选择性胆管造影在诊治复杂肝内胆管结石中的临床应用*

Clinical application and experience of selective cholangiography in diagnosis and treatment of complicated calculus of intrahepatic duct*

摘要:

探讨胆道镜引导下选择性肝内胆管造影在复杂肝内胆管结石治疗中的临床价值。方法 回顾性分析该科2010年8月－2017年7月收治的复杂肝内胆管结石术后T管造影及胆道镜未发现结石的患者96例，在胆道镜引导下对可疑胆管行选择性胆管造影以确定狭窄胆管及结石部位，同时行取石和解除狭窄治疗。结果 肝内胆管狭窄伴结石组88例，86例经胆管球囊扩张、Cook网篮取石等结石全部取净，操作时间为（58.4±11.5）min，2例取石失败，结束手术。肝内胆管狭窄不伴结石组8例，直接行胆道镜下高频电切术。两组肝内狭窄胆管的位置分布比较，差异无统计学意义（P>0.05）；取石和电切过程中共出血8例，采取针状刀高频电凝成功止血，术后发生胆管炎9例，迟发性胆道出血4例，均给予对症治疗，两组并发症发生率比较，差异无统计学意义（P>0.05）。随访6～24个月，肝内胆管结石复发15例，采取经皮经肝胆管穿刺引流及经皮经肝胆道镜治疗，术中发现17处胆管狭窄。结论 针对复杂肝内胆管结石或结石合并狭窄，规范的选择性胆管造影技术不失为一种准确、安全、有效的诊治方法。

Abstract:

To evaluate the clinical value of cholangioscopy guided selective cholangiography in treatment of complicated calculus of intrahepatic duct. Methods This study selected 96 patients with no calculus were found in patients with complicated calculus of intrahepatic duct by routine T-tube cholangiography and choledochoscopy after operation from August 2010 to July 2017. Under the guidance of choledochoscopy, selective cholangiography was performed to determine the location of calculus and bile duct strictures and take stone and relieve stenosis at the same time. Results 88 cases were found to have strictured bile duct combining with stones by selective cholangiography, 86 cases stones were removed by balloon dilatation of bile duct and Cook basket stone extraction. The average operating time is (58.4±11.5) min. 2 cases failed to get stones and then ended the operation. 8 cases of bile duct stricture without stone and directly received choledochoscopic high frequency electrotomy. There was no significant difference in distribution of intrahepatic stricture bile duct between the two groups (P>0.05). During lithotomy and electroresection, the bile duct tissue bleeding occurred in 8 cases but were resolved by endoscopic high-frequency electric cautery. After the operations, 9 cases of cholangitis and 4 cases of delayed hemobilia were observed symptomatic treatment. There was no significant difference in the incidence of complications between the two groups (P>0.05). The follow-up period ranged from 6 to 24 months. Hepatolithiasis recurred in 15 cases cured with PTBD and PTCS. Conclusions The standard selective cholangiography is an accurate and effective method for diagnosis and treatment of complicated calculus of intrahepatic duct or hepatolith combining with stricture of the bile duets.