摘要
目的探讨胆道镜引导下选择性肝内胆管造影在复杂肝内胆管结石治疗中的临床价值。方法回顾性分析该科2010年8月-2017年7月收治的复杂肝内胆管结石术后T管造影及胆道镜未发现结石的患者96例,在胆道镜引导下对可疑胆管行选择性胆管造影以确定狭窄胆管及结石部位,同时行取石和解除狭窄治疗。结果肝内胆管狭窄伴结石组88例,86例经胆管球囊扩张、Cook网篮取石等结石全部取净,操作时间为(58.4±11.5)min,2例取石失败,结束手术。肝内胆管狭窄不伴结石组8例,直接行胆道镜下高频电切术。两组肝内狭窄胆管的位置分布比较,差异无统计学意义(P>0.05);取石和电切过程中共出血8例,采取针状刀高频电凝成功止血,术后发生胆管炎9例,迟发性胆道出血4例,均给予对症治疗,两组并发症发生率比较,差异无统计学意义(P>0.05)。随访6~24个月,肝内胆管结石复发15例,采取经皮经肝胆管穿刺引流及经皮经肝胆道镜治疗,术中发现17处胆管狭窄。结论针对复杂肝内胆管结石或结石合并狭窄,规范的选择性胆管造影技术不失为一种准确、安全、有效的诊治方法。
Objective To evaluate the clinical value of cholangioscopy guided selective cholangiography in treatment of complicated calculus of intrahepatic duct.Methods This study selected 96 patients with no calculus were found in patients with complicated calculus of intrahepatic duct by routine T-tube cholangiography and choledochoscopy after operation from August 2010 to July 2017.Under the guidance of choledochoscopy,selective cholangiography was performed to determine the location of calculus and bile duct strictures and take stone and relieve stenosis at the same time.Results 88 cases were found to have strictured bile duct combining with stones by selective cholangiography,86 cases stones were removed by balloon dilatation of bile duct and Cook basket stone extraction.The average operating time is(58.4±11.5) min.2 cases failed to get stones and then ended the operation.8 cases of bile duct stricture without stone and directly received choledochoscopic high frequency electrotomy.There was no significant difference in distribution of intrahepatic stricture bile duct between the two groups(P>0.05).During lithotomy and electroresection,the bile duct tissue bleeding occurred in 8 cases but were resolved by endoscopic high-frequency electric cautery.After the operations,9 cases of cholangitis and 4 cases of delayed hemobilia were observed symptomatic treatment.There was no significant difference in the incidence of complications between the two groups(P>0.05).The follow-up period ranged from 6 to 24 months.Hepatolithiasis recurred in 15 cases cured with PTBD and PTCS.Conclusions The standard selective cholangiography is an accurate and effective method for diagnosis and treatment of complicated calculus of intrahepatic duct or hepatolith combining with stricture of the bile duets.
引文
[1]毛伟坤.腹腔镜联合胆道镜取石术治疗肝内胆管结石的临床疗效[J].中国内镜杂志,2014,20(6):636-638.[1]MAO W K.Clinical efficacy of laparoscopic combined with choledochoscope in the treatment of intrahepatic bile duct stones[J].China Journal of Endoscopy,2014,20(6):636-638.Chinese
[2]杨玉龙,谭文翔,付维利,等.纤维胆道镜治疗肝胆管良性狭窄的临床探讨[J].中国普外基础与临床杂志,2005,12(6):572-573.[2]YANG Y L,TAN W X,FU W L,et al.Clinical investigation about value of diagnosis and treatment for benign biliary stricture by choledochoscopy[J].Chinese Journal of Bases and Clinics in General Surgery,2005,12(6):572-573.Chinese
[3]李立祥,欧松柏,许丽,等.胆道镜在难治性胆管残余结石中的应用[J].肝胆外科杂志,2015,23(5):341-343.[3]LI L X,OU S B,XU L,et al.The therapeutic effect of fiber choledochescope on refractory residual bile duet stones[J].Journal of Hepatobiliary Surgery,2015,23(5):341-343.Chinese
[4]黄志强.肝内胆管结石治疗演变和发展[J].中国实用外科杂志,2015,35(5):468-470.[4]HUANG Z Q.Evolution and development of hepatolithiasis treatment[J].Chinese Journal of Practical Surgery,2015,35(5):468-470.Chinese
[5]李大江,别平.肝内胆管结石的外科治疗方案的演变[J].肝胆外科杂志,2013,21(2):81-83.[5]LI D J,BIE P.Evolution of surgical treatment for intrahepatic hepatolithiasis[J].Journal of Hepatobiliary Surgery,2013,21(2):81-83.Chinese
[6]赵本泉,吴伟,项建斌,等.肝切除术联合术中胆道镜治疗17例肝内胆管结石的疗效分析[J].重庆医学,2015,44(19):2652-2653.[6]ZHAO B Q,WU W,XIANG J B,et al.The therapy experience of liver resection combined intraoperative choledochoscope for intrahepatic biliary calculi in 17 cases[J].Chongqing Medicine,2015,44(19):2652-2653.Chinese
[7]张诚,杨玉龙,张洪威,等.胆道镜下高频电切技术在肝内胆管狭窄中的应用[J].肝胆胰外科杂志,2015,27(5):383-385.[7]ZHANG C,YANG Y L,ZHANG H W,et al.Application of choledochoscopic high-frequency electrotomy for intrahepatic bile duct strictures[J].Journal of Hepatopancreatobiliary Surgery,2015,27(5):383-385.Chinese
[8]BRAZHNIKOVA N A,TSKHA?V F,MERZLIKIN N V,et al.Hepatolithiasis[J].Vestn Khir Im I I Grek,2014,173(1):39-43.
[9]郭跃华,张卓,马杨,等.胆道镜治疗肝切除术后肝内胆管结石合并胆管狭窄的疗效分析[J].中华消化外科杂志,2013,12(8):616-619.[9]GUO Y H,ZHANG Z,MA Y,et al.Efficacy of choledochoscopy for the treatment of postoperative intrahepatic duct stones and strictures[J].Chinese Journal of Digestive Surgery,2013,12(8):616-619.Chinese
[10]KONG J,WU S D,XIAN G Z,et al.Complications analysis with postoperative choledochoscopy for residual bile duct stones[J].World Journal of Surgery,2010,34(3):574-580.
[11]李美荣,叶观瑞,李运福,等.胆道镜治疗胆管残余结石首次失败原因分析[J].中国内镜杂志,2003,9(7):60-61.[11]LI M R,YE G R,LI Y F,et al.Analysis of the failure causes for the first time in the treatment of residual stone with choledochoscopy[J].China Journal of Endoscopy,2003,9(7):60-61.Chinese
[12]郭跃华,张卓,马杨,等.胆道镜治疗术后肝内胆管结石并狭窄13年经验总结:附697例报告[J].中国普通外科杂志,2014,23(2):141-146.[12]GUO Y H,ZHANG Z,MA Y,et al.Thirteen-year experience in choledochoscopic treatment of postoperative intrahepatic stones with biliary strictures:a report of 697 case[J].Chinese Journal of General Surgery,2014,23(2):141-146.Chinese
[13]冯秋实,边大鹏.胆道镜技术在肝内胆管结石诊治中的价值及评价[J].中国实用外科杂志,2016,36(3):269-272.[13]FENG Q S,BIAN D P.Value and evaluation of choledochoscopy technique in hepatolithiasis[J].Chinese Journal of Practical Surgery,2016,36(3):269-272.Chinese
[14]杨玉龙,谭文翔,付维利,等.纤维胆道镜下气囊导管肝胆管造影临床分析[J].肝胆胰外科杂志,2006,18(1):38-39.[14]YANG Y L,TAN W X,FU W L,et al.Clinical analysis of fiberoptic choledochoscope balloon catheter and hepatobiliary angiography[J].Journal of Hepatopancreatobiliary Surgery,2006,18(1):38-39.Chinese
[15]刘丹峰,刘志刚,代俭华.胆道镜下球囊扩张术治疗肝内胆管残留结石合并狭窄[J].肝胆胰外科杂志,2016,28(3):217-218.[15]LIU D F,LIU Z G,DAI J H.Balloon dilatation for intrahepatic bile duct residual stones combined with strictures under choledochoscopy[J].Journal of Hepatopancreatobiliary Surgery,2016,28(3):217-218.Chinese
