保胆取石术后胆囊泥沙样结石发生原因的临床分析及应对策略

Clinical Analysis for Reason and Treatment Strategy of Gallbladder Muddy Stones after Cholecystolithotomy

目的探讨保胆取石术后胆囊泥沙样结石的形成原因及应对策略。方法回顾性分析2008年12月至2014年12月期间大连大学附属中山医院胆道微创外科诊治的内镜保胆取石术后反复出现胆囊泥沙样结石的62例患者的临床资料。结果 62例患者中为无症状性胆囊泥沙样结石43例,为胆囊泥沙样结石伴急性胆囊炎19例。结石发生原因：近胆囊管开口处胆囊分隔4例,胆囊管迂曲过长6例,胆囊管结石3例,胆总管结石4例,十二指肠乳头旁憩室39例,胆胰合流异常18例,十二指肠乳头狭窄6例,十二指肠乳头炎29例,十二指肠乳头腺癌3例。行腹腔镜胆囊切除术（LC）2例,行内镜下乳头括约肌切开术（EST）/内镜下乳头括约肌球囊扩张术（EPBD）＋LC 1例,行经皮经肝胆囊穿刺置管引流术（PTGD）＋开腹胆囊切除术1例,行PTGD＋EST/EPBD 14例,行PTGD＋胆囊肝胆管成形术（HG）1例,行EST/EPBD 34例,行EST/EPBD＋经内镜胆道金属支架置入术（EBMSD）3例,行HG 5例,行EST/EPBD＋HG 1例。术后成功保留胆囊的55例患者的胆囊泥沙样结石均消失,脂餐后1 h胆囊收缩率上升至（59±16）%。术后53例患者获访,随访时间为0.5-6.0年（中位随访时间为3.6年）,随访率为85.5%。随访期间胆囊结石复发3例,发生胆总管结石2例,发生肝内外胆管结石2例。结论胆囊胆汁流出不畅是引起保胆术后胆囊泥沙样结石形成的重要原因,HG、EST及内镜下球囊扩张是保持胆囊胆汁流出通畅的有效方法。

Objective To discuss the reason and treatment strategy of gallbladder muddy stones after cholecystolithotomy. Methods The clinical data of 62 patients with gallbladder muddy stones after cholecystolithotomy who were treated in our hospital from December 2008 to December 2014 was analyzed retrospectively. Results There were 43 patients without any symptom and 19 patients with acute cholecystitis in 62 patients. Four patients were diagnosed with septation gallbladder, 6 patients with long and tortuous cystic duct, 3 patients with calculus of cystic duct, 4 patients with common bile duct stones, 39 patients with periampullary diverticula, 18 patients with pancreaticobiliary maljunction, 6 patients with duodenal papilla stenosis, 29 patients with duodenal papillitis, and 3 patients with duodenal papilla adenocarcinoma. Two patients were treated with laparoscopic cholecystectomy（LC）, 1 patient with endoscopic sphincterotomy（EST） /endoscopic balloon dilation（EPBD） and LC, 1 patient with percutaneous transhepafic gallbladder drainage（PTGD） and open cholecystectomy, 14 patients with PTGD and EST/EPBD, 1 patient with PTGD and hepatocholangioplasty with the use of gallbladder（HG）, 34 patients with EST/EPBD, 3 patients with EST/EPBD and endoscopic biliay metal stent drainage（EBMSD）, 5 patients with HG, and 1 patient with EST/EPBD and HG. The gallbladder muddy stones disappeared after operations in 55 patients with gallbladder reserved, and gallbladder ejection fraction increased from（42±12） % to（59±16） %. Of the 62 patients, 53 patients were followed up for 6 months to 6 years（the median time was 3.6-year）. During the follow-up period, 3 patients were diagnosed with gallbladder stones, 2 patients with common bile duct stones, and 2 patients with intrahepatic and extrahepatic bile duct stones. Conclusions Bile efferent tract obstruction is the important reason for the formation of gallbladder stones. HG, EST, and balloon expansion are the efficient methods to resolve the bile efferent tract obstruction.