复杂型肝内胆管结石外科治疗的临床研究-东南大学学报医学版

复杂型肝内胆管结石外科治疗的临床研究

单位：1. 贵州医科大学附属医院肝胆外科, 贵州贵阳 550025;
2. 贵州省德江县中医院普外科, 贵州德江 565200;
3. 贵州医科大学附属肿瘤医院肝胆外科, 贵州贵阳 550025

分类号：R657.42

出版年·卷·期（页码）：2017·36·第四期（594-598）

摘要：

目的：探讨复杂型肝内胆管结石外科治疗的术式选择及疗效评价。方法：对107例复杂型肝内胆管结石患者行胆道探查、胆道镜联合激光碎石，其中行胆道探查+T管引流术77例，规则性肝叶切除术16例，胆总管空肠吻合术9例，肝4b段切除+肝门部胆管整形空肠盆式吻合术5例；术后经T管窦道胆道镜取石、激光碎石、球囊扩张62例。结果：首次手术结石取净率为38.32%，肝叶切除术组（75.00%）优于胆道探查术组（27.27%）；残余结石患者二期经窦道取石62例，取净结石53例，取净率为85.48%。107例患者取净结石94例，取净率为87.85%。围手术期胆总管空肠吻合术组和肝门胆管空肠盆式吻合术组严重并发症发生率高；远期疗效优良率胆总管探查术组为94.37%，肝叶切除术组为93.75%。结论：胆道探查取石术是治疗肝内胆管结石的首选术式，肝叶切除术适用于局部肝实质萎缩，胆肠吻合术适用于胆管口括约肌功能障碍患者。术后经窦道胆道镜取石是解决肝内胆管残余结石的重要手段，疗效显著。对复杂型肝内胆管结石治疗应提倡个体化、精准化及器官保护。

Objective:To investigate the therapeutic effects of various surgical procedures for the treatments of refractory hepatolithiasis. Methods:107 cases who had attained a definite diagnosis of hepatolithiasis underwent bile duct explorations and partial hepatectomy.There were 77 cases been performed bile duct exploration and T-tube drainage,16 anatomical hepatectomy,9 cholangiojejunostomy and 5 liver resection in 4b combined with hepaticojejunostomy. Post-operation residual bile duct stones were taken out for many times by laser lithotripsy and balloon dilatation under choledochoscope through sinus tracts in 62 cases. Results:The stone free rate was 38.32%.75.00% in hepalobectomy groups were better than bile duct exploration groups(27.27%).The residual stone rate in 62 cases were taken out most times through sinus tracts,and the stones were completely cleared in 53 cases, The free rate 85.48%.There were 94 patients been removed completely in 107 cases,and the free rate 87.85%.In perioperative period, the incidence of complications was higher in cholangiojejunostomy and hepaticojejunostomy. The rate of satisfactory clinical results was 94.37% in bile duct exploration groups and 93.75% in hepalobectomy groups. Conclusion:Bile duct exploration is the most effective procedure for the treatments of hepatolithiasis. Hepalobectomy is appropriate for those with obvious hepatatrophia, and cholangiojejunostomy for those with dysfunction of oddi s sphincter.Laser lithotripsy under choledochoscope is effective for taking residual stones out. Individualized and precise treatment and organ protection are advocated in treating refractory hepatolithiasis.

参考文献：

[1] 中华医学会外科学分会胆道外科学组.肝胆管结石病诊断治疗指南[M].北京:人民卫生出版社,2011.
[2] LI F Y,CHENG N S,MAO H,et al.Significance of controlling chronic proliferative cholangitis in the treatment of hepatolithiasis[J].World J Surg,2009,33(10):2155-2160.
[3] 余正平,杨文军,金约明,等.肝胆管结石合并胆管癌的临床特点及防治[J].中华普通外科杂志,2010,25(5):360-362.
[4] 修典荣,彭颖.复杂胆道结石的外科治疗进展[J].中华普通外科杂志,2014,29(7):489-490.
[5] 黄志强.新世纪的胆道外科[J].临床外科杂志,2004,12(1):12-14.
[6] YE X,NI K,ZHOU X,et al.Laparoscopic versus open left hemihepatectomy for hepatolithiasis[J].J Surg Res,2015,199(2):402-406.
[7] LING X,XU Z,WANG L,et al.Is Oddi sphincterotomy an indication for hepatolithiasis?[J].Surg Endosc, 2009,23(10):2268-2272.
[8] 时鑫,刘衍民,文辉清,等.经皮肝胆道造瘘硬质胆道镜治疗肝内胆管结石[J].中华腔镜外科杂志:电子版,2010,3(5):10-12.
[9] 谷化剑,冯贤松,辛小燕.医源性胆道损伤的原因分析与防治策略[J].中国普通外科杂志,2013,22(2):192-196.
[10] NARAYANAN S K,CHEN Y,NARASIMHAN K L,et al.Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst:a systematic review and meta-analysis[J].J Pediatr Surg,2013,48(11):2336-2342.
[11] 吴思源,王晓荣, 朱厢南,等.游离空肠通道式胆道造口成形术治疗肝胆管结石并狭窄的体会[J].现代医学,2003,31(4):247-248.
[12] CUI L,XU Z,LING X F,et al.Laparoscopic hepaticoplasty using gallbladder as a subcutaneous tunnel for hepatolithiasis[J].World J Gastroenterol,2014,20(12):3350-3355.

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