肝切除术治疗肝内胆管结石

目的研究肝切除和不同范围肝切除术对肝内胆管结石的治疗效果。方法分析我院近14年择期手术治疗的肝内胆管结石病人498例，比较肝切除组和无肝切除组、不同范围肝切除组的术后残余结石率、治疗效果和手术并发症。结果本组63．7％的病人行肝切除术。2001年后肝切除术的比例（74．6％）明显高于1991-1995年（49．5％）和1996-2000年（51．1％），而胆肠吻合术和单纯胆管切开取石T管引流术的比例逐渐减少。肝切除组术后结石残余率明显低于无肝切除组（19．2％vs31．7％，X^2=9．996，P=0．002）；肝切除组的优良率明显优于无肝切除组（85．2％vs74．7％，X^2=7．251，P=0．007），但肝切除组术后的并发症（伤口并发症除外）发生率和死亡率与无肝切除者无统计学差异。局限在肝左外叶的结石，肝左外叶切除效果好，术后无一例有残余结石。对结石分布超过左外叶时，左外叶切除、左半肝切除、右半肝切除和肝段切除的结石残余率分别为51．2％，14．3％，6．25％和11．5％，左外叶切除术后结石残余率明显高于左半肝切除、右半肝切除和肝段切除（P〈0．001）。半肝切除和肝段切除的优良率明显高于左外叶切除（94．8％．US76．1％，X^2=15．454，P〈0．001）。结论肝切除是治疗肝内胆管结石最有效的方法，对于非局限在左外叶的肝内结石，半肝切除和肝段切除术优于左外叶切除。

Hepatectomy for hepatolithiasis

Objective To investigate the therapeutic effects of hepatectomy and different hepa-tectomized procedures for hepatolithiasis. Methods The clinical data of 498 consecutive cases of hepatolithiasis surgically treated during the past 14 years in our hospital were retrospectively analyzed. The postoperative residual stone rate, outcome and morbidity were compared between the patients received hepatectomy and those underwent non-hepatectomy. Results There were 63. 7% of the patients in this series underwent various types of hepatectomy. The percentage of patients undergoing hepatectomy during 2001-2004 (74. 6%) was significantly higher than that during 1991 - 1995 (49. 5%) and 1996-2000 (51. 1%). Meanwhile, the percentage of patients undergoing choledochojejunostomy and choledochostomy T tube drainage was decreased. The patients undergoing hepatectomy had less postoperative residual stone rate (19. 2% vs 31. 7%, P=0. 002), higher rate of good outcome (85. 2% vs 74.2%, P= 0.007) as compared with those receiving non-hepatectomy. However, there was no marked difference in the postoperative morbidity (wound complications were excluded) between the patients receiving hepatectomy and those undergoing non-hepatectomy. Eighty patients whose stones were localized at the left lateral lobe had no postoperative residual stone after left lateral segmentectomy. In those patients whose stones distributed beyond the left lateral lobe, the postoperative residual stone rate was 51. 2%, 14. 3%, 6. 25 and 11. 5% after the left lateral lobectomy, left hepatectomy, right hepatectomy and selective combined segmentectomy, respectively. The former was significantly higher than the latter three (P<0. 001). The long-term outcome of left/right hepatectomy and selective combined segmentectomy was markedly better than the left lateral segmentectomy (P<0. 001). Conclusions Hepatectomy is the most effective procedure for the treatment of hepatolithiasis. The long-term outcome of left/right hepatectomy and selective combined segmentectomy is better than that of left lateral segmentectomy in the patients whose stones distributing beyond the left lateral lobe.