胆囊切除术后综合征(2)
3PCS的治疗
PCS的治疗的关键是查明病因，对因治疗才能取得良好效果。由于PCS的病因较多，临床上应该根据不同病因采用相应治疗，治疗方法包括内科保守治疗,内镜治疗及外科手术治疗等。
3.1保守治疗其主要适应证：胆管蛔虫症、胆道感染尚无明显胆管梗阻、胆系外疾病如消化性溃疡、慢性胰腺炎者等。可采取的治疗方法有：注意控制饮食、抗感染、抑酸、保护胃黏膜、促胃肠动力、驱虫等。
3.2内镜治疗对胆管残留及再发结石可行内镜乳头括约肌切开术和内镜乳头气囊扩张术(EPBD)后取石；对乳头炎性狭窄行EST或EPBD治疗对乳头旁憩室压迫乳头开口和Oddi括约肌功能紊乱(SOD)行EPBD治疗；对乳头肿瘤和肝门胆管癌行内镜胆管金属内支架治疗(EMBE)；对化脓性胆管炎，继发性胆总管多发结石、结石难一次取净及术后胆瘘，胆管中段狭窄行内镜鼻胆营引流(ENBD)[17]。
, http://www.100md.com
3.3手术治疗胆囊或胆囊管残留过长者，可再次行手术切除残留胆囊或胆囊管。胆管结石内镜治疗无效者可行胆总管切开取石术等。Oddi括约肌狭窄内镜治疗失败者可行括约肌切开成型术或胆肠吻合术。胆管狭窄者可行胆总管成型修复术，或胆道消化道重建术，包括胆总管十二指肠吻合术、胆管空肠Roux-Y吻合术等。
4PCS的预防
PCS关键在于预防，胆囊手术前应完善相关检查，设法排除胆囊以外疾病所引起的症状[18]，作出全面而明确的诊断。因胆总管结石为PCS最常见原因，若术前诊断明确可明显减少PCS发病率。另外，手术过程中需注意手法，避免损伤胆总管、避免遗留结石、避免将结石挤入胆总管中。还应严格掌握胆囊切除的手术适应证,可通过脂餐试验等检查判断术前胆囊功能分级，综合考虑是否行胆囊切除术。
参考文献
[1]Steven S，Amy I,David CL,et al.Postcholecystectomy Biliary Symptoms.J Surg Edu,2007,64(4):228-234.
, http://www.100md.com
[2]Madura J,Madura JA.Diagnosis and management of sphincter of Oddi dysfunction and pancreas divisum.Surg Clin North Am,2007,87(6):1417-1429.
[3]Glenn F,McSherry CK.Secondary abdominal operations for symptoms following biliary tract surgery.Surg Gynecol Obstet,1965,121(5):979-988.
[4]Madura J,Madura JA.Diagnosis and management of sphincter of Oddi dysfunction and pancreas divisum.Surg Clin North Am,2007,87(6):1417-1429.
, http://www.100md.com
[5]Walsh RM,Chung RS,Grundfest-Broniatowski S.Incomplete excision of the gallbladder during laparoscopic cholecystectomy.Surg Endosc,1995,9(1):67-70.
[6]Hassan H,Vilmann P.Insufficient cholecystectomy diagnosed by endoscopic ultrasonography.Endoscopy,2004，36(3):236-238.
[7]Demetriades H,Pramateftakis MG,Kanellos I,et al.Retained gallbladder remnant after laparoscopic cholecystectomy.J Laparoendosc Adv Surg Tech A,2008,18(2):276-279.
, http://www.100md.com
[8]Casillas RA,Yegiyants S,Collins JC.Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis.Arch Surg,2008,143(6):533-537.
[9]Siddiqui T,MacDonald A,Chong PS,et al.Early versus delayed laparoscopic cholecystectomy for acute cholecystitis:a meta-analysis of randomized clinical trials.Am J Surg,2008;195(1):40-47.
[10]Madácsy L,Fejes R,Kurucsai G,et al.Characterization of functional biliary pain and dyspeptic symptoms in patients with sphincter of Oddi dysfunction:effect of papillotomy.World J Gastroenterol,2006,12(42):6850-6856.
, 百拇医药
[11]毕永林，朱彤，潘晓峰,等.胆囊切除术后综合征116例ERCP分析.中华肝胆外科杂志,2007,13(1):32-34.
[12]闵志钧,叶敏,徐明,等.腹腔镜胆囊切除术并发症原因分析.肝胆胰外科杂志,2009,21(1):65-67.
[13]Behar J,Corazziari E,Guelrud M. Functional gallbladder and sphincter of Oddi disorders.Gastroenterology,2006,130(5):1498-509.
[14]Shawc-Fenlon HM.Cysticduct remnant and the postchole-cystectomy syndrome.Hepatogastroenterology,2004，51(55)：36-38.
, 百拇医药
[15]李家福,周家军.腹腔镜胆囊切除术后上腹痛原因分析.腹腔镜外科杂志,2010,15(10):775-776.
[16]Filip M，Saftoiu A，Popescu C，et a1.Postcholecystectomy syndrome-an algorithmic approach.J Gastrointestin Liver Dis，2009,18(1)：67-71.
[17]周平红,姚礼庆,高卫东,等.胆囊切除术后综合征的内镜诊断和治疗.中华消化内镜杂志,2001,18(6):335-338.
[18]李哲夫,陈孝平,李洪,等.开腹胆囊切除术后黄疸的病因及诊治.中华肝胆外科杂志,2007,13(4):269-270.
【收稿日期】2011-04-18
(本文编辑：郎威), 百拇医药(王志强 张志坚)
PCS的治疗的关键是查明病因，对因治疗才能取得良好效果。由于PCS的病因较多，临床上应该根据不同病因采用相应治疗，治疗方法包括内科保守治疗,内镜治疗及外科手术治疗等。
3.1保守治疗其主要适应证：胆管蛔虫症、胆道感染尚无明显胆管梗阻、胆系外疾病如消化性溃疡、慢性胰腺炎者等。可采取的治疗方法有：注意控制饮食、抗感染、抑酸、保护胃黏膜、促胃肠动力、驱虫等。
3.2内镜治疗对胆管残留及再发结石可行内镜乳头括约肌切开术和内镜乳头气囊扩张术(EPBD)后取石；对乳头炎性狭窄行EST或EPBD治疗对乳头旁憩室压迫乳头开口和Oddi括约肌功能紊乱(SOD)行EPBD治疗；对乳头肿瘤和肝门胆管癌行内镜胆管金属内支架治疗(EMBE)；对化脓性胆管炎，继发性胆总管多发结石、结石难一次取净及术后胆瘘，胆管中段狭窄行内镜鼻胆营引流(ENBD)[17]。
, http://www.100md.com
3.3手术治疗胆囊或胆囊管残留过长者，可再次行手术切除残留胆囊或胆囊管。胆管结石内镜治疗无效者可行胆总管切开取石术等。Oddi括约肌狭窄内镜治疗失败者可行括约肌切开成型术或胆肠吻合术。胆管狭窄者可行胆总管成型修复术，或胆道消化道重建术，包括胆总管十二指肠吻合术、胆管空肠Roux-Y吻合术等。
4PCS的预防
PCS关键在于预防，胆囊手术前应完善相关检查，设法排除胆囊以外疾病所引起的症状[18]，作出全面而明确的诊断。因胆总管结石为PCS最常见原因，若术前诊断明确可明显减少PCS发病率。另外，手术过程中需注意手法，避免损伤胆总管、避免遗留结石、避免将结石挤入胆总管中。还应严格掌握胆囊切除的手术适应证,可通过脂餐试验等检查判断术前胆囊功能分级，综合考虑是否行胆囊切除术。
参考文献
[1]Steven S，Amy I,David CL,et al.Postcholecystectomy Biliary Symptoms.J Surg Edu,2007,64(4):228-234.
, http://www.100md.com
[2]Madura J,Madura JA.Diagnosis and management of sphincter of Oddi dysfunction and pancreas divisum.Surg Clin North Am,2007,87(6):1417-1429.
[3]Glenn F,McSherry CK.Secondary abdominal operations for symptoms following biliary tract surgery.Surg Gynecol Obstet,1965,121(5):979-988.
[4]Madura J,Madura JA.Diagnosis and management of sphincter of Oddi dysfunction and pancreas divisum.Surg Clin North Am,2007,87(6):1417-1429.
, http://www.100md.com
[5]Walsh RM,Chung RS,Grundfest-Broniatowski S.Incomplete excision of the gallbladder during laparoscopic cholecystectomy.Surg Endosc,1995,9(1):67-70.
[6]Hassan H,Vilmann P.Insufficient cholecystectomy diagnosed by endoscopic ultrasonography.Endoscopy,2004，36(3):236-238.
[7]Demetriades H,Pramateftakis MG,Kanellos I,et al.Retained gallbladder remnant after laparoscopic cholecystectomy.J Laparoendosc Adv Surg Tech A,2008,18(2):276-279.
, http://www.100md.com
[8]Casillas RA,Yegiyants S,Collins JC.Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis.Arch Surg,2008,143(6):533-537.
[9]Siddiqui T,MacDonald A,Chong PS,et al.Early versus delayed laparoscopic cholecystectomy for acute cholecystitis:a meta-analysis of randomized clinical trials.Am J Surg,2008;195(1):40-47.
[10]Madácsy L,Fejes R,Kurucsai G,et al.Characterization of functional biliary pain and dyspeptic symptoms in patients with sphincter of Oddi dysfunction:effect of papillotomy.World J Gastroenterol,2006,12(42):6850-6856.
, 百拇医药
[11]毕永林，朱彤，潘晓峰,等.胆囊切除术后综合征116例ERCP分析.中华肝胆外科杂志,2007,13(1):32-34.
[12]闵志钧,叶敏,徐明,等.腹腔镜胆囊切除术并发症原因分析.肝胆胰外科杂志,2009,21(1):65-67.
[13]Behar J,Corazziari E,Guelrud M. Functional gallbladder and sphincter of Oddi disorders.Gastroenterology,2006,130(5):1498-509.
[14]Shawc-Fenlon HM.Cysticduct remnant and the postchole-cystectomy syndrome.Hepatogastroenterology,2004，51(55)：36-38.
, 百拇医药
[15]李家福,周家军.腹腔镜胆囊切除术后上腹痛原因分析.腹腔镜外科杂志,2010,15(10):775-776.
[16]Filip M，Saftoiu A，Popescu C，et a1.Postcholecystectomy syndrome-an algorithmic approach.J Gastrointestin Liver Dis，2009,18(1)：67-71.
[17]周平红,姚礼庆,高卫东,等.胆囊切除术后综合征的内镜诊断和治疗.中华消化内镜杂志,2001,18(6):335-338.
[18]李哲夫,陈孝平,李洪,等.开腹胆囊切除术后黄疸的病因及诊治.中华肝胆外科杂志,2007,13(4):269-270.
【收稿日期】2011-04-18
(本文编辑：郎威), 百拇医药(王志强 张志坚)