选择性肝血流控制下的解剖性肝叶切除在肝内胆管结石治疗中的应用

Role of anatomic hepatectomy performed under vascular exclusion in management of hepatolithiasis

目的 总结采用选择性肝血流控制下的解剖性肝叶切除治疗肝内胆管结石的经验。方法 回顾性分析2002年5月至2005年3月采用解剖性肝叶切除治疗的53例单侧肝内胆管结石的临床资料和治疗效果。全组病例中结石局限分布于左外叶12例（23％）、左半肝26例（49％）、右后叶8例（15％）、右半肝7例（13％）。其中38例合并有相应肝叶的萎缩。有14例经历过1～4次以上的手术治疗（包括胆管空肠ROUX—Y吻合5例）。9例患者在术前合并有急性胆管炎的表现，4例合并有肝脓肿，3例术后病理诊断合并有胆管细胞癌。结果 全部患者均成功采用选择性肝血流隔离技术控制入肝和出肝血流，施行左外叶切除12例（23％），左半肝切除26例（49％），右后叶切除8例（15％），右半肝切除7例（13％）。附加术式包括，肝门部胆管切开取石39例，胆管空肠ROUX—Y吻合5例。术中输血3例。全组无死亡病例。术后并发症包括结石残留2例（4％），胆漏3例（6％），膈下感染2例（4％），胸腔积液5例（9％），切口感染5例（9％）。结论 对单侧的肝内胆管结石，采用选择性肝血流控制下解剖性肝叶切除以最大限度的切除包括结石和以术中胆道造影为标准的病变胆管在内的病灶是治疗肝内胆管结石有效的手段；同时可减少术中出血量和术后并发症。

Objective To evaluate the effect of anatomic hepatectomy performed under vascular exclusion in management of hepatolithiasis. Methods From May 2002 to March 2005, fifty-three patients with unilateral hepatolithiasis underwent anatomic hepatectomy with exposure and control of inferior vena cava and main trunk of hepatic veins. The hepatic lobes involved by hepatolithiasis were left lateral lobe （ S2, S3 ） in 12 patients, left lobe （S2,S3, S4 ） in 26 patients, right posterior lobe （S6,S7 ） in 8 patients and right lobe （ S5 ,S6 ,S7 ,S8 ） in 7 patients. Atrophy of involved hepatic lobes was found in 38 patients. Fourteen patients had experienced more than one operation on biliary tract. Nine patients showed the symptoms of acute cholangitis preoperatively and 4 patients complicated with liver abscess. Results Vascular exclusion was successfully performed on all patients to control the blood inflow and outflow of liver. The anatomicly resected hepatic lobes were left lateral lobe （ S2, S3 ） in 12 patients, left lobe （ S2, S3, S4 ） in 26 patients, fight posterior lobe （ S6 ,S7 ） in 8 patients and right lobe （S5 ,S6 ,S7 ,S8 ） in 7 patients. Except hepatectomy, the additional procedures performed on the patients were choledocholithotomy in 39 cases, choledochojejunostomy in 5 cases. The majority of complications were bile leakage in 3 cases, subphrenic infection in 2 cases, hydrothorax in 5 cases and wound infection in 5 cases. Conclusions Anatomic hepatectomy under vascular exclusion is effective treatment to eradicate inrahepatic stone foci in case of unilateral hepatolithiasis, and help to reduce intraoperative blood loss and decrease postoperative complications.