肝胆管结石术后择期再手术58例原因分析

Reasons for selective reoperation in 58 cases of hepatolithiasis

目的 通过分析肝胆管结石术后择期再手术原因,提出防治措施。方法对1994年6月至2002年3月期间58例肝胆管结石术后择期再手术病例的原因进行回顾性分析。结果再手术原因主要为:①首次手术仅行胆囊切除或加胆总管探查T型管引流术,未能彻底去除充满结石并纤维化的肝内病灶。②首次手术时未能对肝内胆管狭窄部位、尤其是开口部位高、难以显露的二级胆管狭窄部位予以整形。③首次手术清除结石不彻底,尤其是位于肝尾状叶胆管内的结石未能彻底清除。④胆肠吻合为胆总管空肠吻合,开口低,吻合口小,术后狭窄,残石积蓄于胆总管,易再发梗阻性黄疸。结论强调应严格遵循“解除梗阻、去除病灶、通畅引流”的基本原则,充分注意首次手术时对肝内病灶的处理、必要时的病肝切除,胆管狭窄处的整形,尾叶胆管的开口探查、取石,肝门部大口胆肠吻合等,加强规范化手术实施和医师素质培训,是提高手术治疗效果的重要环节。

Objective To analyze the reasons for selective reoperation for hepatolithiasis and determine measures for its prevention and treatment. Methods The reasons for selective reoperation in 58 patients with hepatolithiasis treated in our hospital from June 1994 to March 2002 were retrospectively analyzed. Results The reasons were as follows: 1) In the first operation, only cholecystectomy and/or choledochotomy with T tube drainage was performed and the clearance of focal lesions in the liver not conducted. 2) The repair of hepatic strait bile duct, especially in stage-2Ⅱ bile duct that was difficult to expose, was not performed in the first operation. 3) The clearance of stones was not complete, especially in the caudate lobe, in the first operation. 4) Anastomotic stoma of choledochojeju-nostomy was lower and smaller so that the stones were easily incarcerated and obstructive jaundice recurred. Conclusions The surgeons should pay close attention to procedures such as removal of foci, plastic surgery for hepatic strait bile duct, clearance of stones and choledochojejunostomy etc. in the first operation. Meanwhile, the operation should be standard.