胆道镜配合选择性肝切除术治疗肝胆管结石探讨

目的 探讨胆道镜在选择性肝切除术治疗肝胆管结石中的价值.方法 将2000年1月至2009年12月收治的278例肝胆管结石患者分为取石组(172例)和肝切除组(106例).取石组患者经肝外胆管切开取石,106例因肝萎缩或胆管狭窄行肝切除术.术中术后常规使用胆道镜诊断取石.结果 278例肝胆管结石患者手术残余结石率为18.0％(50/278),结石取净率为99.6％(277/278)；194例无肝萎缩的患者胆管狭窄发生率为44.8％ (87/194),膜状狭窄占74.7％ (65/87),管状狭窄占25.3％(22/87)；取石组的术后并发症率为7.0％ (12/172),明显低于肝切除组15.1％ (16/106)],差异有统计学意义(x2=4.771,P＜0.05).胆管膜状狭窄65例平均随访42个月,无结石复发和胆管炎发作.结论 重视胆道镜应用,可准确掌握肝胆管结石的肝切除术适应证,提高结石清除率,减少不必要的肝切除.

Select hepatectomy for hepatolithiasis by intraoperafive cholangioscopy

Objective To investigate the value of cholangioscopy in selecting hepatectomy for hepatolithia- sis. Methods Between Jan. 2000 and Dec. 2009, 278 patients with hepatolithiasis were divided into hepatic re- section group and remove stone group. 172 patients underwent removal of intrahepatic stones via extrahepatic bile duct. 106 patients with hepatic atrophy or bile duct strictiire underwent hepatectomy. Fibrocholedochoscope was used to diagnose and remove stones during and after operation. Results The postoperative residual stones rate was 18.0% （50/278） in 278 patients; stone clearance rate was 99.6% （277/278）. The incident of bile duct stricture was 44.8% （87/194） in patients without hepatic atrophy. Membraniform strictures accounted for 74.7% and tubi- form strictures accounted for 25.3%. The morbidity rates in stone removing group was 7.0% （ 12/172）, which was significantly lower than that in liver resection group 15.1% （16/106） ] （X2 = 4. 771, P 〈 0.05 ）, none of recur- rent stones and cholangitis occurred in 65 patients with membraniform bile duct stricture during a median follow-up of 42 months. Conclusion Cholangioscopy can help select hepatectomy for hepatolithiasis accurately, increase stone clearance rate and decrease unnecessary hepatectomy.