肝内胆管结石外科治疗选择(附407例分析)

目的 探讨肝内胆管结石术式选择原则。方法 回顾性分析407例肝内胆管结石病人，根据结石分布类型和伴随的病理变化以解除梗阻、去除病灶、通畅引流为基本要求，采取术中胆道镜和术中B超相结合取石160例，无这两项辅助手段取石207例；肝切除去除病灶144例；胆管空肠Roux-en-Y吻合内引流92例；T管引流86例；肝切除 胆肠Roux-en-Y内引流62例；肝切除 T管引流82例。结果 术中胆道镜 术中B超取石组残石率4．3％，无辅助手段取石组残石率40％。随访1～10年，肝切除 内引流和单纯内引流组优良率分别为93．5％和80．43％，肝切除 T管引流组和单纯T管引流组优良率分别为95％和82．56％，统计学上有显著性差异，肝切组无论是否作胆肠内引流，优良率均无显著性差异。结论 肝内胆管结石手术应根据结石分布类型和伴随的病理变化以解除梗阻、去除病灶、通畅引流为基本要求，个体化地选择术式，术中应把时间和精力放在解除梗阻、去除病灶上，胆肠内引流只作为补助性治疗措施。

Selection of surgical treatments for hepatolithiasis:an analysis of 407 cases

Objective To determine the principle for selection of surgical treatments for hepato-lithiasis. Methods The clinical data of 407 patients with hepatolithiasis treated in our hospital were retrospectively analyzed. Intrahepatic stones were removed by combined application of intraoperative choledochofiberscopy and ultrasonography in 160 cases. Neither intraoperative choledochofiberscopy nor ultrasonography was used in 207 cases. Partial hepatectomy was perfomed in 144 cases, cholan-giojejunostomy in 92, T tube drainage in 86, hepatectomy + cholangiojejunostomy in 62 and hepatectomy + T tube drainage in 82. Results The rate of residual stones was significantly lower in the group using combined intraoperative choledochofiberscopy and ultrasonography (4. 3%) than in the other group without these auxiliary measures (40%). The follow-up study for 1-10 yr showed that the excellent curative rate was 93. 5% and 80. 43% in the group of hepatectomy + cholangiojejunostomy and the group of simple cholangiojejunostomy, respectively. Meanwhile, it was 95% and 82. 56% in the group of hepatectomy + T tube drainage and the group of simple extra-drainage. There was significant difference (P<0. 05). Among groups of partial hepatectomy with or without cholangiojejunostomy, there was no significant difference for the outcome. Conclusions Operations for hepatolithiasis should be performed according to the type of distribution of stones and pathological modification following the principle of relieving obstruction, removing pathological foci and expediting drainage. The personalized operative procedure should be selected to focus on relieving obstruction and removing pathological foci. Furthermore, cholangiojejunostomy should be used as an auxiliary therapeutic meas-