同期三镜下经腹顺行推进法逐级导管肝管扩张会师术43例

Laparoscopic Hepatic Duct Step by Step Dilatable Catheter Dilatation and Realignment of Three Endoscopes at the Same Time through Transabdominal Consequent Propulsive Guidance Technology: A Report of 43 Cases

摘要: 目的：探讨在同期三镜下，经肝内胆管至胆总管顺行推进法逐级导管肝管扩张会师术(LHSCD)治疗肝左外叶和肝右后叶肝胆管结石、合并肝胆管梗阻或肝胆管狭窄的临床应用体会。方法：回顾性分析成都市第二人民医院2005年12月至2019年4月期间，符合入选标准的43例患者的临床资料。结果：本组43例行LCBDE和LHSCD，行肝左外叶切除术40例、行肝右后叶切除术3例，行LC腹腔检查21例。逐级导管经左肝管会师和经胆总管扩张乳头并留置鼻胆管34.8% (15/43)，经左肝管会师和推挤左肝管结石出总管切口并留置鼻胆管9.3% (4/43)，经左肝管会师和经胆总管扩张乳头、内镜乳头小切开并留置鼻胆管7.0% (3/43)，经左肝管会师、左肝管整形、肝圆韧带修补缺损并留置鼻胆管7.0% (3/43)；逐级导管经右肝管会师并留置鼻胆管4.7% (2/43)。经左肝管会师和经胆总管扩张乳头、内镜乳头小切开并留置乳头部T管双导管20.9% (9/43)，经左肝管会师和推挤左肝管结石出总管切口、内镜乳头小切开并留置乳头部T管双导管7.0% (3/43)，经左肝管会师、留置乳头部T管双导管4.7% (2/43)，经左肝管会师、左肝管整形、肝圆韧带修补缺损并留置左肝内胆管T管双导管2.3% (1/43)；经右肝管会师并留置乳头部T管双导管2.3% (1/43)。术后左肝内胆管残石2例(4.7%)，胆汁漏4例(9.3%)，轻度胰腺炎1例(2.3%)。无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症，无围手术期再次手术和死亡患者。术后总并发症发生率为16.3% (7/43)。结论：对本医院有限病例进行初步研究发现，只要病例选择合适，在同期三镜下，采用LHSCD治疗肝左外叶和肝右后叶肝胆管结石、合并肝胆管梗阻或肝胆管狭窄是可行、有效和安全的。

Abstract: Objective: To explore the experiment of clinical application of laparoscopic hepatic duct step by step dilatable catheter dilatation and realignment of three endoscopes at the same time through intrahepatic bile duct to common bile duct consequent propulsive guidance technology (LHSCD) for the treatment of the intrahepatic bile duct of the left hepatic lateral lobe and the right back hepatic lobe and common bile duct stones with obstruction and stenosis of the hepatic bile duct. Methods: The clinical data of 43 cases which met the inclusion criteria were retrospectively researched from December 2005 to April 2019 in the Second People,s Hospital of Chengdu. Results: In this group, 43 cases were treated with LCBDE and LHSCD, 40 cases with left lateral hepatic lobectomy, 3 case with right posterior hepatic lobectomy, and 21 cases with LC by laparoscopy. Through step by step dilatable catheter realignment expanded left hepatic duct and duodenal papilla, indwelling nasobiliary was in 34.8% (15/43); step by step dilatable catheter realignment expanded left hepatic duct and push the stones into the common hepatic duct, indwelling nasobiliary was in 9.3% (4/43); step by step dilatable catheter realignment expanded left hepatic duct and duodenal papilla, duodenoscopic papillary sphincterotomy of small incision, indwelling nasobiliary was in 7.0% (3/43); step by step dilatable catheter realignment expanded left hepatic duct, left hepatic duct plastic surgery, and the liver round ligament repairing the defect, indwelling nasobiliary was in 7.0% (3/43); step by step dilatable catheter realignment expanded right hepatic duct, indwelling nasobiliary was in 4.7% (2/43). Through step by step dilatable catheter realignment expanded left hepatic duct and duodenal papilla, and the small incision of papillary sphincterotomy, indwelling T tube + double biliary catheter drainage of duodenal papilla was in 20.9% (9/43); step by step dilatable catheter realignment expanded left hepatic duct and push the stones into the common hepatic duct, and the small incision of papillary sphincterotomy, indwelling T tube + double biliary catheter drainage of duodenal papilla was in 7.0% (3/43); step by step dilatable catheter realignment expanded left hepatic duct, indwelling T tube + double biliary catheter drainage of duodenal papilla was in 4.7% (2/43); step by step dilatable catheter realignment expanded left hepatic duct, left hepatic duct plastic surgery, and the liver round ligament repairing the defect, indwelling T tube + double biliary catheter drainage of left hepatic duct was in 2.3% (1/43); step by step dilatable catheter realignment expanded right hepatic duct, indwelling T tube + double biliary catheter drainage of duodenal papilla was in 2.3% (1/43). Residual stone of the left medial lobe hepatic duct was occurred in two cases (4.7%). Bile leakage was occurred in four cases (9.3%). The slight pancreatitis was occurred in one case (2.3%). No cases had perforation of intestine and bile duct, bleeding, severe pancreatitis. There is no perioperative reoperation and death. Total postoperative complication formation rate was in 16.3% (7/43). Conclusion: A preliminary study of the limited cases in our hospital found that under the three endoscopy over the same period, using the LHSCD is feasible, effective and safe for the treatment of hepatolithiasis, hepatobiliary duct obstruction or hepatobiliary duct stenosis of the left hepatic lateral lobe and the right back hepatic lobe as long as the appropriate cases are selected.