经肝切开胆管取石术临床疗效分析

目的 评价经肝切开胆管取石术治疗肝内聚焦性胆管结石的合理性和有效性。方法 35例肝内胆管结石病人在实施经肝切开胆管取石术后1-5年复查1-4次，每次复查均给予肝脏B超等影像学检查。其中8例还接受了再次手术治疗。结果 在术后5年内，切开取石的胆管内结石复发14例，复发率为40%。结石复发致肝叶段组织纤维化萎缩12例。发生率为34.3%。结石复致再手术8例。再手术率为22.9%。结论 经肝切开胆管取石术不是治疗内肝内聚集性胆管结石的适宜术式。术后的中远期疗效差。     

肝内胆管囊腺瘤1例

患者男 ,33岁。无意中自扪及右上腹包块 1周而入院。查体 :右上腹剑突下有一包块 ,表面光滑 ,质地中等 ,边界清楚 ,有囊性感 ,活动度差。上消化道钡餐透视见胃体受压 ;B型超声发现左肝叶占位性病变 19cm× 18cm,囊性内见点状回声 ,壁不规则 ;CT扫描见肝左叶低密度影占位 ,肝动脉分支及门静脉分支受压移位 ,增强扫描见肿瘤内有分隔状结构 ;术中见肿瘤位于肝左内叶 ,呈囊性 ,包膜完整 ,囊液为暗褐色。游离肝脏后 ,行左半肝切除。病理诊断 :肝内胆管囊腺瘤。讨论 :肝内胆管囊腺瘤是极少见的肝脏肿瘤性疾病 ,占全部胆管来源的肝内囊肿的 4 .6 …     

肝内胆管结石治疗演变和发展

肝内胆管结石发病率明显下降,但其下降幅度存在地区性差别,同时早期肝内结石病例的诊断更多了。切除病灶是彻底治疗肝内胆管结石最有效的方法,目前肝内胆管结石肝切除治疗已趋向于肝段化和亚肝段化。“肝门上径路”肝切除术特别适用于右侧的和合并门静脉海绵样化的肝内胆管结石外科治疗。肝内胆管结石终末期病人,最有效的治疗应是肝切除同种异体原位肝移植术。     

切开肝内胆管治疗复杂肝内胆管结石的手术入路和方法

目的 探讨显露和剖开肝内各叶、段胆管的手术方法,提高复杂性肝内胆管结石病的治疗效果。方法 从肝内胆管手术显露的角度,研究了30个成人肝脏标本肝内各叶、段胆管与血管走行位置的解剖关系,设计了新的手术方法、用于治疗复杂性肝内胆管结石46例。结果 肝内胆管与血管走行的位置关系。从肝脏的脏面观：左右肝管均位于门静脉左右干的前上缘。左内叶胆管、右前叶胆管位于相应门静脉支的前内侧（近肝门侧）。右后叶胆管有73.3%(22/30)位于门静脉右前支（18／30）或门静脉右前下段支（4／30）脏面深侧;80％（24／30）走行于门静脉右后叶支脏面深侧（20／30）或后上缘（4／30）。左外叶胆管基本上都走行于门静脉矢状部脏面深侧,只有2个标本的左外叶下段支胆管在其浅侧。肝动脉在肝内各叶段的分支基本上走行与Glisson鞘内胆管与门静脉之间或侧旁。从肝脏膈面观：肝内各叶、段胆管与血管的解剖位置关系大致与脏面观相反或接近相反。据此,从肝脏脏面显露肝门、可以连续切开左右肝管和多数左内叶及右前叶胆管,但难以显露右后叶及右叶各段胆管和左外叶胆管;而从肝脏膈面进路切开肝方叶或肝中裂、再沿右后叶胆管投影方向切开肝实质,则可避开右肝内的门静脉主要分支,比较容易显露和切开右肝内各叶、段胆管汇合部及狭窄段。从肝左叶膈面切开左外叶胆管,可避免损伤左门静脉矢状况。设计经肝的脏面显露和剖开肝门及左右肝管与经肝的膈面显露和剖开肝内叶、段胆管相结合的手术方法,治疗复杂性肝内多叶、多段胆管多发结石并胆管狭窄的病人46例。无手术死亡。31例平均随访39个月,效果优良28例（90％）,好转2例（6.5%),无效1例（3.5%)。结论 经肝的脏面和膈面相结合的手术入路,显露和剖开肝内外胆管及其狭窄段,便于取出结石。将剖开的肝内外胆管与空肠Roux－en-y大口吻合,则可解除胆道狭窄,建立通畅的胆流通道,是治疗复杂性肝内胆管结石有效的手术方法。     

肝内胆管结石治疗演变和发展

肝内胆管结石发病率明显下降,但其下降幅度存在地区性差别,同时早期肝内结石病例的诊断更多了。切除病灶是彻底治疗肝内胆管结石最有效的方法,目前肝内胆管结石肝切除治疗已趋向于肝段化和亚肝段化。“肝门上径路”肝切除术特别适用于右侧的和合并门静脉海绵样化的肝内胆管结石外科治疗。肝内胆管结石终末期病人,最有效的治疗应是肝切除同种异体原位肝移植术。     

肝内胆管结石伴肝门部血管变异的手术处理

目的 研究肝内胆管结石伴肝门部血管变异的手术处理方法。方法 回顾性分析57例肝内胆管结石伴肝门部血管变异行胆道手术病人的临床资料。结果 57例中，行单纯胆道手术13例，异位血管切断，结扎术14例，胆管血流交叉换位术22例，肝内胆管空肠吻合术8例。本组未发生严重术后并发症和围手术期死亡。51例（89．6％），获得随访，随访时间4－15（平均9．6）年。疗效优良率84．3％（43／51）。7例有胆道残余结石，其中5例表现为间歇性右上腹隐痛不适，另2例因反复发作胆管炎需再次手术。1例术后1．5年死于门静脉高压症所致的食道胃底曲张静脉破裂大出血。结论 采用合适的手术方式治疗肝内胆管结石伴肝门部血管变异，既能完成复杂胆道手术，又能避免肝脏缺血性损害。     

复杂肝内胆管结石的诊断与处理

复杂肝内胆管结石是指在治疗上不容易达到“祛除病灶,取尽结石,矫正狭窄,通畅引流,防治复发”20字标准的肝内胆管结石,涉及到解剖复杂性、病理生理复杂性、结石分布的广泛性与结石位置特殊性。运用精准外科理念,通过术前精准评估肝功能、结石分布范围、肝脏萎缩和胆道狭窄状况,制定合理的手术规划;术中综合应用围肝门外科技术、胆道镜技术、解剖性肝切除技术和黏膜对黏膜的胆肠吻合技术,以达到降低残石率和复发率的目标。对于门静脉高压伴肝功能不全的肝内胆管结石应兼顾取尽结石与保证手术安全之间的平衡。肝移植是终末期肝内胆管结石的惟一安全有效治疗手段。     

肝左外叶胆管结石腹腔镜左肝蒂阻断肝左外叶切除术效果分析

目的探讨腹腔镜下左肝蒂阻断行肝左外叶切除术治疗肝左外叶胆管结石的效果。方法按照不同手术方法将78例肝左外叶胆管结石患者分为2组,各39例。开腹组行开腹肝左外叶切除术,腹腔镜组采用腹腔镜下左肝蒂阻断肝左外叶切除术。比较2组手术时间、术中出血量、恢复排气时间、住院时间和手术前后总胆红素(TBil)、白蛋白(ALB)水平。结果腹腔镜组手术时间长于开腹组,出血量低于开腹组,术后恢复排气时间、住院时间短于开腹组,差异均有统计学意义(P0.05)。术后2组患者的血清TBil、ALB均较术前有所改善,但组内及组间的差异均无统计学意义(P0.05)。结论腹腔镜下左肝蒂阻断肝左外叶切除术治疗肝左外叶胆管结石,虽然手术时间较长,但术中出血量少、患者康复快,而且有利于改善肝功能。     

肝叶切除治疗肝内胆管结石并胆管狭窄的疗效分析

目的　探讨肝叶切除治疗肝内胆管结石并胆管狭窄的效果。方法　对我院 17例肝内胆管结石并胆管狭窄行肝叶切除的治疗结果进行回顾性分析。结果　本组 17例术后发生膈下感染1例 ,胆瘘 2例 ,切口裂开 1例 ,肺部感染 2例。本组 17例均治愈 ,无手术死亡。随访 4月～ 3年 ,本组病例无症状复发、结石残留、结石复发及胆管狭窄。结论　肝叶切除是治疗肝内胆管结石并胆管狭窄的有效而安全的方法 ,能彻底去除病灶 ,解除梗阻和建立通畅的引流     

肝叶切除治疗肝内胆管结石139例临床分析

目的 研究肝叶切除在治疗肝内胆管结石中的作用与疗效.方法 回顾性分析2006年3月至2010年8月安徽省立医院收治的139名行肝叶切除术的肝内胆管结石患者资料,观察手术治疗肝内胆管结石的疗效.结果 本组患者行肝脏部分切除术97例(69.8％),肝脏部分切除+胆总管探查34例(24.5％),肝脏部分切除+胆肠内引流术5例(3.6％),保守治疗3例(2.2％),全组并发症13例(9.4％),其中腹腔感染5例(3.6％),胆瘘3例(2.2％),切口感染2例(1.4％),肺部感染3例(2.2％),术后5年结石复发14例(10.1％).结论 合理的肝叶、肝段切除术是治疗肝内胆管结石安全有效的方法,术中纤维胆道镜探查可降低残石率.对于弥漫性肝内胆管结石,肝叶或肝段切除结合内引流术是治疗的有效手段.     

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??Selection and evaluation of different imaging technology for hepatolithiasis REN Ke??ZHANG Xin. Department of Radiology?? the First Hospital of China Medical University??Shenyang110001??China
Corresponding author??REN Ke??E-mail??renke815@sina.com
Abstract Color ultrasound is a common examination method??suitable for the screening of stones. CT plain scan can diagnose high density stones??difficult to find isodense stones.Enhanced CT can find most stones of hepatic bile duct and the complications??such as liver abscess and intrahepatic cholangiocarcinoma.Plain MRI can display the stones in bile duct and the dilation of the distal duct.It’s helpful to find the abnormal signal in liver.Enhanced MRI can find intrahepatic lesions??such as liver abscess and intrahepatic cholangiocarcinoma??and also has some diagnosis value for the inflammation and tumor of bile duct. MRCP can display the biliary tree and the obstruction site??while have to combine with enhanced CT or MRI in the diagnosis of common hepatic duct and common bile duct lesions.     

有胆道手术史肝胆管结石的腹腔镜胆总管切开取石术的应用

目的 探讨腹腔镜胆总管切开取石术在有胆道手术史的肝胆管结石患者中的应用价值。 方法 2009年3月至2013年3月期间,中航工业三六三医院普外科收治的86例肝胆管结石患者接受了腹腔镜胆总管切开取石术,其中26例既往有胆道手术史（PBS组）,60例无胆道手术史（NPBS组）。左肝内胆管结石15例,右肝内胆管结石52例,双侧肝内胆管结石19例。回顾性分析患者围手术期的临床资料。 结果 PBS组与NPBS组手术时间分別为（161.4±31.5） min和（155.7±28.1） min,其差异无统计学意义（P＞0.05）;术中出血量分别为（69.2±50.7） mL及（44.1±27.4） mL,PBS组多于NPBS组（P＜0.05）;PBS组术后并发症发生率为53.8%,尤其是腹腔积液明显多于NPBS组（P＜0.05）;2组总残余结石发生率为15.1%,总结石清除率为98.8%;PBS组术后远期并发症发生率为23.1%,明显高于NPBS组（P＜0.05）。 结论 腹腔镜胆总管切开取石术是有胆道手术史肝胆管结石患者一项安全可行且有效的微创治疗选择,尤其适用于无肝萎缩肝胆管结石、结石弥漫分布合并胆管狭窄的双侧肝胆管结石以及合并胆汁性肝硬变的肝胆管结石。     

内镜下胆道支架置入治疗肝胆外科术后胆漏的临床观察

目的探讨内镜下胆道支架置入对肝胆外科手术后胆漏的治疗效果。方法回顾性分析我院2001年1月～2005年12月收治的11例肝胆外科术后胆漏，提出胆漏新的临床分型：Ⅰ型，胆囊管漏；Ⅱ型，肝外胆管漏（漏口直径小于胆管直径1／3的为A型，大于1／3为B型）；Ⅲ型，肝内胆管漏（肝内胆管盲端漏为A型，引流肝段以下的肝内胆管漏为B型，引流肝段以上的肝内胆管漏为C型）；Ⅳ型，Luschka管漏。结果11例中Ⅰ型6例，ⅡA型2例，ⅢA型1例，ⅢB型2例。4例行单纯支架置入，7例行Oddi括约肌切开联合支架置人。术后3周拔除支架6例，1个月拔除支架2例，2周、6个月和9个月拔除支架各1例。11例经内镜治疗后腹痛缓解，腹腔胆汁引流消失，黄疸消退。1例随访6个月，10例随访1—3年，均未复发腹痛、发热、黄疸、腹腔积液，血胆红素正常。结论内镜下胆道支架置入是治疗肝胆外科术后大多数胆漏的有效手段之一，胆漏新临床分型对治疗方法的选择具有一定的指导意义。     

肝外胆道手术中胆道损伤的原因分析及处理对策

目的探讨肝外胆道术中胆道损伤的原因及处理方法的选择. 方法对61例肝外胆道术中胆道损伤进行回顾分析.术中及时发现13例:3例右肝管损伤给予对端吻合、T管引流;8例胆总管或肝总管破口者,利用肝圆韧带修复;2例胰头部胆管穿孔者,予Roux-en-Y吻合.余48例为术后发现者:4例保守治疗,21例肝总管、胆总管被部分或完全缝扎者,予拆除缝线、T管引流;5例胆管轻度破口者,予肝圆韧带修复;18例腹腔炎症严重者,予T管引流,3个月后行胆肠Roux-en-Y吻合. 结果经平均2年的随访,本组无死亡病例.术中右肝管对端吻合的3例,术后2例出现轻度胆漏;术中利用肝圆韧带修补8例,术后3例出现轻度胆漏,均经充分引流非手术疗法治愈.术后发现的48例中,经充分引流保守治愈4例;再手术44例,术后3周内治愈20例,4周内治愈6例,另外18例3个月后行胆肠Roux-en-Y吻合,术后1～2个月治愈.合并膈下脓肿3例,肺部感染4例,轻度反流性胆管炎3例,均经抗感染和对症治疗而愈.结论尽早发现、及时处理对提高疗效和防止术后胆管狭窄起着决定性作用.术中发现胆管损伤,应立即进行修补或对端吻合,T管引流.术后数天发现者,则宜行规范的胆肠Roux-en-Y吻合术.     

Bile duct varices

The diagnosis of biliary duct varices and portal vein occlusion should be considered when nodular or notched defects in the wall of the biliary duct system are shown by cholangiography or when pedunculated vascular structures in the bile ducts are seen at surgery. We present two cases of common hepatic and common bile duct varices due to portal vein occlusion.     

规则性肝段(叶)切除治疗肝内胆管结石并狭窄

目的探讨规则性肝段(叶)切除治疗肝内胆管结石并狭窄的临床疗效。方法48例肝胆管结石并狭窄患者,行左外叶切除19例,左半肝切除2例,左外叶+右后叶(或单纯Ⅵ、Ⅶ段)切除7例,右半肝(或单纯Ⅵ、Ⅶ段)切除20例;均行胆总管探查、T管引流术;行胆管空肠Roux-en-Y吻合术13例。结果术后胆管残石5例(10.4%),切口感染3例(6.2%),胆漏2例(4.2%)。随访41例(85.4%),2例肝内胆管结石复发,1例右上腹隐痛,其余随访结果优良。结论根据患者结石及狭窄的具体情况采用以肝段切除为主的手术方式是治疗肝内胆管结石并狭窄的有效手段。     

Clinical experience of intrahepatic cholangiocarcinoma associated with hepatolithiasis

Between 1960 and 1986, seven patients with intrahepatic cholangiocarcinoma and one patient with intrahepatic bile duct adenoma, related to hepatolithiasis, were seen among 112 cases of hepatolithiasis. Histopathologically, the tumors associated with hepatolithiasis arose from the periphery of the stone-containing bile duct, spread chiefly along the luminal surface, and invaded the ductal wall or periductal tissue. The tumors showed papillary to papillo-tubular proliferation and were diagnosed as the intraductal or periductal spreading type of cholangiocarcinoma. In addition, atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that chronic relapsing cholangitis in patients with hepatolithiasis can induce progressive changes to atypical epithelial hyperplasia which may develop into cholangiocarcinoma.     

Clinical experience of intrahepatic cholangiocarcinoma associated with hepatolithiasis

Between 1960 and 1986, seven patients with intrahepatic cholangiocarcinoma and one patient with intrahepatic bile duct adenoma, related to hepatolithiasis, were seen among 112 cases of hepatolithiasis. Histopathologically, the tumors associated with hepatolithiasis arose from the periphery of the stone-containing bile duct, spread chiefly along the luminal surface, and invaded the ductal wall or periductal tissue. The tumors showed papillary to papillo-tubular proliferation and were diagnosed as the intraductal or periductal spreading type of cholangiocarcinoma. In addition, atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that chronic relapsing cholangitis in patients with hepatolithiasis can induce progressive changes to atypical epithelial hyperplasia which may develop into cholangiocarcinoma.     

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??Diagnosis and treatment of complicated intrahepatic bile duct stone??An efficacy analysis of 60 cases LI Chun-yang, NI Qi-hong, WANG Jian. Department of Hepatic and Biliary-Pancreatic Surgery, Renji Hospital of Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
Corresponding author: WANG Jian, E-mail: dr_wangjian@126.com
Abstract Objective To investigate the reasonable approach of diagnosis and treatment to complicated intrahepatic bile duct stone Methods The radiological diagnosis??surgical approach??complication and clinical efficacy of 60 cases of complicated intrahepatic bile duct stone performed surgical treatment from January 2011 to October 2015 in Renji Hospital of Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. Results According to the classification of hepatolithiasis??44 cases were type I (regional type)??16 cases were type II (diffused type)??and 28 cases were type E (additional type??combined with extrahepatic bile duct stone). A total of 59 cases were Child A grade and 1 case was Child B grade. The sensitivity of diagnosis of single-CT??single-MRI+MRCP??and CT combined with MRI were 86.7%??93.9% and 97.2% respectively. All the 60 cases underwent anatomical liver resection??and 12 cases with high-position bile duct stricture underwent cholangioenterostomy. The complication rate was 25% with no liver failure or perioperative death. The residual stone rate in patients using intraoperative ultrasound combined with choledochoscope was 0 (0/25)??which was significantly lower than that in patients using choledochoscope only (20%??7/35). A total of 55 cases had follow-up from three months to five years. The follow-up rate was 91.6%; high life quality rate was 96.2%; residual stone rate was 11.7%??and recurrence rate was 9.61%. Conclusion Using ultrasound combined with upper abdominal CT and MRI+MRCP can increase the detection rate of intrahepatic bile duct stone. Using choledochoscope combined with intraoperative ultrasound can decrease the residual stone rate. Anatomical liver resection can decrease the residual stone rate and recurrence rate.     

经皮肝穿刺一期硬镜碎石术在治疗肝胆管结石的应用

目的：探讨经皮肝穿刺一期硬质胆镜碎石术对肝胆管结石的治疗效果。 方法：对65例肝胆管结石患者的肝胆管通过B超定位进行直接穿刺建立窦道，扩张窦道直径至16~18 F后，采用硬质胆道镜取出肝胆管结石。 结果：一次性扩张取尽结石患者达60例；2例由于右肝胆管与胆总管之间的角度<90°而放弃；术后因胆管出血行介入栓塞治疗3例；39例存在胆管狭窄（60.0%），均根据具体情况同时行相应处理。对所有治疗的患者进行26个月随访，肝胆管结石的复发率为7.7%（5/65）。 结论：经皮肝穿刺一期硬质胆镜碎石术治疗肝胆管结石安全、有效，其清除率结石的同时处理胆管狭窄可利于结石复发率降低，是一种避免传统手术治疗的可取方法。