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.     

肝内胆管结石肝部分切除术的断面处理

目的:总结肝部分切除治疗肝内胆管结石肝断面处理经验.方法:根据术中探查情况,结合B超、CT及术中胆道镜检查结果,确定肝部分切除范围.肝断面采取缝闭、开放、生物蛋白胶或ZT胶加明胶海绵覆盖.近端肝内胆管梗阻不能解除行肝断面胆管与空肠内引流术.结果:肝断面缝闭40例,肝断面生物蛋白胶或ZT胶加明胶海绵覆盖51例(其中肝断面胆管与空肠内引流术4例),肝断面开放38例.术后发生胆漏20例,膈下感染6例,切口感染11例,死亡3例.结论:肝部分切除首选规则性肝切除,同时解除肝内胆管二重梗阻.肝断面肝组织缺血坏死、感染可引起胆瘘,纤维胆道镜应用可减少肝内结石残留,术中关闭或覆盖肝断面可减少胆瘘、出血、膈下积液等并发症的发生,肝断面胆管与血管应单独处理.胆瘘试验是预防术后胆瘘的有效方法.     

肝切除治疗肝内胆管结石

目的探讨肝切除治疗肝内胆管结石的疗效。方法回顾性分析了1991年1月至2004年6月255例肝胆管结石采用肝切除治疗的术式和治疗效果。结果肝切除术式:左外叶切除175例(68.62%),左半38例(14.90%),右肝叶或段切除35例(13.73%),其中右半肝切除5例,双侧多肝段切除22例(8.63%),同时作胆肠内引流73例(28.63%),手术并发症22(8.63%),无术后死亡。结石残留32例(12.55%),其中29例经胆道镜取干净。221例(86.67%)获随访1至13年平均7.5年,优良率达89.59%。结论肝切除是治疗肝内胆管结石安全、有效的方法,其中早期肝胆管结石的肝切除治疗效果最佳,术中B超及纤维胆道镜在处理肝内胆管结石中起重要作用。     

胆肠内引流术后再发肝内胆管结石的外科治疗

目的:探讨胆肠内引流术后再发肝内胆管结石的原因及其处理。方法:回顾性分析2006年1月—2013年6月治疗的28例胆肠内引流术后再发肝内胆管结石的患者资料。结果:28例患者根据既往肝外胆管连续性是否保留分为保留组与未保留组。保留组16例中,8例Oddi括约肌功能良好,拆除原胆肠吻合口,修复胆总管并行T管外引流,7例Oddi括约肌功能障碍,行胆肠吻合口拆除重建、标准胆肠Roux-en-Y吻合,1例合并胆管肿瘤无法切除仅行胆总管切开取石;未保留组12例中,7例胆肠吻合口狭窄行吻合口修复重建,5例行吻合口切开取石后重建。两组共11例发生术后并发症(39.3%),其中胆瘘3例,切口感染6例,腹腔出血2例,均治愈,无围手术期死亡。保留组与未保留组即时结石取净率、最终结石取净率分别为68.8%和66.7%、87.5%和83.3%;术后随访生存状态的优良率分别为85.7%和90%,差异均无统计学意义(均P0.05)。结论:对于胆肠内引流术后再发肝内胆管结石患者,应明辨既往手术方式及分析结石再形成原因,尽量取尽结石,依据Oddi括约肌功能选择胆道内外引流术式。     

先天性胆管囊性扩张症的外科治疗(附49例临床分析)

本文统计分析1980年至1997年我院收治手术的先天性胆管囊肿病人49例，阐述本病在发病情况、临床表现、术前检查等方面的一般规律，认为治疗上对于肝外囊肿应尽量切除囊肿后行胆肠内引流，可降低并发症及再手术率，对于肝内囊肿应根据囊肿的具体情况来决定手术方法，可行肝叶（段）切除，清除结石，整形，解除主要胆管狭窄，再行胆肠内引流术。     

肝内胆管结石的手术治疗

为了解肝内胆管结石的手术治疗效果。方法：对手术治疗的１２０例肝内胆管结石及合并肝内胆管狭窄的病例进行随访研究。手术方法为：（１）肝门部大口径胆吻合术４４例，（２）胆管切开取石引流术３５例；（３）胆肠内引流术３７例；（４）肝脏部分切除术４例。结果：随访发现，肝门部大口径胆肠吻合术和肝脏部分切除术疗效好，优良率分别为８４％和７５％，而胆管切开取石引流术和胆肠内引流术疗效不理想。结论 肝门部大口径胆肠吻     

先天性胆管囊性扩张症的外科治疗

本文统计分析１９８０年至１９９７年我院收治手术的先天性胆管囊肿病人４９例，阐述本病在发病情况、临床表现、术前检查等方面的一般规律，认为治疗皮对于肝外囊肿应尽量切除囊肿后行胆肠内行流，可降低并发症及再手术率，对于肝内囊肿应根据囊肿的具体情况来决定手术方法，可行肝叶切除，清除结石，整形，解决主要胆管狭窄，再行胆肠内引流术。     

肝胆管结石胆肠吻合“翻修”手术的临床研究

目的探讨胆肠侧侧吻合术后再发肝内外胆管结石的有效治疗方式,以及胆肠内引流"翻修"手术的适应症。方法 7例胆肠内引流术后再发结石病人再手术,术中利用纤维胆道镜尽可能取尽结石,同时发现Oddi括约肌功能良好,复原胆道的原有解剖结构,放置胆总管T管引流,若已有肝叶或段积累大量结石或已发生肝纤维化甚至脓肿、癌变者则同时行相应的肝叶或段的切除。术后6周行T管造影,无结石者拔除T管,若有结石残留,则经T管窦道纤维胆道镜多次取石,直至取尽结石为止。电话结合门诊复查的方式随访,随访时间截至2015年07月31日。结果 7例患者均有胆道感染症状,肝内胆管和/或胆总管存在结石;5例联合肝叶切除,其中4例因肝叶萎缩,而1例因癌变;7例均手术复原胆肠吻合,其中4例术后胆道造影未见结石残留,3例均经一次纤维胆道镜取尽结石。结石最终清除率为100%。术后7例患者均出现不同程度的并发症,经过禁食、抗感染、胸腔穿刺、再手术等处理均好转。随访中位数30个月,均无结石复发与胆道感染的症状。结论胆肠内引流术应严格限制在其适应症内;在Oddi括约肌功能良好的情况下,翻修胆肠内吻合后放置胆总管T管联合纤维胆道镜是胆肠侧侧吻合术后再发肝内外胆管结石的有效治疗方法。     

肝切除术治疗肝胆管结石316例报告

目的总结用肝切除术治疗肝内胆管结石的经验及评价其疗效。方法回顾性分析近20年间采用肝部分切除术治疗原发性肝内胆管结石316例的临床资料,统计结石的分布、术式选择、术后并发症及治疗效果。肝切除术式采用左外叶切除192例(60.76%),左半肝切除58例(18.35%),肝方叶切除12例(3.80%),右前叶切除6例(1.90%),右后叶切除25例(7.91%),右半肝切除9例(2.85%),双侧多区段肝切除14例(4.43%);其中附加胆肠内引流术184例(58.23%)、经肝实质切开取石4例。结果全组手术后发生并发症56例(17.72%),包括胆漏、胆道出血、膈下脓肿等。术后1个月内分别因应激性溃疡、肝肾衰竭、二重感染并多器官衰竭死亡各1例(0.95%)。258例获11个月至18年的随访,平均随访10.3年,优良率90.31%。结论规则性肝叶/段切除是治疗原发性肝胆管结石的有效手段。     

肝切除术为主的联合手术治疗肝内胆管结石

目的探讨肝切除术为主的联合手术治疗肝内胆管结石的方法及疗效。方法回顾分析2000年7月至2005年7月采用以肝切除为主的联合手术治疗肝内胆管结石169例的治疗效果。结果本组无手术死亡;有结石残留23例,残石率13.61%;随访145例,术后有轻度胆管炎症状者13例,占8.97%;再手术3例,手术优良率92.4%。术后并发症:本组36例发生手术并发症,发生率21.43%,包括胆瘘、肝断面感染、切口感染、胆道术后出血。结论以肝切除术为主的联合手术是治疗肝内胆管结石的有效办法,可降低残石率和复发率,提高手术疗效,肝叶、段切除是肝内胆管结石手术治疗的核心。     

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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.     

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.     

219例肝内胆管结石的外科治疗

目的:总结并评价肝内胆管结石的外科手术治疗效果。方法:单纯胆道探查T管引流72例,肝叶(段)切除和胆肠内引流109例,胆总管切开并胆道镜钬激光碎石术取石 T管引流38例。结果:总治疗优良率83.8%,并发症率15.1%,死亡率0.5%,结石残石率14.1%。胆总管切开合并胆道镜碎石术应用者明显优于其他组。结论:充分利用先进的诊疗技术,选择合理的术式,保留Oddi括约肌功能,可有效提高治疗效果,降低并发症及残石率。     

复杂肝内胆管结石60例诊治分析

目的 探讨复杂肝内胆管结石合理的诊断与治疗方式。方法 回顾性分析上海交通大学医学院附属仁济医院2011年1月至2015年10月手术治疗60例复杂肝内胆管结石的影像学资料、手术方式、并发症与疗效。结果 根据肝胆管结石病分型,Ⅰ型（区域型）44例,Ⅱ型（弥漫型）16例,E型（附加型,合并肝外胆管结石）28例。肝功能Child分级59例为Child A级,1例为Child B级。术前单用CT诊断灵敏度为86.7%,单用MRI+磁共振胰胆管造影（MRCP）诊断灵敏度93.9%。术前用CT+MRI诊断灵敏度为97.2%。60例均行肝叶或肝段切除术,其中12例合并高位胆管狭窄行胆肠吻合。手术并发症发生率25%。无术后肝功能衰竭和围手术期死亡病例。术毕联合应用B超和胆道镜检查,残石率为0（0/25）,明显低于单用胆道镜取石探查组的20%（7/35）。55例获得3个月至5年的随访,随访率91.6%,其中优良率达96.2%,残石率11.7%,复发率9.61%。结论 联合B超、上腹部CT和MRI+MRCP能提高肝内胆管结石的检出率,术中联合运用胆道镜与术中B超能降低残石率,解剖性肝切除能降低残石率与结石复发率。     

Evaluation of the results of external choledochoduodenostomy for retained, recurrent, or primary common duct stones.

Twenty-five patients were treated for retained, recurrent, or primary common duct stones by permanent drainage of the biliary tract with external choledochoduodenostomy. Twenty-one patients had common duct stones which became evident two to fifty years after the initial biliary tract procedure and which may represent stones formed in the common duct. Three recent patients had a clinical history of primary common duct stones, had stones which were soluble in chloroform-methanol solution, and had hepatic bile which was lithogenic as determined by evaluating the molar percentage of cholesterol, phospholipid, and bile salt in bile samples obtained at the time of choledochoduodenostomy. These data suggest that further stone formation is possible and that permanent bypass of the sphincter of Oddi is indicated to prevent recurrent bile duct obstruction. Long-term evaluation of the results of external choledochoduodenostomy indicates that the procedure is safe and effective in the prevention of recurrent biliary tract calculi.     

老年病人肝内胆管结石外科治疗的临床分析

目的 探讨老年人肝内胆管结石治疗的有效方法.方法 收集我院诊治的75例肝内胆管结石患者的临床资料.结果 肝切除术组和胆总管切开加胆道镜取石术组患者治疗的优良率明显高于总管切开取石加内引流术组;肝切除术组患者的残石率明显低于胆总管切开取石加内引流术组.结论 肝切除术治疗肝内胆管结石,效果好,残石率低,是一种有效的手术方式...     

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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     

肝叶切除治疗肝内胆管结石487例临床体会

目的　探讨肝叶切除治疗肝内胆管结石的方法及疗效。方法　回顾性总结 1982年 1月 -2 0 0 2年 6月间肝叶切除治疗 487例肝内胆管结石的经验与体会。结果　肝左 (外 )叶切除 415例(占肝叶切除的 85 .2 % ) ;肝方叶切除 3 1例 ( 6.4% ) ;肝右叶切除 41例 ( 8.4% )。术后并发症 5 3例( 10 .9% ) ,包括隔下感染、胆道出血等。死亡 5例 ,死亡率 1.0 %。结论　肝叶切除是治疗部分肝内胆管结石的较好方法 ,但对肝右叶及左右肝胆管结石病例仍有扩大适应证之可能。     

Laparoscopic choledochoduodenostomy

Laparoscopic cholecystectomy has become the gold standard for treatment of patients with symptomatic cholelithiasis. Management of common bile duct stones in the era of laparoscopy is an area of controversy. Although perioperative endoscopic retrograde cholangiography remains as a widely used procedure, experience is accumulating on the exploration of the common bile duct with the laparoscope. A biliary drainage procedure is indicated in selected patients with choledocholithiasis. Initially described by Reidel in 1892, side-to-side choledochoduodenostomy has become a popular biliary-enteric anastomosis technique in the last century. We describe two patients with recurrent choledocholithiasis and biliary obstruction due to benign biliary strictures. Both patients underwent laparoscopic common bile duct exploration and stone extraction. A side-to-side choledochoduodenostomy is then performed laparoscopically as a drainage procedure. Laparoscopic choledochoduodenostomy resulted in resolution of jaundice and relief of biliary obstruction. Laparoscopic choledochoduodenostomy can be an acceptable alternative to the open choledochoduodenostomy. In addition to a tension-free anastomosis and an adequate-sized stoma, intracorporeal suturing and knot-tying skills are also essential to the success of this procedure.