肝左右叶联合切除治疗复杂原发性肝胆管结石47例疗效分析

目的 总结肝左右叶联合切除治疗复杂肝胆管结石的经验及其疗效。方法 回顾性分析1991年8月至2007年8月第三军医大学西南医院肝左右叶联合切除治疗复杂的原发性肝胆管结石47例病人的临床资料,统计结石的分布、手术方式、术后并发症及治疗效果。结果 47例病人中15例有胆道手术史。所有病例左右肝均有结石,其中7例合并尾叶结石,21例合并肝外胆管结石。术中发现合并肝内外胆管狭窄23例。所有病例均采用肝左右叶联合切除术,其中3例行右肝胆管树切除术,6例行右肝后叶胆管树切除术。附加手术：28例行胆道探查、T管引流术,19例附加胆管空肠Roux-en-Y吻合术,3例附加肝实质切开取石术。47例病人手术死亡2例。术后出现腹腔感染3例,右前叶结石残留1例,左内叶结石残留1例。随访16个月至17年,生活质量优良率为88.89%。结论 肝左右叶联合切除治疗肝胆管结石并发症少、残留结石少、远期疗效好,是治疗复杂肝胆管结石的有效手段之一。     

肝胆管结石的手术与胆道镜联合治疗

我院1981年11月至1997年12月采用手术与胆道镜联合治疗肝胆管结石618例,取得良好的治疗效果。现总结如下。临床资料1.一般资料:本组,男293例,女325例,年龄19～79岁,平均426岁。结石分布:左肝内胆管结石297例,右肝内胆管结石180例,尾叶内胆管结石4例,左右肝管均有多发结石137例,618例中合并胆总管结石396例。2.手术与胆道镜治疗方法:本组采用的手术方法为肝叶切除5例,肝叶切除加胆管外引流76例,肝叶切除加胆肠内引流45例,狭窄肝胆管切开成形加胆肠内引流4例,狭窄肝胆管切开成形加胆管外引流2例,肝表面切开取石加胆管外引流29例,胆肠内引流加…     

肝胆管结石合并肝内胆管开口针尖样狭窄25例治疗体会

目的 探讨肝胆管结石合并肝内胆管开口针尖样狭窄患者的治疗体会。方法 回顾性分析接受胆道镜及肝总管高位切开、肝部分切除技术治疗的25例肝内胆管针尖样狭窄的肝胆管结石患者临床资料。结果 本组25例患者,行肝内胆管开口针尖样狭窄扩张术14例,行左肝外叶切除术9例,行萎缩右半肝+右尾状叶切除术2例。术中经胆道镜结石取净23例,术中胆管有结石残留2例,术后经T管窦道以胆道镜取净结石,随访6个月至2年未见结石复发。结论 肝总管高位切开、肝部分切除及胆道镜的应用在合并肝内胆管开口针尖样狭窄的肝胆管结石患者的治疗中起重要的作用。     

经T管窦道胆道镜下气囊导管扩张治疗胆管良性狭窄

自1989年以来，我们对6例术后肝胆管残余结石伴肝内胆管良性狭窄病人采用纤维胆道镜下经T管窦道置入气囊导管扩张治疗，取得了较好的效果，现报告如下。1临床资料1.1一般资料本组6例中，男女各3例，年龄32～68岁，其中3例既往有2～3次胆道手术史。本次手术方法均为胆管切开取石、胆总管T管引流，其中4例为急诊手术。术后2周经T管逆行造影提示：左肝外叶残余结石伴左肝外叶胆管开口狭窄2例；左肝多发残余结石伴左肝管狭窄1例；左右肝内胆管残余结石伴右肝后叶胆管开口狭窄1例。其中2例术后仍有胆管炎表现。1．2操作方法术后6～8周，操作前3…     

合并尾状叶结石的肝内胆管结石20例临床分析

目的 探讨合并尾状叶结石的肝内胆管结石的合适的诊治方法.方法 20例合并尾状叶结石的肝内胆管结石,采用肝尾状叶切除联合左外叶切除10例,采用左外叶切除联合尾状叶胆管切开取石T管引流5例,肝右叶切除联合尾状叶切除1例.肝左叶切除联合尾状叶胆管切开取石T管引流2例,肝右后叶切除联合尾状叶切除2例.结果 并发胸腔积液12例,切口感染1例,胆漏2例,死亡1例.随访2年,2例联合尾状叶胆管切开取石T管引流患者仍有胆管结石复发,间断出现胆道感染症状.结论 联合尾状叶切除术可以达到良好的远期效果,是合并尾状叶结石的肝内胆管结石的较好的治疗方法.     

肝内胆管结石外科手术治疗(附33例报告)

一般资料:本组男14例,女19例,年龄22～71岁,平均48岁。左肝内胆管多发结石18例,右肝内胆管多发结石5例,左右肝内胆管多发结石12例,其中属再次手术者18例。1.手术方法:肝门区胆管汇合部狭窄成形外支架引流3例,左肝叶或段切除10例,右后叶切除2例,肝叶切除联合胆肠内引流6例,肝门区胆管狭窄成形胆肠内引流7例,切开肝实质取石引流5例,其中,应用术中胆道镜检、取石28例,本组均留胆道Ｔ管引流。2.结果:本组病人无死亡,平均住院386ｄ,3例病人术后残余结石,经术后胆道镜取净残石治愈,大部病人随访作者单位:666100　云南省西双版纳傣族自治州人民医院…     

肝内胆管结石外科手术方法探讨

目的: 探讨肝内胆管结石并狭窄的手术治疗方法及其效果。方法: 总结8年间住院的165例肝内胆管结石并胆管狭窄患者的外科手术治疗情况。其中A组85例行肝叶(或肝段)切除的各种术式，同时行胆管空肠吻合40例，肝断面扩张胆管、肝门胆管与空肠双口吻合10例，T管和U管引流分别为21例和14例；B组80例行非肝叶(或肝段)切除术的各种术式，其中胆总管切开取石+T管引流23例，胆总管切开取石+U形管引流15例，胆肠吻合+胆总管取石42例。肝门部肝胆管狭窄整形46例。结果: A组无手术死亡；随访2～7年，术后残留结石4例，残石率4.71%；症状复发3例，复发率3.53%，无再手术者。B组无手术死亡；B组随访2～7年，术后残留结石12例，残石率15.00%。10例术后常有上腹隐痛或发热，症状复发率12.5%。术后经胆道镜取石5例，其余6例中有3例再次行肝叶切除治愈。结论: 肝段(叶)切除联合其他手术是治疗肝内胆管结石较为理想而有效的手术方式。     

免T管腹腔镜辅助肝切除治疗肝内外胆管结石11例

目的 探讨不放置T管的腹腔镜辅助肝切除治疗肝内外胆管结石的可行性和安全性。方法 11例左肝内胆管结石，其中合并胆总管结石8例，胆囊结石5例。采用腹腔镜辅助规则肝切除，均经左肝管残端插入电子胆道镜肝外胆管取石和右肝管探查，不切开胆总管，不放置T管引流。结果 11例手术均获得成功，其中腹腔镜辅助肝左外叶切除5例，左半肝切除6例。手术时间110～150min，平均128min；术中出血50～150ml，平均95ml。术后无并发症。术后住院5～10d，平均7d。11例随访2～16个月，平均7．6月，优10例，良1例，无结石残留、复发。结论 腹腔镜辅助左肝切除、经左肝管残端胆道镜取石，不放置T管，有利于降低手术难度，缩短手术时间，减少并发症，是可供选择的手术方式。     

胆道镜微创技术联合常规手术治疗肝胆管结石合并狭窄

目的探讨肝胆管结石及狭窄常规手术治疗结合胆道镜微创技术以改善疗效、降低手术残石率及最终残石率的方法。方法对1981年11月～2004年12月收治的1076例肝胆管结石合并胆管狭窄的患者分别在术前、术中、术后采用胆道镜治疗（包括膜状狭窄胆管的扩张治疗），并根据术中胆道镜探查结果指导手术方式。手术分别采用或组合应用肝门部胆管切开成型术、肝叶切除术（包括肝叶、肝段、契形、不规则切除术）、肝实质切开取石术、胆肠吻合术（含皮下空肠盲襻）、肝内胆管引流术、肝内外胆管U形管引流术、胆总管T管引流术等术式。术后采用胆道镜取除残石、术后胆道镜介入下微创技术包括等离子体冲击波碎石、狭窄胆管球囊导管扩张、狭窄胆管微波切开治疗等。结果对带有T管的拟手术的4例肝内外胆管广泛结石患者，术前应用胆道镜治疗，手术费时少，术后较早拔除了T管。应用术中胆道镜，取除残留结石、扩张膜状狭窄胆管、指导术式选择，使手术残石率由78．0％（409／524）降低为24．4％（128／524）。术后经胆道镜取石治疗，最终残石率为2．4％（26／1076），其中17例胆管狭窄，经胆道镜球囊导管扩张治疗，狭窄胆管均有不同程度的扩张；15例胆管狭窄，经胆道镜微波切开治疗，狭窄得以解除；25例巨大的或嵌顿性残石，经胆道镜等离子体冲击波碎石，结石取净。结论肝胆管结石及狭窄常须手术联合胆道镜微创技术才能达到理想的疗效。术中胆道镜的应用有利于手术方法的正确选择，既可有效减少手术残石，又能减少手术创伤；术后胆道镜及胆道镜介入下的微创治疗直接关系到肝胆管结石及胆管狭窄的最终治疗效果，应争取常规应用。     

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。     

������Ҷ�����г����Ƹ���ԭ���Ըε��ܽ�ʯ47����Ч����

??Treatment of complicated primary hepatic lithiasis by combined right and left lobectomy??an analysis of 47 cases WANG Huai-Zhi, HE Zhen-Ping, BIE Ping, et al. Institute of Hepatobiliary Surgery of PLA, Southwest Hospital, the Third Military Medical University, Chongqing400038??China Corresponding author: WANG Huai-Zhi, E-mail??whuaizhi@gmail.com Abstract Objective To summarize the experience and evaluate the therapeutic effect of combined right and left lobectomy for complicated primary hepatic lithiasis. Methods To analyze retrospectively the clinical data of 47 patients suffering from complicated primary hepatic lithiasis underwent combined right and left lobectomy from Aug.1991 to Aug. 2007. Stones distribution, operation style, postoperative complications and therapeutic effects were evaluated. Results 15 patients out of 47 patients had underwent operations on bile duct. All of the patients have stones in both right lobe and left lobe. Out of 47 patients, 7 patients have stones in caudate lobe, 21 patients have stones in extrahepatic bile duct. 23 cased of biliary stricture were found during operations. All of the patients underwent combined right and left lobectomy. Out of 47 patients, 3 patients underwent the resection of biliary tree of right lobe, 6 patients underwent the resection of biliary tree of right posterior lobe. Additional procedures include exploration of common bile duct in 28 patients, chole-enterostomy(Roux-en-Y) in 19 patients and intrahepatic lithotomy through hepatic parenchyma. Two patients died perioperatively. Three patients had intraperitoneal infection after operation. One patient had residual stone in right anterior lobe. One patient had residual stone in left interior lobe. The follow-up time is from 16 months to 17 years.88.89% of patients has excellent life quality. Conclusion Combined right and left lobectomy has less complications, less residual stones, excellent long-term results, thus is one of the effective procedures treating complicated primary hepatic lithiasis.     

腹腔镜胆道镜联合钬激光治疗肝内胆管结石115例体会

目的探讨腹腔镜胆道镜联合钬激光治疗肝内胆管结石的疗效及应用价值。方法应用腹腔镜、胆道镜、钬激光治疗肝内胆管结石115例,经胆总管取石。术后2—3个月经T管窦道再次胆道镜探查及取石。结果顺利完成手术106例,成功率92．2％,9例中转开腹（7．8％）。30例术后Ⅲ级胆管残留结石（26．1％）,8例Ⅱ级胆管残留结石（7．0％）,胆总管无残留结石。经T管窦道胆道镜探查97例,取石27例（27．8％）,其中单纯取石篮套取石19例（19．6％）,再次钬激光碎取石8例（8．2％）。多次镜下取石6例,1例镜下取石多达12次。再次手术3例（2．6％）。结论腹腔镜胆道镜联合钬激光治疗肝内胆管结石微创、高效,且安全实用。     

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     

肝段(叶)切除治疗肝内胆管结石疗效分析

目的探讨肝段(叶)切除治疗肝内胆管结石的临床价值。方法回顾性分析1997年1月～2004年1月采用肝段(叶)切除治疗肝内胆管结石的115例病例资料。结果肝段(叶)切除 胆管空肠Roux-en-Y吻合28例(24．3％)；肝段(叶)切除 胆道探查72例(62．6％)；肝段(叶)切除 胆肠吻合口切开探查10例(8．7％)；肝段(叶)切除 胆道探查 右肝表面切开取石术5例(4．3％)，术后胆道常规留置T管。其中肝段(叶)切除手术包括左外叶88例，左半肝12例，右前叶7例，右后叶1例。不规则左和(／或)右肝切除术7例。病人均治愈，无死亡。术后发生并发症10例(8．7％)，其中切口感染7例，切口裂开3例，均治愈。术后均经T管行胆道造影及胆道镜检，发现结石15例，残石率13．0％。结论肝段(叶)切除术治疗肝内胆管结石具有疗效较好。残石率较低，并发症较少的优势。     

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。     

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。     

经口胆道子母镜碎石治疗胆管巨大嵌顿性结石21例

目的探讨经口胆道子母镜液电联合机械碎石治疗胆管巨大嵌顿性结石的可行性。方法常规经内镜逆行胰胆管取石（ERCP）治疗困难的胆管巨大嵌顿性结石患者21例,用子母镜液电先将结石击散,再用机械碎石网篮碎清除结石。结果21例患者子母镜取石治疗均获成功。18例肝外胆管结石中14例一次性取净结石,4例两次取净结石。3例左右肝管嵌顿结石病例,2例取净结石;1例合并右肝内胆管多发嵌顿结石,未能取净结石。术中短暂出血3例,术后胆管炎1例,术后胰腺炎2例,无穿孔、死亡等严重并发症。结论对常规ERCP治疗困难的胆管巨大嵌顿性结石,子母镜液电联合机械碎石是一种安全和有效的办法。     

广泛肝内胆管结石合并左右肝叶萎缩尾状叶明显肥大行保留尾状叶次全肝切除术1例报道

目的探讨广泛肝内胆管结石合并左右肝叶萎缩而尾状叶明显肥大的患者行保留尾状叶次全肝切除术的可行性和安全性。方法回顾性分析四川大学华西医院2020年2月收治的1例肝内胆管结石患者的临床病理资料。结果患者左右肝叶结石伴左右肝叶明显萎缩而尾状叶明显肥大。患者术前一般情况良好,心、肺和肾功能正常,肝功能Child-Pugh A级,肝脏储备功能良好。患者体表面积为1.745 m2,标准肝体积为1 235 mL,CT图像三维重建评估肝尾状叶体积为735 mL,占标准肝体积59.5%,经评估患者能耐受手术。患者成功经历保留尾状叶次全肝切除术,术后肝功能恢复良好,术后第2天拔除胃管,术后第5天拔除腹腔引流管,术后第6天出院。术后病理诊断:肝内胆管扩张伴胆管结石,胆管周围大量炎细胞浸润,门管区纤维组织增生、小胆管增生、炎细胞浸润,病变符合肝内胆管结石改变。结论通过对本病例的分析结果看,对于广泛肝内胆管结石合并左右肝明显萎缩而尾状叶明显肥大的患者,保留尾状叶次全肝切除术是安全、可行的。