W;Stryker Corporation, MI | ||
| Medical syringe | – | ||
| puncture needle | – | ||
| suction apparatus | – | ||
| surgical gauze | – | ||
| trocar | – | ||
| Wolf nephroscope | 12-degree Ultra-Wide-Angle Ureteroreno-scope; Richard Wolf GmbH, Germany | ||
| zebra guide wire | type HAW; Cook Medical, Bloomington, IN |
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