肝左外叶切除术在左肝胆管结石治疗中的地位(附112例临床分析)

The position of left lateral segmentectomy in the surgical treatment of left localized hepatolithiasis.

为了探讨肝左外叶切除术在孤立性左肝胆管结石（ＬＬＨ）外科治疗中的地位，对２０年收治的１１２例ＬＬＨ进行回顾性临床分析。结果：①ＬＬＨ的常见病理类型是同时累及左外肝管（ＬＥＨＤ）和左内肝管（ＬＭＨＤ），占８３１％，孤立性ＬＥＨＤ或ＬＭＨＤ结石分别为１２３％和０。②左肝管狭窄合并率为５９８％，ＬＥＨＤ和ＬＭＨＤ分别为８４０％和８４８％，均以重度狭窄为主。③左半肝切除术较肝左外叶切除术的结石残留率低（７１％ｖｓ２１２％，Ｐ＜００１），随访良好率高（８５７％ｖｓ４７０％，Ｐ＜００５）；临床上对ＬＬＨ主要采用肝左外叶切除术为主的综合治疗（５８９％），左半肝切除术仅占１２５％。④影响远期疗效的主要原因是ＬＭＨＤ结石残留或复发和对左肝管狭窄处理不当，分别占６２５％和３７５％。⑤左半肝切除术在手术用时、术中失血、术后并发症等方面与左外肝切除术无明显差异。认为大多数ＬＬＨ的病理改变系弥漫性（左内和左外均有）和多级性（一、二级肝管均受累），用肝左外叶切除术处理常可导致ＬＭＨＤ和左肝管病变遗留，影响远期治疗效果。

bjective:To evaluate the position of left lateral hepatic segmentectomy in the surgical management of left localized hepatolithiasis(LLH).Patients and Methods:112 cases with LLH treated in our center in recent two decades were analyzed retrospectively.Results:①Coexisting left external hepatic duct(LEHD)and left medical hepatic duct(LMHD) lesions were detected in 83 1% of patients,and solitary LEHD or LMHD lesions in 12 3% and 0 respectively.②Left hepatic duct(LHD)stricture complicates LLH in 59 8%,and LMHD or LEHD stricture in 84 8% and 84 0% respectively.③Comprehensive therapy with lateral segmentectomy as the primary procedure to eradiate the foci was the most common clinical practice for LLH(58 9%),and left lobectomy was much less frequently used(12 5%),although the latter led to a smaller chance of residual(7 1%)than the former(21 2%)and had a rate of good follow up result of 85 7% being superior to lateral segmentectomy(47 0%).④Residual or recurrence stones of LMHD(62 5%) and residual LHD stricture(37 5%)were the two leading causes of poor long term results.⑤There is no significant difference between left lobectomy and lateral segmentectomy in length of operation,intraoperative bleeding,and postoperative complications,meaning that left lobectomy remains a safe therapy.Conclusions:Majority of the patients with LLH have diffused pathological changes in the left liver.Lateral segmentectomy commonly leads to omission of LMHD and LHD lesions,affecting the long term results.If a coexiting LMHD involvement is definite,left lobectomy should be performed.