治疗肝内胆管结石一定要切除胆囊吗

目的 探讨胆囊在肝内胆管结石手术治疗中的应用价值，并论证保留胆囊的可行性。方法 收集1994～2002年所有肝胆管结石病人的临床资料，总结既往胆囊切除的情况和原因；研究存在胆囊的肝胆管结石病人的胆囊功能状况。介绍一种应用完整胆囊解除肝门胆管狭窄的新术式——皮下通道型胆囊肝胆管成形术(STHG)，并总结其临床疗效。结果 8年间肝胆管结石病人共计247例，81例已切除胆囊，占32．8％，胆囊存在的肝胆管结石病人166例，其中胆囊形态功能正常者125例，占75．3％。其中有102例实施了STHG，不但保留了胆囊，而且使它发挥下列重要作用：①纠正肝门狭窄，改善肝内胆管的引流；②提高肝内胆管中胆汁酸浓度，从而防止该处色素结石复发；③保留了肝外胆管及Oddi括约肌的功能，防止肠胆反流；④为日后处理肝内结石复发提供一条便利通道。结论 肝胆管结石病人大多数胆囊功能正常。STHG应用正常完整的胆囊作为肝门胆管狭窄的修补材料，其术后近远期疗效好，值得推广应用。

Doses gallbladder have to be ablated in surgical treatment of hepatolithiasis

jective To discuss the value of gallbladder for surgical treatment of hepatolithia-sis and explore the feasibility of reserving the gallbladder in the operatioa Methods The clinical data of 247 patients hepatolithiasis treated in our hospital between 1994 and 2002 were summarized to understand the cause of previous cholecystectomy and study the function of the gallbladder in patients with hepatolithiasis. A new approach, subcutaneous tunnel and hepatocholangioplasty with the use of gallbladder (STHG), was introduced for treatment of hepatolithiasis. Results Of the 247 patients, 81 received cholecystectomy. The reasons for undergoing the operation were as follow: (1) 19 patients were misdiagnosed to suffer from cholecystitis; (2) 33 received the operation in choledocholithotomy; (3) 29 underwent in choledochojejunostomy. A total of 166 patients had gallbladder with them and 125 of them had normal gallbladder function. One hundred and two patients suffering from hepatolithiasis in combination with bile duct stricture underwent STHG. This new approach saved the gallbladder and its function. The gallbladder was anastomosed to the widely opened bile duct in the hilus to form a widened passway through intrahepatic to extrahepatic duct. The recurrence of pigment stone was prevented by increasing the concentration of bile acid in the intrahepatic bile duct. The Oddi's sphincter was saved so that the reflux from the jejunum to the bile duct was prevented. The fundus of gallbladder was mobilized and pulled into abdominal wall so that the subcutaneous tunnel was formed and could be used for re-entry to biliary tree at any time. Conclusions Most of the patients with hepatolithiasis have normal gallbladder. STHG can result in better outcome. This approach should be the first choice for the patients with hepatolithiasis having normal gallbladder and Oddi's sphincter.