术中胆道镜取石失败原因分析及对策探讨

Analysis of failure reasons of removal of gallstones by choledochoscope in operation and exploration of countermeasure

目的分析术中使用胆道镜治疗胆道结石常见的失败原因以及对策。方法对自1997年1月至2006年12月间292例曾经使用胆道镜术中取石的病例进行回顾分析。结果292例患者中,术后有胆道残石39例,残石率为13.4﹪。其中术中明确结石未取净者19例;经术后T管造影及胆道镜明确胆道残石者20例。胆道镜术中取石失败原因是多方面的。39例残石者中包括肝内胆管结石伴胆管变异14例;肝内胆管结石伴胆管开口狭窄11例;肝内胆管大结石嵌顿3例;胆总管下段节段性狭窄伴结石3例。结论术中要细致进行胆道镜检查,要逐叶逐段检查各条胆管,要注意有无胆管变异,要找出狭窄的胆管开口以及胆总管下段有无节段性狭窄等情况,对于大的胆管结石建议行激光或液电碎石。术中B超定位有助于降低术后残石率。

Objective To analyze common reasons of failure in removal of gallstones with choledochoscope during operation and explore the countermeasure. Methods The date of two hundred and ninty-two patients undergone choledochoscope in operation for removal of gallstones during the period of Jan.1997-Dec,2006 were analyzed retrospectively. Results Of 292 patients, residual stones in the bile duct after the operations were found in 39 patients, Residual stones rate was 13.4%. Gallstones could not be completely removed during the operation in 19 patients, Residual stones were found in the bile duct after operation with T-tube cholangiography and choledochoscope in the other 20 patients. There were many failure reasons of removal of gallstones using choledochoscope during operation. It was found that 39 patients with residual stones, 14 complicated with stones in intrahepatic bile duct and variation of bile duct, 11 complictated with stones in intrahepatic bile duct and narrow debouchments of bile duct, 3 complicated with big impacted stones in intrahepatic bile duct, 3 complicated with stones at the inferior segment of choledochus stenosis, Conclusion The bile duct of every hepatic lobe and segment should be carefully checked with choledochoscope during operation in order not to omit any stones. It is important to pay attention to variation of bile duct and narrow debouchments of bile duct and inferior segment of choledochus stenosis. Laser or electrohydraulic lithotripsy is advisable for big gallstones. The method of localization with B-ultrasound is helpful to reduce residul stones rate in operation.