肝胆管结石再次手术方式的选择

Choice of surgical approach in patients with hepatolithiasis underwent reoperation

目的分析肝胆管结石再次手术的原因和探讨再次手术方式的选择。方法回顾性分析1997年1月至2007年12月因肝胆管结石病在我院进行再次手术的病例136例,其中男60例,女76例,平均年龄55.3岁。肝胆管结石分型:Ⅰ型101例(74.3%),Ⅱa型5例(3.7%),Ⅱb型27例(19.8%),Ⅱc型3例(2.2%)。结果再次手术的原因为:①前次手术时结石残留31例(22.8%);②结石再生52例(38.2%);③肝内胆管狭窄未纠正23例(16.9%);④肝外胆管囊状扩张未处理18例(13.2%);⑤初次手术为急诊手术12例(8.8%)。再次手术方式分别为:①胆管切开取石+T管引流术33例(24.3%);②单纯肝叶(肝段)切除术3例(2.2%);③胆管切开取石+胆道口括约肌成形术5例(3.7%);④胆管切开取石+肝叶(肝段)切除+T管引流术29例(21.3%);⑤胆管切开取石+胆肠吻合术40例(29.4%);⑥胆管切开取石+肝叶(肝段)切除+胆肠吻合术26例(19.1%)。手术后并发症包括:胆漏6例(4.4%),膈下脓肿形成3例(2.2%),胆肠吻合口出血1例(0.7%),肺部感染2例(1.5%),切口感染7例(5.1%)。围术期死亡1例,死亡率0.7%。术后结石残留14例(10.3%)。再次手术后的胆管结石复发率为18.8%。结论肝胆管结石再次手术前应对疾病状态进行充分评估和准备,尽可能选择以肝叶(肝段)切除为基础的合理的手术方式,以减少术后结石复发率。

Objective To analyze the causes of reoperation in patients with hepatolithiasis and to investigate the choice of surgical approach. Methods The data of 136 patients （men 60, women 76） who underwent reoperation due to hepatolithiasis from January 1997 to December 2007 were reviewed. The classification of hepatolithiasis were： type Ⅰ101 cases （74.3%）, type Ⅱa 5 cases （3.7%）, type Ⅱb 27 cases （19.8%） and type Ⅱc 3 cases （2.2%）. Results The causes of reoperation included remnant bile stone（22.8%）, recurrence of bile stone （38.3%）, failed to correct the stricture ofintrahepatic bile duct（16.9%） or dilatation of extrahepatic bile duct （13.2%）, and emergent cases of primary operation（8.8%）. The procedures of reoperation were choledochotomy＋＂T＂tube drainage （24.3%）, hepatectomy（2.2%）, choledochotomy＋Oddis sphincteroplasty（3.7%）, choledochotomy＋hepatectomy＋＂T＂ tube drainage（21.3%）, choledochotomy＋ choledochojejunostomy（29.4%）, and choledochotomy＋hepatectomy＋ choledochojejunostomy（19.1%）. The main perioperative complications included bile leakage （4.4%）, subphrenic abscess （2.2%）, bleeding of bilio-enteric anastomosis （0.7%）, pulmonary infection（1.5%）, and infection ofincision（5.1%）. The perioperative mortality was 0.7%. Fourteen patients had remnant bile stones after reoperation. The recurrent rate of bile stone was 18.8% during follow up. Conclusions Full estimation of the status of hepatolithiasis and ample preparation should be done before reoperation. In order to decrease the recurrent rate of hepatolithiasis, hepatectomy may be choosed as far as possible.