肝内外胆管结石多次手术原因及预后分析

发布时间：2018-07-15 09:49

【摘要】：目的:探讨肝内外胆管结石多次手术原因及再次手术治疗方式和预后。方法:采用回顾性队列研究的方法。收集2006年1月至2016年1月安徽医科大学第一附属医院肝胆胰二病区收治124例多次胆道结石手术史患者的临床资料。再次手术根据肝内外胆管结石分布及肝脏储备情况选择个体化手术方式,治疗遵循“取净结石、去除病灶、矫正狭窄、通畅引流”原则。其手术方式主要包括胆总管切开取石外引流术、胆管空肠Roux-en-Y吻合术、联合肝叶或肝段切除术。术中抽取胆汁予以细菌培养,术后常规行抗炎、止血、保肝、抑酸和营养支持等对症处理。观察指标:(1)患者再次手术的原因;(2)再次手术的术中情况:手术方式、手术时间、术中出血量、术中输血量、术中肝门阻断时间、结石清除情况;(3)再次手术的术后情况:术后并发症及治疗情况、胆汁细菌培养结果、病理学检查结果、术后住院时间;(4)随访结果:采用门诊、电话及短信方式随访,主要监测患者术后生活状态和质量、腹部超声检查结果。术后6周开始定期随访,若有结石残留则1个半月随访1次;若无结石残留则3个月或半年随访1次,随访时间截止2016年6月。正态分布的计量资料以X±S表示,偏态分布的计量资料以M(范围)表示。计数资料用χ2检验和Fisher精确检验,多因素分析采用logistic回归方法,检验水准α=0.05,p0.05为差异有统计学意义。结果:(1)再次手术的原因:124例患者均合并结石,结石分布于肝内胆管69例,肝外胆管7例,肝内外胆管48例。其中合并原胆肠吻合口狭窄11例,继发胆道恶性肿瘤6例,合并胃肠道间质瘤侵犯肝内胆管2例。(2)再次手术中情况:既往胆道已行1次手术76例,2次及2次以上手术48例。本次手术时间为(250±69)min,术中出血为(180±165)ml,17例术中行输血治疗,其中联合部分肝切除13例。总计切肝75例,23例术中阻断第一肝门,时间为(13±5)min。124例术中均行胆道镜探查。即时结石清除率为75.8%(94/124),最终结石清除率为89.2%(99/111)。(3)再次手术后情况:124例中,54.8%(68/124)发生术后并发症。其中17.7%(22/124)为切口感染,经过换药、抗感染及营养支持治疗后均好转。15.3%(19/124)为胸腔积液,经有效的穿刺引流及营养支持治疗后均治愈。6.4%(8/124)为胆漏,经腹部引流管保持通畅引流后治愈。4.8%(6/124)为肺部感染,经有效的抗感染、雾化等支持治疗后均治愈。4.8%(6/124)为切口感染合并胸腔积液,经伤口换药、胸腔穿刺、抗感染及营养支持治疗而愈。4.0%(5/124)为胆道出血,行再手术止血1例、经保守治疗好转4例。1.6%(2/124)患者发生腹水,经保肝、利尿及营养支持治疗后好转出院。75.0%(93/124)患者胆汁细菌培养阳性,常见细菌依次为大肠埃希菌、铜绿假单胞菌、肺炎克雷伯菌、阴沟肠杆菌。病理学检查结果为肝胆管结石病116例、胆管细胞腺癌合并结石6例,胆管结石伴发胃肠间质瘤2例。总住院时间为20±8d。(4)随访结果:111例患者获得术后随访,总体随访率为89.5%(111/124),随访中位时间为24个月(3~108个月)。随访期间,72例患者术后生活状态达到优良标准,39例患者术后生活状态差(其中结石残留19例,结石复发12例,结石继发胆管癌变或间质瘤8例)。随访期间8例患者因继发肿瘤未行手术治疗死亡,4例因肝功能差而无法耐受手术,3例因其他社会因素而未行手术治疗,1例因继发肿瘤扩散无法手术。(5)结石残留复发的临床因素分析:单因素分析显示既往胆道手术次数≥2次、胆汁细菌培养阳性、双叶结石、Oddi括约肌功能障碍是影响术后结石残留复发的危险因素。多因素分析显示既往胆道手术次数≥2次、胆汁细菌培养阳性、双叶结石、Oddi括约肌功能障碍是影响术后结石残留复发的独立危险因素。结论:1.肝内外胆管结石残留与复发是再手术的主要原因,前期手术方式不当、Oddi括约肌功能判断有误、吻合口及胆管狭窄是促使结石复发及残留的主要原因。2.再手术前明确结石分布的范围、肝叶是否萎缩、有无癌变以及肝功能状况,采取个体化手术方式,联合术中胆道镜检查取石有助于提高结石取净率,降低结石残留和复发率,有效减少再次手术。3.既往胆道手术次数、胆汁细菌培养阳性、双叶结石、Oddi括约肌功能障碍是影响术后结石残留复发的独立危险因素。
[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.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R657.4

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