肝内结石的手术抉择

肝内结石的手术抉择西安医科大学第一附属医院肝胆外科研究室（西安，７１００６１）石景森历经数十年的不断努力，肝内胆管结石的外科治疗效果已有明显提高，然而胆道的残石，症状复发，进行性肝脏损害诸多问题与手术的抉择仍应不断地探索改进治疗技术。黄志强提出的肝胆...     

肝内胆管结石的手术治疗

为了解肝内胆管结石的手术治疗效果。方法：对手术治疗的１２０例肝内胆管结石及合并肝内胆管狭窄的病例进行随访研究。手术方法为：（１）肝门部大口径胆吻合术４４例，（２）胆管切开取石引流术３５例；（３）胆肠内引流术３７例；（４）肝脏部分切除术４例。结果：随访发现，肝门部大口径胆肠吻合术和肝脏部分切除术疗效好，优良率分别为８４％和７５％，而胆管切开取石引流术和胆肠内引流术疗效不理想。结论 肝门部大口径胆肠吻     

肝内胆管结石的手术治疗体会

本院从1984．1～1995．12经手术治疗肝内胆管结石32例，疗效较满意，现将我们的体会报告如下。116床资料1．1一般资料本组男15例，女17例，年龄33～64岁。病史中均有典型的胆道病史，最长达20余年。其中2例系2次手术。急诊手术6例，择期手术26例。1．2术前检查本院1986年以前3例以急腹症剖腹探查，术中发现肝内胆管结石。1986年后，均行B超检查，29例均提示肝内胆管结石，1988年后术前PTC检查15例，CT检查2例。1．3结石分布及胆管狭窄部位结石位于左肝管18例，右肝管7例，双侧肝管7例，31例合并胆总管结石，有2例胆总管内有死蛔虫体。左…     

肝内胆管结石应用术中B超的价值

自１９９１年１０月～１９９２年１１月，作者应用术中Ｂ超指导肝内胆管结石的治疗４５例。其中指导硬质胆镜取石３０例；肝切除术１１例；肝实质切开取石４例。本文对其在肝内胆管结石治疗中的实用价值进行了讨论。     

肝内胆管结石的外科治疗

肝内胆管结石在我国属常见病 ,病因至今仍未阐明。在治疗方面 ,现有治疗方法的疗效均不够理想 ,手术治疗后的结石残留率在 30 %以上 ,再次手术率也高达 37%。本文结合作者在这方面的诊治体会 ,对肝内胆管结石在治疗过程中的几个问题进行讨论。1　术前诊断的目标与方法目前 ,作出肝内胆管结石的诊断已无困难 ,但这样的诊断远远不能满足对肝内胆管结石进行治疗的要求。从治疗的角度来考虑 ,术前诊断至少应达到如下几个目标 :1明确结石在肝内的分布情况 ,确定结石是在肝脏的哪一叶、哪一段、哪一级胆管。 2明确肝内胆管病变情况 ,尤其要确定有…     

肝内胆管结石术中结石残留原因浅析

肝内胆管结石术中结石残留问题一直受到普遍关注，本文对我科１９８９～１９９７年经手术治疗的１２８例肝内胆管结石进行了总结，分析了手术中２４例结石残留的原因，并对残留结石的防治进行讨论。１临床资料本组病人１２８例，其中男性５７例，女性７１例，年龄１７～７...     

肝内胆管结石112例手术治疗

目的:探讨肝内胆管结石的手术治疗及术后残石对策.方法:回顾性分析肝内胆管结石112例临床资料,行肝叶(段)切除术29例,肝叶(段)切除+胆管空肠Roux-en-Y吻合术8例,肝叶(段)切除+胆总管切开取石术6例,胆总管切开取石+胆管空肠Roux-en-y吻合术20例,胆总管切开取石+T管引流术49例.结果:术后残石28例(25.0%),经胆道镜等技术取石后残石4例(3.6%),再次手术2例(1.8%).结论:残石率为3.6%,解除梗阻,去除病因是治疗肝内胆管结石的基本原则,合理选择手术方式,术中和术后配合胆道镜治疗,可有降低残石率.     

肝内胆管结石的手术选择

近年来,胆石症的发病谱已发生了根本性的变迁,一些大城市的胆囊结石发病率逐步增加,过去常见的肝内胆管结石已明显减少; 但多数地区肝内胆管结石发病率仍较高,仍是我国的常见病之一,其治疗也仍是胆道外科中的困难问题.运用现代肝脏外科手术技术,处理肝门部和肝内胆管及血管,获得良好的显露,基本上可达到"解除梗阻,去除病灶,通畅引流"的肝胆管结石外科治疗原则.由于肝内胆管结石本身的复杂性,目前尚无一种手术方式可使所有患者获得满意效果,因此,应根据患者的实际情况采用"个体化治疗方案".常用的手术方法有胆管探查取石、胆肠引流、肝叶切除术等.根据病情、患者的身体素质、技术条件和病变的性质等综合考虑来决定术式.     

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.     

The significance of hepatectomy for primary intrahepatic stones

(Received for publication on Aug. 13, 1998; accepted on Mar. 11, 1999)     

肝内胆管结石内镜诊治进展

肝外胆管结石的内镜治疗已经很成熟了,但是因为种种原因,肝内胆管结石的内镜治疗却面临着诸多困难与挑战。随着新型设备的诞生和技术的进步,肝内胆管结石的内镜治疗迎来了新的机遇,包括经口胆管镜技术、超声内镜技术等均已显示出良好的应用前景,内镜治疗将成为肝内胆管结石治疗中不可或缺的重要组成部分。     

Clinical significance of intrahepatic biliary stricture in efficacy of hepatic resection for intrahepatic stones

In the Far East, hepatic resection is the definitive treatment for complicated intrahepatic stones (IHS). However, many investigators have reported that the associated intrahepatic biliary stricture is the main cause of treatment failure. A retrospective comparative study was undertaken to clarify the long-term efficacy of hepatic resection for treatment of IHS and to investigate the clinical significance of intrahepatic biliary stricture in treatment failure after hepatic resection performed in 44 patients with symptomatic IHS. The patients were divided into two study groups: group A, with intrahepatic biliary stricture (n = 28) and group B, without stricture (n = 16). Residual or recurrent stones, recurrence of intrahepatic biliary stricture, late cholangitis, and final outcomes were analyzed and compared statistically between the two groups. The patients were followed up for a median duration of 65 months after hepatectomy. The overall incidence of residual or recurrent stones was 36% and 11%, respectively, in groups A and B. The initial treatment failure rate was 50% in group A and 31% in group B. Intrahepatic biliary stricture recurred in 46% of patients in group A, while none of the group B patients had biliary stricture recurrence (P = 0.001). More than two-thirds of the restrictures in group A were identified at the primary site. The incidence of late cholangitis was higher in group A (54%) than in group B (6%) (P = 0.002). Three-quarters of the patients with cholangitis in group A had severe cholangitis, that was recurrent, and related to stones and strictures (n = 11). They and 2 asymptomatic patients in group B required secondary procedures done at a median of 12 months after hepatectomy. Final outcomes after hepatectomy with or without secondary management were good in 80%, fair in 16%, and poor in 4% of our 44 patients. Most recurrent cholangitis after hepatectomy in patients with IHS was related to recurrent intrahepatic ductal strictures. Therefore, to be effective, hepatic resection should include the strictured duct. However, with hepatectomy alone it is difficult to clear the IHS or relieve the ductal strictures completely, particularly in patients with bilateral IHS, so perioperative team approaches that include both radiologic and cholangioscopic interventions should be combined for the effective management of IHS. Received for publication on Oct. 15, 1997; accepted on Feb. 2, 1998     

复杂肝内胆管结石的取石策略

目的探讨复杂肝内胆管结石取石技巧,尽量降低残石率。方法回顾性分析近四年来我院收治的复杂肝内胆管结石病例225例,术中首先用取石钳钳取胆总管、肝门部胆管结石,其次胆道镜检查胆道系统,确定取石策略。然后应用取石钳钳取、胆道镜取石网篮套取、活检钳咬碎、冲击波碎石、脉冲式冲洗等多种方法联合取石,部分病人结合肝叶切除、胆肠吻合等术式。结果行胆道引流术者(含肝叶切除术)201例行T管造影结石取尽133例,结石取尽率66.2%(133/201)。行胆肠吻合术者4例术后残余结石伴胆管炎。无死亡病例。结论肝内胆管复杂结石治疗棘手,术前应准备充分、准确评估、术中遵循基本手术原则、联合多种方法取石,争取获得最佳手术效果。     

末梢型肝内胆管细胞癌的诊断及外科治疗效果分析

目的 探讨末梢型肝内总胆管细胞癌（PIHCC）的诊断及外科治疗结果,以提高其诊治水平。方法 回顾性分析1970－1999年间外科治疗的20例PIHCC患者诊断、治疗及预后的资料。结果 （1）本病缺乏特异性临床表现,部分病例可并发乙型肝炎（35．0％）、肝硬化（45．0％）和血清AFP升高（25．0％）;（2）影像学检查：B超、CT、MRI及ECT的诊断率分别为90．0％（18／20）、94．4％（17／18）、3／3及4／3;（3）手术切除率为60％,全组病例的1、3、5年生存率分别为55．0％（11／20）、35．0％（7／20）及20．0％（4／20）,其中肝切除术病例分别为83．3％（11／12）、58．3％（7／12）、33．3％（4／12）;（4）生存5年以上的4例患者中,直径≤3cm的小肝癌3例、包膜完整的结节型大肝癌1例,且术后均辅助选择性肝动脉灌注化疗,有助于生存率的提高。结论 本病缺乏特异性血清肿瘤标志物,治愈性切除术（包括术后辅助治疗）可获得良好生存率。     

术中超声用于腹部外科手术研究进展

术中超声(IOUS)是腹部外科手术中最便捷的实时成像技术,能通过高分辨率图像提供更丰富、细微的诊断信息,帮助术中及时、准确地弥补术前诊断及手法探查的不足,优化手术流程,引导完成多种介入性操作,有效减少并发症发生。近年来IOUS发展迅速,为腹部外科精准化、微创化发展提供了有力支持。本文就IOUS用于腹部外科手术的研究新进展进行综述。     

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.     

手术治疗肝内胆管结石的探讨

目的探讨手术治疗肝内胆管结石的策略。方法回顾性分析2002年11月至2009年3月666例肝内胆管结石的临床资料,按手术方式分为三组：A组切开胆总管取石;B组切除萎缩的肝叶及肝段并切开胆总管或肝断面的胆管取石;C组切除肝外狭窄胆管（包括先天性的胆道扩张症）取石并行胆道与肠道的消化道重建术。结果三组的手术的成功率均为100％,肝内的结石均取干净。手术难度及风险C组〉B组〉A组,C组可能出现吻合口漏。结论在没有肝段及肝叶纤维化及萎缩,没有肝内外胆管管状狭窄及先天性胆管扩张症的情况下,应采取A组手术方式。     

Postoperative choledochofiberscopic removal in intrahepatic stones

An endoscopic approach for the diagnosis and treatment of intrahepatic stones is presented based on the experience of 4 cases, in which complete removal of intrahepatic stones was done by postoperative choledochoscopy. Postoperative choledochoscopy for the diagnosis and treatment of gall-stone disease is not difficult to perform. The choledochofiberscope is inserted into the bile duct via choledochal fistula 3 weeks after the operation. Stones are crushed or grasped with forceps under direct vision. In some cases, the stricture in the intrahepatic biliary tree is dilated with the use of a high frequency waves cutting knife to facilitate stone removal. In fact, over 410 stones were successfully removed in one case by 28 postoperative choledochoscopies without any complications. The details of the choledochofiberscope developed by us with the close cooperation of Machida Company of Tokyo was presented. Postoperative choledochoscopy seems to be a safe and simple procedure and is useful in the treatment of intrahepatic stones.