不同临床分型肝胆管结石病手术方式选择的分析

Analysis of selection of surgical approaches for hepatolithiasis with different clinical classifications

目的:探讨不同分型肝胆管结石病手术方式的合理选择。方法:回顾性分析2005年1月—2012年12月手术治疗的667例肝胆管结石病患者的临床资料,患者分别行胆道探查取石术(BDE)、肝切除术(HT)、胆肠吻合术(HJS)中一种或联合多种手术方式处理,参照新的分型方法进行分型后,比较同种类型肝胆管结石病不同手术方式的结石清除率、术后并发症发生率及随访优良率。结果:I型129例中,HT与BDE+HT的结石清除率、随访优良率均优于其他术式(均P<0.05),术后并发症发生率各术式间无统计学差异(P>0.05);IIa型72例中,BDE+HT结石清除率及随访优良率都优于其他术式(P<0.05),BDE+HJS术后并发症发生率最低(P<0.05);IIb型98例中,BDE+HT的结石清除率及随访优良率最高(均P<0.05),HT术后并发症发生率最高(均P<0.05);IIc型25例中,各术式各指标间无统计学差异(均P>0.05);Ea型251例中,BDE+HT结石清除率及随访优良率都优于其他术式,BDE术后并发症发生率较其他术式低(均P<0.05);Eb型55例与Ec型37例中,BDE+HT+HJS的术后结石清除率及随访优良率优于其他术式(均P<0.05),术后并发症各术式间无统计学差异(P>0.05)。结论:根据肝胆管结石病合理分型选择合理的手术方式,加上各种有效的辅助手段,个体化治疗有助于提高结石清除率,减少术后并发症发生。

Objective： To investigate the rational selection of surgical approaches for hepatolithiasis with different classifications. Methods： The clinical data of 667 hepatolithiasis patients undergoing surgical treatment from January 2005 to December 2012 were retrospectively analyzed. Patients underwent a single procedure or combined procedures of bile duct exploration （BDE）, hepatectomy （HT）, and hepaticojejunstomy （HJS）. After classification by the classification method, the stone clearance rate, incidence of postoperative complications and excellent follow-up rate were compared among different surgical approaches for the same type ofhepatolithiasis. Results： In the 129 type I patients, the stone clearance rate and excellent follow-up rate after HT and BDE＋HT were better than those after other procedures （all P〈0.05）, while no difference was found in incidence of postoperative complication among the procedures （P〉0.05）. In the 72 type IIa patients, stone clearance rate and excellent follow-up rate after BDE＋HT were better than those after other procedures, while BDE＋HJS showed the lowest incidence of postoperative complications （all P〈0.05）. In the 98 type IIb patients, the stone clearance rate and excellent follow-up rate were the highest after BDE＋HT, while HT had the highest incidence of postoperative complications （all P〈0.05）. In the 25 type IIc patients, no difference in any of the parameters was noted among the procedures （all P〉0.05）. In the 251 type Ea patients, both stone clearance rate and excellent follow-up rate after BDE＋HT were better than those after other procedures, while the incidence of postoperative complications after BDE was lower than that after other procedures （all P〈0.05）. In the 55 type Eb patients and the 37 type Ec patients, the stone clearance rate and excellent follow-up rate after BDE＋HT＋HJS were better than those after other procedures （all P〈0.05）, while no difference in postoperative complications was observed among the procedures （all P〉0.05）. Conclusion： Based on the rational selection of surgical approaches according to the classification of hepatolithiasis, and with appropriate adjuvant treatments, the tailored and individualized therapy is helpful to improve stone clearance rate and reduce postoperative complications.