经T管窦道带鞘管小儿经皮肾镜联合EMS三代超声/气压弹道碎石取石治疗肝内外胆道残石

Combination of Percutaneous Nephrolithotomy with Fibrous Sheath and Swiss LithoClast Master(EMS Ⅲ) through T-Tube Tract for Retained Choledocholithiasis:Report of 32 Cases

目的探讨经T管窦道带鞘管小儿经皮肾镜联合EMS三代超声/气压弹道碎石取石治疗胆道术后残余结石的可行性、优越性及疗效。方法2004年8月～2007年8月,对32例胆总管切开取石T管引流术后胆道残余结石,经T管窦道用带鞘管小儿经皮肾镜联合EMS三代超声/气压弹道碎石取石。结果32例取石36次,手术时间33～78min,平均43min。一次取净结石28例,两次取净结石2例,结石取净率为94%(30/32),术后随访26～48个月,平均29个月,无腹痛、发热、黄疸症状,B超未见结石复发。残留结石2例,其中1例为肝内广泛多发胆管结石,经3次取石仍残留有较多结石,行Roux-en-Y肝胆管空肠吻合术临床治愈,另1例为70岁老年人,一次取石后因不愿意再手术而放弃二次取石,残留肝右前叶少量结石。32例均无胆管撕裂、胆道大出血、胆漏、胆管炎、术后腹胀及其他严重并发症发生。结论经T管窦道带鞘管小儿经皮肾镜联合EMS三代超声/气压弹道碎石取石治疗胆道残石具有安全、快捷、简单、方便、并发症少等优点,而且设备损耗低、价格便宜、实用性和可操作性强,值得临床推广应用。

Objective To study the feasibility, superiority and curative effect of percutaneous nephrolithotomy with fibrous sheath and Swiss LithoClast Master （EMS Ⅲ ） through T-tube tract for retained choledocholithiasis. Methods This study involved 32 patients with hepatolithiasis who were treated in our hospital from August 2004 to August 2007. By combining pereutaneous nephrolithutomy （with a fibrous sheath on） and Swiss LithoClast Master （EMS Ⅲ ） through a T-tube tract, retained eholedoeholithiasis was removed. Results The 32 patients totally underwent 36 operations. The mean operation time was 43 minutes （ ranged from 33 to 78 minutes）. In 28 of the cases, the stones were extracted completely by one session; and 2 were cured by two operations. The final stone-free rate was 94% （30/32）. Follow-up was carried out in all the patients for 26 to 48 months （ mean, 29 months） , during which no patients developed abdominal pain, jaundice or fever, no recurrence was detected by B-ultrasonography. Two patients showed residual stones after the treatment, one of them received Roux-en-Y hepatoeholangioenterostomy because of extensive multiple biliary stones in the liver, which could no be removed completely after three sessions of nephrolithotomy; another patient who was a 70-year old man refused the secondary operation and thus retained a few stones in the right inferior lobe of the liver. In this series of 32 eases, no bile duct tear, massive hemorrhage, biliary leakage, cholangitis or abdominal distension occurred. Conclusions It is a safe, convenient, and simple method to combine pereutaneous nephrolithotomy with Swiss LithoClast Master via T-Tube tract for retained choledoeholithiasis. The procedure results in less pain in patients, and reduced equipment spoilage, while the cost is low. As the surgery is easy to perform, it is worth being widely used.