改良的经皮经肝胆道镜术治疗肝内胆管结石(附15例报告)

目的:探讨经皮经肝胆道镜术(PTCS)的新方法及其临床应用价值。方法:改良传统的PTCS方法,选择剑突旁入路。在经皮经肝胆管引流(PTCD)一周后,进行瘘道扩张并将隔离鞘套置入瘘道内,然后应用各种腔镜经鞘套进行胆道内碎石、取石、胆道扩张,置内支架治疗肝内胆管结石。就15例进行回顾性分析。结果:手术全部成功,完全取净率为86.7%(13/15),术后无胆瘘与出血并发症。结论:对部分肝内胆管结石,尤其是残留或复发结石及其伴随的胆道狭窄和阻塞性黄疸,改良的PTCS是一种创伤小、安全有效的术式。     

经皮经肝胆道镜对原发性肝内胆管结石的疗效评价

目的 探讨经皮经肝胆道镜(PTCS)治疗肝内胆管结石的临床应用价值.方法 回顾性分析70例进行PTCS手术的肝内胆管结石患者,评价患者术后结石清除情况以及在接受PTCS手术后随访评价结石复发情况.结果 肝内胆管结石患者的彻底清除60例,术后清除率为85.7％.61例患者的平均随访时间为6年,经影像学检查证实有12例结石复发.结论 PTCS对治疗肝内胆管结石是一种安全、有效、易重复的方法,具有取石快、结石残留率低、术后并发症少、微创等优点.PTCS是原发性胆管结石中具有较大临床应用价值.     

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.     

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.     

Value of percutaneous transhepatic cholangioscopy (PTCS)

Since July 1975, percutaneous transhepatic biliary drainage (PTBD) has been performed in 533 cases, and since April 1977 we have developed percutaneous transhepatic cholangioscopy (PTCS) as a diagnostic and therapeutic endoscopical tool in 198 cases of malignant disease and 195 benign cases. After dilating the sinus tract of PTBD using a 15-Fr catheter about 2 weeks after PTBD, PTCS was carried out through the sinus tract. PTCS has diagnostic advantages: the lesion can be accurately diagnosed histologically and the extent of cancer in the biliary tract can be assessed by taking biopsy specimens before the operation. PTCS has been applied for cholangioscopic lithotripsy in 145 cases of gallstone disease. In 44 cases, the Nd-YAG laser and/or electrohydraulic shock wave has been used to break up the stones. The PTCS morbidity was 6% and mortality was 0.3%.     

消化道重建术后肝内外胆管结石经皮经肝胆道镜治疗的临床分析

目的探讨消化道重建术后肝内外胆管结石经皮经肝胆道镜（PTCS）治疗的临床价值。 方法回顾性分析2014年3月至2018年6月什邡市人民医院行PTCS治疗的26例消化道重建术后肝内外胆管结石患者临床资料,分析PTCS临床治疗效果。 结果3例术中扩张瘘管时误操作导致瘘管断裂后中转开腹,手术中转率为11.54%（3/26）。23例手术成功,成功率88.46%（23/26）,其中1次取净结石9例（39.13%）,2次6例（26.09%）,3次6例（26.09%）,4次2例（8.70%）。术后患者间接胆红素（IBIL）、直接胆红素（DBIL）和总胆红素（TBIL）均显著低于术前水平,差异有统计学意义（P<0.05）。随访8~41（19.03±4.06）个月,结石复发率为26.92%（7/26）,再次行PTCS取石治疗,随访期间未再次复发。围手术期无一例死亡,并发症发生率为11.54%（3/26）,其中1例术中胆道壁损伤后大量出血,2例术后发生胆管炎,给予对症治疗措施后好转。 结论PTCS是治疗消化道重建术后肝内外胆管结石的有效手段。     

Ramification of the intrahepatic portal vein identified by percutaneous transhepatic portography

We carried out percutaneous transhepatic portography (PTP) in 182 patients with liver, biliary tract, or pancreatic disease. With anterior and lateral views of selective portograms and stereoscopic x-rays, we investigated the ramifications of the intrahepatic portal vein. There were 3 patterns of branching of the portal trunk and of the left branch of the portal vein. There were 8 such patterns for the right anterior branch, with either 4 or 5 major branches arising from it. Branching of the right posterior branch was classified into 4 patterns; simple branching into 2 (one, the posterior superior branch, the other, the posterior inferior branch) was found in only 97 of the 164 cases inspected. These results suggested that the liver cannot necessarily be divided into 8 segments. Branching of the intrahepatic portal vein is very complex; therefore, the pattern of ramifications of the portal vein must be ascertained anew for every patient for whom systematic segmentectomy is contemplated.

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Resumen Hemos realizado portografía percutánea transhepática (PPT) en 182 casos de enfermedad del hígado, del tracto biliar o del páncreas. Mediante el uso de proyecciones anterior y lateral, de portogramas selectivos y de radiografías estereoscópicas, procedimos a investigar las ramificaciones de la vena porta intrahepática. Se presentaron tres patrones de ramificaciones del tronco portal y de la rama izquierda de la vena porta. Se identificaron ocho de tales patrones para la rama anterior derecha, con 4 o 5 ramas principales originándose en ella. La ramificación de la rama posterior derecha fue clasificada en cuatro patrones; la simple ramificación en dos vasos (uno, la rama posterior y superior, el otro, la rama posterior e inferior) fue encontrada en sólo 97 de 164 casos inspeccionados. Estos resultados sugieren que el hígado puede no ser obligatoriamente dividido en 8 segmentos. La ramificación de la vena portal intrahepática es muy compleja. Es por ello que el patrón de ramificación de la vena porta debe ser establecido en cada paciente en quien se contemple realizar una segmentectomía sistemática.

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Résumé Les auteurs ont pratiqué 182 portographies percutanées transhépatiques au cours d'affections du foie, des voies biliaires et du pancréas. En se basant sur des clichés antérieurs et latéraux, des portogrammes sélectionnés, ils ont étudié les ramifications intrahépatiques de la veine porte. Ils ont pu établir ainsi: que le tronc porte et sa branche gauche présentent 3 types de branches terminales; que la branche portale antérieure droite se divise suivant 8 modalités en donnant 4 ou 5 rameaux principaux; et que la branche portale postérieure droite se divise suivant 4 modalités, la modalité la plus simple c'est à dire la division en 2 rameaux principaux (branche postéro-supérieure et branche postérieure inférieure) n'ayant été retrouvé que chez 97 des 164 cas étudiés. Ces constatations indiquent que le foie n'est pas toujours constitué de 8 segments et que la ramification portale intrahépatique est très complexe. Il en résulte que le mode de ramification intrahépatique de la veine porte doit Être établie par portographie chez tout sujet qui doit Être soumis à une segmentectomie hépatique.

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Presented at the 8th World Congress of the Collegium Internationale Chirurgiae Digestivae in Amsterdam, The Netherlands, September 1984.     

Limitations of percutaneous transhepatic cholangioscopy in the removal of complicated biliary calculi

To investigate the limitations of percutaneous transhepatic cholangioscopic lithotomy (PTCSL) in the management of retained or reformed biliary calculi, we conducted a retrospective study of 50 patients who had received PTCSL for complicated biliary calculi during a period of 32 months. The calculi were located in the common bile duct (24%), the intrahepatic bile ducts (60%), and in both the common bile duct and intrahepatic bile ducts (16%). The adjunctive techniques in PTCSL included balloon dilatation for the biliary stricture, electrohydraulic lithotripsy (EHL) for crushing large impacted stones, and flushing techniques, biliary spoons, and basket catheters for stone fragmentation and grasping. The overall percutaneous manipulations totaled 221 procedures, including 124 sessions of PTCS. In each patient, the number of sessions of PTCS varied from 1 to 7. In our series, the main complications of PTCS therapy, rarely reported in the literature, included pain intolerance in 7 cases (14%), minor bleeding in 7 cases (14%), and massive bleeding which needed angiographic diagnosis and therapy for hemostasis in 5 cases (10%). Secondary biliary cirrhosis, severe biliary stricture and angulations, previous shunt surgery, neovascularization surrounding the chronic inflammatory stenotic intrahepatic bile ducts, pseudoaneurysm formation, and coexistent cholangiocarcinoma contributed to the vulnerability of bleeding during manipulations. The complications resulted in treatment failure in 11 patients (22%). We conclude that PTCS is a useful alternative treatment to surgery for biliary calculi, but it has limitations that obviate complete stone clearance.

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Resumen Con el objeto de investigar las limitaciones de la litotomía colangioscópica percutánea transhepática (LCPT) en el manejo de cálculos biliares recurrentes o reformados, realizamos un estudio retrospectivo de 50 pacientes que habían sido sometidos a LCPT por cálculos biliares complicados en un período de 32 meses. Los cálculos estuvieron ubicados en el colédoco (24%), los canales intrahepáticos (60%) y el colédoco y los canales intrahepáticos (16%). Los procedimientos adyuvantes de la LCPT incluyeron dilatación con balón para estenosis biliares, litotripsia electrohidráulica (LEH) para destruir cálculos grandes impactados, y técnicas de lavado, cucharillas biliares, y catéteres de canastilla para la fragmentación y extracción. El total de manipulaciones percutáneas fue de 221 procedimientos que incluyeron 124 sesiones de CPT.En cada paciente individual el número de sesiones de CPT osciló entre 1 y 7. En nuestra serie la mayor complicación de la terapia CPT, por lo demás muy raramente reportada en la literatura, incluyó intolerancia al dolor en 7 casos (14%), hemorragia menor en 7 casos (14%), y hemorragia masiva que requirió diagnóstico angiográfico y terapia para hemostasia en 5 casos (10%). La cirrosis biliar secundaria, las estrecheces biliares severas con angulaciones, cirugía de derivación portacava previa, la neovascularización alrededor de ductos biliares intrahepáticos afectados por estenosis inflamatoria, la formación de pseudoaneurismas, y el colangiocarcinoma coexistente, fueron las entidades que contribuyeron a la vulnerabilidad a la hemorragia en el curso de las manipulaciones. Las complicaciones resultaron en falla del tratamiento en 11 pacientes (22%). Nuestra conclusión es que la CPT representa una alternativa útil a la cirugía en el tratamiento de cálculos biliares, pero que posee limitaciones que pueden impedir la remoción completa de los cálculos.

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Résumé Pour évaluer les limites de l'extraction lithiasique ou la lithotomie transhépatique percutanée par cholangioscopie (LTPCS) dans le traitement des lithiases biliaires résiduelles ou récidivées, nous avons étudié rétrospectivement les résultats chez 50 patients traités par la LTPCS pour complications lithiasiques pendant une période de 32 mois. Ces calculs étaient localisés dans la voie biliaire principale dans 24% des cas, dans les voies intrahépatiques dans 60% des cas, et dans les deux dans 16% des cas. Les techniques utilisées avec l'aide de la LTPCS étaient la dilatation des sténoses biliaires par cathéter à ballonnet, la lithotritie (électrohydraulique) pour faire éclater les lithiases de grosse taille, et les techniques de lavage, de draguage et de cathéters à panier pour fragmenter et récupérer les morceaux. On a pratiqué un total de 221 manipulations percutanées dont 124 séances de LTPCS chez les 50 patients.Chez chaque patient, le nombre de séances variait entre 1 et 7. Dans notre série, les complications principales de la LTPCS, rarement rapportées dans la littérature, ont été la douleur dans 7 cas (14%), une hémorragie mineure, dans 7 cas (14%), une hémorragie importante, nécessitant le recours aux moyens diagnostiques et thérapeutiques (embolisation) de la radiologie dans 5 cas (10%). La cirrhose biliaire secondaire, les sténoses et les coudures des voies biliaires, la chirurgie antérieure, la néovascularisation autour de l'inflammation chronique et sténosante des voies biliaires intrahépatiques, les formations pseudoanévrysmales et la coexistence de carcinome cholangiocellulaire contribuent à la fragilité hémorragique pendant ces manoeuvres. Les complications ont été la cause d'échec chez 11 patients (22%). Nous concluons que la LTPCS est une possibilité thérapeutique face à la chirurgie des lithiases biliaires mais elle a ses limites et ne réussit pas dans tous les cas.

     

经皮肝胆道镜术两种不同路径治疗复杂肝内外胆管结石的临床疗效比较

目的比较经皮肝胆道镜两种不同路径手术治疗复杂肝内外胆结石的临床疗效。方法以本院2014年1月~2016年6月收治的105例复杂肝内外胆管结石患者为研究对象,均行经皮肝胆道镜手术,根据术中不同路径将其分为A组(一步造瘘取石)与B组(二步造瘘取石),比较两组手术成功率、结石取净率、术中出血量、术后并发症等情况,并对两组手术前后细胞免疫功能测定。结果 A组手术成功率、结石取净率、术后并发症总发生率分别为92.00%、80.00%、28.00%,较B组的97.50%、82.50%、20.00%差异无统计学意义(P0.05);A组平均术中出血量、住院时间分别为(53.48±20.34)m L、(19.29±5.48)d,较B组的(39.15±16.87)m L、(22.58±5.56)d差异有统计学意义(P0.05);两组治疗前后CD3+、CD4+水平比较差异无统计学意义(P0.05)。结论经皮肝胆道镜一步造瘘法、二步造瘘法在复杂肝内外胆管结石患者结石取净、并发症方面上效果类似,且对机体免疫功能影响小,但一步造瘘法术中出血量相对明显多,而住院时间显著短。     

Ultrasonic guided percutaneous transhepatic bile drainage for cholangitis due to intrahepatic stones

Acute cholangitis due to intrahepatic stones is frequently associated with biliary sepsis. Emergency surgery for these high-risk patients is usually associated with a high mortality. Therefore, we recommend nonoperative methods for the management of this acute disease. Percutaneous transhepatic cholangiography and drainage (PTCD) combined with antibiotic and fluid treatment was used successfully in the management of 41 patients with acute pyogenic cholangitis due to intrahepatic stones. The general condition of these patients improved after treatment with PTCD. Repeated cholangiography should be performed so that the entire biliary tree and lesions can be viewed. Elective surgery (21 patients) or removal of the stone through the sinus tract via PTCD (14 patients) was performed when the patients' general condition improved following emergency PTCD. Therefore, we recommend PTCD over emergency surgery in the treatment of acute septic intrahepatic stones.     

Diagnosis and management of benign biliary strictures with percutaneous transhepatic cholangioscopy (PTCS)]

From January 1981 through March 1991, we encountered twenty four cases of benign biliary strictures. In 10 cases of anastomotic stricture, percutaneous dilatation was carried out in 1 patient under fluoroscopy and in 3 patients under PTCS without recurrence. Endoprosthesis with silicone or polyurethane catheters was carried out under PTCS in 5 patients. One of them died of hepatic failure due to clogging of the catheter, and in other four patients the endoprosthetic catheter was dislodged spontaneously or removed by PTCS because of dislodgement or obstruction of the catheter, and PTCS revealed that the anastomotic stricture had improved. Reoperation of cholangiojejunostomy was carried out in 1 patient, who died of hepatic failure 5 years later due to recurrent of stricture. In 8 cases of the iatrogenic and 1 case of traumatic stricture, percutaneous dilatation was carried out (1 under fluoroscopy and 4 under PTCS) without recurrence. Cholangiojejunostomy was carried out in 3 cases without anastomotic stricture. PTCS was performed for 5 cases of the inflammatory stricture of the hepatic hilus due to cholecystitis to confirm the histological findings by cholangioscopic biopsy. And all cases could be managed by cholecystectomy. Authors recommend that PTCS should be used for the diagnosis and treatment of benign biliary stricture.     

数字医学技术在经皮肝胆道镜碎石治疗肝胆管结石病中的应用

目的 探讨医学图像三维可视化系统(MI-3DVS)在经皮肝胆道镜碎石(PTCSL)治疗肝胆管结石病中的临床应用价值.方法 回顾性分析2007年1月至2012年9月两家临床研究中心收治的66例肝胆管结石病患者(南方医科大学附属顺德第一人民医院55例、南方医科大学珠江医院11例)的临床资料.运用MI-3DVS对CT图像进行三维重建,明确结石分布范围、数量、大小、形状等特点,以及与周围肝组织、血管、胆管的关系;术前确定疾病分型,制订PTCSL手术预案,指导施行PTCSL手术,根据术中及术后恢复情况综合评价三维重建可视化技术的应用价值.患者术后采用电话、门诊复查等方式进行随访.结果 采用MI-3DVS成功完成66例患者肝脏、胆道系统、结石、血管三维重建;清晰显示结石的大小、数量、形态、空间位置,胆管狭窄的位置、程度、长度以及周围血管的空间解剖关系.PTCSL手术预案与实际手术的符合率为95.5％(63/66).63例患者手术时间为(117±9)min,术中出血量为(18±1)ml,术后结石清除率为92.4％(61/66),术后并发症发生率为6.1％(4/66),术后住院时间为(15 ±4)d.本组患者随访时间截至2012年9月,中位随访时间为16个月(1～69个月),随访率为100.0％(66/66),术后结石复发率为9.1％(6/66),术后因肿瘤转移并发MODS死亡1例.结论 应用MI-3DVS对肝胆管结石病患者进行诊断和指导PTCSL手术,可有效提高PTCSL手术的安全性和有效性.     

Percutaneous transhepatic cholangioscopy in the treatment of complicated intrahepatic biliary strictures and hepatolithiasis with internal metallic stent

For recurrent hepatolithiasis coexisting with a complicated long-segment intrahepatic biliary stricture, repeated surgeries, balloon dilation of the stricture, and external-internal stenting may still fail to solve the problem. We tried using a Gianturco-Rosch metallic Z internal stent (Wilson-Cook Medical, Inc., Bloomington, IN, USA) with the aid of percutaneous transhepatic cholangioscopy (PTCS) to treat such patients. Eight patients had a Z stent placed through a percutaneous transhepatic biliary drainage tract. Immediately after stent placement, PTCS was inserted via the percutaneous transhepatic biliary drainage route and a part of the wire skirt not firmly anchored in one of the eight patients was detected. It was successfully repositioned using PTCS. Recurrent cholangitis developed in three patients 6, 7, and 30 months, respectively, after stent placement. PTCS was undertaken again through a reestablished percutaneous transhepatic biliary drainage route and revealed sludge in their stent lumens. We cleared it by PTCS. No further cases of cholangitis occurred in later follow-up. PTCS is useful in ensuring adequate stent position, diagnosing and treating the causes of recurrent cholangitis, and prolonging the function of stents.     

Experience with percutaneous transhepatic cholangioscopy (PTCS) in the management of biliary tract disease

Background: Biliary tract disorders often present significant management difficulties, particularly in patients who are poor surgical candidates. Percutaneous transhepatic cholangioscopy (PTCS) is an infrequently utilized alternative that might offer significant therapeutic benefit. We reviewed our experience with the use of this modality as a definitive therapy for biliary tract disorders. Methods: Patient records at the Atlanta VAMC and Emory University hospitals were reviewed. We identified 17 patients who had undergone 25 PTCS interventions between August 1994 and December 1998. The indications for PTCS included dilatation of biliary-enteric anastomoses in four patients, biliary stone removal (with or without lithotripsy) in eight patients, stricturoplasty in four patients, biopsy of suspected biliary neoplasms in seven patients, and removal of obstructing clot in one patient. Most procedures (n= 17) were performed through percutaneous transhepatic tracts (12–18 Fr) that were <1 week old. All tracts were dilated to operating size on the day of the procedure. All patients received periprocedural antibiotics. Results: The interventions were successful in seven of eight stone removals, four of five stricturoplasties, three of four anastomotic dilatations, seven of seven biopsies, and the single clot removal. The only complication involved one episode of hemobilia, requiring angio-embolization of a small branch of the right hepatic artery. Conclusions: PTCS is a safe, useful, and well-tolerated adjunct to the more common endoscopic and surgical techniques for managing complicated biliary tract disorders. Our experience suggests that PTCS can be performed early, without prolonged sequential dilatation of the percutaneous transhepatic tract, and may allow avoidance of operation in high-risk surgical candidates. Received: 1 April 1999/Accepted: 2 July 1999     

Branching patterns of the intrahepatic portal vein and hepatic segments identified by percutaneous transhepatic portography

We studied branching of the intrahepatic portal vein and hepatic segment by percutaneous transhepatic portograms in 237 patients with liver, biliary tract, or pancreatic disease. At the hilum, the pattern was normal in 74% of the patients. In the others, branching of the right posterior branch was trifurcated or independent. Caudate branches usually ramified from first-order branches, but sometimes ramified from the right posterior branch. The left portal branch divided into a laterodorsal branch (second-order) and umbilical portion, from which the lateroventral branch (third-order) and several medial branches (fourth-order) arose. It seems to be better to divide the left lobe into anterior segment (supplied by medial and a lateroventral branch) and posterior segments (supplied by a laterodorsal branch) than into the lateral and medial segments. The right anterior branch of 27% of the patients was bifurcated. In the others, there were six other patterns, with four or five fourth-order branches arising from this branch. The anterior segment should be considered having not two subsegments, but four or five small subsegments. Small branches divided off from the main trunk of the right posterior branch. In resection for hepatoma, each such branch can be thought of as one small subsegmental branch.     

Reappraisal of percutaneous transhepatic cholangioscopic lithotomy for primary hepatolithiasis

BACKGROUND: A review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery. METHODS: A retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome. RESULTS: Complete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p < 0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p < 0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p < 0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p > 0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p > 0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p < 0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p < 0.01). CONCLUSIONS: The findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.     

A case of renal failure due to primary cholesterol atheroembolism

We report a patient presenting rapid deterioration of renal function due to primary cholesterol atheroembolism. The patient was 75-year-old hypertensive male and was admitted to a hospital because of rt. hemiplegia which developed 2 weeks earlier. On admission, his blood pressure was 200/100 mmHg and serum creatinine level was 2.9 mg/dl with urinalysis 1+ both for protein and hematuria. 2 weeks later, an angiotensin converting enzyme inhibitor (ACE inhibitor, delapril 15 mg/day) was given to control high blood pressure. Immediately after this medication, his renal failure rapidly progressed with a fall in blood pressure (110/60 mmHg) and oliguria (100 ml/day). Although he was transferred to our hospital and was treated with hemodialysis, he died of an attack of acute myocardial infarction in a week. At post-mortem examination, microscopic findings of the kidney disclosed numerous occlusions of medium-sized artery by cholesterol emboli. These emboli were also observed in other organs, but not so prominent as in the kidney. The coronary arteries exhibited severe sclerosis. In this presented case, acute deterioration of renal function was caused by ACE-inhibitor, although which was administered in a volume depleted condition. Therefore, further study would be necessary whether or not ACE-inhibitors predispose the patients with this disease to acute renal failure.     

经皮肝胆道硬镜碎石术治疗肝内胆管结石68例临床分析

目的探讨经皮肝胆道硬镜碎石术治疗肝内胆管结石的有效性和安全性。方法回顾性分析我院2014年1月至2015年7月68例应用经皮肝胆道硬镜碎石术治疗肝内胆管结石患者的临床资料。结果 68例患者均成功施行经皮肝胆道硬镜碎石术,其中56例一次性取净结石,结石取净率为82.4%(56/68),12例经2次、3次手术取净结石。手术时间50~210 min,平均100.0±12.5 min;取石次数为1~3次,平均1.2±0.9次;术中出血量2~180 mL,平均20.0±5.5 mL;住院3~21 d,平均8.0±3.1 d。术后并发右侧胸腔积液1例,并发症发生率为1.5%,术后未发生胆漏、严重出血等并发症。随访2年,3例结石复发,复发率为4.4%。结论经皮肝胆道硬镜碎石术对于肝内胆管结石的治疗是微创、安全和有效的,但并发症、解释残余率高是其实施的主要限制。     

全腹腔镜肝叶切除联合经皮经肝胆道硬镜治疗左肝内胆管结石的效果

目的探讨模式化全腹腔镜肝叶切除联合经皮经肝胆道硬镜碎石治疗左肝内胆管结石的临床疗效。 方法回顾性选取2015年1月至2017年12月期间100例左肝内胆管结石患者为研究对象,根据手术方式分为腹腔镜联合胆道镜组(腔镜组,n＝50)和开腹联合胆道镜组(开腹组,n＝50),采用SPSS19.0软件进行数据分析。术中术后等计量资料采用均数±标准差描述,组间比较采用独立t检验;术后残石、并发症、近期疗效和复发情况等分类资料和有序资料组间比较采用Pearson χ²检验、Kruskal－Wallis检验。P<0.05为差异有统计学意义。 结果两组的手术时间差异无统计学意义(P>0.05);腔镜组术中出血量、术后下床锻炼时间、肠道排气时间和住院时间显著优于开腹组(P<0.05);两组患者术后2周的ALT、AST、TBIL水平均较术前显著下降,且腔镜组的ALT、AST水平显著低于开腹组(P<0.05);腔镜组总并发症发生率显著低于开腹组(10.0% vs. 26.0%),P<0.05;腔镜组的近期疗效显著优于开腹组(P<0.05),两组的术后1年复发率差异无统计学意义(P>0.05)。 结论模式化全腹腔镜肝叶切除联合经皮经肝胆道硬镜取石术治疗左肝内胆管结石安全有效,具有术后恢复快、并发症少、临床疗效好的优点,具有较好的临床使用价值。