经皮胆管镜治疗肝内外胆管结石的探讨

The percutaneous cholangioscopy therapy in treating intra and extra hepatic calculi

目的 探讨经皮胆管镜治疗肝内外胆管结石的疗效和结石复发的防治。方法 43例经皮经肝胆管引流和窦道扩张后,经皮经肝胆管镜(PTCS)治疗肝内外胆管结石;22例术后T管留置>3周者,行术后胆管镜(POCS)治疗。该65例中肝内胆管结石(IHS)40例(I型12例,IE型28例),胆总管结石(CBI)结石)25例。结果 43例PTCS扩张窦道直径平均19.1 F,建立窦道时间平均17.1d。65例中11例直接取石,54例行液电碎石(EHL)后取石,其中25例配合乳头括约肌切开。40例IHS至结石清除每例治疗次数平均5.2次,25例CBD结石平均1.9次。37例(56.9％)有胆管或胆肠吻合口狭窄,用探条或气囊扩张,3例留置金属支架,结石清除率98.5％(64/65)。11例合并胆道感染,1例IHS伴胆汁性肝硬化合并肾功能不全死亡。 平均随访30.8个月,结石复发率7.1％。结论 经皮胆管镜和EHL是治疗胆系结石安全、有效的办法;胆管或胆肠吻合口狭窄长度<0.5 cm者,器械扩张效果良好;治疗狭窄可提高结石清除率,降低结石复发率。

Objective To study on the percutaneous cholangioscopy therapy in treating intra and extra hepatic calculi and preventing their recurrence. Methods Forty-three patients with biliary tract stones were treated by percutaneous transhepatic cholangioscopy ( PTCS) after percutaneous transhepatic cholan-giostomy, and 22 patients with residual stones installed T-tube more than 3 weeks underwent postoperative cholangioscopy (POCS) therapy. In a total of 65 patients, there were 40 cases of hepatolithiasis ( intrahepat-ic type in 12, intra and extrahepatic type in 28) and 25 cases of choledocholithiasis. Results All sinus tracts of 43 PTCS were dilated up to 19. 1 Fr in mean size before inserting cholangioscopy and the period of establishing sinus tract was in average 17. 1 days. POCS was performed in patients with postoperative placement of T-tube over 3 weeks. Cholangioscopic removal of stones were carried out with basket in 11 cases and electrohydraulic lithotripsy (EHL) in 54 cases due to large or impacted stones, combined with EST with stones extraction in 25 cases. Repeated cholangioscopies were required in 40 cases of IHS with a mean of 5. 2 sessions and 25 cases of choledocholithiasis with an average of 1. 9 sessions per patient until complete stone-extraction. Biliary duct or bilio-enteric anastomotic stricture was dilated with bougienage or balloon dilator in 37 cases; metallic stents were placed at the strictured site in 3 of them. Complete clearance of stones was a-chieved in 64(98. 5% ) patients. Complications of cholangitis occurred in 11 cases and one case of secondary biliary cirrhosis with biliary tract stones died of complicated renal insufficiency when stone extraction was completed. There were no complications associated with the procedure. The rate of stone recurrence was 7. 1% after an average of 30. 8 months follow-up. Conclusion Percutaneous cholangioscopy and EHL are safe and effective techniques for the treatment of biliary tract stones. The use of dilator in treating biliary stricture less than 0. 5cm in length is more effective, it increases clearance rate and decreases recurrent rate.