术中纤维胆道镜治疗胆道结石常见失败原因及改进方法

Common failure reasons and improvement ways in treatment of gallstones by choledochoscope in operation

目的分析术中胆道镜治疗胆道结石时碰到的问题和常见的失败原因以及改进方法。方法对1995年1月至2005年9月期间的762例曾经使用纤维胆道镜术中治疗胆道结石的病例进行分析和总结。结果762例患者中,136例术后有胆道结石残留,残余结石率为17.8%,其中术中已知结石残留55例,术后经T管造影和术后胆道镜证实有结石残留81例。81例中包括肝内胆管结石伴胆管开口狭窄29例,肝内胆管结石伴胆管变异39例,胆总管下段节段性狭窄伴结石13例。结论术中胆道镜治疗胆道结石时要注意有无胆道变异和病变胆管开口狭窄或胆总管下端节段性狭窄等情况,术中B超对降低结石漏诊率有帮助。在使用纤维胆道镜时,术者要耐心细致,按顺序逐支逐段地检视,对胆道应采用连续窥视的方法和导向钳夹法以尽量避免主观和客观因素引起的术后结石残留。

Objective To analyze common problems, failing causes and improvement ways for curing gallstones by choledochoscope in operation. Method To analyze a case group of 762 individual patients who had undergone choledochoscope operations in the period of Jan, 1995 ～ Sep, 2005. Results 136 cases are found with residual stones in the bile duct after the operations. Residual stone rate amounts to 17.8%. 55 patients are known that bile duct stones could not be remove completely during operations. 81 patients are proved that stones still remain in their bile ducts by T-tube cholangiography and choledochoscope after operations. Among them, 29 patients complicate with narrow in intrahepatic bile ducts and debouch of bile ducts, 39 patients complicate with stones of intrahepatic bile and variation of bile duct, 13 patients complicate with stones and narrow at the inferior segment of choledochus. Conclusions It is important to pay attention for bile duct variation and debouchment of affection bile duct or inferior segment of choledochus stenosis. B-hypersound is useful to reduce residual stones in operations. The surgeon should check different lengths of the duct methodically, and use the endoscope to explore the bile duct in order not to omit any stones.