解剖式肝段切除治疗左肝胆管结石 ——保肝手术的探讨

1、解剖式肝段切除治疗左肝胆管结石 保肝手术的探讨         10-09-03 15:12:00     编辑：studa20           作者：陈燕凌朱金海韩圣华陈辉星叶敬旻杜强 【摘要】  目的： 总结解剖式肝段切除治疗左肝胆管结石的效果。方法：采用解剖式肝段切除治疗左肝胆管结石38例。其中左肝内外叶胆管均有结石12例，单纯左肝外叶胆管结石26

2、例，合并胆囊结石19例，胆总管结石30例。同时伴有左肝管口狭窄10例;伴肝门部胆管狭窄3例。结果： S2切除26例，S3切除12例，另附加S4a切除5例，S4a+b切除3例。合并行带蒂自体组织瓣肝门部胆管及左肝管狭窄部成形13例;加行胆总管空肠Roux-en-Y吻合术2例;术中使用纤维胆道镜探查取石者29例，术中经纤维胆道镜通路高能震波碎石者16例。术后并发症发生率为13.1%;无手术死亡。疗效总优良率97.36%。结论： 解剖式肝段切除术能够有效清除结石，并发症少，可防止术后胆石复发及肝脏旋转变形。 【关键词】  胆结石·肝切除术【ABSTRACT】 Objective:

3、 To investigate the therapeutic effects of anatomical segmental hepatectomy for patients with hepatolithiasis. Methods: From January 2005 to June 2008，anatomical liver resection procedure were completed in 38 patients with left intrahepatolithiasis and the therapeutic efficacy were evaluated.Results

4、: Thirt-eight patients with left intrahepatolithiasis were included in this study, 12(31.5%) with left lateral intrahepatolithiasis, 26(68.4%) with left intrahepatolithiasis, 19(50%)with cholecystolithiasis, 30(78.4%) with common duct stones,10 with hepatobiliary stricture,3 with hilar stricture. Of

5、 38 patients，26 received II segmentectomy ，12 received ，5 received additional a segmentectomy， 3 received additional IVa+b segmentectomy.13 patients received recondition of hepatobiliary stricture by self tissue piece with blood supply. All operations included segmentectomy associated with hepaticoj

6、ejunostomy in 2 cases. The postoperatice complications were found in 5 cases(13.1%)and no patients died post operation.21cases had been followed up for 3 months to 7 years，and the effect of 20 cases(97.3%)was excellent or good.Conclusion: Anatomic 1iver resection is safe and effective for left intra

7、hepatolithiasis，and it could decrease the incidence rate of the liver proliferation and rotation.【KEY WORDS】 Cholelithiasis· Hepatectomy肝内胆管结石病情复杂，局部肝组织内结石、胆管狭窄、胆管梗阻感染、肝实质病变互为因果，且难以治疗彻底，术后残石发生率、再次手术率和结石复发率均较高，是肝胆外科一个棘手的问题1-2。近年来，由于外科技术的改进和内镜技术的发展，肝内胆管结石的治疗效果明显提高，但仍有很多问题值得探讨3。对多发性肝内胆管结石要即时取净结石及行

8、规则肝切除治疗已成为共识，但大部分肝切除常可导致术后残肝不规则增生及旋转变形。本研究通过对38例肝内外胆管结石患者行解剖性左肝段切除手术治疗，以探讨既能彻底根除病灶，又尽可能保存相对健康的肝脏，防止术后胆石复发及肝脏旋转变形的方法。1资料与方法1.1一般资料收集我院2005年6月2008年3月肝内外胆管结石患者38例，其中男13例，女25例;年龄3874岁，平均年龄56.8岁;病程3个月21年，平均(8.0±2.6)年。均有反复发作的胆管炎，临床表现为右上腹疼痛、寒战、发热，其中15例伴有黄疸。既往有胆囊切除、胆总管切开取石史31.5% (12/38)，左肝内外叶胆管均有结石 31.

9、5%(12/38)，单纯左肝外叶胆管结石68.4% (26/38);合并胆囊结石50% (19/38)，胆总管结石78.4%(30/38);同时伴有左肝管口狭窄10例,伴肝门部胆管狭窄3例。1.2手术方式采用左肝2段(S2)、3段(S3)或4段(S4)切除+胆总管切开取石的手术方式，其中S2切除26例，S3切除12例，另附加S4a切除5例，S4a+b切除3例。合并行带蒂胆囊瓣肝门部胆管及左肝管狭窄部成型8例，行带蒂肝圆韧带肝门部胆管及左肝管狭窄部成型3例;带血管蒂胃浆肌瓣肝门部胆管及左肝管狭窄部成型2例;行胆囊切除29例;加行胆总管空肠Roux-en-Y吻合术2例。术中使用纤维胆道镜探查取石2

10、9例，术中经纤维胆道镜通路采用高能震波碎石16例。1.3评价标准在出院时或术后1个月无腹痛、恶心、呕吐、发热、黄疸等症状发作，实验室检查未见异常为疗效优良;仍有上述症状发作者为疗效差。随访3个月3年。2结果本组病例手术均实施顺利，无术中及术后大出血，无围手术期死亡病例。术中出血量经纱布称重法精确测量约为20120 mL，平均(30±16) mL，全组术中及术后未输血。术后并发症发生率为13.1%(5/38)，包括切口脂肪液化2例，切口感染1例，肺部感染1例，少量胆汁漏致膈下感染1例，经腹腔持续冲洗治愈。术后经T管造影和B超证实1例有肝内胆管结石残留(左肝内叶胆管末支少量残余结石)。随访的