胆肠吻合术后肝内胆管结石、狭窄的防治

The prevention of hepatolithiasis and biliary stricture post choledochojujenostomy

目的探索利用胆道镜技术解决胆肠吻合治疗术后肝内胆管狭窄、结石复发的策略,探讨胆肠吻合术、胆肠吻合输出肠袢防胆肠返流人工瓣膜的可行性和有效性。方法总结行胆肠Roux-en-Y吻合术的47例肝胆管结石患者的资料,患者全部采取输出肠袢人工防返流瓣。其中19例在空肠输入出袢处放置银夹标志。术后观察胆肠返流、复发、吻合口狭窄及其处理情况。结果术后32例发生胆肠返流(32/47,68·1%),说明Roux-en-Y吻合术式中的人工瓣并没有很好的防返流作用;2例肝内胆管结石患者术后复发通过金属标记物穿刺置管建立窦道,避免了再手术。6例胆肠吻合术后胆肠吻合口狭窄,5例通过经皮经肝胆道镜(PTCS)进行取石和吻合口狭窄扩张处理获得成功,1例死亡。结论胆肠吻合术的银夹标志应用为胆道镜的治疗提供了简捷进入胆道内的路径,使复发的狭窄、结石治疗简捷化和安全化,充分发挥了胆道镜技术治疗肝胆管狭窄及残余结石的作用;PTCS微创、安全、有效,值得临床应用。

Objective To investigate the prevention of hepatolithiasis and biliary stricture post choledochojujenostomy using choledochoscopy technique and evaluate feasibility and efficacy of choledochojujenostomy and artificial valve of efferent loop in preventing reflux. Methods To analyze the data of 47 patients with hepatolithiasis who had been operated with Roux-en-Y cholangiojejunostomy and artificial valve of efferent loop to prevent biliointestinal regurgitation. Of the patients, 19 were marked with silver nip at the jejunum export of biliointestinal anastomosis. The regurgitation, recurrence, anastomotic stricture and their managements after the surgery were investigated. Results The biliointestinal regurgitation were found in 32 cases （ 32/47,68. 1% ）, it suggested that artificial valve could not prevent biliointestinal regurgitation efficiently. Two cases of hepatolithiasis recurred and were cured by sinus tract placement with the aid of silver nip mark under choledoehoscope instead of re-operation. Of the 6 cases with anastomotic stricture, 5 cases were treated successfully with stone extraction, biliary stent dilatation under the percutaneous transhepatic cholangioscopy （PTCS） and the other one case died. Conclusions Sliver nip mark provides safe and simple path for the cholangioscopy, it made the treatment of the recurrent biliary stricture and stone safe and brief, made the cholangioscopy play more important role in the hepatolithiasis, residual stone and biliary stricture. PTCS is mini-invasive, safe, simole and effective.