【正文】 ically guided wire baskets or balloons ? Two randomised trials have shown 60%70% of patients are able to have their calculi cleared via the cystic duct (Cuscherieri et al, Surg Endoscopy 1999 amp。 No history of stone migration。 Anomalies in liver tests (more than twice the normal level )。 5h MAST87h 同上 70%90%可輕度升高 同上 ALP 肝＞骨小腸胎盤(pán)腎 510倍 肝細(xì)胞內(nèi)與脂膜結(jié)合、近匯管區(qū) 3d 反映膽道梗阻的酶 幾乎 100％升高 膽汁反流誘導(dǎo)肝細(xì)胞大量合成；膽汁酸解離；膽道排泄受阻 GGT 腎＞胰肺肝；血清中主要來(lái)自肝膽 ? 肝細(xì)胞膽管側(cè) , 小膽管頂膜 。 Common Bile Duct Stones Management Options 解放軍 324醫(yī)院肝膽外科 張豐深 Gallstones ? Incidence 12% men and 24% women (from autopsy study in UK) ? 1030% of gallstones will bee symptomatic (12% per year) ? Incidence of CBD stones found before or during cholecystectomy 12% Composition Cholesterol (7080%) ? Unmonly pure cholesterol stones (10%) ? Most have calcium salts in their centre (90%) and 10% of these have enough calcium to be radioopaque Pigment (2030%) ? BLACKsecondary stones associated with haemolysis or cirrhosis ? BROWNprimary stones associated with bile stasis or infection Shojaiefard A, et al. Various techniques for the surgical treatment of mon bile duct stones: a Meta review. Gastroenterology Research and Practice, 2022。 另有胞漿內(nèi)游離部分 710d 同上，無(wú)黃疸不全梗阻也可顯著升高 100％升高，比 ALP更敏感 小膽管細(xì)胞合成更加 。 Dilatation of the mon biliary duct (10mm) 50 49 50 Group 2 (intermediate probability) History of stone migration (antecedents of cholangitis or biliary pancreatitis)。 Narrow mon biliary duct(≤7mm on US) 2 2 2 Initial classification of suspected choledocholithiasis according to Cotton criteria as determined by ERCP and MRCP (Calvo et al, Mayo Clin Proc, 2022) Risk Stratification Factor Criteria Score Age ＜ 55years 0 ≥ 55years 1 Sex F 0 M 1 Jaundice Absent 0 Resolved 1 Current 2 Ascending cholangitis Absent 0 Present 3 Transaminases Normal 0 ＞ normal, but＜ double 2 Greater than double 4 CBD diameter (US) Normal 0 Dilated 3 CBD stone (US) Absent 0 Present 3 Predictive scores for each multivariate factor used to produce the scoring system (Menezes et al, BJS, 2022) Risk stratification High risk ifCBD 6mm 2 or more abnormal LFTs cholecystitis/pancreatitis ? Preoperative ERCP Intermediate riskMRCP Low riskUSS then LC Imaging ? Plain xray ? Ultrasound ? CT ? MRCP ? ERCP Ultrasound ? Most widely used ? Easy to perform ? Causes little disfort ? Avoid irradiation and contrast media ? High reliability of diagnosing gallbladder stones (95%) ? Variable reliability of detecting CBD stones 23%80% depends on body habitus and experience of sonographer Endoscopic ultrasound ? Studies using EUS to evaluate prior to ERCP ? Avoids cannulation of papilla and avoids the risk of cholangitis and pancreatitis ? Sensitivity 93% ? Specificity 97% ? Approaches ERCP with experience CT ? Sensitivity for CBD stones causing obstructive jaundice 75% ? Stones usually isodense with bile (not useful for assessment of cholelithiasis) ? CT cholangiogram – unsuitable in jaundice as contrast not excreted ? Important for imaging of pancreas if suspicion of malignant disease and other abdominal ans MRCP ? Detail now approaches ERCP ? Technique relies on the principle of imaging fluid columns that are static, better images with dilated ducts and flow artifact can give false positive results ? Sensitivity 95% ? Specificity 89% ? Accuracy 92% MRCP Advantages ? No irradiation ? Avoids plications of ERCP in 5%10% of patients Disadvantages ? Claustrophobic amp。 Rhodes et al, Lancet 1998) ? 12% patients managed without cholangiogram will present with a retained stone Transcystic exploration ? Standard dissection to identify cystic duct ? Cystic duct opened distal to a previously applied clip ? Milk stones from cystic duct ? Cholangiogram ? Assessment of stone and duct size ? Tiny stones or possible sphincter of oddi spasm try glucagon and flush with saline then repeat cholangiogram Transcystic exploration ? Nathanson basket fed into CBD (ensure tip of basket well back from tip to avoid duct perforation) ? Under image intensification tip positioned, basket opened and stone removed ? If stone impacted can dislodge with 4Fr fogarty catheter or perform choledochoscopy Techniques to improve transcystic clearance ? Careful dissection of cystic duct/CBD junction ? Avoidance of spiral valves when entering cystic duct ? Careful examination of cholangiogram ? Approach cystic duct from different or extra ports ? Dilation of cystic duct with a balloon ? Choledochoscopy via cystic duct ? Vary retraction on fundus ? Cystic duct closure clips or endoloops ? Subhepatic drainage Trans cystic exploration success ? Stones few in number ? Small in size (1cm) ? Situated in the mon duct or distal to the cystic duct entry Choledochotomy preferable if ? Large and/or numerous stones ? Common hepatic duct or intrahepatic ducts ? Careful consideration of laparoscopic strategies to be employed, equipment required and adequacy of assistance Indications for choledochotomy ? Unsuccessful transcystic exploration ? Cystic duct diameter smaller than stones ? CBD 8mm ? Multiple large stones ? Impacted stones with features of cholangitis ? Ampullary diverticulum on IOC ? Previous bilroth 2 gastrectomy ? Previous failed ERCP ? Contraindication to post postop ERCP ? ERCP unavailable Laparoscopic choledochotomy ? 35% of patients transcystic approach fails to clear the CBD ? Only absolute contraindication in a CBD 8mm ? Consider that 1/3 stones detected at IOC will pass spontane