肝胆管结石的肝切除术中存在的问题与对策

Problems and strategies on perioperative assessment and management in liver resection for primary hepatolithiasis

胆管狭窄、复发性胆管炎、肝组织萎缩或肝脓肿、后期胆管癌变系肝胆管结石主要的病理改变。肝胆管结石的含石病变胆管呈严格的肝段分布,独有的胆管病变及肝组织炎症,使肝胆管结石为指征的肝切除在术前评估及术中、术后的管理上应与肝癌肝切除有不同的侧重。术前评估应侧重于精准的连带病变胆管肝切除的可行性,以期获得良好的远期疗效,术前有严重胆道感染者应争取先行梗阻胆管的经皮引流。在肝门分离、肝组织离断、胆管的显露、胆管断端的处理及肝断面的引流等关键技术细节上,应充分考虑胆管病变及肝组织炎症可能带来的术中大量失血、术后胆漏及肝断面感染性胆汁瘤形成,在确定胆道重建的指征时应对Oddi括约肌的功能进行评估。

Ductal strictures,recurrent cholangitis,liver atrophy or hepatic abscess,and ultimate cholangiocarcinoma are the major pathological entities of primary hepatolithiasis.Because of distinctive bile ductal lesion and hepatic tissue inflammation,liver resection indicated for hepatolithiasis should have different emphasis on perioperativer assessments and managements from hepatectomy for liver cnacer.Preoperative assessment should focus on the feasibility of precise hepatectomy for good long-term outcome.Percutaneous bile duct drainage is considered preferentially for patients with cholangitis.Attention should be paid to avoiding major blood loss,postoperative bile leakage and infectious biloma formation in surgical steps such as hepatic hilum dissection,liver parenchymal transection,bile duct exposure,bile duct stump closure and drainage of liver raw surface.The indication for biliary reconstruction should be based on the estimation of function of the Oddi sphincter.For residual hepatolithiasis,choledochoscopical trans-T tube stone withdraw should carried out 3 months postoperatively in prevention of laceration of T-tube fistula.