摘要
目的探讨围肝门外科技术治疗弥漫型肝胆管结石病的临床疗效。方法采用回顾性描述性研究方法。收集2010年1月至2015年12月湖南省人民医院收治的122例弥漫型肝胆管结石病病人的临床病理资料;男39例,女83例;中位年龄为51岁,年龄范围为21~82岁。所有病人行围肝门切除术显露高位胆管后,行1~3级胆管切开;通过胆管拼合整形、内吻合解除狭窄后,直视下多种方法结合取尽结石;沿肝脏萎缩或胆管狭窄平面切除严重萎缩肝脏后,行T管或肝胆管盆式内引流。观察指标:(1)手术情况。(2)狭窄解除及结石清除情况。(3)随访情况。采用微信、电话或门诊方式随访。术后第1年每3个月门诊随访1次,行肝功能及腹部B超检查。随后每年复查1次肝功能和腹部B超。怀疑胆管炎或结石复发时行磁共振胰胆管成像和CT检查,了解结石复发情况和病人生存情况。随访时间截至2020年7月。正态分布的计量资料以x±s表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。结果(1)手术情况:122例病人手术时间为(253±71)min、肝门阻断时间为15 min(14~38 min)、术中出血量为200 mL(100~1100 mL)、术后住院时间为(12±5)d。122例病人中,40例发生术后并发症,其中切口感染9例、胆汁漏8例(肝断面胆汁漏5例和胆肠吻合口漏3例)、败血症8例、胸腔积液7例、腹腔脓肿5例、肝衰竭3例、胆道出血1例(部分病人合并多种并发症)。122例病人中,术后死亡2例,其中1例为术后肝衰竭、1例为胆肠吻合口漏并发脓毒血症导致弥散性血管内凝血。胆汁漏及腹腔脓肿病人经B超引导下穿刺置管引流后好转;胆道出血病人为胆肠吻合口出血,经肝右动脉介入栓塞止血;其余并发症经保守治疗后好转。(2)狭窄解除及结石清除情况:88例合并胆管狭窄病人中,85例狭窄解除,狭窄解除率为96.59%(85/88)。122例病人中,103例结石彻底清除,19例残留结石,术后即刻结石清除率为84.43%(103/122)。19例残留结石病人中,3例拒绝行胆道镜取石,16例行T管窦道胆道镜取石碎石术(7例结石清除、9例仍残留结石)。122例病人中,110例最终结石清除,12例最终残留结石,最终结石清除率为90.16%(110/122)。(3)随访情况:122例病人中,120例获得随访(110例最终结石清除、10例残留结石),随访时间为(78±14)个月。120例获得随访病人的1、3、5年结石复发率分别为0.83%(1/120)、6.67%(8/120)、9.17%(11/120)。110例最终结石清除病人的1、3、5年结石复发率分别为0、5.45%(6/110)、5.45%(6/110)。10例残留结石病人的1、3、5年结石复发例数分别为1、2、5例。120例获得随访的病人中,1例因终末期肝病死亡,其余病人生存状态良好。结论围肝门外科技术治疗弥漫型肝胆管结石病安全、有效。
Objective To investigate the clinical efficacy of perihilar surgical techniques for diffuse hepatolithiasis.Methods The retrospective and descriptive study was conducted.The clinicopathological data of 122 patients with diffuse hepatolithiasis who were admitted to Hunan Provincial People's Hospital from January 2010 to December 2015 were collected.There were 39 males and 83 females,aged from 21 to 82 years,with a median age of 51 years.After perihilar hepatectomy,the first,second and third divisions of hepatic ducts were opened longitudinally.Strictures in the bile ducts were relieved by stricturoplasty and internal bile duct anastomosis,and stones were removed by multiple methods under direct vision.After resection of severe atrophic liver segment along the plane of hepatic atrophy or bile duct stricture,T-tube or hepaticojejunos-tomy was used for internal drainage.Observation indicators:(1)surgical situations;(2)stricture relief and stone removal.(3)Follow-up.Follow-up was conducted by Wechat,telephone interview or outpatient examination.Patients were followed up once every 3 months in the postoperative 1 year through liver function and abdominal B-ultrasound examination.Subsequently,liver function and abdominal B-ultrasound were reexamined once a year.Magnetic resonance cholangiopancreato-graphy and computed tomography were performed when cholangitis or stone recurrence was suspected to analyze stone recurrence and patient survival.The follow-up was up to July 2020.Measurement data with normal distribution were represented as Mean±SD,and measurement data with skewed distribution were represented as M(range).Count data were expressed as absolute numbers or percentages.Results(1)Surgical situations:for the 122 patients,the operation time,hepatic portal occlusion time,volume of intraoperative blood loss,duration of postoperative hospital stay were(253±71)minutes,15 minutes(range,14‒38 minutes),200 mL(range,100‒1100 mL),(12±5)days.Postoperative complications occurred to 40 of 122 patients.There were 9 cases of incision infection,8 cases of bile leakage(5 cases of bile leakage at hepatic section,3 cases of choledochojejunostomy leakage),8 cases of septicemia,7 cases of pleural effusion,5 cases of abdominal abscess,3 cases of liver failure,1 case of biliary bleeding.Some patients had multiple complications.Among the 122 patients,2 cases died after operation,including 1 case of postoperative liver failure and 1 case of disseminated intravascular coagulation caused by biliary-intestinal anastomotic leakage complicated with sepsis.Patients with bile leakage and abdominal abscess were improved after puncture and drainage under the guidance of B-ultrasound.Patients with cholangiojejunal anastomotic bleeding were embolized through the right hepatic artery.The other complications were improved after conservative treatment.(2)Stricture relief and stone removal:85 of 88 patients with biliary stricture were relieved,with the stricture relief rate of 96.59%(85/88).Among the 122 patients,103 cases had stones completely removed and 19 cases had residual stones.The immediate stone clearance rate was 84.43%(103/122).Of the 19 patients with residual stones,choledochoscopy was refused in 3 cases and choledochoscope lithotripsy was performed in 16 cases,of which 7 cases were removed and 9 cases were still residual stones.Of the 122 patients,110 cases were finally removed stones,12 cases were eventually residual stones,and the final stone clearance rate was 90.16%(110/122).(3)Follow-up:among the 122 patients,120 cases including 110 cases with find stone removal and 10 cases with residual stones were followed up for(78±14)months.The 1-,3,5-year stone recurrence rates of 120 patients were 0.83%(1/120),6.67%(8/120),9.17%(11/120),respectively.The 1-,3-,5-year stone recurrence rates of 110 patients with final stone removal were 0,5.45%(6/110),5.45%(6/110),respectively.The number of cases with stone recurrence at postoperative 1-,3-and 5-year of 10 patients with residual stones were 1,2,5 cases,respectively.Of 120 patients with follow-up,1 case died of end-stage liver disease,and the other patients had good survival.Conclusion Perihilar surgical techniques for diffuse hepatolithiasis is safe and effective.
作者
李佳
李国光
胡脉涛
蒋超
郭超
刘毅
陈梅福
吴金术
彭创
成伟
Li Jia;Li Guoguang;Hu Maitao;Jiang Chao;Guo Chao;Liu Yi;Chen Meifu;Wu Jinshu;Peng Chuang;Cheng Wei(Department of Hepatobiliary Surgery,Hunan Provincial People's Hospital,the First Affiliated Hospital of Hunan Normal University,Changsha 410005,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2021年第8期883-889,共7页
Chinese Journal of Digestive Surgery
基金
湖南省肝胆胰肠诊疗能力提升项目(湘卫[2019]118号)。
关键词
胆道疾病
胆石症
肝胆管结石病
弥漫型
围肝门切除
高位胆管切开
胆管整形
Biliary tract diseases
Cholelithiasis
Hepatolithiasis
Diffuse type
Perihilar Hepatectomy
High bile duct incision
Strictureplasty
