原发性肝内胆固醇结石:附38例报告

Primary intrahepatic cholesterol stones:a report of 38 cases

目的探讨原发性肝内胆固醇结石的临床特征及诊治方法。方法回顾性分析2007—2009年收治的肝内胆固醇结石并手术治疗的38例患者相关临床资料。结果全组男18例,女20例;临床症状主要有腹痛、发热及黄疸,腹痛合并黄疸14例(36.8%),腹痛合并发热12例(31.5%),Charcot三联征9例(23.7%);术前B超肝内结石发现率为100%(38/38),CT肝内结石发现率77.4%(24/31);38例均接受手术治疗,胆囊切除胆道探查(含再次胆探)及T管引流术25例次,胆肠Roux-en-Y内引流术(含内引流重建1例)5例次,肝叶切除术24例次;术后并发胆汁漏1例,并发反应性胸腔积液等胸部并发症4例;6个月随访发现结石残留3例(7.9%),2例未引起临床症状予以观察随访,1例曾合并胆管炎给予抗感染等治疗后好转。结论术前结合B超及CT检查能明确肝内胆固醇结石部位及其合并症诊断;手术是治疗肝内胆固醇结石的主要手段;合理应用肝叶切除术、胆道镜等技术可获得低残石率。

Objective To investigate the clinical characteristics,diagnosis and treatment of the primary cholesterol hepatolithiasis. Methods The clinical data of 38 patients with cholesterol hepatolithiasis,who were admitted and underwent surgical treatment from 2007 to 2009,were retropectively analyzed. Results The data included 18 male and 20 female patients.The main clinical signs of the patients were abdominal pain,fever and jaundice.Fourteen patients presented with abdominal pain and jaundice（36.8%）,12 patients had abdominal pain with fever（31.5%） and 9 patients presented with Charcot Triad（23.7%）.The detection rate of hepatolithiasis before operation by B ultrasonic and CT scan was 100%（38/38） and 77.4%（24/31）,respectively.All of the 38 cases underwent surgical treatment that comprised 25 cases of cholecystectomy and bile duct exploration（including re-exploration） with T-tube drainage,5 cases of internal drainage by Roux-en-Y choledochojejunostomy（with 1 case of reconstruction） and 24 cases of hepatic lobectomy.One case developed postoperative bile leakage and 4 cases developed thoracic complications,such as reactive pleural effusion.Residual stones were found in 3 cases during the period of 6-month follow-up,two of whom had no symptoms and were followed-up by observation,and one complicated by cholangeitis was treated with antibiotics and improved. Conclusions Preoperative examination combined with B ultrasonic and CT scan can ascertain the locations of the intrahepatic cholesterol stones and also help in the diagnosis of concomitant diseases.Surgical treatment is the main method to manage cholesterol hepatolithiasis,and the proper employment of hepatic lobectomy and use of cholangioscope results in a low incidence of residual stone.