目的:总结肝部分切除治疗肝胆管结石的临床经验。方法:回顾性分析91例肝胆管结石的定位诊断、手术方式、临床效果和手术并发症等情况。结果:术前行彩超检查91例（100％）、CT检查78例（85.7％）、MRI检查6例（5.5％）。术中发现合并胆管狭窄24例（26.4％），合并胆管癌2例（2.1％）。左外叶或左半肝切除71例（78.0％）、右叶各段切除18例（19.8％）、右半肝切除2例（2.2％）。术后并发症发生率19.8％，残石率18.7％。结论:彩超+CT对肝胆管结石的术前定位诊断基本能满足术前对手术方式的制定；以肝段叶切除为主的综合治疗方案是治疗肝胆管结石的有效手段；术中、术后彩超、纤维胆道镜的运用及术后针对患者具体情况的对症治疗措施可提高临床效果，减少并发症。
ObjectiveTo explore the curative effect of precise hepatectomy techniques in hepatolithus. MethodsTotally 132 patients underwent precise hepatectomy and 52 patients underwent irregular hepatectomy were retrospectively analyzed, and the intraoperative and postoperative indexes such as operation time, blood loss, postoperative complications, hospitalization time, clearance rate of calculus, and cost of hospitalization were analyzed. ResultsCompared with the patients in irregular hepatectomy group, although the operative time was longer in precise hepatectomy group 〔(364.6±57.8) min vs. (292.9±44.7) min, Plt;0.001〕, but the patients in precise hepatectomy group had less blood loss 〔(558.3±90.6) ml vs. (726.7±88.7) ml, Plt;0.001〕, less postoperative complications (11.4% vs. 23.1%，P=0.004 3), and higher clearance rate of calculus (89.4% vs. 73.1%, P=0.005 5). Thus, the patients in precise hepatectomy group had shorter hospital stay 〔(22.9±4.4) d vs. (28.8±3.5) d, Plt;0.001〕 and less cost of hospitalization 〔(1.8±0.7)×104 yuan vs. (2.1±0.9)×104 yuan, P=0.016 5〕. Conclusion Precise hepatectomy is better than irregular hepatectomy in treatment for hepatolithus.
目的 探讨纤维胆道镜在肝胆管结石手术术中及术后的操作技巧，提高肝胆管结石的临床治愈率。方法 总结分析180例肝胆管结石病例，在纤维胆道镜下观察，使用取石篮取石、钳咬、抓取、冲洗，行术中、术后经T管窦道取出结石。结果 本组180例中158例行术中取石，结石取净率为94.3%（149/158）； 余22例系术后再次经Ｔ管窦道取石，结石取净率为86.4%（19/22）。术中、术后取净结石共168例，结石取净率93.3%（168/180）。结论 纤维胆道镜能有效治疗肝胆管结石，降低术中、术后残余结石发生率，提高治愈率。
目的探讨减少肝胆管结石术后残余结石的方法，降低术后结石残余率。方法回顾分析112例肝胆管结石术后残余结石病例的胆管造影X线片，观察残余结石的分布情况。结果胆总管残余结石者11例（9.8%），左肝管残余结石者15例（13.4%），右肝管残余结石者34例（30.4%），尾叶支肝管残余结石者20例（17.9%），左右肝管、胆总管残余结石者32例（28.6%）。结论合理选择手术方案是降低肝胆管结石术后残余结石的关键。
Objective To discuss the effective surgical treatment of intrahepatic lithiasis combined with high hepatic duct strictures. MethodsTwo hundreds and sixteen cases of intrahepatic lithiasis and high hepatic duct strictures treated in this hospital from January 1993 to October 2002 were analysed retrospectively.ResultsOne hundred and eightythree cases underwent different selective operation by selected time; 33 cases complicated with acute obstructive suppurative cholangitis underwent emergency were performed single biliary drainage, in which 30 cases were reoperated. The operative procedure were: hepatic lobectomy,high cholangiotomy and plastic repair,exposure of hepatic duct of the 2nd and the 3rd order,and plastic repair with own patch and choledochojejunostomy.Two hundreds and six cases were cured,the curative rate was 95.4%; 8 cases improved (3.7%), and 2 cases died (0.9%).Conclusion The best effective surgical treatment of intrahpatic lithiasis is hepatic lobectomy. Exposure of hepatic duct of the 2nd and the 3rd order is a satisfactory to release the hepatic duct strictures and to clear the intrahepatic lithiasis. For patients with normal extrahepatic bile duct and Oddi’s function, plastic repair of bile duct with own patch is possible to keep the normal form and function. Cholangioscopy may play an important role in the treatment of intrahepatic tract lithiasis during operation.
这个题目，讨论的文章已经很多，现只就几个问题谈一些个人看法。1我国多见的肝胆管结石病有许多特点1.1西方国家极少见原因何在？除感染因素早已确定外，可能有代谢因素和基因等其它问题。1.2病变部位可在肝内各处，较多见于左外叶。可能由于肝内胆管与其下游胆管间的交角较锐，胆流相对迂滞，固形物如结晶颗粒，或异物如蛔虫尸皮等，较易停留。除左肝外，右肝后叶或某些其它部位胆管支也有相似情况。我们还发现畸形发育的右后叶肝管开口于左肝管者，其右后叶中存积结石。1.3胆道蛔虫病仍是主因结石绝大多数是含菌的，这与胆道寄生虫感染有关。除广东、香港等地人们多吃鱼生致中华肝蛭病外，大陆多数地区是由肠蛔虫引致的胆道蛔虫病，都是肠属菌脓性胆管炎。我们还发现，人蛔虫与猪蛔虫不但形态无区别，它们的组织液成分也无区别，故可能交叉感染。我国各地特别是农村几乎家家养猪，这给预防带来很大困难。1.4胆管炎很难净化结石中含菌，有残石即不断感染。结石清除后，管壁的炎性反应伴腺体中残留的细菌将长期存在，以大肠杆菌为主，据文献报道可持续半年以上，很难清除。1.5病灶长期持续慢性炎症与急性发作反复交替，管壁增厚，管腔因结石存在而扩张，管口则常狭窄。受害区的肝组织逐渐萎缩，纤维化，成为一个包括结石、病变胆管和肝组织为一体的病灶。未病的邻近胆管和肝组织常为正常。病灶可能多数，甚至全肝多处分散存在。病灶较常位于肝内亚段胆管，可能的解释是蛔虫上入肝内时，纂到最细处，不能退出，死于其中。其后虫尸腐烂断落，大部可随胆汁流出，而在亚段中的虫尸未被排出者，日后便形成病灶。
After analysising 15 patients with portal hypertension (PHT) in secondary biliary cirrhosis due to hepatolithiasis, the authors consider that the surgical procedure depends on indivedual’s specificity: majority of patients with PHT but no hemorrhage may be treated by removing the hepatobiliary stone, resolving the bile duct stricture and then reconstructing it as the first step. Whether or not to dispose of PHT depended on the postoperative condition. If the patient had previous hemorrhage and is accompanied by severe obstructive jaundice, splenectomy with shunt and simple biliary external drainage is the choice and removal of stone with biliary tract reconstruction will be performed in the second stage. Meanwhile, it is very important to monitor perioperative condition of the patient and treat the complications.
Four hundred and eighty two paients suffering from intrahepatic bile duct stone undergoing lobectomy and segmental resection (from 1975 to 1994,9) has reported. 63% of the patient in this group underwent 1-5 operations, including different types of biliary-intestinal anastomosis (21.6%). 482 cases underwent different types of hepatectomy, including left lateral-lobetomy 321 cases (66.6%),left hemihepatectomy 80 cases(16.6%), right hemihepatectomy 19 cases (3.9%), and multiple segmental resections 39 cases (8.1%, including Ⅴ+Ⅷ 11 cases, Ⅵ+Ⅶ 28 cases). Other type hepatectomy combined with guadrate lobectomy 20 cases (4.1%). Postoperative complication rate was 10.2%, including diliary fistula. hemobilia and subdiaphragmatic and resectional surface infectioin, 85% of the patients were followed up with an excellent result of 88%. The authors emphsize that hepatic lobectomy nad segmental resection is the core of treatment and selection of operative methods depends on clinical-patholigic types of the disease.
目的 探讨腹腔镜下胆道镜联合微爆破碎石术仪治疗肝胆管结石的安全性及治疗效果。 方法 回顾分析2008年7月－2012年6月183例胆道结石患者，行腹腔镜下胆道镜联合微爆破碎石仪治疗或单纯经内镜Oddi括约肌切开取石治疗的临床资料。87例患者在术中均应用微爆破碎石仪碎石（微爆破组），96例患者行单纯经内镜Oddi括约肌切开术或经内镜乳头切开术碎石（对照组）。 结果 微爆破组碎石成功率100%，结石取净率85.06%（74/87），微爆破组的碎石时间、平均住院时间、平均住院总费用、并发症发生率均明显低于对照组（P＜0.05）。 结论 腹腔镜下胆道镜联合微爆破碎石术在治疗肝胆管结石病方面，具有微创、安全、经济有效的优点，能降低结石残留率及取石次数，值得临床推广。