肝胆管结石合并胆汁性肝硬化和门静脉高压症的外科治疗

Surgical treatments for hepatolithiasis complicated with biliary cirrhosis and portal hypertension

目的探讨肝胆管结石合并胆汁性肝硬化和门静脉高压症的外科治疗方案。方法回顾性分析2004年6月至2013年6月在南方医科大学南方医院行外科手术治疗的31例肝胆管结石合并胆汁性肝硬化和门静脉高压症患者临床资料。其中男21例,女8例;平均年龄（49±8）岁。所有患者均签署知情同意书,符合医学伦理学规定。手术方案包括一期行胆管结石手术26例,二期胆管结石手术5例。观察患者围手术期情况及疗效。结果 26例一期行胆管结石手术患者术中出血量的中位数为537（300-1 800）ml,术后出血2例,分别急诊行贲门胃底周围血管离断术和经颈静脉肝内门体分流术（TIPS）后出血停止。其余5例二期行胆管结石手术的术中出血量为350（300-450）ml。患者术后肝功能恢复顺利,均无发生肝衰竭、肝性脑病。术后胆道镜下结石残余率16%（5/31）,超声检查结石残余率26%（8/31）。疗效优14例,良17例。结论肝胆管结石合并胆汁性肝硬化和门静脉高压症的外科治疗手术难度大、风险高,需设计个体化手术方案,联用多种手术方式。

Objective To investigate surgical treatments for hepatolithiasis complicated with biliary cirrhosis and portal hypertension. Methods Clinical data of 31 patients with hepatolithiasis complicated with biliary cirrhosis and portal hypertension receiving surgical treatments in Nanfang Hospital, Southern Medical University from June 2004 to June 2013 were analyzed retrospectively. There were 21 males and 8 females with the mean age of（49±8） years old. The informed consents of all patients were obtained and local ethical committee approval had been received. The surgical treatments included onestage cholangiolithotomy（n=26）, two-stage cholangiolithotomy（n=5）. The perioperative situation and the treatment efficacy were observed. Results The median intraoperative blood loss was 537（300-1 800） ml for the 26 cases undergoing one-stage cholangiolithotomy. Postoperative bleeding was observed in 2 cases. Pericardial fundus devascularization and transjugular intrahepatic portosystem shunt（TIPS） were performed emergently in the patients respectively and then the bleeding was ceased. The intraoperative blood loss was 350（300-450） ml for the left 5 cases undergoing two-stage cholangiolithotomy. The liver function of the patients recovered well and no liver failure, hepatic encephalopathy were observed. The postoperativecholedochoscope residual rate of calculus was 16%（5/31） and the ultrasound residual rate of calculus was 26%（8/31）. Good efficacy was observed in 14 cases and fine in 17 cases. Conclusions The surgical operation for hepatolithiasis complicated with biliary cirrhosis and portal hypertension is with high difficulty and risk. It is necessary to design personalized surgical plan and to perform multiple surgical procedures.