腹腔镜规则性左半肝切除联合胆道镜取石治疗肝内外胆管结石

目的：探讨腹腔镜下规则性左半肝切除联合胆道镜取石治疗肝左叶肝内胆管结石合并胆总管结石的临床疗效。 方法：回顾性分析2010年3月—2013年9月间收治的12例肝内外胆管结石患者的临床资料。患者术前均明确诊断为左肝内广泛胆管结石合并胆总管结石,均行腹腔镜规则性左半肝切除联合胆总管切开胆道镜取石术。 结果：所有手术均顺利完成,无中转开腹。手术用时（182.6±36.3）min,术中出血（213.5±65.5）mL,术后肛门排气时间（38.5±8.2）h,术后平均住院时间（10.3±3.1）d。术后发生肝断面出血1例,胆瘘1例,均通过保守治疗痊愈。随访时间3个月至3年,平均23个月,未发现胆道结石残留或再生。 结论：对于肝左叶广泛肝内胆管结石合并胆总管结石的患者,腹腔镜规则性左半肝切除联合胆道镜行胆总管切开取石术是安全有效的手术方式。

     

腹腔镜胆总管切开取石术的几个问题

目的　解决腹腔镜下治疗胆总管结石的几个问题,推广应用腹腔镜胆总管切开取石这 项微创技术。方法　自1997年7月～2003年9月共收治265例肝外或肝外、肝内胆管并存结石,均 采用腹腔镜胆总管切开取石后置T管,胆道镜手术中取石。术后胆道镜取石,或术中胆道一期缝合。 结果　265例肝内外胆管结石病人在术中或术后完全取净结石,无结石残留,随访3个月～6年,2例 于术后1年复发。结论　腹腔镜手术治疗肝内外胆管结石能达到微创目的,避免传统剖腹手术给患 者带来的创伤,缩短住院及治疗时间。这种微创手术方法应作为胆管结石治疗的首选方法进行推广。     

肝内胆管结石的治疗体会

目的 比较肝左外叶切除术和仅行胆总管切开取石术两种方法 治疗肝内胆管结石的效果.方法 对新郑市人民医院1996年10月至2006年10月收治的42例肝内胆管结石病人同期分别采用两种手术方法 治疗.第一组22例,采用胆总管切开取石、肝左外叶切除和T管引流术的方法 ;第二组20例,采用胆总管切开取石和T管引流术的方法 .对两组的疗效进行分析总结.结果 第一组术后近期效果优良率为81.9%;第二组为70%.第一组病人在术后残石率、胆道感染率和再手术率方面优于第二组.结论 肝左外叶切除术治疗肝内胆管结石能取得比较好的临床效果,远期疗效明显好于仅行胆总管切开取石术.对肝内胆管结石较多,病灶较复杂,肝内胆管病变严重的病例,胆总管切开取石、T管引流术不是一种"根治性"手术.     

肝内胆管结石手术方式的选择——附56例报告

目的探讨外科手术治疗肝内胆管结石的最佳术式。方法全组患者采用高位胆管或I-Ⅲ级胆管切开取石，对肝内孤立性结石加作肝实质切开取石，右肝叶结石并肝实质纤维化者采用亚肝段切除，左肝萎缩或左肝管多发性结石则同时加作左肝或左肝外叶切除，纠正解除胆管狭窄原位整形，选择病例作各种胆肠吻合等方法；对56例肝内胆管多发结石病人进行其临床观察及跟踪随访。结果56例病人均经手术治愈出院，无严重并发症发生；切口感染5例，切口脂肪液化2例，经理疗和换药治愈；结石复发9例，复发率为16．07％，偶有胆管炎发作2例，占3.57％。结论对肝内胆管结石应根据各种不同情况选择不同术式、方法治疗方能取得良好的临床疗效。     

肝内胆管结石治疗体会(附334例报告)

目的探讨肝内胆管结石治疗方法。方法将334例肝内胆管结石患者分成4组：单纯胆总管切开取石术组、胆总管切开取石加胆肠内引流术组、胆总管切开取石加纤维胆道镜取石术组和肝切除术组。比较术后优良率、术后残石率和术后并发症发生率在各组间的差异。结果胆总管切开加纤维胆道镜取石术及肝切除术的术后优良率和术后残石率均优于单纯胆总管切开取石术或胆总管切开取石加胆肠内引流术（P〈0.05）;而胆总管切开取石术及胆总管切开加纤维胆道镜取石术的术后并发症发生率比其他手术方式低（P〈0.05）。结论肝内胆管结石较好的治疗方法为肝切除术或胆总管切开加纤维胆道镜取石术。     

肝内胆管残留或再发结石的外科治疗分析

目的探讨肝内胆管残留或再发结石的外科治疗方法及疗效。方法对1998年7月至2004年10月期间收治的96例肝内胆管残留或再发结石患者的资料进行回顾性分析。结果行肝叶切除44例；肝段切除11例；肝门部胆管切开并肝膈面实质切开联合取石引流术11例，其中附加胆肠大口径Roux-en—Y吻合术10例；肝门部胆管整形、肝管空肠大口径Roux-en-Y吻合术30例。全组术中均采用胆道镜检查取石，术后经T管窦道检查取石6例。术后随访1～6年，76例（79．2％）无结石残留或再发。结论据结石部位及肝脏病变合理选择手术方法是有效治疗肝内胆管残留或再发结石的较好方法。     

肝胆管结石再次手术治疗(附301例报告)

目的 探讨降低肝内胆管结石再次手术的方法。方法 地３０１例肝胆管结石再手术病例的临床资料进行回顾性分析。结果 本组有２９５例（９８％）肝胆管结石病人,因多种原因致结石残留或复发,导致术后症状复发而需再次手术。再次手术时采用１～３级胆管切开解除胆管狭窄并整形胆管为盆式,做胆肠内引流术,局限于左肝外叶结石,可行左肝外叶切除,终末胆管结石,可经肝表面切开取石治疗;术中使用牛角式灌洗器以清除结石。再次术后     

左肝外叶切除术治疗肝内胆管结石效果的评价

目的 比较左肝外叶切除术和仅行胆总管切开取石术两种方法治疗肝内胆管结石的效果。方法对中山大学第三医院2000年1月至2004年12月收治的85例肝内胆管结石病人同期分别采用两种手术方法治疗。第1组44例，采用胆总管切开取石、左肝外叶切除和T管引流术的方法，第2组41例病人采用胆总管切开取石、T管引流术的方法。对两组的疗效进行分析总结。结果第1组术后近期效果优良率为90．9％。而第2组为80．5％。第2组在手术时间、术中出血量和输血量方面较第1组有明显的优势。第1组病人在术后残石率、胆道感染率和再手术率方面明显低于第2组。结论左肝外叶切除术治疗肝内胆管结石能取得比较好的临床效果，远期疗效明显好于仅行胆总管切开取石术。对肝内胆管结石较多、病灶较复杂、肝内胆管病变严重的病例，胆总管切开取石、T管流术不是一种“根治性”手术。     

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。     

180例肝内胆管结石的外科治疗

目的 探讨肝内胆管结石的特点和治疗效果。方法 对180例肝内胆管结石的术前检查、结石部位和分布、手术方式和效果、术后并发症以及结石残留进行分析。结果 左侧肝胆管发生结石率高于右侧:79.4％合并肝外胆管结石,24.4％合并胆管狭窄;手术方式以胆管切开取石或加用胆肠内引流为主,少数施行肝切除;治愈92.8％,死亡7.2％;术后出现并发症11.7％;术后残留结石38.5％。结论 肝内胆管结石的手术治疗效果满意。胆管切开取石、建立通畅引流为主要术式,术中、术后配合胆道镜治疗可解决残留结石问题;严重胆管狭窄以肝切除或胆管成形术为主。     

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??Diagnosis and treatment of complicated intrahepatic bile duct stones WANG Jian. Department of Biliary-pancreatic Surgery, Renji Hospital of Shanghai Jiao Tong University School of Medicine,Shanghai200127,China
Abstract Complicated intrahepatic bile duct stone is defined as not easy to achieve the treatment standard of lesion eliminating??total stone clearance??stricture removal??unobstructed drainage and recurrence preventing??which related to complexity of anatomy??complexity of pathophysiology??extensiveness of stone distribution and particularity of stone location. The treatment goal is to reduce the residual stone rate and recurrence rate by using precise surgery concept via accurate preoperative assessment of liver function??liver atrophy and stone distribution to develop a reasonable surgical planning??and intraoperative comprehensive application of perihilar surgical techniques??choledochoscope techniques??anatomical liver resection techniques and mucosa-to-mucosa cholangioenterostomy techniques. The treatment principle of intrahepatic bile duct stone combined with portal hypertension and liver dysfunction should meet the balance between the total stone clearance and the guarantee of surgical safety. Liver transplantation is the only safe and effective treatment for end-stage hepatolithiasis.     

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。     

肝内胆管结石并胆管狭窄的外科治疗

目的 为探讨肝内胆管结石并胆管狭窄的外科治疗。方法 从１９９１年６月至１９９７年１２月,对２４例肝内胆管结石并狭窄的患者行肝胆管切开取石,其中１０例加行硬性经皮胆钳术中取石;左外叶及左半肝切除１２例所有病人均行肝胆管空肠大口吻合术。结果 ２４例病人均行随访,优良效果９６．０％。结论 肝叶、肝段切除联合肝胆管空肠大口吻合是肝内胆管结石并胆管狭窄的最佳治疗方法选择。     

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。     

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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.     

腹腔镜超声对于胆囊切除术中同期治疗胆道结石决策的价值

目的 观察腹腔镜超声(LUS)用于制定胆囊切除术中同期治疗肝内胆管结石及胆总管结石(CBDS)决策的价值。方法 回顾性分析53例明确诊断胆囊结石(GS)并接受择期腹腔镜下胆囊切除术患者,术中根据LUS所见判断有无肝内胆管结石及CBDS,进而决定是否同期行病变部分肝脏切除术和(或)腹腔镜胆总管探查术(LCBDE)。结果 53例均成功切除胆囊,术中LUS检查胆囊结果与术中及术后所见相同,LUS诊断准确率100%(53/53)。24例术前诊断为单纯GS,其中19例术中LUS诊断与术前相符、5例术中LUS诊断为GS合并CBDS而同期行LCBDE;25例术前诊断为GS合并CBDS,其中23例术中LUS诊断与术前相符而同期行LCBDE,2例术中LUS未发现CBDS、术后影像学复查亦未见CBDS;4例术前诊断GS合并肝内胆管结石,其中3例术中LUS所见与术前相符而行部分肝脏切除,1例术中LUS发现CBDS而行部分肝脏切除术+LCBDE。结论 LUS有助于胆囊切除术中同期治疗肝内胆管结石及CBDS制定决策,可及时完善诊断、调整术式并辅助实施手术。     

The treatment of intrahepatic calculosis by applying helix hydro-jet lithotripsy under video choledochoscope: a report of 30 cases

Background and aims Intrahepatic lithiasis is a common disease in southeast Asia [Sheen-Chen and Chou, Acta Chir Scand 156:387–390, 1990], and a difficult problem of biliary surgery. There is no established method of treating patients with intrahepatic stones [Uchiyama et al., Arch Surg 137:149–533, 2002]. In recent years, resection of the affected liver lobe or segment is the best therapeutic option to completely remove the source of recurrent infection. The need for endoscopic treatment modalities is evident because hepatic resections are combined with a high morbidity and mortality rate [Andersson et al., HPB Surg 2:145–147, 1990; Adamek et al., Scand J Gastroenterol 34:1157–1161, 1999]. Hepatic resection only fit the cases in which the stones localized in one lobe or segment, while it doesn’t fit the cases which have polystones in left and right biliary tract. Duodenoscope can only get the stones in the common bile duct and cannot deal with the intrahepatic lithiasis. The management of intrahepatic lithiasis can only be treated by intraoperative or postoperative choledochoscope. For big stones or compact stones, lithotripsy should be applied. But the laser lithotripsy and the electrohydraulic lithotripsy can cause serious complications such as perforation of bile duct. It needs a safer and more reliable treatment for intrahepatic lithiasis. The aim of our work is to study the lithotrity treatment of intrahepatic lithiasis by using helix hydro-jet under Video Choledochoscope.Materials and methods From March 31, 2003 to October 20, 2004, 30 intrahepatic stone patients were treated. Eighteen of them were women and 12 were men, with ages ranging from 35 to 80 years (mean, 58 years). According to B ultrasound and computed tomography (CT) scan report, there were five cases of intrahepatic lithiasis and common bile duct stones, 25 cases of left and right hepatic duct stones, and one case with giant intrahepatic stone (1.5 × 1.5 × 1.2 cm). Intraoperative or postoperative choledochoscopic helix hydro-jet lithotripsy was applied through a video choledochoscope. For the patients to have the intraoperative choledochoscopic helix hydro-jet lithotripsy, they should be diagnosed correctly by B ultrasound or CT scan. The biliary tract reconstruction by spiral CT scan is as helpful as MRCP or ERCP for clinical diagnosis. For the patients to have the postoperative choledochoscopic helix hydro-jet lithotripsy, they should be diagnosed correctly by T-tube cholangiography and BUS and CT scan. All patients should be verified without stones remaining in the bile duct after lithotripsy by choledochoscopic examination and T-tube cholangiography, and should be examined by BUS again after 6 months to 1 year. We decide whether complications occurred by observation of symptoms and signs after choledochoscopy and lithotripsy.Results Seventy-five intrahepatic stones with diameter ranging from 0.6 to 1.5 cm were successfully fragmentized in 30 patients using of helix hydro-jet lithotripsy. These fragmentized stones mainly are bilirubin stones. The lithotripsy was carried for 45 times and the procedure needs 1–1.5 h. Helix hydro-jet lithotripsy are used in 16 cases during operation and 12 cases after operation; two cases during operation and after operation. Intrahepatic calculosis was cleaned out completely and verified by postoperative choledochoscope examination and postoperative T-tube cholangiography examination. No complications were observed.Conclusion Helix hydro-jet lithotripsy under video choledochoscope is a safe and effective method for the removal of intrahepatic stone. No bile duct damnified and perforation was observed. The procedure is without pain and heat, and the pressure can be adjusted easily. The research provides a new way of using the helix hydro-jet, and a new way of curing the intrahepatic lithiasis.Electronic Supplementary Material Supplementary material is available for this article at     

手术治疗肝胆管结石198例临床效果分析

目的：探讨肝段切除与胆管切开取石术治疗肝内胆管结石的效果。方法对１９８例肝内胆管结石的手术治疗进行分析。全部病例分为２组,一组采用肝段切除为主的联合手术９０例（下称肝段切除组）,另一组采用胆管切开为主的联合手术１０８例（下称胆管切开组）。结果随访肝段切除组优良率为９２．５４％,胆管切开组优良率为６８．６１％,肝段切除组较胆管切开组术后残石率低（８．９６％;２７．９１％Ｐ〈０．０５）;再手术率低（０     

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??Etiology and treatments of re-stenosis of bile duct after surgical repair for iatrogenic bile duct injury LI Shao-qiang, LIANG Li-jian. Department of Hepatobiliary Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
Corresponding author: LIANG Li-jian, E-mail: lianglj@medmail.com.cn
Abstract Iatrogenic bile duct injury (IBDI) is a severe complication of cholecystectomy. The major factors related to re-stenosis of bile duct after initial surgical repair includes type of IBDI, timing of initial surgical repair, initial surgical procedures, being accompanied by hepatic arterial injury and performed operation. The treatment for re-stenosis of bile duct is difficult. Preoperat imaging studies especially the cholangiogram of the whole biliary tree are critical important for surgical planning. The treatment modality adopted should comprehensively depend on the general condition of patient, liver function and liver function reserve, the site of biliary stricture, with or without intrahepatic stones and biliary cirrhosis. Metal stent placement is only indicated for patients who are intolerance of operation, or whose life expectancy are less than 2 years. Removal of the biliary stricture and hilar bile duct-jejunum Roux-en-Y anastomosis is the common used procedure for re-stenosis of bile duct after initial surgical repair for IBDI, and the long-term outcome is a satisfactory. For those with right or left hepatic duct stricture accompanied by intrahepatic stone or affected side liver atrophy, and with a good liver function, and without liver cirrhosis at the contralateral side, liver resection is indicated.     

解剖性肝切除术治疗复杂肝内胆管结石体会

目的探讨解剖性肝切除术治疗复杂肝内胆管结石的价值。方法回顾性分析2012年1月至2017年3月行肝切除术的98例复杂肝内胆管结石病人的临床资料,男性42例,女性56例,年龄28~69岁,平均47.2岁。其中行解剖性肝切除术51例(AR组),非解剖性肝切除术47例(NAR组)。对比两种手术方式病人的术中出血量、手术时间、肝功能恢复情况、住院时间、术后并发症、术后残石率和结石复发率。比较两种手术方式的治疗效果。结果 AR组病人术中出血量为(466.0±52.1)ml、术后并发症8例(17.65%)、术后残石率为0和结石复发1例(2.04%),明显优于NAR组的(741.0±46.3)ml、15例(29.79%)、3例(6.67%)和4例(8.89%)。而手术时间、肝功能恢复情况、住院时间差异均无统计学意义。术后2个月至5年获随访94例,其中AR组49例,NAR组45例,失访4例。均行B超、CT、MRCP等检查,AR组无结石残留,术后胆总管结石复发1例,行内镜下十二脂肠乳头括约肌切开术(EST)取石治愈。NAR组结石残留3例,结石复发4例。在术后8个月至3年内再次行解剖性肝叶肝段切除3例,1例行EST取石成功,1例长期服用熊去氧胆酸等药物治疗未手术,另2例因经济原因放弃治疗。结论解剖性肝切除术治疗复杂肝内胆管结石,具有术中出血少、术后并发症少、术后残石率和复发率低的优势,是一种可选择的手术方式。