精准肝脏外科理念在肝胆管结石病治疗中的临床价值

Clinical efficacy of precision liver surgery in the management of hepatolithiasis

目的 探讨精准肝脏外科理念在肝胆管结石病治疗中的临床价值.方法 回顾性分析2011年8月至2012年12月安徽医科大学第一附属医院收治的68例肝胆管结石病患者的临床资料.术前联合使用彩色多普勒超声、CT、MRI或MRCP检查评估结石分布及肝脏功能,依据术前评估和分型,制订个体化手术方案.术中应用胆道镜辨别胆管结石分布,引导取石或者网篮协助取石,评估胆总管下端Oddi括约肌功能.依据Oddi括约肌功能评估结果结合术中是否取尽结石个体化选择胆道引流方式：Oddi括约肌功能正常者选择留置T管外引流;Oddi括约肌松弛者选择胆肠Roux-en-Y吻合内引流,术中均不留置胃管,留取胆汁进行细菌培养及药物敏感试验.术后48 h开始进食流质食物,早期下床活动,经验性选择广谱抗生素,并依据胆汁细菌培养和药物敏感试验结果予以调整;术后第1、3、7天检查肝功能,对症处理术后近期并发症.术后4～6周开始定期随访,随访时间截至2013年12月.随访监测患者术后生活状态、肝功能、腹部超声,带T管者术后6周行胆道镜检查.结果 所有患者术前接受2种及以上的影像学检查,彩色多普勒超声、CT及MRI检查的诊断准确率分别为97.1％（66/68）、91.9％（57/62）、95.0％ （57/60）.胆色素性结石66例,胆固醇性结石2例.肝左叶结石32例,肝右叶结石15例,双侧肝叶结石21例,其中合并肝外胆管结石36例.肝胆管结石病Ⅰ型47例,Ⅱa型3例,Ⅱb型15例,Ⅱc型3例;其中附加型（E型）36例.肝功能Child A级50例,Child B级18例.52例患者行胆总管切开取石联合肝叶切除术,其中肝左外叶切除30例、左半肝切除5例、肝左外叶＋尾状叶切除1例、肝右叶部分切除9例、右半肝切除1例、双侧肝叶部分切除6例;16例患者行单纯胆管切开取石术.胆道引流方式：T管外引流49例,胆肠内引流19例,其中胆肠吻合附带T管外引流3例.手术时间为（237± 65） rmin.68例患者术中行纤维胆道镜探查,66例患者行术中Oddi括约肌功能评估,发现17例Oddi括约肌松弛.68例患者即时结石清除率为73.5％（50/68）,最终结石清除率为94.1％（64/68）.58例患者行胆汁细菌培养和药物敏感试验,45例胆汁细菌培养阳性患者（革兰氏阴性菌35例、革兰氏阳性菌12例）.术后16例患者发生并发症,其中胆汁漏7例、肺部感染6例、切口感染4例、术后腹腔出血2例（1例出血并发生粘连性肠梗阻行肠粘连松解痊愈）,均经对症支持引流治疗后痊愈.无围手术期死亡,术后住院时间为（13±7）d.患者随访时间为（16±4）个月,随访率为86.8％ （59/68）;5例合并胆管癌患者术后死亡3例,2例随访期间未见复发.患者术后生活状态评价优良率为91.5％（54/59）.结论 精准肝脏外科理念运用于肝胆管结石病的治疗,能够减少结石残留,具有较好的临床疗效.

Objective To investigate the clinical efficacy of precision liver surgery in the management of hepatolithiasis. Methods The clinical data of 68 patients with hepatolithiasis who were admitted to the First Affiliated Hospital of Anhui Medical University from August 2011 to December 2012 were retrospectively analyzed. The distribution of stones and the hepatic function were analyzed using the color Doppler uhra-sonography, magnetic resonance imaging and magnetic resonance cholangiopancreatography. Individualized surgical plan was made according to preoperative evaluation and typing. Choledochoscope was applied to detect the distribution of stones and help to extract the stones. The function of sphincter of Oddi at the lower part of common bile duct was evaluated.The methods of biliary drainage were selected according to the function of sphincter of Oddi and whether the stones were cleared： patients with normal function of sphincter of Oddi were treated by T-tube drainage; patients with sphincter of Oddi dilatation received biliojejunal Roux-en-Y anastomosis ＋ internal drainage, gastric tube was not installed, and the bile was collected for bacilli culture and drug sensitivity test. Liquid diet was given to the patients at postoperative 48 hours. Patients were encouraged to take off-bed activity in the early period after operation. Broad-spectrum antibiotics were selected and adjusted according to the results of bacilli culture. The hepatic function was tested at postoperative day 1, 3, 7, and the short-term complications were treated symptomatically. Follow-up began at postoperative week 4-6, and ended in December 2013. The general condition and hepatic function were monitored during the follow-up. Patients with T-tube drainage received choledochoscopy at postoperative week 6. Results Two or more than 2 types of imaging examinations were applied to all the patients before operation. The accurate rates of color Doppler ultra-sonography, computed tomography and magnetic resonance imaging were 97.1% （66/68）, 91.9% （57/62） and 95.0% （57/60）, respectively. Two patients were with cholesterol stones and 66 with bile pigment stone. Stones located at the left lobe in 32 patients, the right lobe in 15 patients and the bilateral lobes in 21 patients. Thirty-six patients were complicated with extrahepatic bile duct stones. The numbers of patients with type I, IIa, IIb,IIc and E hepatolithiasis were 47, 3, 15, 3 and 36. The numbers of patients with hepatic function in Child A and Child B were 50 and 18. Fifty-two patients received choledocholithotomy ＋ hepatectomy, including 30 of left lateral lobectomy, 5 of left hemihepatectomy, 1 of left lateral lobectomy ＋ caudate lobectomy, 9 of partial resection of right lobe, 1 of right hemihepatectomy and 6 of partial resection of bilateral lobes. Sixteen patients received choledocholithotomy. Forty-nine patients received T-tube drainage, 19 received internal drainage and 3 received biliojejunal anastomosis ＋ T-tube drainage. The operation time was （237 ± 65） minutes. Sixty-eight patients received intraoperative fiber-choledochoscopy, 66 received function evaluation of sphincter of Oddi （17 patients with sphincter of Oddi dilatation were detected）. The immediate stone clearance rate was 73.5% （50/68） , and the final stone clearance rate was 94.1% （64/68）. The bile of 58 patients underwent bacilli culture and drug sensitivity test, and the result was positive in 45 patients （35 with gram-negative bacteria infection and 12 with gram-positive bacteria infection）. Sixteen patients had postoperative complications, including 7 with bile leakage, 6 with pulmonary infection, 4 with wound infection and 2 with postoperative intraabdominal bleeding （1 with bleeding and adhesive intestinal obstruction was cured by enterodialysis） , and all of them were cured by symptomatic treatment. No patient died perioperatively, and the duration of postoperative hospital stay was （ 13 ± 7 ） days. The time and rate of follow-up were （ 16 ±4 ） months and 86, 8% （ 59/68 ）. Of the 5 patients with cholangiocarcinoma, 3 patients died postoperatively and 2 patients did not have tumor recurrence during the follow-up. Fifty-four patients had good life situation with the rate of 91.5% （54/59）. Conclusion It is helpful to reduce the residual rate of stones and improve the clinical efficacy of treatment for hepatolithiasis with the guidance of precision liver surgery.