肝方叶切除联合肝门胆管高位劈开整形在肝门胆管狭窄合并结石中的应用  

Application of quadrate lobectomy combined with high-level splitting and plasty of the hilar bile ducts in treatment of hilar bile duct stricture with hepatolithiasis

作　　者：刘剑鸣[1] 易为民[1] 彭创[1] 钟振东[2] 刘苏来 吴金术[1] LIU Jianming;YI Weimin;PENG Chuang;ZHONG Zhendong;LIU Sulai;WU Jinshu(Department of Hepatobiliary Surgery,Hunan Provincial People's Hospital/the First Affiliated Hospital of Hunan Normal University,Changsha 410005,China;Department of Hepatobiliary Surgery,People's Hospital of Changsha County/Hunan Provincial People's Hospital Xingsha Branch,Changsha 410100,China)

机构地区：[1]湖南省人民医院/湖南师范大学第一附属医院肝胆外科,湖南长沙410005 [2]长沙县人民医院/湖南省人民医院星沙院区肝胆外科,湖南长沙410100

出　　处：《中国普通外科杂志》2020年第2期198-203,共6页China Journal of General Surgery

基　　金：湖南省自然科学基金资助项目(2019JJ50320)。

摘　　要：背景与目的:对于肝胆管结石多次手术后复发患者,如何安全取尽结石,最大限度解除肝门甚至是肝内胆管的狭窄,并建立或修复通畅的胆流通道,一直是胆道外科治疗领域中的难点。本研究探讨肝方叶切除联合肝门胆管高位劈开整形在肝门胆管狭窄合并结石中的治疗效果及应用价值。方法:回顾性分析2015年7月-2019年6月湖南省人民医院收治的36例复杂肝胆管结石患者的临床资料,36例患者既往平均手术2.4次,均存在不同程度的肝门部胆管狭窄,其中肝门胆管汇合部狭窄18例,合并右肝管狭窄8例,合并左肝管狭窄10例。结果:所有患者均行肝方叶切除、肝门胆管高位劈开整形、胆肠内引流手术,术中采用取石钳取石、塑形管冲洗、胆道镜探查等多种方式取尽结石。平均手术时间354.4 min,平均失血量230.5 mL。术后平均结石清除率在90%以上。术后2例患者出现胆汁漏,经积极引流治疗后好转,3例患者出现切口脂肪液化、感染,1例患者不完全性肠梗阻,均保守治疗后好转。术后采用门诊、电话随访12~48个月,4例患者出现反流性胆管炎,无胆肠吻合口再发狭窄病例。结论:肝方叶切除联合肝门胆管高位劈开整形能有效解除肝门胆管高位狭窄,达到取尽结石、通畅引流的目的,同时能避免大范围的肝切除,因此具有一定的临床应用价值。Background and Aims:For patients with recurrent hepatobiliary stones after a repeated operation,how to safely and completely remove the stones,maximally relieve the stenosis in the hilar and even intrahepatic bile ducts,and then construct or repair a patent passage for bile flow has always been a difficult problem in the therapeutic field of biliary surgery.This study was undertaken to determine the clinical efficacy and application value of resection of the quadrate lobe of the liver combined with high-level splitting and plasty of the hilar bile ducts in treatment of hilar bile duct stenosis complicated with hepatolithiasis.Methods:The clinical data of 36 patients with complicated hepatobiliary stones treated in Hunan Provincial People’s Hospital from July 2015 to June 2019 were retrospectively analyzed.All the 36 patients had a different degree of hilar bile duct stricture,with an average number of previous operations of 2.4.Of them,the stricture located only at the hilar bile duct confluence in 18 cases,and with combined stricture at the right hepatic duct in8 cases or left hepatic duct in 10 cases.Results:All patients underwent hepatic quadrate lobe resection,hilar bile duct splitting and plasty,and bilioenteric drainage,and the stones were thoroughly removed during operation by means of lithotomy forceps,tube flushing and choledochoscopic exploration.The average operative time was 354.4 min,and the average intraoperative blood loss was 230.5 mL,and the final stone clearance rate exceeded 90%.After operation,bile leakage occurred in 2 patients,which was improved after aggressive drainage treatment,fat liquefaction and infection of incision occurred in 3 patients and partial intestinal obstruction occurred in 1 patient,which were all improved after conservative treatment.During the 12-48 months of follow-up by telephone and clinic visits,4 patients developed reflux cholangitis and none of them had recurrent stricture of bilioenteric anastomosis.Conclusion:Quadrate lobectomy combined with high-level splittin

关 键 词：胆结石 胆管 缩窄 病理性 肝切除术 胆管肠吻合术 肝 

分 类 号：R657.4[医药卫生—外科学]