肝内外胆管结石多次手术原因及再次手术治疗方法和预后研究  

Causes and prognosis of repeated operations in patients with intra-and extrahepatic cholangiolithiasis

作　　者：何启雄 吴志扬 黄铭祥 李盛海 李刚 周成茂 谢启明[1] He Qixiong;Wu Zhiyang;Huang Mingxiang(Department of Surgery,Affiliated Hospital,Zhaoqing Medical College,Zhaoqing 526060,Guangdong Province,China)

机构地区：[1]肇庆医学高等专科学校附属医院外科,广东省肇庆市526060 [2]肇庆市中医院普外科

出　　处：《实用肝脏病杂志》2018年第5期781-784,共4页Journal of Practical Hepatology

基　　金：肇庆市科技局医药科技计划项目(编号:20173092)

摘　　要：目的探讨肝内外胆管结石多次手术的原因及再次手术治疗的结果。方法 2010年1月~2015年1月我院收治的100例有多次胆道结石手术史患者,分析再次手术的原因和手术方法,使用影像学检查评估疗效,采用健康调查简表(SF-36)对生活质量进行评估。结果 100例患者均为结石复发或残留,合并原胆肠吻合口狭窄9例(9.0%),合并继发性胆管癌7例(7.0%),合并胃间质瘤侵袭肝内胆管3例(3.0%);29例(29.0%)行部分肝叶切除术,24例(24.0%)行部分肝叶切除术联合胆总管切开取石术,14例(14.0%)行胆总管切开取石术联合胆道镜探查术,10例(10.0%)行胆总管切开取石术联合胆道镜探查和胆管空肠Roux-en-Y吻合术,5例(5.0%)行部分肝叶切除术联合原胆管空肠Roux-en-Y吻合口拆除和胆道镜探查术,6例(6.0%)行原胆肠Y攀切除联合胆道镜取石术和胆管空肠Roux-en-Y吻合术,4例(4.0%)行肝内胆管切开取石术和胆道镜探查术,4例(4.0%)行部分肝叶切除联合残留胆囊切除术,3例(3.0%)行部份肝叶切除术联合残留胆囊切除术1例(1.0%)行残留胆囊切除联合胆道镜探查、原胆肠吻合口拆除和胆管空肠Roux-en-Y吻合术;即时结石清除率为63%,最终结石清除率为88%;出现术后并发症45例,其中19例出现切口感染、10例术后胆瘘、9胸腔积液、7例术后胆道出血;胆汁培养细菌阳性75例,其中主要为大肠杆菌(35%)、铜绿假单胞菌(28%)、肺炎克雷伯菌(19%)和阴沟肠杆菌(18%);术后患者住院时间为22.7±6.1 d;术后6 m,79例生存患者躯体疼痛评分为87.9±3.1,生理机能、生理职能、一般健康状况、情感职能和精神健康评分分别84.9±6.3、73.8±9.9、73.9±8.1、65.4±5.8、76.0±10.0,与术前比,显著改善(P<0.05)。结论结石残留和复发为胆道多次手术的主要原因,临床如何提高结石清除率,防止复发,还是一个需要克服的课题。Objective To investigate the reasons and prognosis of repeated operations in patients with intraand extrahepatic cholangiolithiasis.Methods 100 patients with cholangiolithiasis between January 2010 and January 2015 were recruited in this study.The causes of reoperation,options of operations and the quality of life were analyzed.Results 100 patients received reoperation for residual and/or recurrent stones,and 9 were found with concurrent primary biliary enteric anastomotic stenosis,7 with cholangiocarcinoma,and 3 with gastrointestinal stromal tumor and invasion of intrahepatic bile duct;the operation mainly included hepatectomy in 29（29%）,hepatectomy and choledocholithotomy in 24（24%）,choledochoscopic exploratoin and cholangiojejunostomy in 14（14%）;the immediate stone clearance rate was 63%,and the final stone clearance rate was 88%;postoperative incision infection occurred in 19 patients,biliary fistula in 10 patients,pleural effusion in 9 patients,and postoperative biliary tract hemorrhage in 7 patients;75 patients were bile culture positive,and the bacteria were Escherichia Coli（35%）,Pseudomonas aeruginosa（28%）,Klebsiella pneumoniae（19%） and Enterobacter cloacae（18%）;the postoperative hospital stay was（22.7 ±6.1） d;at 3 and 4 months after operation,2 patients died of secondary tumor and 19 lost;at the end of six months after operation,the physiological function,body pain,general health,role emotional and mental health scores in 79 patients were 92.8 ±11.6,30.1±9,87.1±9,98±6.3,81.2±6.7,much improved as compared to those before operation（P〈0.05）.Conclusions The main causes of repeated operations were residual stones and recurrence of stones,and surgeons should find more practical and scientific approaches for the radical clearance of stones.

关 键 词：胆石症 部分肝叶切除术 胆总管切开取石术 胆总管切开探查术 胆管空肠吻合术 生活质量 

分 类 号：R657.4[医药卫生—外科学]