Value of multidisciplinary team (MDT) in minimally invasive treatment of complex intrahepatic bile duct stones

Zhang, Zhihong; Li, Yanyang; Li, Kejia; Zhai, Guang; Dang, Xueyuan; Zhong, Chao; Shi, Zhitian; Zou, Renchao; Wei, Lin; Wei, Dong; Tang, Bo; Ge, Jiayun

doi:10.5582/bst.2021.01169

Cited by 9 publications

(2 citation statements)

References 21 publications

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“…A multidisciplinary team (MDT) discussion of a benign tumor is recommended for all patients requiring surgery. Previous studies have also emphasized the importance of MDT in the treatment of both benign and malignant diseases (57)(58)(59). Follow-up is necessary for all patients, typically with imaging every 6 months.…”

Section: Surgical Indicationsmentioning

confidence: 99%

Surgical indications for solid hepatic benign tumors: An updated literature review

Zhang,

Ji,

Qiu

et al. 2023

BST

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Hepatic hemangioma, focal nodular hyperplasia, and hepatic adenoma are the most common benign solid liver tumors. However, their surgical indications have been the subject of debate. Minimally invasive liver resection reduces the cost of surgery and may lead to overtreatment of benign liver tumors. Recently, there has been a growing understanding of the etiology, pathogenesis, and natural history of these tumors. Great progress has also been made in imaging. The use of MRI and contrast agents has improved the accuracy of non-invasive diagnosis of these tumors, and especially in the identification of specific molecular subtypes of liver adenoma. These factors have resulted in alterations of surgical indications for these tumors. This article examines recent literature and it discusses the surgical indications for hepatic hemangioma, focal nodular hyperplasia, and hepatic adenoma while summarizing modifications in clinical management.

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Section: Surgical Indicationsmentioning

confidence: 99%

Surgical indications for solid hepatic benign tumors: An updated literature review

Zhang,

Ji,

Qiu

et al. 2023

BST

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“…的普及，继发性胆总管结石的手术方式得到了丰富的发展，基于多学科团队使胆道结石患者获得个体化、微创化的治疗逐渐成为了医生的目标之一 (2) 。免T管留置的胆道探查是近年来胆道结石外科治疗的发展方向，基于内镜技术，可以选择放置支架内引流，或者鼻胆管外引流。我们之前的研究指出，在胆道探查术中增加内镜下鼻胆管引流术(ENBD)能够降低腹腔镜下胆总管切开取石(LCBDE)术后胆漏风险 (1) 。胆总管一期缝合(PC)后增加引流能够降低胆道压力，从而减低胆漏风险。目前何种胆道结石需要引流尚不明确，一般以术中胆道情况判断，如胆总管明显扩张，胆管壁薄等 (3) 。通常胆总管直径≥8mm被认为是胆总管扩张，在这些患者中一期缝合胆总管也被认为是安全的 (4) (4,5) (14)(15)(16)(17)(18) 。在笔者所在中心，为了避免胆漏和胆道狭窄，胆总管一期缝合通常倾向于在胆管更粗的患者中进行，而且通常均放置鼻胆管引流。然而，普遍性的使用内镜下鼻胆管需要警惕内镜相关并发症，毕竟使用ENBD的初衷就是为了减少并发症，使一期缝合更安全。本研究ENBD组中20例采用顺行-逆行结合插管的ENBD，结果4例(10%)出现术后胰腺炎。我们之前的研究也指出，完全顺行插管的ENBD可以明显减少PEP风险 (1,19) 。我们建议不管采用ENBD还是放置支架，均使用完全顺行插管的方法，更符合胆道解剖学，仅需通过一次十二指肠乳头，对十二指肠乳头损伤最小。 ENBD组由于需要额外的内镜操作，明显延长了手术时间，但这并未带来另外的风险 (20) 。虽然ENBD组手术时间明显延长，但是完全避免了术后胆漏，无引流组则有2 例发生术后胆漏，其中1例术后再次接受腹腔镜手术和T 管引流。由于胆道探查术后单纯一期缝合无任何胆道引流手段，术后胆漏是最令人担忧的并发症之一 (21)(22)(23)(24) 。胆道引流可减轻胆总管压力，促进缝合部位愈合，T管引流有许多负担，而鼻胆管有护理简单、引流确切和置管时间短等优势 (12,25) 。通常术后3-7天拔除鼻胆管，而且拔除前无需常规进行鼻胆管造影，除非患者存在临床症状。需要指出，胃和十二指肠的生理条件一定程度上限制了内镜操作，特别是十二指肠憩室的存在，导致许多内镜手术的失败，笔者团队也出现过十二指肠憩室难以完成 ENBD的情况。本研究中ENBD组1例(2.5%)、无引流组2例(5%)存在十二指肠憩室，但未影响手术。既往病史和术前影像学检查应该得到更加充分的重视，ENBD失败时T管引流术可作为替代手术 (13,26) 。在总体并发症上，两组对比无统计学差异。LCBDE 术中进行ENBD难以被接受的一个原因是其需要额外的费用，包括鼻胆管、斑马导丝等，但本研究中两组住院费用比较并无统计学差异。而且完全顺行插管的ENBD并不需要斑马导丝，仅需要输尿管导管和鼻胆管，降低了成本。这一手术方式的另一推广难点是内镜技术的壁垒，但是完全顺行插管的ENBD所需要的内镜操作难度低，仅需要术者经口放入十二指肠镜或胃镜，到达十二指肠降段，找到输尿管导管并夹持拉出即可，在具备设备的基层医院也可完成，同时缩短这一手术的学习曲线。胆总管结石的治疗选择多种多样，免T管留置的胆道探查也进入了是否需要引流的探讨中 (27) 。最近，一些研究指出不仅鼻胆管引流可减少胆道探查和一期缝合术后并发症，放置胆道支架也可有相似的效果，而且之前支架需要在术后一周进行另一次胃镜拔除，这一缺点现在也被自脱落支架避免 (28)(29)(30)…”

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The New Perspectives Journal of Medicine

2024

N Perspect J Med

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昆明医科大学第二附属医院，昆明市 650101； 2. 云南省中医药大学第三附属医院，昆明市 650599 摘要: 目的：评估腹腔镜下胆囊切除术(LC)和腹腔镜胆总管探查术(LCBDE)联合胆总管一期闭合(PC)以及内镜下鼻胆管引流(ENBD)治疗胆总管大于8mm的胆囊结石合并胆总管结石的安全性和有效性。方法：回顾性分析昆明医科大学第二附属医院肝胆胰外科2018年1月至2022年1月连续治疗的168例胆囊结石合并胆总管结石患者。患者被分为两组， ENBD组患者(n=96)接受LC+LCBDE+PC+ENBD，无引流组患者(n=72)接受LC+LCBDE+PC。使用倾向性评分匹配 (1:1匹配)后，两组患者各纳入40例。分析患者特征、围术期指标、术后并发症等指标。结果：患者基线特征具备可比性。ENBD组患者的手术时间明显延长[206.55±66.51分钟 vs. 132.38±33.44分钟, (P<0.001)]。ENBD组和无引流组术后总体并发症发生率分别为5/40 (12.5%)和4/40(10%)，肺部感染、胆道感染、胆漏、术后胰腺炎等各项并发症比较差异均无统计学意义。两组结石清除率均为100%。结论：在胆总管≥8mm的继发性胆总管结石患者中，采用单纯一期缝合是安全、可行的，增加ENBD明显延长了手术时间，而且没有显示出降低并发症风险的优势。关键词: 胆囊结石，胆总管结石，胆总管切开取石术，内镜下鼻胆管引流术 A comparative study of primary suture and endoscopic nasobiliary drainage for secondary bile duct stones with a diameter ≥ 8 mm

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Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis

Shao

et al. 2022

Surg Endosc

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Background The need for intraoperative endoscopic nasobiliary drainage during laparoscopic cholecystectomy and laparoscopic common bile duct exploration with primary closure is controversial in the treatment of cholecystolithiasis combined with choledocholithiasis. The aim of this study was to evaluate the safety and efficacy of laparoscopic cholecystectomy + laparoscopic common bile duct exploration + intraoperative endoscopic nasobiliary drainage + primary closure (LC + LCBDE + IO-ENBD + PC). The safety of different intubation methods in IO-ENBD was also evaluated. Method From January 2018 to January 2022, 168 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent surgical treatment in our institution. Patients were divided into two groups: group A (n = 96) underwent LC + LCBDE + IO-ENBD + PC and group B (n = 72) underwent LC + LCBDE + PC. Patient characteristics, perioperative indicators, complications, stone residual, and recurrence rates were analyzed. Group A was divided into two subgroups. In group A1, the nasobiliary drainage tube was placed in an anterograde way, and in group A2, nasobiliary drainage tube was placed in an anterograde–retrograde way. Perioperative indicators and complications were analyzed between subgroups. Results No mortality in the two groups. The operation success rates in groups A and B were 97.9% (94/96) and 100% (72/72), respectively. In group A, two patients were converted to T-tube drainage. The stone clearance rates of group A and group B were 100% (96/96) and 98.6% (71/72), respectively. Common bile duct diameter was smaller in group A [10 vs. 12 mm, P < 0.001] in baseline data. In perioperative indicators, group A had a longer operation time [165 vs.135 min, P < 0.001], but group A had a shorter hospitalization time [10 vs.13 days, P = 0.002]. The overall complications were 7.3% (7/96) in group A and 12.5% (9/72) in group B. Postoperative bile leakage was less in group A [0% (0/96) vs. 5.6% (4/72), P = 0.032)]. There were no residual and recurrent stones in group A. And there were one residual stone and one recurrent stone in group B (all 1.4%). The median follow-up time was 12 months in group A and 6 months in group B. During the follow-up period, 2 (2.8%) patients in group B had a mild biliary stricture. At subgroup analysis, group A1 had shorter operation time [150 vs. 182.5 min, P < 0.001], shorter hospitalization time [9 vs. 10 days, P = 0.002], and fewer patients with postoperative elevated pancreatic enzymes [32.6% (15/46) vs. 68% (34/50), P = 0.001]. Conclusion LC + LCBDE + IO-ENBD + PC is safer and more effective than LC + LCBDE + PC because it reduces hospitalization time and avoids postoperative bile leakage. In the IO-ENBD procedure, the antegrade placement of the nasobiliary drainage tube is more feasible and effective because it reduces the operation time and hospitalization time, and also reduces injury to the duodenal papilla.

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Value of multidisciplinary team (MDT) in minimally invasive treatment of complex intrahepatic bile duct stones

Cited by 9 publications

References 21 publications

Surgical indications for solid hepatic benign tumors: An updated literature review

Surgical indications for solid hepatic benign tumors: An updated literature review

The New Perspectives Journal of Medicine

Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis

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