孤立性左肝胆管结石并肝管狭窄的外科治疗

Management of solitary left hepatolithiasis complicated with hepatic ductal strictures

目的总结近２０年来孤立性左肝胆管结石并发左肝胆管狭窄的临床治疗体会．方法原发性肝胆管结石１０１８例，年龄２７～７２岁，其中孤立性左肝胆管结石１３３例，手术治疗１１２例，对其临床资料进行回顾性分析，包括各肝管狭窄并发率，术前各项检查确诊率，手术治疗方式，再狭窄率．结果左肝管狭窄的发生率为５９８％，左外肝管和左内肝管分别为８４０％和８４８％，均以重度狭窄为主．狭窄切开整形后高位胆肠吻合术是处理左肝管狭窄的常用手术方式（５２２％），远期再狭窄率为１７１％；左半肝切除术施实率为１９４％，再狭窄率为００％；狭窄整形术和狭窄扩张术的施实率分别为９０％和１９４％，再狭窄率分别为５００％和９２３％．左外肝管狭窄通常采用肝段或肝叶切除术（７８７％），而左内肝管狭窄的处理则通常采用非左半肝切除术（８４８％）．左内肝管狭窄的术前／后影像学确诊率明显低于左肝管和左外肝管，平均确诊率依次２５９％，９３３％和８７９％．结论二级肝管狭窄是孤立性左肝管结石的常见并发症，肝叶或肝段切除术是其首选治疗原则．

AIM To summarize the experience in the clinical management of the solitary left hepatolithiasis complicated with biliary ductal strictures in the recent two decades. METHODS 1018 patients aged between 27～72 years with primary intrahepatic lithiasis were treated at our center between June 1976 and June 1996, among whom 133 had solitary left hepatolithiasis and 112 of them underwent operations. A retrospective analysis was made regarding patient′s age, gender, diagnosis, operative findings, treatment and postoperative courses. RESULTS The incidence of the left hepatic duct (LHD) stricture was 59 8%, and that of the left external hepatic duct (LEHD) stricture or left medial hepatic duct (LMHD) stricture 84 0% and 84 8% respectively, in which strictures of severe degree dominate. Among the operative procedures in the management of LHD strictures, plastic operation plus biliary enteric anastamosis ranks the first in frequency (52 2%), with a restrictured rate of 17 1%. While left lobectomy ranks the third (19 4%) with no restricture. Simple plastic performance or dilation has a high occurrence rate of restricture (50 0% and 92 3% respectively) and usually need subsequent operation(s). Most LEHD strictures (78 7%) were eradiated by lateral segmentectomy or lobectomy, whereas most LMHD strictures (84 8%) were not treated by left lobectomy. The definite diagnosis rates of LMHD stricture by endoscopic retrograde cholangiography, or percutaneous transhepatic cholangiography, or computed tomography, or intraoperative and postoperative trans T tube cholangiography were much lower than these of LEHD strictures or LHD strictures. The mean definite diagnosis rates of LMHD, LEHD and LHD were 25 9%, 93 3% and 87 9%, respectively. CONCLUSION Ductal strictures of the 2nd class are common complications of the solitary left hepatolithiasis, clinical management of choice is hepatic segmentectomy or lobectomy. Too much dependence on the managements of non hepatic segmentectomy or lobectomy is an important cause of remnant of strictures and poor prognosis.