类似腹膜癌病的溢出胆结石：病例报告和文献综述

概要
介绍
腹腔镜胆囊切除术（LC）已成为治疗症状性胆结石的“金标准”。然而，这种手术技术增加了胆管损伤和胆结石丢失的风险。由于超过90％的分离胆结石从未出现过症状，因此它们通常表现为CT扫描的偶然发现。小心地去除尽可能多的石头，建议进行强烈的灌洗和抽吸。据报道，8.5％的胆结石会导致并发症，最常见的是脓肿。

演讲案例
作者报告了一例溢出胆结石模拟腹膜转移的放射学研究。诊断非常困难，甚至超声引导的病变活检也不是决定性的。只有诊断性腹腔镜检查才能确诊。

讨论
与胆结石丢失相关的反应可以模拟其他原因，例如软组织肉瘤，恶性淋巴瘤或者如作者的腹膜癌病。

结论
溢出的胆结石与罕见但显著的并发症有关，甚至这种病症的诊断也可能导致严重的困难。必须认真努力防止胆囊穿孔，并应及时识别和妥善处理意外的石块溢出。

关键词：胆结石，腹膜癌病，腹膜慢性脓肿形成，腹腔镜胆囊切除术，病例报告

1.简介
腹腔镜胆囊切除术（LC）是症状性胆汁淤积的金标准。在经验丰富的人手中，这是一个安全的程序，发病率和死亡率低。在外科手术过程中，最常见的术中并发症之一是胆囊穿孔，结石扩散到腹膜腔[1]。这种发病率在6％和40％之间变化2,3。与这种并发症相关的风险被认为是微不足道的，并且仍然存在某种争议[2]，但Khan等人[3]证实了在同一手术中切除所有丢失的胆结石的必要性，尽可能在腹部冲洗时切除腹部。为了避免并发症，如肝下或盆腔脓肿，肉芽肿形成，端口部位感染[4]。作者的工作符合SCARE标准[109]。

2.病例报告
一名73岁的男性接受了腹腔镜胆囊切除术治疗症状性胆石症。术中疗程仅对胆汁和胆结石的腹腔内溢出有显著意义。在手术过程中，外科医生尽可能地检索它们。病理检查显示慢性胆囊炎。在术后第二天，发生与尿潴留相关的腹痛。患者接受腹部X线平片显示肾结石，并接受药物治疗。患者术后第4天出院。 16个月后，患者接受Uro-TC尿路结石随访，结果显示有一些腹膜结节，表现为肿瘤性结节（最大的位于5cm宽的上腹部）图1.超声引导的活检组织主要病变和病理显示炎症过程。上消化道和结肠内窥镜检查均为阴性。在多学科会议后，患者接受了探查性腹腔镜检查并切除了腹膜结节。移除的结节的病理学检查显示异物类型的显著炎症反应，包括巨细胞反应。异物由胆固醇针代表。患者术后一天出院，伤口清洁。后续行动平安无事（表1）。


图1
腹部和骨盆的CT扫描显示多个高密度软组织结节，类似腹膜癌病。

表 1


3.讨论
腹腔镜胆囊切除术（LC）已成为治疗症状性胆结石的“金标准”。与开腹胆囊切除术相比，LC的优点包括切口更小，术后疼痛减少，恢复时间更短。然而，有限的可视化和腹腔镜检查的技术挑战增加了胆管损伤和胆结石丢失的风险。由于超过90％的分离胆结石从未出现过症状，因此它们通常表现为CT扫描的偶然发现。已经描述了特定的位置，例如Morison囊甚至是胸内的结石[5]，[6]。据报道，8.5％的胆结石会导致并发症。一些危险因素，如胆汁感染的急性胆囊炎，色素结石，易患高细菌污染，多发结石（> 15），结石大小（> 1.5cm）和年龄，已被描述[7]。建议尽可能多地去除尽可能多的结石，强力冲洗和抽吸（10mm装置），避免扩散到难以接近的部位，以及使用腹腔袋和腹腔镜抓取器[7]。

据文献报道，高达80％-90％的色素结石含有大肠埃希菌，肺炎克雷伯菌和肠球菌等细菌[8]。 LC后脓肿形成的平均时间为4个月至10年[9]。当LC后数月至数年出现腹膜脓肿或瘘管形成时，应考虑诊断为胆结石丢失（图2）。


图2
与肾脏相比，T1加权图像显示质量为等强度区域。

与胆结石丢失相关的脓肿形成可以类似其他原因，例如软组织肉瘤，恶性淋巴瘤或者如作者的腹膜癌病。

仔细的文献检索可以找到114篇论文，报告198例与溢出的胆结石有关的并发症。 手术至症状发作的距离为手术后一周至十五年。 临床表现如下：偶然发现仅两例，一例疼痛，87例脓肿，窦或皮肤瘘，18例肠瘘或器官糜烂或瘘管，7例无需治疗或仅需抗生素治疗 在44例放射或外科引流术中，需要56例腹腔镜或剖腹手术（表2）。

表2


4.结论
溢出的胆结石与罕见但显著的并发症有关。 必须认真努力防止胆囊穿孔，并应及时识别和妥善处理意外的石块溢出。 如果发生溢出，应保持清晰的文件记录和对并发症的高度怀疑，以便早期识别和治疗该手术的并发症（图3）。


图3
A  -  4倍放大。 B  -  10倍放大率。 C  -  20倍放大倍数。 D  -  20倍放大倍数。

在作者的病例中，16个月前腹腔镜胆囊切除术的历史，以及腹膜结节的发现，使得诊断非常困难。

放射科医师在识别这些并发症方面起着关键作用，但是，当放射学检查不明确时，建议进行诊断性腹腔镜检查以确认诊断。

参考：
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