胆道镜联合钬激光经T管窦道治疗肝内外胆管残余结石

T-tube tract choledochoscopy and holmium laser for management of retained stones in intra-or extra-hepatic bile ducts

目的：探讨胆道镜联合钬激光经T管窦道碎石治疗肝内、外胆管残余结石的临床价值和安全性。方法：回顾性分析2010年2月-2011年6月经术后T管窦道置入胆道镜联合钬激光碎石治疗300例肝内、外胆管残余结石患者的临床资料。结果：292例经胆道镜下钬激光碎石治疗结石全部取净，碎石时间4-12min，碎石次数1-5次，13例经5次碎石；8例患者结石位于Ⅲ，Ⅳ级肝管碎石未成功，带管2个月后经等离子体冲击波碎石，6例患者成功取出结石，2例患者结石未取出。碎石总数568枚，结石排净率97．3％（292／300）。术中无胆道大出血、穿孔、胆管壁灼伤、胆瘘等严重并发症发生；15例术后出现低热。268例随访6-18个月，平均10个月，未发现结石复发及残留，无胆道狭窄。结论：胆道镜联合钬激光碎石可显著提高肝内、外胆管残余结石的治疗效果，是一种简便、安全、有效的方法，值得临床应用推广。

Objective： To investigate the clinical value and safety of choledochoscopy combined with holmium laser lithotripsy through T-tube tract for treatment of retained stones in the intraor extrahepatic bile ducts. Methods： The clinical data of 300 patients with retained stones in the intraor extrahepatic bile ducts from February 2010 to June 2011, who underwent the combination treatment of choledochoscopy and holmium laser lithotripsy through the postoperative T-tube tract, were retrospectively analyzed. Results： Two hundred and ninety-two patients were completely stone-free after the holmium laser lithotripsy in combination with choledochoscopy. The lithotripsy procedures took 4 to 12 min and were performed oneto 5 times. Thirteen patients underwent lithotripsy 5 times. Lithotripsy failed in 8 patients with stones in the hepatic grade Ⅲ or Ⅳ bile ducts, of whom, stone extraction was successful in 6 cases and failed in 2 cases by plasma shock wave lithotripsy after 2 months of tube retention. A total of 568 stones were fragmented and the clearance rate was 95.2% （292/300）. No severe complications, such as massive biliary bleeding, perforation, biliary wall burns or biliary fistula occurred during operation, and 15 cases experienced low grade fever after operation. Follow-up was performed in 268 patients for 6 to 18 months with an average period of 10 months, and no recurrent or residual stones or biliary strictures were noted. Conclusion： Choledochoscopy combined with holmium laser lithotripsy can significantly improve the therapeutic effect on retained intraor extrahepatic stones, and is a simple, safe and effective technique which deserves to be widely used in clinical practice.