肝内胆管结石不同治疗方式长期疗效报告

Comparison of long-term outcomes of different treatment for hepatolithiasis

目的比较肝内胆管结石不同治疗方式的长期疗效，探讨合理可靠的治疗方法。方法回顾性分析1993年1月-2002年12月我院159例肝内胆管结石的临床资料，比较保守治疗、胆总管切开取石术、肝切除术、肝胆管肠吻合术以及保留Oddi括约肌的肝门胆管狭窄成形术5种治疗方法的术后并发症和远期疗效。结果146例随访2—12年，中位时间7年，随访率91．8％（146／159）。保守治疗16例（Ⅰ组），随访15例，15例出现胆管炎，其中死亡1例；肝外探查47例（Ⅱ组），残留结石率100％，随访43例，术后胆管炎32例（74．4％），其中死亡7例；肝叶或肝段切除16例（Ⅲ组），残留结石3例（18．8％），随访15例，术后胆管炎4例（26．7％），其中死亡1例；肝胆管肠吻合32例（Ⅳ组），残留结石11例（34．4％），随访29例，术后胆管炎14例（48．3％），其中死亡3例；保留Oddi括约肌48例（Ⅴ组），残留结石8例（16．7％），随访44例，术后胆管炎7例（15．9％）。Ⅱ组残留结石率显著高于其他手术组（P均=0．000）；Ⅰ组和Ⅱ组胆管炎复发率显著高于其他各组（P均〈0．05）；Ⅳ组胆管炎复发率显著高于Ⅴ组（P=0．003）。结论治疗肝内胆管结石，保守治疗和肝外探查疗效最差，保留Oddi括约肌的肝门胆管成形术优于肝胆管肠吻合术。

Objective To explore rational and effective treatment strategies by comparing long - term effects of different treatment methods for hepatolithiasis. Methods One hundred and fifty - nine cases of hepatolithiasis treated in this hospital from January 1993 to December 2002 were analyzed retrospectively. Five treatment methods： conservative treatment, choledocholithotomy followed by choledochostomy, hepatolobectomy, hepaticojejunostomy, and hepaticoplasty with the conservation of the Oddi＇ s sphincter, were compared in respect of postoperative complications and long - term outcomes. Results Out of the 159 cases, follow - up was completed in 146 cases （91.8% , 146/159） for 2 - 12 years （ median, 7 years）. Of 16 cases of conservative treatment, 15 were followed. Cholangitis occurred in all the 15 cases, with 1 fatal case. Of 47 cases of extrahepatic surgical exploration, the incidence of residual stones was 100%. Follow - up in 43 cases found 32 cases of cholangitis （74.4%） with 7 fatal cases. Of 16 cases of hepatolobectomy, residual stones were noted in 3 cases （12.5%）. Follow -up in 15 cases found 4 cases of cholangitis （26.7%） with 1 fatal case. Of 32 cases of hepaticojejunostomy, residual stones were found in 11 cases （34.4%）. Follow - up in 29 cases found 14 cases of cholangitis （48.3%） with 3 fatal cases. Of 48 cases of sphincter - sparing operation, residual stones were found in 8 cases （ 16.7% ）. Follow - up in 44 cases found 7 cases of cholangitis （ 15.9% ）. The incidence of residual stones was significantly higher in cases of extrahepatic surgical exploration than in cases of other treatment （ P = 0. 000）. The recurrence rate of cholangitis was significantly higher in cases of conservative treatment and extrahepatic surgical exploration than in cases of other treatment （P 〈 0.05 ）, and in cases of hepaticojejunostomy than in cases of sphincter - sparing operation （P -- 0. 003 ）. Conclusions Conservative treatment and choledocholithotomy are the least effective options for treating hepatolithiasis. Hepaticoplasty with the preservation of the Oddi＇ s sphincter is superior to hepaticojejunostomy.