肝内胆管结石外科治疗的术式选择

Surgical therapy for intrahepatic hepatolithiasis

目的探讨肝内胆管结石外科治疗术式及效果。方法回顾性分析总结我院近3年择期手术治疗的176例肝内胆管结石患者的术后近期残石率、围手术期并发症及术后远期疗效。肝内胆管结石分型：I型45例，Ⅱa型25例，Ⅱb型25例，1／e型3例，Ea型52例，Eb型19例，Ec型7例。手术方式：胆道探查取石＋T管引流术71例（Ea型31例，I型15例，1Ia型25例）；胆道探查＋胆肠吻合术25例（Ea型14例，Eb型7例，Ec型4例）；胆道探查＋肝胆管空肠盆式吻合术10例（Ⅱb型5例，ⅡC型3例，Ea型2例）；肝段（叶）切除＋外或内引流术70例（I型30例，1Ib型20例，Ea型5例，Eb型12例，Ec型3例）。结果肝切除组术后近期残石率、术后远期疗效均优于非肝切除术组[17．1％（12／70）对43．4％（46／106），91．4％（53／58）对77．0％（67／87）]，但围手术期并发症发生率高于非肝切除术组[37．1％（26／70）对14．2％（15／106）]。结论肝切除是I型、IIb型肝内胆管结石患者的首选术式，肝门部胆管空肠盆式吻合术是ⅡC型肝内胆管结石患者的主要术式。

Objective To investigate the therapeutic effects of varied operative for the treatment of intrahepatic bile duct stones. Methods The clinical data of 176 consecutive cases of hepatolithiasis surgically treated in the past 3 years in our hospital were retrospectively analyzed. There were 45 type I patients, 25 type Ⅱ a patients, 25 type Ⅱb patients, 3 type Ⅱc patients, 52 type Ea patients, 19 type Eb patients, and 7 type Ec patients. These 176 patients were divided into 4 groups according to modus operandi： choledocholithotomy and T-tube drainage in 71 patients （type Ea 31 patients, type ] 15 patients, type Ⅱ a 25 patients） ; choledocholithotomy and choledochojejunostomy in 25 patients （type Ea 14 patients, type Eb 7 patients, type Ec 4 patients） ; choledocholithotomy and hepaticojejunostomy in 10 patients （type Ⅱb 5 patients, type Ⅱ c 3 patients, type Ea 2 patients ） ; hepatectomy plus T-tube drainage or choledochojejunostomy in 70 patients （type I 30 patients, type Ⅱ b 20 patients, type Ea 5 patients, type Eb 12 patients, type Ec 3 patients） . The postoperative residual stone rate, perioperative complications and long term results were compared between groups. Results Patients undergoing hepatectomy have less postoperative residual stone rate, higher rate of good long term efficacy as compared with those who did not undergo hepatectomy （ 17.1% （12/70） vs 43.4% （46/106）, 91.4% （53/58） vs 77.0% （67/87） ）. Though patients undergoing hepatectomy had higher rate of perioperative complications （ 37.1% （26/70） vs 14.2% （15/106））. Conclusions Hepatectomy is the most effective procedure for the treatment of type I and type Ⅱ b hepatolithiasis. Hepaticojejunostomy is the main procedure for the treatment of type Ⅱ c hepatolithiasis.