ObjectiveTo investigate the feasibility and safety of percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) in the treatment of recurrent type Ⅱa hepatolithiasis.MethodsAll of 293 patients with recurrent type Ⅱa hepatolithiasis admitted to the Second Affiliated Hospital of Chongqing Medical University from December 2010 to December 2017 were collected retrospectively, 82 of whom were treated with the PTCSL (PTCSL group), 211 of whom were treated with traditional open surgery (open group). The patients were matched according to the ratio of 1∶1 by using the method of propensity score matching, then the patients were compared after matching.ResultsA total of 59 pairs were successfully matched, that was, there were 59 patients in the PTCSL group and open group, respectively. Compared with the open group, the PTCSL group had the similar conditions such as the gender, age, preoperative Child-Pugh classification, and times of previous biliary operations, etc. (P>0.050). There was no perioperative death in both groups. There were no significant differences between the two groups in the success rate, operation time, times of operations, time of T tube removal after operation, stone residual rate, and stone recurrence rate (P>0.050). Although the hospital costs of the PTCSL group was higher than that of the open group (P<0.050), the PTCSL group had various advantages, such as less intraoperative bleeding, smaller incisional scar, shorter hospital stay and postoperative ventilation time, and lower rate of total postoperative complications (P<0.050).ConclusionsAfter learning curve, PTCSL has many advantages over traditional open surgery in treatment of recurrent type Ⅱa hepatolithiasis. PTCSL is a minimally invasive surgery, which is safe and effective.
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.
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。
Objective To evaluate the clinical value of ureteroscope in cholelithiasis treated by laparoscopic surgery. Methods The clinical data of 36 patients admitted because of hepatolithus with ureteroscope combination in laparoscopic surgery from February 2007 to September 2009 in Guidong People’s Hospital of Guangxi were analyzed retrospectively. Results In 33 cases, stones were removed once by ureteroscope in laparoscopic surgery with residual stones (in 3 cases residual stone were removed secondarily through T tube) and the other 3 cases were transferred to laparotomy forcedly due to bleeding of biliary duct and vessels of porta hepatis and tearing of bile duct. During operation, blood loss was 30-280 (94.51±54.70) ml; operation time was 110-260 (147.22±48.45) min; recovery time of bowel movement was 1-3 (2.03±0.76) d; postoperative hospitalization time was 6-13 (7.12±1.65) d (some discharged with T tube); the time of patients of T tubes pulled out was 28-45 (38.92±6.52) d. Bile leakage happened in 1 case and infection of biliary tract in 1 case, no complications such as biliary stricture or bile duct bleeding were found after operation. Conclusions Treatment of intrahepatic bile duct or a single extra-hepatic sand-like stones with ureteroscopy usage in laparoscopic surgery is feasible and less invasive. It is a minimally invasive treatment for intra- or extra-hepatic stones due to rapidly postoperative rehabilitation.
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。
ObjectiveTo discuss the clinical effects of T-tube with side holes in the gallbladder-common hepatic duct anastomosis. MethodsThe clinical data of 60 cases that performed gallbladder-common hepatic duct anastomosis from Jul. 2009 to Jul. 2012 were retrospectively analyzed. The contractile functions and mucosal recovery of gallbladder were compared between the conventional T-tube and T-tube with side holes. ResultsTwenty-four cases of gallbladder-common hepatic duct anastomosis used conventional T-tube, the gallbladder were not developing in 6-8 weeks after operation by T-tube cholangiography, the gallbladder mucosa of 17 cases were normal without edema, congestion and edema were observed in 6 cases, and the normal gallbladder mucosa structure disappeared in 1 case. The gallbladder were developing in 6-8 weeks after operation by T-tube cholangiography in 36 cases that used T-tube with side holes, the gallbladder mucosa structure had not congestion, edema, and erosion. The gallbladder contractile function were normal. ConclusionsThe floc, blood clots, and inflammatory substances in gallbladder can be discharged into the intestine or drainage in vitro, and the bile can go into gallbladder and can be concentrated through the T-tube with side holes. Physiological flow of bile can return to normal and the function of gallbladder can recover early.
Objective To summarize the experience of applying biliary balloon dilator to prevent rebleeding after operation for hepatolithiasis combined with hemobilia. Methods From 2003 to 2008, 11 patients were reoperated to stop from hemobilia by biliary balloon dilator’s application after operation for hepatolithiasis combined with hemobilia, and whose clinical data were collected and analyzed. Results In 11 cases, 7 were males and 4 were females. Eight cases were transferred from other hospitals. When intrahepatic duct bleeding was stopped, the biliary balloon dilator was placed at the right site under the guide of choledochoscope. Hemobilia occurred in 4 patients and biliary balloon dilator was opened to compress for 2 h, then decompress for 0.5 h alternately. In all of 4 patients, bleeding was stopped successfully, of which, 1 patient got hemobilia again 5 d after the first bleeding, and was also stopped by the same method. Conclusions After operation on hepatolithiasis combined hemobilia, rebleeding happens in some cases. Preset of biliary balloon dilator at the prebleeding site and opening it when rebleeding happens can get instant hemostasis, which may be a simple and effective treatment choice.