肝内胆管结石的手术治疗(附325例报告)

目的 探讨外科治疗肝内胆管结石的手术方法及临床价值。方法 回顾性分析5年来该科采用肝切除术联合术中胆道镜治疗肝内胆管结石的病例资料。结果 全组325例，其中单纯胆总管探查取石 T管引流46例；肝段(叶)切除 胆总管探查取石 T管引流104例；肝段(叶)切除 肝胆管探查取石 胆管空肠Y型吻合75例；肝段(叶)切除 肝胆管探查取石 狭窄胆管切开成形 胆管空肠Y型吻合95例；胆总管探查取石 胆总管十二指肠吻合5例。276例术中联合胆道镜取石，38例行术中胆道造影。术后残余结石46例，其中左内叶20例，右前叶17例，右后叶9例，经术后胆道镜结合液电碎石等处理治愈41例，再次手术5例。胆瘘12例，伤口感染15例，膈下脓肿4例，肺部感染5例，上消化道出血2例，均经积极非手术治疗痊愈。未发生手术死亡。结论 肝切除术联合术中胆道镜治疗肝内胆管结石能提高疗效、降低残石率、减少并发症，值得临床推广。

Surgical treatment for hepatolithiasis (a report of 325 cases)

Objective: To investigate the operative techniques and clinical value of hepatolithiasis treatment. Methods: The clinical data of 325 patients with hepatolithiasis, who underwent hepatectomy combined with intraoperative choledochoscopy in our department in recent 5 years, were retrospectively analysed. Results: In 325 cases with hepatolithiasis, common bile duct exploration combined with T tube drainage was performed in 46 cases; hepatectomy and choledochotomy combined with T tube drainage were performed in 104 cases; hepatectomy and hepaticolithotomy combined with Y type hepatocholangiojejunostomy were performed in 75 cases; hepatectomy, hepaticolithotomy and hepaticoplasty(on narrow bile duct) combined with Y type hepatocholangiojejunostomy were performed in 95 cases; and common bile duct exploration combined with choledochoduodenostomy was performed in 5 cases. Intraoperative choledochoscopy for extracting stones was performed in 276 cases and intraoperative cholangiography in 38 cases. Postoperative residual stones occurred in 46 cases,including left intrahepatic lobe in 20 cases,right fronthepatic lobe 17 and right rearhepatic lobe 9, 41 cases with debris were cured by electrohydraulic lithotripsy(EHL) with peroral choledochoscopy and 5 received reoperation. Bile leak occurred in 12 cases, incision infection 15, subphrenic abscess 4, lung infection 5,and upper gastrointestinal bleeding 2. All theses complications were cured by non-operative treatment.No death occurred in perioperative period. Conclusions: Hepatectomy combined with intraoperative choledochoscopy is capable of improving outcome,decreasing postoperative debris and complications occurrence rate in treatment of hepatolithiasis,deserving clinical popularization.