【摘要】：目的:探討肝內(nèi)外膽管結(jié)石多次手術(shù)原因及再次手術(shù)治療方式和預(yù)后。方法:采用回顧性隊列研究的方法。收集2006年1月至2016年1月安徽醫(yī)科大學(xué)第一附屬醫(yī)院肝膽胰二病區(qū)收治124例多次膽道結(jié)石手術(shù)史患者的臨床資料。再次手術(shù)根據(jù)肝內(nèi)外膽管結(jié)石分布及肝臟儲備情況選擇個體化手術(shù)方式,治療遵循“取凈結(jié)石、去除病灶、矯正狹窄、通暢引流”原則。其手術(shù)方式主要包括膽總管切開取石外引流術(shù)、膽管空腸Roux-en-Y吻合術(shù)、聯(lián)合肝葉或肝段切除術(shù)。術(shù)中抽取膽汁予以細(xì)菌培養(yǎng),術(shù)后常規(guī)行抗炎、止血、保肝、抑酸和營養(yǎng)支持等對癥處理。觀察指標(biāo):(1)患者再次手術(shù)的原因;(2)再次手術(shù)的術(shù)中情況:手術(shù)方式、手術(shù)時間、術(shù)中出血量、術(shù)中輸血量、術(shù)中肝門阻斷時間、結(jié)石清除情況;(3)再次手術(shù)的術(shù)后情況:術(shù)后并發(fā)癥及治療情況、膽汁細(xì)菌培養(yǎng)結(jié)果、病理學(xué)檢查結(jié)果、術(shù)后住院時間;(4)隨訪結(jié)果:采用門診、電話及短信方式隨訪,主要監(jiān)測患者術(shù)后生活狀態(tài)和質(zhì)量、腹部超聲檢查結(jié)果。術(shù)后6周開始定期隨訪,若有結(jié)石殘留則1個半月隨訪1次;若無結(jié)石殘留則3個月或半年隨訪1次,隨訪時間截止2016年6月。正態(tài)分布的計量資料以X±S表示,偏態(tài)分布的計量資料以M(范圍)表示。計數(shù)資料用χ2檢驗和Fisher精確檢驗,多因素分析采用logistic回歸方法,檢驗水準(zhǔn)α=0.05,p0.05為差異有統(tǒng)計學(xué)意義。結(jié)果:(1)再次手術(shù)的原因:124例患者均合并結(jié)石,結(jié)石分布于肝內(nèi)膽管69例,肝外膽管7例,肝內(nèi)外膽管48例。其中合并原膽腸吻合口狹窄11例,繼發(fā)膽道惡性腫瘤6例,合并胃腸道間質(zhì)瘤侵犯肝內(nèi)膽管2例。(2)再次手術(shù)中情況:既往膽道已行1次手術(shù)76例,2次及2次以上手術(shù)48例。本次手術(shù)時間為(250±69)min,術(shù)中出血為(180±165)ml,17例術(shù)中行輸血治療,其中聯(lián)合部分肝切除13例。總計切肝75例,23例術(shù)中阻斷第一肝門,時間為(13±5)min。124例術(shù)中均行膽道鏡探查。即時結(jié)石清除率為75.8%(94/124),最終結(jié)石清除率為89.2%(99/111)。(3)再次手術(shù)后情況:124例中,54.8%(68/124)發(fā)生術(shù)后并發(fā)癥。其中17.7%(22/124)為切口感染,經(jīng)過換藥、抗感染及營養(yǎng)支持治療后均好轉(zhuǎn)。15.3%(19/124)為胸腔積液,經(jīng)有效的穿刺引流及營養(yǎng)支持治療后均治愈。6.4%(8/124)為膽漏,經(jīng)腹部引流管保持通暢引流后治愈。4.8%(6/124)為肺部感染,經(jīng)有效的抗感染、霧化等支持治療后均治愈。4.8%(6/124)為切口感染合并胸腔積液,經(jīng)傷口換藥、胸腔穿刺、抗感染及營養(yǎng)支持治療而愈。4.0%(5/124)為膽道出血,行再手術(shù)止血1例、經(jīng)保守治療好轉(zhuǎn)4例。1.6%(2/124)患者發(fā)生腹水,經(jīng)保肝、利尿及營養(yǎng)支持治療后好轉(zhuǎn)出院。75.0%(93/124)患者膽汁細(xì)菌培養(yǎng)陽性,常見細(xì)菌依次為大腸埃希菌、銅綠假單胞菌、肺炎克雷伯菌、陰溝腸桿菌。病理學(xué)檢查結(jié)果為肝膽管結(jié)石病116例、膽管細(xì)胞腺癌合并結(jié)石6例,膽管結(jié)石伴發(fā)胃腸間質(zhì)瘤2例。總住院時間為20±8d。(4)隨訪結(jié)果:111例患者獲得術(shù)后隨訪,總體隨訪率為89.5%(111/124),隨訪中位時間為24個月(3~108個月)。隨訪期間,72例患者術(shù)后生活狀態(tài)達(dá)到優(yōu)良標(biāo)準(zhǔn),39例患者術(shù)后生活狀態(tài)差(其中結(jié)石殘留19例,結(jié)石復(fù)發(fā)12例,結(jié)石繼發(fā)膽管癌變或間質(zhì)瘤8例)。隨訪期間8例患者因繼發(fā)腫瘤未行手術(shù)治療死亡,4例因肝功能差而無法耐受手術(shù),3例因其他社會因素而未行手術(shù)治療,1例因繼發(fā)腫瘤擴散無法手術(shù)。(5)結(jié)石殘留復(fù)發(fā)的臨床因素分析:單因素分析顯示既往膽道手術(shù)次數(shù)≥2次、膽汁細(xì)菌培養(yǎng)陽性、雙葉結(jié)石、Oddi括約肌功能障礙是影響術(shù)后結(jié)石殘留復(fù)發(fā)的危險因素。多因素分析顯示既往膽道手術(shù)次數(shù)≥2次、膽汁細(xì)菌培養(yǎng)陽性、雙葉結(jié)石、Oddi括約肌功能障礙是影響術(shù)后結(jié)石殘留復(fù)發(fā)的獨立危險因素。結(jié)論:1.肝內(nèi)外膽管結(jié)石殘留與復(fù)發(fā)是再手術(shù)的主要原因,前期手術(shù)方式不當(dāng)、Oddi括約肌功能判斷有誤、吻合口及膽管狹窄是促使結(jié)石復(fù)發(fā)及殘留的主要原因。2.再手術(shù)前明確結(jié)石分布的范圍、肝葉是否萎縮、有無癌變以及肝功能狀況,采取個體化手術(shù)方式,聯(lián)合術(shù)中膽道鏡檢查取石有助于提高結(jié)石取凈率,降低結(jié)石殘留和復(fù)發(fā)率,有效減少再次手術(shù)。3.既往膽道手術(shù)次數(shù)、膽汁細(xì)菌培養(yǎng)陽性、雙葉結(jié)石、Oddi括約肌功能障礙是影響術(shù)后結(jié)石殘留復(fù)發(fā)的獨立危險因素。
[Abstract]:Objective: To investigate the causes and reoperation methods and prognosis of multiple operations of intrahepatic and extrahepatic bile duct stones. Methods: a retrospective cohort study was used to collect the clinical data of 124 cases of cholelithiasis hand surgery in two cases of hepatobiliary and pancreatic disease in the First Affiliated Hospital of Medical University Of Anhui from January 2006 to January 2016. The distribution and liver reserve of intrahepatic and extrahepatic bile ducts were selected by individualized operation. The treatment followed the principle of "removing the stones, removing the focus, correcting the stenosis and drainage." the main operation includes bile duct incision and drainage, bile duct jejunostomy Roux-en-Y anastomosis, combined hepatic lobectomy or hepatic segmental resection. Bacteria culture, postoperative routine treatment of anti-inflammatory, hemostasis, liver preservation, acid suppression and nutritional support. (1) the cause of the reoperation; (2) surgical procedures, operation time, intraoperative bleeding, intraoperative blood transfusion, intraoperative portal blocking time, stone clearance; (3) postoperative operation: postoperative conditions: surgery: surgery: postoperative conditions: surgery: surgery: surgery: surgery: postoperative situation: surgery: surgery: surgery: surgery: surgery: surgery: postoperative situation: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: operation: surgery: postoperative conditions: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: operation: surgery: postoperative conditions: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: operation: operation: postoperative situation: surgery: surgery: postoperative situation: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: surgery: (3) operation: postoperative situation: surgery: postoperative situation: surgery: surgery: surgery: surgery: surgery: postoperative situation: surgery: surgery: surgery: surgery: surgery: surgery: surgery: Postoperative complications and treatment, bile bacterial culture results, pathological examination results, hospitalization time after operation; (4) follow-up results: follow up outpatient, telephone and SMS, mainly monitor the patient's postoperative life and quality, abdominal ultrasound examination results. 6 weeks after the operation, regular follow-up, if there is residual stones in 1 and a half months of 1 times; if no The residual stones were followed up for 1 times in 3 months or half a year. The time of follow-up was up to June 2016. The measurement data of normal distribution were expressed in X + S. The measurement data of partial distribution were expressed in M (range). The count data were tested by x 2 and Fisher, and logistic regression method was used for multivariate analysis to test the level of alpha =0.05, and P0.05 was statistically significant. Results: (1) the cause of reoperation: 124 cases were all combined with stone, 69 cases of intrahepatic bile duct, 7 cases of extrahepatic bile duct, 48 cases of intrahepatic bile duct, 11 cases of biliary tract anastomotic stenosis, 6 cases of secondary biliary malignant tumor, and 2 cases of intrahepatic bile duct invasion with gastrointestinal stromal tumor. (2) the situation of the second operation was 1 times. The operation time was 76 cases, 2 times and more than 2 times. The operation time was (250 + 69) min, the intraoperative bleeding was (180 + 165) ml, 17 cases were treated with blood transfusion, including 13 cases of combined partial hepatectomy, total hepatic resection 75 cases, 23 cases blocking the first hepatic portal during operation, time was (13 + 2) cases of choledochoscopy. The immediate stone clearance rate was 94/1 24), the final stone clearance rate was 89.2% (99/111). (3) after reoperation: 124 cases, 54.8% (68/124) had postoperative complications. 17.7% (22/124) was incision infection, after dressing, anti infection and nutritional support treatment improved.15.3% (19/124) as the pleural effusion, after effective puncture drainage and nutritional support after the treatment of.6.4% (8/12) 4) for the bile leakage, after the abdominal drainage tube kept open drainage,.4.8% (6/124) was cured for pulmonary infection. After effective anti infection and atomization,.4.8% (6/124) was cured by incision infection combined with pleural effusion, wound dressing, thoracic puncture, anti infection and nutritional support treatment and.4.0% (5/124) for biliary bleeding, and 1 reoperation stop bleeding. After conservative treatment, 4 patients with.1.6% (2/124) had ascites. After the treatment of liver preservation, diuresis and nutritional support, the bile bacteria culture was positive in patients discharged from.75.0% (93/124). The common bacteria were Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter cloacae. Pathological examination results were 116 cases of hepatolithiasis. 6 cases of cholangiocarcinoma combined with stones, 2 cases of choledocholithiasis accompanied by gastrointestinal stromal tumors. The total hospitalization time was 20 + 8D. (4) follow-up results: 111 patients were followed up after operation, the overall follow-up rate was 89.5% (111/124), and the median follow-up time was 24 months (3~108 months). During the follow-up period, the postoperative living conditions of 72 patients were excellent and 39 patients were treated after operation. Poor living conditions (19 cases of residual stones, 12 cases of calculi recurrence, secondary bile duct carcinogenesis or interstitial tumor in 8 cases). 8 patients died of secondary tumor without surgical treatment, 4 cases were unable to tolerate operation due to poor liver function, 3 cases were not operated for other social factors, 1 cases were unable to operate due to secondary tumor diffusion. (5) calculi Clinical analysis of residual recurrence: single factor analysis showed more than 2 times of previous biliary surgery, positive bile bacteria culture, double leaf stone, and Oddi sphincter dysfunction as a risk factor for postoperative recurrence of residual stones. Multiple factors analysis showed that the number of biliary tract operations was more than 2 times, bile bacteria culture was positive, double leaf stone, and Oddi included Conclusion: 1. residual and recurrent intrahepatic bile duct stones are the main causes of reoperation. The main cause of reoperation is the residual and recurrent intrahepatic bile duct stones, improper preoperation methods, misdiagnosis of Oddi's sphincter function, and the main cause of recurrence and residual of the stones by the anastomotic and bile duct stricture is the clear stone before reoperation.2.. The range of distribution, the atrophy of hepatic lobes, canceration and liver function, individualized operation and choledochoscopy combined with intraoperative choledochoscopy help to improve the rate of stone removal, reduce the residual and recurrence rate of stones, effectively reduce the number of previous operation of.3. biliary tract, bile bacteria culture, double leaf stone and Oddi sphincter. Energy barrier is an independent risk factor for postoperative residual stone recurrence.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R657.4

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