肝胆管结石再手术107例体会

目的探讨肝胆管残余或复发结石的再手术方式及其临床效果。方法回顾性分析107例肝胆管结石病人再次手术的临床资料,其中行胆总管探查+T管引流术58例,左肝外叶切除+胆总管探查T管引流术32例,肝左外叶切除+胆总管探查+(肝)胆管空肠Roux-en-Y吻合术8例,左半肝切除+胆总管探查T管引流术2例,胆总管探查+胆总管空肠Roux-en-Y吻合术2例,肝右叶部分切除+胆总管探查T管引流术3例,胆管空肠Roux-en-Y吻合口重建术2例。结果本组无死亡病例,术后发生胆漏4例,胆道出血1例,腹腔出血1例,切口感染3例,肺部感染3例,除1例腹腔出血行开腹止血外,余均经非手术治愈。86例获随访,平均10月(6月~3年),优良率占89.5%,9例(10.5%)结石再次复发,仍需进一步手术。结论肝胆管结石病人视病灶部位决定术式,以胆总管探查经胆道镜取石为主,联合肝叶切除,适当进行(肝)胆管空肠Roux-en-Y吻合术效果良好。     

肝胆管结石的再手术治疗

胆石病中肝内外胆管结石是胆道外科治疗中的难题 ,往往需再手术。我院 1994年 1月～ 2 0 0 1年1月收治再次手术的肝胆管结石患者 35例 ,现报告如下。临床资料一、一般资料　本组病例中 ,男 16例 ,女 19例 ;年龄 32～ 80岁。二、手术方式　胆总管切开取石加Ｔ管引流术5例 ,其中 1例因术后残余结石行胆道镜取石 ;胆肠吻合术 2 7例 ,其中胆肠Ｒｏｕｘ Ｙ型吻合术 2 3例 ,胆总管十二指肠吻合术 4例 ;肝脏部切除术 8例 ,其中左外叶切除 2例 ,左半肝切除 2例 ,肝方叶切除 4例。三、再手术原因　 (1)术后残余结石或结石复发 ;(2 )术后反复胆道感染 …     

肝胆管结石的再手术原因分析

目的 分析肝胆管结石的再手术原因与治疗措施。方法 回顾性分析17年间因肝胆管结石接受手术治疗的病例。按术式分组比较其再手术率。结果 17年间因肝胆管结石接受手术治疗者1100例．再手术197例,再手术率17．9％;T管引流、胆肠吻合、联合肝段／叶切除术式术后再手术率分别为36．4％、10．1％和8．1％。结论 病灶是否上除是影响再手术率的主要因素,但也应重视术后并发症的防治。     

肝胆恶性肿瘤皮下抗癌药泵植入的应用

抗癌药泵是用于人体内埋藏,行区域性化疗的装置。我科自１９９３年８月至１９９８年２月为１７９例肝胆恶性肿瘤手术切除并行皮下埋泵３１２例次。现对有关解剖、技术等进行探讨。临床资料本组男１４８例,女３１例;年龄２２～７５岁,平均４８岁。手术切除：各类右肝肿瘤８８例,左肝肿瘤３６例,双侧肝肿瘤１７例,包括尾状叶６例。晚期肿瘤单纯植人３８例。动脉插管１５７例,其中胃十二指肠动脉（ＧＤＡ）１２８例,胃网膜右动脉（ＲＧＥＡ）１５例,胃右动脉（ＲＧＡ）１３例,脾动脉１例;静脉插管１５５例,其中胃网膜右静脉（ＲＧ…     

肝胆管结石多次胆道术后再手术对策

肝胆管结石疾病具有高残留率、高复发率以及高并发症发生率的特点。由于肝胆管结石本身的特殊性、首次治疗措施的不当或医源性损伤等因素,相当一部分病人需要接受多次手术治疗。再次手术的复杂性及其并发症发生率均明显高于初次手术。治疗肝胆管结石疾病的主要方法为外科手术,包括传统开放手术、腹腔镜手术及机器人辅助手术。其手术方式多样化,包括胆管切开取石、肝切除、胆管狭窄修复成形、胆肠内引流,甚至肝移植等。此外,消化内镜和经皮经肝胆道镜（PTCS）是上述治疗方式的有效补充,有助于提高其治疗效果。     

38例肝胆管结石患者再手术原因分析

目的明确肝胆管结石患者再手术的原因。方法回顾性分析2010年笔者所在医院38例肝胆管结石再手术患者的临床资料,分析患者再手术原因及治疗情况。结果患者再手术原因主要是肝内病灶清除不彻底、肝内病灶未处理、肝胆管残留结石及狭窄等,术后优良率为89.5%。结论术前行详细的影像学检查,术中仔细、深入探查是避免再手术的关键。     

胃肠道肿瘤的再手术问题

近年来国内外学者在复发性胃肠肿瘤再手术方面积累了小少经验，其处理已从姑息手术和镇痛药为主的保守治疗到目前积极的及早外科干预，为胃肠道复发性肿瘤的治疗提供了新的视角，本文对此进行简要介绍。     

肝胆管结石再手术治疗23例分析

胆石病手术后复发肝胆管结石的再手术治疗困难大、预后不佳 ,仍是当今胆道外科努力解决的难题之一。本院自1996年 6月至 2 0 0 0年 10月共对 2 3例胆石病患者进行外科再手术治疗 ,取得一定疗效 ,报告如下。1　临床资料1.1　一般资料　共 2 3例 ,男 10例 ,女 13例。年龄为 2 1～ 74岁 ,平均 47岁。病程 2～ 2 2年 ,平均 13年。左肝管结石 14例 ,伴Ⅰ～Ⅱ级胆管狭窄 10例 ,其中Ⅱ级以上 2例 ,右肝管结石 5例 ,伴Ⅰ～Ⅱ级胆管狭窄 3例 ,左右肝管汇合处结石 4例 ,伴胆管狭窄 2例。临床表现均有不同程度的右上腹痛、畏寒、发热、黄疸 ,其中夏科氏…     

肝胆管结石的再手术治疗

肝胆管结石病的再手术治疗特别在基层医院仍存在一定困难 ,现将我院 1990～ 1999年间经再次手术治疗肝胆管结石5 9例治疗体会报告如下。临床资料一般资料 :男 14例 ,女 45例 ,年龄 2 7～ 61岁 ,均为 1～ 3次手术后病人 ,其中行 2次手术者 11例 ,3次手术者 8例 ,第 1次手术为单纯胆囊切除者 3例 ,Ｔ形管引流 15例 ,胆总管十二指肠吻合术 2 2例 ,第 2次手术方式为Ｔ形管管引流术 5例 ,胆总管十二指肠吻合 4例 ,胆管空肠Ｒｏｕｘ Ｙ吻合 2例 ,第 3次手术方法为胆管十二指肠吻合 2例 ,胆管空肠Ｒｏｕｘ Ｙ吻合 6例。全组病人合并胆汁性肝硬化 7…     

肝胆管结石术后择期再手术58例原因分析

目的 通过分析肝胆管结石术后择期再手术原因，提出防治措施。方法 对1994年6月至2002年3月期间58例肝胆管结石术后择期再手术病例的原因进行回顾性分析。结果 再手术原因主要为：①首次手术仅行胆囊切除或加胆总管探查T型管引流术，未能彻底去除充满结石并纤维化的肝内病灶。②首次手术时未能对肝内胆管狭窄部位、尤其是开口部位高、难以显露的二级胆管狭窄部位予以整形。③首次手术清除结石不彻底，尤其是位于肝尾状叶胆管内的结石未能彻底清除。④胆肠吻合为胆总管空肠吻合，开口低，吻合口小，术后狭窄，残石积蓄于胆总管，易再发梗阻性黄疸。结论 强调应严格遵循“解除梗阻、去除病灶、通畅引流”的基本原则，充分注意首次手术时对肝内病灶的处理、必要时的病肝切除，胆管狭窄处的整形，尾叶胆管的开口探查、取石，肝门部大口胆肠吻合等，加强规范化手术实施和医师素质培训，是提高手术治疗效果的重要环节。     

经内镜胆管引流对恶性胆管梗阻术前肝功能恢复的疗效观察

目的　比较经内镜胆管引流术对梗阻性黄疸术前肝功能恢复的疗效。方法　腹壶周围癌、胰头癌共 76例 ,引流组 3 6例 ,其中行内置管引流 2 9例 ,鼻胆管引流 7例 ;对照组 40例 ,未做任何方式的胆管减压引流。结果　入院后第 14 d丙氨酸氨基转移酶 (ALT)、凝血酶原时间 (PT)和血清总胆红素 (TBIL)水平下降幅度分别为 :引流组 71.46± 11.81% ,2 3 .0 9±9.5 6% ,81.5 8± 7.5 0 % ;对照组 48.87± 19.3 2 % ,18.3 7± 9.3 1% ,5 .88± 3 .65 %。结论　经内镜胆管引流术能迅速改善梗阻性黄疸病的肝功能 ,为后续治疗创造良好的条件     

原发性肝癌患者术前肝储备功能的预测和术后评价

目的 运用脉动色素浓度法(PDD)测定吲哚氰绿潴留率(ICGR15)及有效肝脏血流量(EHBF)评估原发性肝癌患者术前肝脏的储备功能.方法 对55例原发性肝癌患者术前应用PDD法检测ICGR15和EHBF并根据ICGR15分为3组,并行Child-Pugh评分;根据术后肝功的恢复情况将患者分为肝功能恢复良好(G)、轻度不全(M)和重度不全组(S).分析ICGR15三组中术后肝功不全的发生率以及在不同肝功恢复组中ICGR15、EHBF与Child-Pugh评分比较.结果 术后肝功不全在ICGR15三组中的发生率差异具有统计学意义(P＜0.05);肝功恢复不同组间ICGR15、EHBF同Child-Pugh评分比较具有显著性差异(P＞0.05);在不同的Child-Pugh分级之间,ICGR15及EHBF值差异有统计学意义(P＜0.05).结论 ICGR15、EHBF比传统Child-Pugh评分可以更准确的评估肝储备功能并指导确定手术方案.     

肝硬化伴门静脉血栓患者行肝移植术的处理

目的 分析合并门静脉血栓的肝硬化患者肝移植术中及术后的处理方法和疗效.方法 回顾分析2005年10月至2007年3月我院完成的161例良性终末期肝病患者的临床资料,比较门静脉血栓发生率,不同级血栓手术情况和生存率.结果 161例患者之中共有15例患者合并有门静脉血栓,其中1级8例,2级4例,3级3例.脾切除史中发生P...     

复杂肝胆管结石症多次手术后合并胆汁性肝硬变门脉高压的处理

目的 探讨复杂肝内胆管结石并胆汁性肝硬变的外科处理方案。方法 对１例复杂肝内胆管结石多次手术后并胆汁性肝硬变门脉高压患者进行了再次手术治疗。结果 进行了脾切除门奇断流,左肝叶切除及肝门原位整形Ｔ管引流后随访１年半,无胆管炎发生,迄今亦无复发征象。结论 对复杂肝内胆管结石同期行肝叶切除及脾切除门奇断流术是可行的。     

MANAGEMENT OF BILIARY TRACT COMPLICATIONS FOLLOWING LIVER TRANSPLANTATION

Background : A review of biliary tract complications was performed in 32 patients who underwent liver transplantation by the Western Australian Liver Transplantation Service during a 2-year period. Methods : A review was made of patient data collected prospectively, and confirmed by retrospective casenote review. Results : A total of 30 patients (31 grafts) survived more than 2 days after transplantation, and of these 28 had an end-to-end biliary anastomosis. Analysis of these 28 patients found that eight of 17 patients with T-tubes had complications: three leaks at T-tube removal; two strictures and leaks; and three strictures. Six of 11 patients without a T-tube had complications: one leak; three strictures and leaks; and two strictures. Predisposing factors were present in eight of the 14 patients with biliary tract complications: hepatic artery stenosis in three; and one each with hepatic artery thrombosis; biliary calculi; donor–recipient bile duct mismatch; severe cellular rejection; and prolonged postoperative hypotension. Acute rejection, steroid-resistant rejection and cytomegalovirus infection were all significantly more common in those patients with biliary tract complications compared with those without. There was no difference in cold ischaemic time or donor age. Twelve of the 14 patients with biliary complications required endoscopic stenting with or without balloon dilation, and eight patients required radiological percutaneous drainage of bile collections. Only one patient required biliary reconstruction and two patients required re-transplantation. One patient died of uncontrolled infection. Of three patients who underwent choledochojejunostomy, biliary leak developed in two patients, both of whom required operative biliary and hepatic repair. One of the three patients died from disseminated Aspergillus infection. The median total hospital stay of patients with biliary complications was 61 days (range: 30–180 days) compared with 33.5 days (range: 22–70 days) for patients without. Of patients with end-to-end biliary anastomosis, 50% had biliary tract complications and more than half of these had predisposing factors. The majority of biliary complications were managed without the need for surgery. Conclusion : A total of 50% of patients with end-to-end biliary anastomosis had biliary tract complications. Biliary strictures presented later than leaks, and the majority of these complications were managed without the need for surgery.     

OPERATIVE LIVER BIOPSY ABNORMALITIES IN PATIENTS WITH FUNCTIONAL DISORDERS OF THE BILIARY TRACT

The group of conditions variously termed biliary dyskinesia, acalculous cholecystitis, biliary pain without stones, or functional disorders of the biliary tract, is poorly defined clinically, and no consistent pathological abnormalities have been previously described in patients with this diagnosis. In this paper we report histological abnormalities encountered in operative liver biopsies in such patients. The criteria for the diagnosis of a functional biliary tract disorders were: pain typical of biliary pain, negative results of investigations for organic biliary tract or other gastrointestinal disease, and reproduction of the patient's symptoms by cholecystokinin, or morphine, or both. Twenty of 45 patients with a presumptive diagnosis satisfied these criteria, and had a wedge liver biopsy at the time of operation. The 20 liver biopsy specimens were compared in a blind fashion with similar ones taken from patients having diagnostic laparotomies: patients with stones confined to the gallbladder; patients with gallstone pancreatitis; and patients with proven common bile duct stones. The biopsy findings were found to be similar to those in the latter two groups. Thus the abnormalities were similar to those found in partial or intermittent biliary obstruction, and it is suggested that they may be due to intermittent increases in biliary pressure.     

原发性肝癌术后胸腔积液的预防和治疗

目的探讨原发性肝癌术后胸腔积液的原因并总结防治经验。方法回顾性分析我院2000年7月至2004年6月各类右肝切除手术523例患者的临床资料。结果523例行肝切除术的患者,术中采用氩气电刀游离肝脏,术后出现胸腔积液20例,发生率为3.8%;同期行右肝切除的467例患者,术中采用常规方法游离肝脏且肝切除后常规对拢缝扎膈肌创面,术后出现胸腔积液49例,发生率10.5%,两者比较差异非常显著(P<0.01)。术后膈下积液、术后肝功能不全伴中等量以上腹水、肝门阻断时间长、肝硬化等是肝癌肝切除术后胸腔积液发生的重要原因。结论采用氩气电刀游离肝脏且不常规对拢缝扎膈下创面能较好地预防术后胸腔积液的发生;伴有临床症状的中等量以上的胸腔积液采用中心静脉导管置管引流效果良好,值得临床推广应用。     

单中心125例肝癌合并肝硬化患者术前肝脏储备功能评估的临床价值

目的 探讨Child-Pgh分级和吲哚氰绿(ICG)15分钟潴留率(ICGR15)在肝癌合并肝硬化患者术前肝脏储备功能评估中的临床价值.方法 回顾性分析125例经开腹手术和消融手术治疗的肝癌合并肝硬化患者的临床资料,根据ChildPugh分级与ICGR15水平分组,总结围手术期死亡率.结果 开腹手术治疗组105例,全组...     

恶性梗阻性黄疸的围手术期处理及其对并发症的影响

目的：探讨恶性梗阻性黄胆围手术期处理对手术期处理对术后并发症的影响。方法对１９９２－１９９７年间７８例恶性梗阻性黄疸患者进行回顾分析,并对术后并发症发生原因和采取治疗方法进行总结。结果①认为与梗阻性黄疸患者的高胆红素血症,内毒素血症及肝功能受损有密发关系。②术前行减黄手术与并发症发生率无关（Ｐ〉０．０５）,③外引流术作为姑息手术并不理想,内引流术才是减黄的理想方法。④完全性胆道引流手术和部分分胆道     

EVALUATION OF INDOCYANINE GREEN RETENTION AND AMINOPYRINE BREATH TESTS IN PATIENTS WITH MALIGNANT BILIARY OBSTRUCTION

Impaired hepatic function is a major contributory factor to the high incidence of postoperative morbidity and mortality in patients with malignant biliary obstruction. Dynamic hepatic function tests such as indocyanine green (ICG) retention and aminopyrine breath tests were evaluated in such patients to define whether they were clinically useful for prediction of postoperative morbidity and mortality. Forty-four patients with malignant biliary obstruction undergoing surgery for relief of obstructive jaundice were recruited into the study. Indocyanine green retention and aminopyrine breath tests were carried out in all patients pre-operatively and repeated in 36 patients postoperatively. The ICG retention was abnormal in all patients before surgery and there was significant improvement 2 weeks after surgery (32.8 ± 2.5%vs 18.3 ± 2.8%, P= 0.001). The change in ICG retention levels correlated with the serum bilirubin levels but the pre-operative ICG retention value could not predict postoperative morbidity and mortality. The aminopyrine breath test was abnormal in all but one patient. It correlated with pre-operative prothrombin time of the patients before surgery but it did not improve significantly after surgery and was not predictive of postoperative outcome. It is concluded that both ICG retention and aminopyrine breath tests have limited clinical value in the pre-operative evaluation of patients with malignant biliary obstruction.