中国普外基础与临床杂志

中国普外基础与临床杂志

保留尾状叶肝次全切除治疗肝内胆管结石病

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目的 探讨保留尾状叶肝次全切除治疗肝内胆管结石病的安全性和近期疗效,并针对其术后并发的胆管支气管瘘进行诊治分析。 方法 回顾性分析 2016 年 8 月甘肃省人民医院收治的甘肃省首例肝胆管结石合并左右肝萎缩、尾状叶代偿性肥大患者的临床资料。术前评估患者体表面积为 1.47 m2,标准肝脏体积为 1 040 cm3。根据 CT 检查预计肝切除术后剩余肝脏(肝尾状叶)体积为 643 cm3,剩余肝脏体积占标准肝脏体积的 61%。故行保留尾状叶肝次全切除术及尾状叶胆管 T 管引流术,术后采用定期入院复查进行随访,随访患者的术后并发症及结石复发情况,随访时间截至 2017 年 9 月 6 日。 结果 该例患者成功施行了保留尾状叶肝次全切除术,手术时间 280 min,术中失血量约 3 000 mL,输红细胞 1 400 mL、血浆 800 mL。术后第 8 天拔除腹腔引流管,肝功能恢复良好。术后病理报告:肝内胆管胆色素性结石;胆管管壁纤维组织增生,灶区肝细胞水样变,未见癌变;术后第 40 天出院。患者术后 2 个月 T 管造影检查见胆管下端通畅,肝内外无结石残留,肝功能正常,拔除 T 管。术后 6 个月时出现反复咳嗽、咳胆汁样痰液,痰培养示大肠埃希菌、草绿色链球菌,诊断为胆管支气管瘘,经多学科协作讨论,给予右侧胸腔穿刺引流、肝周双重穿刺引流,同时给予抗炎、保肝、静脉营养支持等,咳胆汁样痰液明显减少。目前已随访 1 年,患者咳嗽、咳痰症状消失,病情稳定。 结论 保留尾状叶肝次全切除治疗严重肝胆管结石病安全、可行,但术后有并发胆管支气管瘘的可能;采用个体化治疗与多学科协作治疗胆管支气管瘘安全、有效。

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.

关键词: 肝胆管结石病; 肝切除术; 胆管支气管瘘

Key words: hepatolithiasis; hepatectomy; bronchobiliary fistula

引用本文: 柴乃俊, 蒋泽斌, 赵慧琪, 高鹏, 杨晓军. 保留尾状叶肝次全切除治疗肝内胆管结石病. 中国普外基础与临床杂志, 2018, 25(2): 207-212. doi: 10.7507/1007-9424.201711058 复制

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