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.
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.
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 investigate safety and short-term effect of subtotal hepatectomy with caudate lobe as sole remnant liver in treatment of hepatolithiasis, and to analyze diagnosis and treatment process of bronchobiliary fistula after hepatectomy. Methods The clinical data of 1 patient with hepatolithiasis combined with liver atrophy-hypertrophy syndrome and caudate lobe with compensatory hypertrophy who was admitted to the Gansu Provincial People’s Hospital in August 2016 were analyzed retrospectively. The body surface area of the patient was 1.47 m2, the standard total liver volume was 1 040 cm3. According to the results of CT, the expected residual 1iver volume (caudate lobe volume) after the hepatectomy was 643 cm3, and the ratio of residual liver volume over the standard total liver was 61%. The patient received the subtotal hepatectomy with the caudate lobe as the sole remnant liver and T tube drainage. The follow-up including the postoperative complications and recurrence of calculus was performed by the regular hospital check up till September 2017. Results The subtotal hepatectomy with caudate lobe as sole remnant liver was performed successfully. The operative time and intraoperative blood loss were 280 min and 3 000 mL, respectively. The peritoneal drainage tube was removed on the 8th postoperative day with a good recovery of liver function. The postoperative pathological examination showed that there were some intrahepatic bile duct pigment stones, the bile duct wall fibrous tissue hyperplasia combined with a focal liver cells hydropic degeneration, and no canceration. The patient was discharged on the 40th postoperative day. Two months later, the T tube cholangiography showed that the inferior extremity bile duct was unobstructed and there was no residual intra- and extra-hepatic stone. The liver function was normal, then the T tube was removed. After 6 months, the patient coughed and exhausted the bilious sputum, meanwhile the sputum culture showed that there were the Escherichia coli and Streptococcus viridans, then the bronchobiliary fistula was diagnosed. After the multidisciplinary discussion, the patient received the right thoracocentesis and double abdominal drainages around liver, meanwhile, combined with the anti-inflammatory, liver protection, intravenous nutrition support, etc., the bilious sputum was obviously reduced. So far, the patient had been followed up for one year, the patient's cough, and expectoration symptoms disappeared and his condition was stable. Conclusions Caudate lobe-sparing subtotal hepatectomy in treatment of hepatolithiasis is safe and feasible, but it is possible that bronchobiliary fistula is followed after operation, individual and multidisciplinary collaboration in treatment of bronchobiliary fistula caused by extensive hepatectomy is safe and feasible.
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。