摘要
目的:比较肝部分切除与经皮经肝穿刺胆道镜取石(PTCSL)治疗肝内胆管结石的近远期疗效,探讨影响结石残留、复发及远期并发症的危险因素。方法:回顾性分析我院2013年6月—2018年6月收治的接受肝部分切除(手术切除组)或PTCSL(PTCSL组)的78例原发性肝内胆管结石患者,对比两种治疗方式的近远期疗效,并分析结石残留复发和治疗后长期并发症(反复发作的胆管炎、肝脓肿、胆汁性肝硬化、胆管细胞癌)与临床资料的关系。结果:平均随访时间为38.3个月。手术切除组患者结石清除率显著高于PTCSL组,而术后复发率显著低于PTCSL组(P<0.05),两组患者病死率比较差异无统计学意义(P>0.05)。78例患者术后共有22例(28.2%)发生结石残留,多因素分析显示,术前合并胆道狭窄(OR:3.026;CI:1.021~7.298)、结石双侧分布(OR:1.542;CI:1.196~3.886)及PTCSL治疗(OR:1.425;CI:1.085~4.238)是影响结石残留的独立危险因素。78例患者术后结石复发24例(30.7%),多因素分析显示,术前合并胆管狭窄(OR:1.528;CI:1.258~5.298)、术后结石残留(OR:1.854;CI:1.326~5.128)、结石双侧分布(OR:1.785;CI:1.236~6.327)及PTCSL(OR:1.367;CI:1.096~5.026)是影响结石复发的独立危险因素。总体与肝胆相关并发症率为17.9%(14/78)。多因素分析显示,年龄(OR:3.022),结石双侧分布(OR:1.793),术前胆道狭窄(OR:2.944)和术后结石残留(OR:1.991)是影响术后并发症的独立危险因素。结论:肝部分切除和PTCSL治疗原发性肝内胆管结石患者远期均可能发生结石残留、结石复发。术前有胆道狭窄、结石呈双侧分布的患者行肝部分切除术的并发症更少;对于老年患者或合并肝硬化、无法耐受手术的患者,若术前合并胆道狭窄可考虑行PTSCL。术后定期随访非常必要。
Objective:To compare the short-term and long-term efficacy of partial hepatectomy and percutaneous transhepatic choledocholithotomy(PTCSL)in the treatment of hepatolithiasis,discuss the risk factors affecting residual stones,recurrence and long-term complications.Methods:Seventy-eight patients with newly diagnosed hepatolithiasis,actively treated for hepatolithiasis during the past 5 years,constituted the cohort of this retrospective study.Patients were treated by partial hepatectomy or percutaneous transhepatic choledocholithotomy.Short-term and long-term complications,such as residual stones,recurrence,recurrent cholangitis,liver abscess,secondary biliary cirrhosis,and cholangiocarcinoma,and their relationships with clinical parameters were analyzed.Results:The mean follow-up period was 38.3 months.The stone clearance rate in the partial hepatectomy group was significantly higher than that in the PTCSL group,while the postoperative recurrence rate was significantly lower than that in the PTCSL group(P<0.05).There was no significant difference in mortality between the two groups.A total of 22(28.2%)of the 78 patients had residual stones after surgery.Multivariate analysis showed that preoperative biliary duct stricture(OR:3.026;CI:1.021~7.298)Bilateral distribution of calculi(OR:1.542;CI:1.196~3.886)and PTCSL therapy(OR:1.425;CI:1.085~4.238)was an independent risk factor for stone residue.Stone recurrence was found in 24(30.7%)of the 78 patients.Multivariate analysis showed that preoperative biliary duct stricture(OR:1.528;CI:1.258-5.298),postoperative stone residual(OR:1.854;CI:1.326-5.128),Bilateral distribution of calculi(OR:1.785;CI:1.236-6.327)and PTCSL(1.367;CI:1.096-5.026)were independent risk factors for stone recurrence.The overall rate of hepatobiliary complications was 17.9%(14/78).Multivariate analysis showed that age(OR:3.022),bilateral distribution of stones(OR:1.793),biliary duct stricture(OR:2.944)and postoperative stone residue(OR:1.991)were independent risk factors for postoperative complications.Conclusion:Hepatolithiasis by liver resection and PTCSL treatment are a percentage of the patients had the complication,compared with PTCSL,hepatectomy has more advantages for the patients with preoperative biliary stricture,calculi in bilateral distribution.However,for the elderly patients with cirrhosis or intolerant surgery,if preoperative biliary stricture is complicated,PTSCL may be used to remove all stones and remove biliary stricture with stent implantation or balloon dilation.Therefore,a comprehensive evaluation should be conducted before the selection of treatment methods to select the most suitable treatment method and make a good surgical planning.For patients aged over 60 years with preoperative biliary stricture,residual stones and bilateral distribution of stones,regular observation is also necessary.
作者
陈佳骏
张海阳
曹学冬
曲岩
宋鑫
罗运权
CHEN Jia-jun;ZHANG Hai-yang;CAO Xue-dong;QU Yan;SONG Xin;LUO Yun-quan(Department of Hepatobiliary Surgery,Shuguang Hospital of Shanghai University of Traditional Chinese Medicine,Pudong Shangahi 201203,China)
出处
《中国现代普通外科进展》
CAS
2020年第2期113-117,共5页
Chinese Journal of Current Advances in General Surgery
关键词
胆石病
胆管
肝内
肝部分切除术
经皮经肝穿刺胆道镜取石
并发症
Cholelithiasis,bile ducts,intrahepatic
Partial hepatectomy
Percutaneous transhepatic choledocholithotomy
Complication
