胆肠内引流术后再发肝内胆管结石的外科治疗

Surgical management of recurrent intrahepatic stones after choledochojejunostomy

目的:探讨胆肠内引流术后再发肝内胆管结石的原因及其处理。方法:回顾性分析2006年1月—2013年6月治疗的28例胆肠内引流术后再发肝内胆管结石的患者资料。结果:28例患者根据既往肝外胆管连续性是否保留分为保留组与未保留组。保留组16例中,8例Oddi括约肌功能良好,拆除原胆肠吻合口,修复胆总管并行T管外引流,7例Oddi括约肌功能障碍,行胆肠吻合口拆除重建、标准胆肠Roux-en-Y吻合,1例合并胆管肿瘤无法切除仅行胆总管切开取石;未保留组12例中,7例胆肠吻合口狭窄行吻合口修复重建,5例行吻合口切开取石后重建。两组共11例发生术后并发症(39.3%),其中胆瘘3例,切口感染6例,腹腔出血2例,均治愈,无围手术期死亡。保留组与未保留组即时结石取净率、最终结石取净率分别为68.8%和66.7%、87.5%和83.3%;术后随访生存状态的优良率分别为85.7%和90%,差异均无统计学意义(均P>0.05)。结论:对于胆肠内引流术后再发肝内胆管结石患者,应明辨既往手术方式及分析结石再形成原因,尽量取尽结石,依据Oddi括约肌功能选择胆道内外引流术式。

Objective： To investigate the causes and treatment strateg y of recurrent intrahepatic stones after choledochojejunostomy for biliary drainage.Methods： The clinical data of 28 patients with recurrent hepatolithiasis after biliary-enteric drainage treated during January 2006 to June 2013 were retrospectively analyzed.Results： According to whether or not the continuity of the extrahepatic bile duct was preserved in former surgery,the 28 patients were divided into preservation group and non-preservation group, respectively. Of the 16 patients in preservation group, in 8 cases with normal function of Oddi＇s sphincter, the original biliary-enteric anastomosis was taken down, and after the bile duct was repaired, a T-tube was inserted for external drainage; 7 cases with Oddi＇s sphincter dysfunction underwent resection and reconstruction of the biliary-enteric anastomosis, and then standard Roux-en-Y choledochojejunostomy was performed; and one case underwent choledocholithotomy only due to unresectable bile duct tumor. Of the 12 patients in non-preservation group, 7 cases with anastomoticstricture underwent anastomosic repair and reconstruction, and 5 cases underwent stone removal by incision of the anastomosis and then its reconstruction. Among the two groups, postoperative complications occurred in 11 patients（39.3%） which included biliary fistula in 3 cases, wound infection in 6 cases, and intra-abdominal bleeding in two cases, and were all resolved. No perioperative death occurred. The immediate stone clearance rate and final stone clearance rate in preservation group was 68.8% and 87.5%, in non-preservation group was 66.7% and 83.3% respectively, and the good rate of living condition during follow-up was 85.7% in preservation group and 90% in non-preservation group. All differences between the two groups showed no statistical significance（all P〉0.05）.Conclusion： For patients with recurrent intrahepatic stones after choledochojejunostomy, the former surgical procedure and cause of stone recurrence should be ascertained, stones should be removed as completely as possible, and method of biliary drainage should be chosen according to the function of Oddi＇s sphincter.