【正文】 概率 =7/9247。 ? Symptomatic CBDS僅保守治療 90％可好轉(zhuǎn)， 10％死亡。 indicators：① clinical： history of 膽管炎、黃疸 and胰腺炎 , symptomatic CBDS 、 present 黃疸 and胰腺炎；② serum chemistries： ALT、 AST、 TB、 DB、 ALP、 GGT、 AMS；③CBDS on US、 CBD dilatation on US。 100％ sen與 100％ PV相對(duì)應(yīng)（排出）； 100％ spe與 100％PV+相對(duì)應(yīng)（納入）；當(dāng) sen和 spe不等于 100％時(shí)， PV依賴于疾病的患病率（驗(yàn)前概率） 、且需逐個(gè)計(jì)算。 〔 d/(b+d)〕 = (1sen)/spe GBS＋ CBDS可能性的評(píng)估及存在的問題 ? 連續(xù)計(jì)量資料的分界值及其對(duì)診斷試驗(yàn)評(píng)價(jià)指標(biāo)的影響： 正常值，截?cái)嘀担?cutoff value），根據(jù)不同需要設(shè)定的閾值（ threshold）。 ③ 病人意愿 /經(jīng)濟(jì)情況 。 234(1): 3340 Group 2 patients Group 1 patients Group 3 patients Group 4 patients Therapeutic ERCP MRCP LC+IOC LC (＋ ) (－ ) Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2022。 elevation in serum liver enzyme values during initial evaluation with decrease in the degree of abnormality during repeat evaluation。 poorly localized upper abdominal pain。 normal serum amylase value Biliary pancreatitis Cholelithiasis。 no CBD dilatation。 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 spontaneously and exploration of a small duct may result in increased morbidity ? Surgeon must be appropriately trained Laparoscopic choledochotomy ? Deflate duodenum with NGT ? Extraport to retract duodenum ? Leave cholangiocatheter in place to prevent deflation of CBD ? Laparoscopic knife for choledochotomy ? Flushing, Fogarty catheter and basket to remove stones ? Once duct confirmed cleared (choledochoscopy) consider: ① T tube。 Dilatation of the mon biliary duct (10mm) 50 49 50 Group 2 (intermediate probability) History of stone migration (antecedents of cholangitis or biliary pancreatitis)。 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。 Anomalies in liver tests (more than twice the normal level )。 Tanaka et al, Gastrointest Endosc, 1998) Difficult bile duct stones at ERCP ? Stones 15mm ? Intrahepatic stones ? Multiple stones ? Impacted stones ? Stone proximal to biliary stricture ? Tortuous bile duct ? Disproportionate size of bile duct stone ? Duodenal diverticulum ? Bilroth 2 reconstruction ? Surgical duodenotomy Adjuvant techniques ? Mechanical lithotripsy ? Extracorporeal shockwave lithotripsy ? Chemical dissolution ? Successful stone fragmentation has been reported in up to 80% of patients, but major drawback is the need for multiple treatment sessions and repeat ERCP to retrieve stone fragments ERCP stent insertion ? 5% of cases where stone extraction fails either a nasobiliary tube or stent should be inserted for CBD depression ? Stents may block after a few months, but bile often drains around stent ? If surgically unfit can change stents if jaundice recurs ? Recurrent episodes of cholangitis can lead to secondary biliary cirrhosis in the long term so careful consideration before surgery is totally discounted Preoperative ERCP ? Eliminates the intraoperative dilemma as to how to manage CBD stones ? Exposes a number of patients to an unnecessary procedure and associated plications