术中胆道镜取石失败原因分析及对策探讨

目的分析术中使用胆道镜治疗胆道结石常见的失败原因以及对策。方法对自1997年1月至2006年12月间292例曾经使用胆道镜术中取石的病例进行回顾分析。结果292例患者中,术后有胆道残石39例,残石率为13．4％。其中术中明确结石未取净者19例;经术后T管造影及胆道镜明确胆道残石者20例。胆道镜术中取石失败原因是多方面的。39例残石者中包括肝内胆管结石伴胆管变异14例;肝内胆管结石伴胆管开口狭窄11例;肝内胆管大结石嵌顿3例;胆总管下段节段性狭窄伴结石3例。结论术中要细致进行胆道镜检查,要逐叶逐段检查各条胆管,要注意有无胆管变异．要找出狭窄的胆管开口以及胆总管下段有无节段性狭窄等情况,对于大的胆管结石建议行激光或液电碎石。术中B超定位有助于降低术后残石率。     

Morphological studies on the pathogenesis and treatment of hepatolithiasis

Review of 108 patients with hepatolithiasis showed a recent increase of primary intrahepatic gallstones. 55 per cent of cases with hepatolithiasis had their gallstones in the left intrahepatic bile ducts. Clinicopathological study on the resected hepatic specimens of 33 patients revealed numerous intrahepatic periductal glandular formations. Periductal glandular formations were classified into the intramural and extramural glands. The mucous substances which might had been released from the periductal glands seemed to play a role in the formation of stones in combination with bilirubin pigments, cholesterin, bacterial organisms, cellular debris and other bile component. Intrahepatic gallstones and extramural glands were seen in the intrahepatic segment and area ducts. The defunctionalized atrophic hepatic lobe or segment should be resected in order to remove the calculi completely and to prevent the recurrence.     

腹腔镜肝左外叶切除联合胆道镜治疗肝左外叶为主的结石23例

目的探讨腹腔镜肝左外叶切除联合术中应用胆道镜在治疗肝左外叶肝内胆管结石中的可行性及安全性。方法 2014年11月至2016年10月对23例肝左外叶为主的肝内胆管结石病人行腹腔镜肝左外叶切除联合胆道镜检查及取石,其中9例病人合并胆总管结石,合并胆囊结石11例,同时合并胆总管结石及胆囊结石7例,合并肝左内叶结石3例。结果 23例病人均成功行腹腔镜下肝左外叶切除,并通过肝断面胆管经胆道镜对肝内胆管及胆总管检查、取石,9例病人通过胆道镜取出胆总管内结石,11例病人联合胆囊切除,3例病人通过胆道镜取出肝左内叶结石。所有病人手术顺利,手术时间为142~188 min,平均(157±27)min;术中出血量为150~550 ml,平均(240±52)ml;胃肠功能恢复时间为1~3 d,平均(1.7±0.6)d;术后住院时间为7~13 d,平均(9.0±2.2)d。术后1例病人发生肝断面渗血,2例病人发生胆漏,均经保守治疗治愈。术后随访病人3~24个月,均未见结石残留及复发。结论腹腔镜肝左外叶切除联合术中应用胆道镜治疗肝左外叶肝内胆管结石具有疼痛轻、恢复快、残石率低的优势,是一种安全、可行的手术方式,可在临床中广泛应用。     

肝内胆管结石的外科手术治疗

目的 探讨肝内胆管结石外科治疗效果。方法 收集总结我科１９９１．１－１９９８．５期间手术治疗肝内胆管结石病人的３６５例,分析结石部闰与手术时机,手术方式之间的关系。结果３６５例病人,３５８例治愈,７例死亡,肝内胆管残余结７１例,肝功能衰竭７例。结论肝内胆管结石是一个较难的问题,肝叶切除是治疗的最佳方法。对于不适合行肝叶切除及术后残余结石者应采取多元化系统化的治疗。     

A clinicopatholgoical study on intrahepatic cholesterol gallstones

In order to clarify the pathogenesis and process of the formation of intrahepatic cholesterol gallstones, we examined the clinical features, cholangiograms and pathological findings of eight patients with intrahepatic cholesterol gallstones. When examining the clinical features, one patient was found to have developed intrahepatic cholesterol gallstones 3 years after a complete lithotomy. The cholangiograms of two patients revealed small gallstones in the peripheral bile ducts of the lateral segment of the liver, and these bile ducts showed localized cystic dilatation and were tightly filled with gallstones. Conversely, their other bile ducts which contained no gallstones showed an entirely normal cholangiogram. Pathologically, these two cases showed mild chronic cholangitis, and cholesterol crystals in the peripheral bile ducts. The other six cases showed moderate or severe dilatation of the bile duct and severe chronic proliferative cholangitis. From the above results, we proposed the following theory to explain the pathogenesis and process of the formation of intrahepatic cholesterol stones: The cholesterol crystals in the peripheral intrahepatic bile ducts may be a primitive form of intrahepatic cholesterol gallstones, and the formation of intrahepatic cholesterol gallstones may precede and cause such deformities of the bile ducts as strictures or dilatations.     

A clinicopathological study on intrahepatic cholesterol gallstones

In order to clarify the pathogenesis and process of the formation of intrahepatic cholesterol gallstones, we examined the clinical features, cholangiograms and pathological findings of eight patients with intrahepatic cholesterol gallstones. When examining the clinical features, one patient was found to have developed intrahepatic cholesterol gallstones 3 years after a complete lithotomy. The cholangiograms of two patients revealed small gallstones in the peripheral bile ducts of the lateral segment of the liver, and these bile ducts showed localized cystic dilatation and were tightly filled with gallstones. Conversely, their other bile ducts which contained no gallstones showed an entirely normal cholangiogram. Pathologically, these two cases showed mild chronic cholangitis, and cholesterol crystals in the peripheral bile ducts. The other six cases showed moderate or severe dilatation of the bile duct and severe chronic proliferative cholangitis. From the above results, we proposed the following theory to explain the pathogenesis and process of the formation of intrahepatic cholesterol stones: The cholesterol crystals in the peripheral intrahepatic bile ducts may be a primitive form of intrahepatic cholesterol gallstones, and the formation of intrahepatic cholesterol gallstones may precede and cause such deformities of the bile ducts as strictures or dilatations.     

Reoperative surgery in cholelithiasis

From 1965 to 1980, reoperations for residual or recurrent stones were performed on 78 out of 962 Japanese patients with cholelithiasis. The majority of patients who required reoperation had intrahepatic stones. Most of the causes of reoperation were residual stones due to incomplete removal or the non-detection of intrahepatic stones at the previous surgery. Very careful examination of the intrahepatic biliary trees should be done in patients with biliary tract diseases, because in many, the first operation was done during their youth. To remove the intrahepatic calculi completely, hepatic lobectomy should be considered as a final procedure. The causes of reoperation of common duct stones were residual in 60 per cent and recurrent in 40 per cent. Definitive surgery should be done at the first or at least the second operation to avoid irreversible hepatic disorders which have untoward effects on the prognosis. It is important not only to remove the stones but also to relieve the bile stasis in the biliary tract.     

Congenital intrahepatic bile duct dilatation is a potentially curable disease: long-term results of a multi-institutional study

OBJECTIVE: To report clinical presentation, perioperative outcome, and long-term results of surgical management of congenital intrahepatic bile duct (IHBD) dilatations (including Caroli disease) in a multi-institutional setting. SUMMARY BACKGROUND DATA: Congenital IHBD dilatations are a rare congenital disorder predisposing to intrahepatic stones, cholangitis, and cholangiocarcinoma. The management remains difficult and controversial for bilobar forms of the disease or when concurrent congenital hepatic fibrosis is associated. METHODS: From 1976 to 2004, 33 patients (range 11 to 79 years) were retrospectively enrolled. Disease extent into the liver was unilobar in 26 patients and bilobar in 7 patients (21%). Cholangiocarcinoma, congenital hepatic fibrosis, and intrahepatic stones were present in 2, 10, and 20 patients, respectively. Transplantations or liver resections were performed in 5 and 27 patients, respectively, whereas 1 asymptomatic patient was managed conservatively. RESULTS: Postoperative mortality was nil. Postoperative complications occurred in 16 of 32 operated patients (50%) and additional procedures for residual stones were required in 5 patients. During a median follow-up of 80 months (1 patient being lost for follow-up) no patient developed metachronous carcinoma. Six patients (30%) developed recurrent intrahepatic stones but satisfactory late outcome was achieved in 27 patients (87%). CONCLUSIONS: Partial or total liver resection achieves satisfactory late outcome in congenital IHBD dilatations, when the affection is treated at an early stage and when the extent of liver resection is tailored to intrahepatic disease extent and takes into consideration the presence and severity of underlying chronic liver and renal diseases.     

Percutaneous post-operative choledochofiberscopic lithotripsy for residual biliary stones

Summary A total of 5,116 post-operative percutaneous choledochofiberscopy (POC) sessions were performed on 739 patients with residual bile duct stones between 1980 and 1988. These residual stones were detected and removed by choledochoscopy. The success rate of non-surgical stone removal using POC was 100% for residual common duct stones and required 414 treatment sessions in this group of 168 patients. The success rate was 92.2% (525/569) for patients with residual intrahepatic stones; in this group a total of 4,694 treatment sessions were needed. Two patients with residual cystic duct stones were also successfully treated with POC. The distribution of residual intrahepatic stones was as follows: 166 (29.2%) in the right hepatic duct, 255 (44.8%) in the left hepatic duct and 148 (26.0%) in both hepatic ducts. Complications after POC were minimal and subsided after conservative treatment except in 2 patients. One patient had hemobilia and another a large subphrenic abscess, which required surgical drainage. Choledochofiberscopic electrohydraulic shockwave lithotripsy was effective treatment for large stones and was well tolerated. Residual stones in Oriental gall-stone disease are not preventable, and we believe that POC should be the first choice for these patients. Many of the problems associated with residual stones can be overcome by this method and good results achieved.Presented at the SAGES Meeting, Atlanta, Ga., 1990     

Postoperative flexible choledochoscopy for residual primary intrahepatic stones.

Postoperative flexible choledochoscopy was carried out in 103 patients with residual biliary calculi. Forty-one patients had residual stones in the common duct, and 63 patients had residual stones in the intrahepatic ducts with or without stones in the common duct. The majority of the intrahepatic stones were primary stones. Postoperative choledochoscopy was very effective in removing residual common duct stones (95% removed, no morbidity). For intrahepatic stones, removal was more difficult and was associated with a higher morbidity (11.2%). Stone extraction through the stenotic intrahepatic ducts was made possible by the balloon dilatation of the ducts. Repeated endoscopic access to the biliary system was made easier by the construction of a hepatico-cutaneous-jejunostomy, which also provides a route to the biliary tree for future stone removal if stone reformation occurs. Complimented by these procedures, postoperative choledochoscopy was successful in removing the residual intrahepatic stones in 82.3% of the patients. At a median follow-up of 17 months, the majority of the patients who had all the stones removed as well as those who had stones left behind were symptom free.     

Long-term results of surgical treatment for intrahepatic stones

One hundred and nineteen patients with intrahepatic stones treated surgically in Nagasaki University Hospital from 1969 to 1984 were reviewed. The patients were divided into four types according to location of the stones and the presence or absence of stenotic lesions and/or localized dilatation of the intrahepatic bile ducts. Types I and II patients were treated with choledocholithotomy or choledochojejunostomy, while type III patients underwent hepatic resection and type IV patients were treated by partial hepatic resection with bilioenteric anastomosis, including extended hepaticocholedochojejunostomy. The majority of operative or early deaths belonged to type IV and residual stones were present in almost all patients. The longterm results for the 88 patients revealed that the rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type III and 84 per cent for type IV. In type IV, the most excellent results (92 per cent) were obtained by extended hepaticocholedochojejunostomy, especially with hepatectomy. It is suggested that extended hepaticocholedochojejunostomy with partial hepatic resection is a reasonable procedure for treating patients with type IV intrahepatic stones.     

Treatment of bilateral intrahepatic stones with high duct strictures through selective central hepatic resection

Bilateral intrahepatic duct stones with strictures, more common in the Orient than elsewhere, are difficult to access surgically. The results of surgical procedures have not been generally successful and are attended by a high postoperative complication and recurrence rate. We report the treatment of 30 patients with intrahepatic calculi and high duct strictures by means of selective central hepatic resection without dissection of the major vessels at the hilum. Central hepatic resection provided satisfactory access to the primary and secondary confluences of the intrahepatic ducts, allowed removal of residual stones and ascariasis, and permitted correction of multiple strictures. Twenty-nine patients so treated were followed for a mean of 32 months after operation. No patients developed recurrent fever, biliary colic, or jaundice after the operation. The technique is therefore recommended as an effective alternative to extensive hepatic lobectomy in the treatment of the intrahepatic calculi with multiple strictures.     

肝内外胆管难取性残留结石经胆道镜钬激光碎石治疗

目的 探讨经胆道镜钬激光碎石治疗肝内、外胆管难取性残留结石的实用性及安全性。方法 观察18例胆道术后肝内、外胆管难取性残留结石患者接受胆道镜下钬激光碎石治疗的临床效果，并进行随访。结果 经1～4次胆道镜下钬激光碎石治疗，18例患者残石全部取尽，未出现近期并发症。16例获得随访，随访时间6月到1年，无结石复发和钬激光碎石相关的胆管狭窄出现。结论 经胆道镜钬激光碎石是治疗肝内、外胆管难取性残留结石的一种安全、有效的方法。     

Long-term results of surgical treatment for intrahepatic stones

One hundred and nineteen patients with intrahepatic stones treated surgically in Nagasaki University Hospital from 1969 to 1984 were reviewed. The patients were divided into four types according to location of the stones and the presence or absence of stenotic lesions and/or localized dilatation of the intrahepatic bile ducts. Types I and II patients were treated with choledocholithotomy or choledochojejunostomy, while type III patients underwent hepatic resection and type IV patients were treated by partial hepatic resection with bilioenteric anastomosis, including extended hepatico-choledochojejunostomy. The majority of operative or early deaths belonged to type IV and residual stones were present in almost all patients. The long-term results for the 88 patients revealed that the rate of improvement was 100 per cent for type I, 87 per cent for type II, 83 per cent for type III and 84 per cent for type IV. In type IV, the most excellent results (92 per cent) were obtained by extended hepaticocholedochojejunostomy, especially with hepatectomy. It is suggested that extended hepaticocholedochojejunostomy with partial hepatic resection is a reasonable procedure for treating patients with type IV intrahepatic stones.     

腹腔镜胆囊切除术前选择性ERC的应用

目的　探索ERC LC对有症状胆囊结石和疑有胆管结石得治疗结果的选择性标准的研究。方法　回顾分析 2 0 0 1年 11月～ 2 0 0 3年 10月我科收治的胆石症患者中 2 0例先行ERC再行LC的情况。结果　本组病人ERC均获成功 ,ERCP EST ESE共取出结石 15例 ,B超等证实者 10例 ,胆总管直径 >8mm 12例 ,有黄疸史者 11例 ,肝功能异常者 11例 ,胰腺炎者 4例。ERC后平均 4 .6d行LC。随访 2月～ 2年未发现胆管残余结石。结论　严格掌握LC前行ERC适应症 ,对于减少不必要ERC率 ,避免LC后胆管残留结石都具有重要作用。     

术中纤维胆道镜治疗胆道结石常见失败原因及改进方法

目的分析术中胆道镜治疗胆道结石时碰到的问题和常见的失败原因以及改进方法。方法对1995年1月至2005年9月期间的762例曾经使用纤维胆道镜术中治疗胆道结石的病例进行分析和总结。结果762例患者中,136例术后有胆道结石残留,残余结石率为17．8％,其中术中已知结石残留55例,术后经T管造影和术后胆道镜证实有结石残留81例。81例中包括肝内胆管结石伴胆管开口狭窄29例,肝内胆管结石伴胆管变异39例,胆总管下段节段性狭窄伴结石13例。结论术中胆道镜治疗胆道结石时要注意有无胆道变异和病变胆管开口狭窄或胆总管下端节段性狭窄等情况,术中B超对降低结石漏诊率有帮助。在使用纤维胆道镜时,术者要耐心细致,按顺序逐支逐段地检视,对胆道应采用连续窥视的方法和导向钳夹法以尽量避免主观和客观因素引起的术后结石残留。     

Intrahepatic stone formation and hepatectomy

In our hospital, we had experienced 3,036 cases of gallstones from January 1968 through December 1983, among which intrahepatic stone cases was 154, (5.1%). Intrahepatic stone formation is classified based on X-ray pictures, i.e., congenital intrahepatic cystic bile duct dilatation, for example, Caroli's disease. anomaly of the bile duct. acquired extrahepatic ductal stones. operation. Hepatectomy was performed in 49 of 154 intrahepatic ductal stone cases. We never experienced operative death. We should select operative methods, taking mode of formation into consideration. Hepatectomy for intrahepatic ductal stones was radical surgery and it shortened therapeutic period. Prognosis is good in 41 cases and poor in 6. In 2 among latter 6 cases, recurrence of stones was observed and in other 4 cases, residual stones and cholangitis were noticed. Two cases died, one due to hepatic abscess and the other another disease.     

胆结石患者垂体－性腺轴激素变化的研究

采用放射免疫法测定１６０例胆结石患者血清ＦＳＨ、ＬＨ和血浆Ｅ２、Ｔ、Ｐ的含量，并与６２例年龄相仿的正常健康者对照分析。实验结果表明育龄女性胆囊结石患者Ｅ２含量升高（Ｐ＜０．０１），Ｔ含量减少（Ｐ＜０．０５）；绝经后胆囊结石患者Ｔ含量减少．Ｐ含量升高（Ｐ＜０．０１）；男性胆囊结石患者Ｐ含量升高（Ｐ＜０．０５），男性肝胆管结石患者Ｔ含量减少（Ｐ＜０．０１）；男性和育龄女性胆囊结石患者Ｔ和ＬＨ含量均减少（Ｐ＜０．０１）。提示胆结石患者存在明显的垂体一性腺轴激素合成或代谢的异常。     

Primary intrahepatic lithiasis: report of a case treated by laparoscopic bilioenteric anastomosis

Recent advances in videolaparoscopic surgery have made this method the treatment of choice for many biliary diseases. However, it has not been used in certain cases, such as primary intrahepatic lithiasis. The authors report a case of a 62-year-old woman with a history of several episodes of cholangitis. Investigation revealed dilated intra- and extrahepatic bile ducts with intrahepatic stones. The patient underwent laparoscopy, and intraoperative cholangiography disclosed an enlarged common duct with absence of stones and the presence of multiple calculi in the intrahepatic biliary tree. A choledochotomy followed by choledochoscopy was performed, which revealed several intrahepatic pigmented stones that were completely retrieved, followed by a laterolateral choledochoduodenostomy to decompress the biliary tree and to allow the migration of residual or recurrent stones. The patient had an uneventful recovery and was discharged on the fourth postoperative day. After 15 months of follow-up the patient is asymptomatic with normal results of liver function tests. Late postoperative upper digestive endoscopy showed a patent choledochoduodenostomy.     

Operative methods for hepatolithiasis based on its etiology

This study was undertaken to clarify the intrahepatic bile flow mechanism in man. The fasting cholescintigraphy was obtained from 40 healthy controls and 5 patients with hepatolithiasis by injection of 2 m Ci of 99mTc-EHIDA. The serial analog images were recorded at each 5 min for 1 hr and the radioactivity was simultaneously counted by a computer connected with a gamma camera at 1 frame per 15 sec. Results obtained are summarized as follows: The analog images and dynamic curves obtained from 32 out of 40 controls demonstrated that the bile flow of the left hepatic duct was significantly delayed than that of the right hepatic duct, and this seemed to coincide with the high incidence of left intrahepatic gallstones. The bile flow was always hampered throughout the biliary tracts in 5 cases of hepatolithiasis regardless of location of stones. Proximal drainage (hepatic portojejunostomy) and distal drainage (transduodenal sphincteroplasty) showed excellent drainage effects on the recovery of the disturbed bile flow in those patients.