术中胆道镜在肝胆管结石手术中的应用

Treatment of intrahepatic cholelithiasis by intraoperative fibercholedochocopy

目的探讨术中使用纤维胆道镜在肝内胆管结石外科手术治疗中的临床应用方法及价值。方法回顾分析我院1991年2月至2011年2月外科手术治疗肝内胆管结石病人352例,根据结石部位的不同采取不同的手术方式,包括胆总管探查术、肝左外叶切除、肝左外叶切除+胆总管探查术、肝左叶切除术、肝左叶切除术+胆总管探查术、肝右后叶切除术、右肝叶切除+胆总管探查术、联合肝叶切除+胆总管探查术,分析术中应用胆道镜取石后不同部位的手术后残石率及术后胆道镜再取石后残石率。结果不伴有肝内胆管狭窄的单纯性左肝外和/或左肝内叶结石行胆总管切开取石78例,术后胆道镜取石后无结石残留;孤立性肝内胆管结石行肝左外叶切除、肝左叶切除或肝右后叶切除术119例,可获治愈性效果,无结石残留;肝左外叶切除+胆总管探查术、肝左叶切除术+胆总管探查术、右肝叶切除+胆总管探查术、联合肝叶切除+胆总管探查术,手术后残石率及术后胆道镜再取石后残石率分别为9.5%、2.3%、14.6%、20.9%及4.8%、0%、6.3%、13.9%,总计352例病人术中应用胆道镜取石后残石率及术后胆道镜再取石后残石率分别为5.7%(20/352)、2.8%(10/352)。结论孤立性肝内胆管结石行肝叶切除,可手术治愈结石病,不同部位的肝内胆管结石病外科手术治疗术中应用纤维胆道镜取石,可减少残石率,结合手术后的胆道镜取石,能更加显著降低残石率。

Objective To explore the clinical value and techniques of using intraoperative fibercholedochocopy in surgical treatment of intrahepatic bile duct cholelithiasis. Methods from 1991. 2 to 2011. 2,352 patients with intrahepatic bile duct cholelithiasis were analyzed retrospectively. The different surgical approach depend on the sites of stone distribution,including the common bile duct exploration,hepatic left lateral lobectomy,left hepatic lateral lobectomy + common bile duct exploration,the left hepatic lobe resection,the left hepatic lobe resection + common bile duct exploration,the right posterior hepatic lobe resection,the right hepatic lobe resection + the common bile duct exploration,joint hepatectomy + common bile duct exploration. The residual stone rate of patients that applied choledochoscopy in operation and applied choledochoscopy in post-operation were stduied. Results No residual stone occurred in patients with left intrahepatic bile duct stones that no intrahepatic bile duct stricture after postoperative applied choledochoscopy. Isolated intrahepatic bile duct stones after the left hepatic lateral lobectomy,left hepatic lobectomy or the right posterior hepatic lobe resection will be curative effect and no residual stones. Left hepatic lateral lobectomy + common bile duct exploration,the left hepatic lobe resection + common bile duct exploration,the right hepatic lobe resection + common bile duct exploration,joint hepatectomy + common bile duct exploration,the residual rate after surgery and postoperative applied choledochoscopy were 9. 5%,2. 3 %,14. 6%,20. 9%and 4. 8%,0%,6. 3%,13. 9%,respectively. The resicual rate of total 352 cases patients in groups of intraoperative applied choledochoscopy and postoperative applied choledochoscopy were 5. 7%( 20 /352),2. 8%( 10 /352),respectively. Conclusion Isolated intrahepatic bile duct stones after hepatectomy can be cured. Intraoperative choledochoscopy for different parts of the intrahepatic bile duct stones can reduce the residual stone rate,combined with post-operative choledochoscopy can significantly reduce the residual stone rate.