肝移植时代肝胆管结石的外科治疗

Surgical interventions for hepatolithiasis in liver transplantation era

复杂肝胆管结石是长期困扰肝胆外科医师的常见病、多发病。虽然近年来逐渐确立了包括规则性肝叶、肝段切除为主的外科综合治疗方针,但对于各种原发性或继发性肝胆管结石导致的弥漫性胆道系统不可逆性损伤、胆汁性肝硬化伴门静脉高压的良性终末期胆病病人,肝移植可能是惟一有效的治疗手段。肝移植术前应重视围手术期胆道感染的处理,及时纠正凝血功能障碍,加强肠内外营养。对于符合肝移植指征的肝胆管结石病人应尽早手术,术前高度警惕合并肝内胆管癌,慎重选择肝移植手术。术中需注意控制出血,必要时采用体外静脉转流,并根据受体胆管条件决定胆道重建方式。

Complicated hepatolithiasis is a common and frequently occurring disease which is seriously disturbing hepatobiliary surgeons. Regular hepatic lobectomy or segmentectomy recently tends to be the major surgical treatment. However, as for benign end-stage patients with biliary diseases such as diffuse irreversible biliary system injury resulting from primary or secondary hepatolithiasis and biliary cirrhosis with portal hypertension, liver transplantation may be likely the only curative modality. Much emphasis should be laid upon perioperative control of biliary infection, correction of coagulation disorders, as well as enhancement of enteral and parenteral nutrition. Early liver transplantation is encouraged to perform when the patients are indicated. Combined cholangiocarcinoma should be highly alert and liver transplantation should be decided with caution for such individUals. In addition, it is of great importance to control hemorrhage during the operation, and employ extracorporeal venous bypass if necessary. Biliary reconstruction may be determined according to the receipts＇ bile duct condition.