肝左外叶切除术在左肝胆管结石治疗中的地位(附112例临床分析)

为了探讨肝左外叶切除术在孤立性左肝胆管结石（ＬＬＨ）外科治疗中的地位，对２０年收治的１１２例ＬＬＨ进行回顾性临床分析。结果：①ＬＬＨ的常见病理类型是同时累及左外肝管（ＬＥＨＤ）和左内肝管（ＬＭＨＤ），占８３１％，孤立性ＬＥＨＤ或ＬＭＨＤ结石分别为１２３％和０。②左肝管狭窄合并率为５９８％，ＬＥＨＤ和ＬＭＨＤ分别为８４０％和８４８％，均以重度狭窄为主。③左半肝切除术较肝左外叶切除术的结石残留率低（７１％ｖｓ２１２％，Ｐ＜００１），随访良好率高（８５７％ｖｓ４７０％，Ｐ＜００５）；临床上对ＬＬＨ主要采用肝左外叶切除术为主的综合治疗（５８９％），左半肝切除术仅占１２５％。④影响远期疗效的主要原因是ＬＭＨＤ结石残留或复发和对左肝管狭窄处理不当，分别占６２５％和３７５％。⑤左半肝切除术在手术用时、术中失血、术后并发症等方面与左外肝切除术无明显差异。认为大多数ＬＬＨ的病理改变系弥漫性（左内和左外均有）和多级性（一、二级肝管均受累），用肝左外叶切除术处理常可导致ＬＭＨＤ和左肝管病变遗留，影响远期治疗效果，以左半肝切除术为主的综合治疗是左内肝管受累时首选而且安全的治疗方式     

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目的 分析胆肠吻合术治疗肝内胆管结石并胆道狭窄的选择和疗效。方法 对１９９１年９月至１９９８年１２月６９例行胆肠吻合术的肝内胆管结石并胆道狭窄病例进行总结,包括临床表现、结石部位、狭窄情况、手术方式和治疗效果等。结果 胆管狭窄主要位于１￣２级胆管内。５１例（７３．９％）行肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,１８例（２６．１％）采用胆总管十二指肠吻合术,随访结果表明,肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合     

肝段联合切除治疗肝内胆管结石及狭窄

目的 探讨肝内胆管结石合并肝内胆管狭窄的手术治疗措施。方法 1994年1月至2002年1月共施行肝段切除治疗肝内胆管结石病人338例。Ⅱ、Ⅲ段联合切除284例，Ⅱ、Ⅲ、Ⅳ段联合切除8例，Ⅴ、Ⅵ段联合切除14例，Ⅵ、Ⅶ段联合切除9例，Ⅱ、Ⅲ、Ⅴ、Ⅵ段联合切除6例，Ⅱ、Ⅲ、Ⅵ、Ⅶ段联合切除5例，Ⅳb段切除12例。结果 本组中3例手术后死亡。28例存在肝内胆管的残余结石，残余结石发生率为8．28％。手术结合纤维胆道镜取石，取净率为97．93％。结论 联合肝段切除为治疗肝内胆管结石并狭窄的有效措施，手术结合术后纤维胆道镜取石能明显提高肝内胆管结百并狭窄的治愈率。     

肝内胆管结石患者行腹腔镜左肝切除术后远期生存质量的影响因素分析

目的:探讨肝内胆管结石行腹腔镜左肝切除术后远期生存质量的影响因素.方法:回顾分析2010年1月至2017年12月216例肝内胆管结石患者行腹腔镜左肝切除术的临床资料,根据远期生存质量情况分组,分析患者术后远期生存质量的影响因素.结果:79例行左半肝切除术,137例行左外叶切除术;术后随访25～80个月,中位随访时间34...     

左肝外侧叶切除术在肝内胆管结石治疗中的作用

目的 了解左肝外侧叶切除术在胆道结石中的治疗作用。方法 总结分析过去14年行左肝外侧叶切除治疗肝内胆管结石51例。结果 疗效优良率87.5％。结论 左肝外侧叶切除不但能切除病灶,而且可经左肝断面的扩张胆管为“借路”,取除其他部位肝内、外胆管的结石,以及便于肝门部狭窄胆管的整形。该手术操作简便、可行,在肝内胆管结石的治疗中可广泛应用。     

Wedge resection of the portal bifurcation concomitant with left hepatectomy plus biliary reconstruction for hepatobiliary cancer

Background/Purpose: We report our experience performing wedge resection of the portal bifurcation and transverse suture closure in patients undergoing left hepatectomy and caudate lobectomy plus biliary reconstruction for hepatobiliary cancer. Methods: The procedure was performed in three patients with hilar or intrahepatic cholangiocarcinoma. After confirming that tumor invasion of the portal bifurcation was not circumferential, the portal trunk and the right posterior and right anterior portal branches were isolated and clamped. Wedge resection of the portal bifurcation was performed, taking care to secure a clear surgical margin. The edges of the portal vein were approximated, using guy-sutures in the dorsal and ventral edges and a temporary central guy-suture, and portal reconstruction was carried out using a continuous transverse suture. After unclamping, good portal flow was confirmed by color Doppler ultrasonography. Results: The procedure was completed successfully in all three patients; the average time of portal vein occlusion was 15 min. Two patients had postoperative complications: bile leakage and wound infection, but no patient developed postoperative hepatic failure or died. The three patients are alive without recurrence at 2, 11, and 22 months after the operation. Conclusions: Wedge resection of the portal bifurcation is easier and simpler than using a venous patch or performing segmental resection. Received: March 31, 2002 / Accepted: June 10, 2002 Offprint requests to: S. Kondo Presented at the 5th World Congress of the International Hepato-Pancreato-Biliary Association, April 25–29, 2002, Tokyo     

肝切除术治疗肝胆管结石的疗效观察

目的:观察应用肝切除术治疗肝胆管结石的疗效。方法:在135例手术治疗的肝胆管结石病人中,61例(45.2%)采用了肝切除术(研究组),74例术中未采用肝切除术(对照组)。比较两组的疗效和并发症的发生率。结果:研究组治愈率(98.4%)高于对照组(85.1%)(P<0.05),残石率(9.8%)低于对照组(29.7%)(P<0.01),而两组的手术并发症并无显著差异(P>0.05)。研究组术后2年和5年随访的疗效优良率(分别为94.2%和89.1%)显著高于对照组(分别为73.3%和68.6%)(P<0.01和P<0.05)。结论:应用肝切除术治疗肝胆管结石的疗效好于对照组病例。     

腹腔镜规则性左肝外侧叶切除术10例分析

目的:总结腹腔镜左肝外侧叶切除术经验。方法:2004年12月至今我们共完成10例完全腹腔镜下规则性左肝外侧叶切除术,其中原发性肝细胞癌6例,肝血管瘤2例,结肠癌肝转移2例。结果:10例均在完全腹腔镜下成功完成规则性左肝外侧叶切除,平均手术时间100m in,平均术中出血量少于100m l,术后腹腔引流管放置3~4d,术后平均住院5d,术后无出血及胆漏并发症。结论:腹腔镜规则性左肝外侧叶切除可作为左肝外侧叶切除术的金标准。     

经肝管窦道纤维胆道镜取石配合手术治疗复杂肝内胆管结石

我们对7例复杂肝内胆管结石患者施行肝部分切除、左右肝管劈开取石、肝管空肠Roux－y吻合、肝内胆管量管引流水，水后经引流管胆道造影以了解术后残余结石。如果存在残余结石则经肝管窦道行纤维胆道镜取石。共取石11次，每例患者最多3次，最少1次，平均1．6次。全部病例经纤维胆道镜检查及再次胆道造影，均证实取净残余结石。     

Applying chemical bile duct embolization to achieve chemical hepatectomy in hepatolithiasis: a further experimental study

Background

Hepatolithiasis is the presence of calculi within the bile ducts of the liver. It represents a significant problem for hepatobiliary surgery because of its high recurrence rate and the associated risk for partial hepatectomy. This study was designed to explore the long-term efficacy of chemical biliary duct embolization (CBDE) to treat recurrent hepatolithiasis.

Materials and methods

A rabbit model of hepatolithiasis was established, and CBDE was achieved using oxybenzene and N-butyl-cyanoacrylate. The short-term (6 wk) and long-term (12 wk) efficacy of CBDE treatment was compared by observing the degree of atrophy, fibrosis, proliferation of collagen fibers, and apoptosis of hepatocytes and hepatic stellate cells in the embolized hepatic lobe. Biochemical measurement of β-glucuronidase was also evaluated to determine the effect of CBDE on stone formation.

Results

Six weeks after CBDE, there was liver cell destruction, collagen accumulation, and bile duct proliferation only in the peripheral part of the target lobe. Twelve weeks after CBDE, “self-cut” chemical hepatectomy was achieved, as manifested by the destruction of almost all the hepatocytes in the target lobe, bile duct proliferation, and collagen fiber accumulation. The β-glucuronidase activity was markedly lower in the embolized lobe than in the nonembolized lobe. In contrast, bax, caspase-3, caspase-9, and α-smooth muscle actin expression was substantially higher in the embolized lobe than in the sham-operation group at 6 wk, but was lower at 12 wk.

Conclusions

CBDE is a potentially effective therapeutic approach for treating and preventing the recurrence of hepatolithiasis.     

腹腔镜下胆管切开取石一期胆管缝合应用于高龄患者的安全性探讨

目的：探讨腹腔镜下胆管切开取石后一期缝合胆管而不放置胆管引流在高龄患者中的安全性和可行性。方法回顾性分析2007年1月至2012年10月接受腹腔镜下胆管切开取石后不放置胆管引流的高龄病例临床资料,共16例作为研究组,收集同时期接受腹腔镜下胆管切开取石不放置胆管引流管的非高龄病例20例作为对照组。对比分析两组患者的平均手术时间、住院时间、术后并发症情况等。结果两组患者术后均康复出院。研究组平均手术时间为（116.31±11.31）min,平均住院时间（10.19±1.22）d;而对照组平均手术时间为（106.80±10.58）min,平均住院时间（7.65±0.88）d;两组比较差异无统计学意义。两组均无胆漏、腹腔出血、膈下感染及术后阻塞性黄疸等术后并发症。两组的切口感染、肺部感染率和结石复发率差异无统计学意义。结论腹腔镜下胆管切开取石后一期缝合胆管而不放置胆管引流用于高龄患者是安全、可行的。     

Subacute liver and respiratory failure after segmental hepatectomy for complicated hepatolithiasis with secondary biliary cirrhosis: A case report

BACKGROUNDDespite being a benign disease, hepatolithiasis has a poor prognosis because of its intractable nature and frequent recurrence. Nonsurgical treatment is associated with high incidences of residual and recurrent stones. Consequently, surgery via hepatic lobectomy or segmental hepatectomy has become the main treatment modality. Clinical management and resolution of complicated hepatolithiasis with bilateral or diffuse intrahepatic stones remain very difficult and challenging. Repeated cholangitis and calculous obstruction may result in secondary biliary cirrhosis, a limiting factor in the treatment of hepatolithiasis.CASE SUMMARYA 53-year-old woman with a 5-year history of intermittent abdominal pain and fever was admitted to the hepatopancreatobiliary surgery department following worsening symptoms over a 3-d period. Blood tests revealed elevated transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, and total bilirubin, as well as anemia. Magnetic resonance cholangiopancreatography showed dilatation of the intrahepatic, left and right hepatic, common hepatic, and common bile ducts, and multiple short T2 signals in the intrahepatic and common bile ducts. Abdominal computed tomography showed splenomegaly and splenic varices. The diagnosis was bilateral hepatolithiasis and choledocholithiasis with cholangitis. Surgical treatment included hepatectomy of segments II and III, cholangioplasty, left hepaticolithotomy, second biliary duct exploration, choledocholithotomy, T-tube drainage, and accretion lysis. Surgical and pathological findings confirmed secondary biliary cirrhosis. Liver-protective therapy and anti-infectives were administered. The patient developed liver and respiratory failure, severe abdominal infection, and septicemia. Eventually, her family elected to discontinue treatment.CONCLUSIONLiver transplantation, rather than hepatectomy, might be a treatment option for complicated bilateral hepatolithiasis with secondary liver cirrhosis.     

腹腔镜胆总管切开取石术的并发症及防治

目的 :探讨电视腹腔镜胆总管切开纤维胆道镜取石T形管引流术 (LCHTD)的并发症及防治措施。方法 :回顾分析LCHTD186例的临床资料。 186例中 15 0例行胆囊切除加胆总管切开术取石 ,36例单纯行胆总管切开术取石。结果 :186例中成功 183例 ,3例中转开腹 ,术中及术后 11例发生并发症 ,其中术中出血 2例 ,术后胆道出血 1例 ,胆管残留结石 3例 ,胆漏 2例 ,腹腔残石致腹腔感染 1例 ,T形管早期脱落 1例 ,胆囊管钛夹脱落于T形管窦道壁内 1例。患者均获治愈 ,无死亡病例。结论 :对电视腹腔镜胆总管切开纤维胆道镜取石T形管引流术的并发症应予以重视 ,掌握适应证 ,提高操作熟练程度 ,及时发现并采取积极治疗措施 ,以减少和防止严重并发症的发生     

Laparoscopic hepatectomy for hepatolithiasis: a feasibility and safety study in 29 patients

Background Hepatolithiasis is a prevalent disease in Southeast Asia. Heaptectomy was considered the best treatment for majority of cases. Laparoscopic hepatectomy is a new procedure for liver lesions that uses a minimal invasive approach. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy for hepatolithiasis by comparing it with open hepatectomy. Methods From November 2002 to March 2006 a total of 30 consecutive patients underwent laparoscopic hepatectomy for hepatolithiasis in Sir Run Run Shaw Hosptial. Twenty-nine were included in this study (a converted case was excluded) and called the laparoscopic hepatectomy group (LH). During the same period 22 patients with hepatiolithiasis who met the inclusion criteria for laparoscopic hepatectomy were selected for open hepatectomy and called the open group (OH). All operations were performed by the authors. There was no significant difference in preoperative data between the two groups. Data were statistically compared. Results Compared with open hepatectomy, those who underwent laparoscopic hepatectomy had a shorter postoperative hospital stay and fasting time, a lower postoperative serum aminotransferase level, and a higher postoperative serum albumin level. Stone clearance rate (intermediate rate, 89.7% vs. 86.4%; final rate, 100% vs. 96.5%), stone recurrence rate (0% vs. 4.5%), operating time, and intraoperative blood loss were similar for the two groups. Six complications occurred, two (6.8%) in LH and four (18.2%) in OH. There was no perioperative mortality in either group. Conclusion Laparoscopic hepatectomy for hepatolithiasis is feasible and safe in selected patients. This work was supported by the Foundation of Science and Technology, Department of Zhejiang Province, No. 2003C33055.     

切断Arantius韧带暴露左肝静脉背侧43例体会

目的 探讨左肝静脉背侧游离的手术方法.方法 在33例尸肝Arantius导管解剖基础上,切断43例患者的Arantius韧带,显露左肝静脉背侧壁并肝外切断左肝静脉.结果 43例左肝静脉背侧均被显露并成功切断,术后顺利恢复.结论 切断Arantius韧带是显露左肝静脉背侧壁并肝外切断左肝静脉的稳妥方法之一.     

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。     

一种治疗肝胆管结石和狭窄的术式——皮下通道型肝胆管成形术35例临床分析

对于肝胆管结石的治疗目前已取得了很多成功的经验，但最常使用的胆肠吻合术虽经不断改进，仍未能从根本上解决返流性胆管炎、胃肠分泌功能紊乱等并发症。为此，设计了一种新术式：即皮下通道型胆囊肝胆管成形术。在清除结石，解除肝内外胆管狭窄、肝门整形的基础上，利用胆囊壶腹部切开相应大小的切口与之吻合，并适当游离胆囊，使其底部可以被固定到切口皮下。患者必须具备基本正常的胆囊、肝外胆管和Ｏｄｄｉ括约肌。同时要求术中基本取尽肝内结石或切除病灶。已完成此手术共３５例，所有患者手术顺利，术后未发现并发症。其中１例３年后结石复发，１例２年后发生胆道蛔虫，均经皮下胆囊通道用胆道镜轻易取出。该术式既能处理好结石和狭窄问题，又能保存胆囊、胆管、Ｏｄｄｉ括约肌的功能，保持胃肠道的正常生理通路，并能以最简捷的方法处理术后结石复发和胆道内其它问题     

医源性胆管损伤的原因及处理(附66例报告)

目的探讨胆管损伤和狭窄的防治方法。方法回顾性分析６６例胆囊切除（或伴）胆总管探查术发生胆管损伤及狭窄的原因和治疗。结果１３例胆管损伤在术中发现并立即修复,其中１２例手术治愈,１例术后发生胆管狭窄。５３例胆管狭窄或胆漏在术后被诊断,其中４例行胆管对端吻合（术后均复发狭窄）;４４例行胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合,３６例治愈;５例吻合口狭窄经再手术治愈。８例死亡（死于胆漏感染５例,胆汁性肝硬化３例）。结论胆管损伤若能术中发现并妥善修复常可避免发生狭窄。胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合治疗胆管狭窄可取得较好疗效。     

左肝管定向穿刺胆管造影术的临床应用

目的探讨左肝管定向穿刺胆管造影术的方法的临床应用。方法对我我科自1998年10月至172例阻塞性黄疸作左肝管定向穿刺胆管造影术进行回顾性分析。结果本组172例左肝管定向穿刺造影术,159例穿刺造影成功,成功率92.44%,手术证实无出血、胆漏发生。余13例中转行右侧径路PTC,中转率7.5%,成功11例,成功率84.62%,13例均行手术,术中证实其中10例均有不同程度出血、胆漏。本组总成功率达98.84%,全部无住院死亡病例。结论左肝管定向穿刺胆道造影术可作为PTC的补充方法,能防止发生出血和胆漏的发生,但不能替代传统的右侧径路PTC。