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目的 研究复杂的肝内胆管结石的手术治疗方法。方法 对１５例肝内胆管广泛多发结石病人,实施左肝外叶切除广口肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,并进行跟踪随访。结果 本组无严重术后并发症。随访３．５￣７．５年,平均４．８年,１４例症状完全消失,１例偶有胆管炎发作。Ｂ超检查;１３例无残石,２例右肝后叶残留少量结石。结论 左肝外叶切除广口肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术治疗肝内胆管广泛多发结石远期疗效较     

损伤性高位胆管狭窄41例报告

目的 总结损伤性高位胆管狭窄外科治疗的经民教训。方法 性调查４１例损伤性高位胆管狭窄患者的治疗方法，并发症及远期疗效。结果 采用胆肠吻主３８例，无手术死亡。其中肝管空肠Ｒｏｕｘ－Ｙ吻合术２６例，随访２～１０年，优良率８３．３％；肝管十二指肠吻合１２例，随访３年以上，优良率７０％。结论 肝管空肠Ｒｏｕｘ－Ｙ吻合术是治疗损伤性高位胆管狭窄的最佳方式，肝管十二指肠吻合术对高危胆管狭窄患者仍然是有效方法之     

多发性肝胆管结石的手术治疗

２１例多发性复杂胆管结石在采用肝门部胆管切开取石胆肠Ｒｏｕｘ－Ｙ吻合术的基础上，对局限于肝段的肝内胆管结石行肝总结切除术。其中行ⅡⅢ肝段切除１８例，行Ⅵ肝段切除３例，行胆管总管空肠Ｒｏｕｘ－Ｙ吻合术１１例，行左右肝管汇合部切开＋原位整形盆状胆肠吻合术８例，左／右肝管残端及肝总管与空肠行双口Ｒｏｕｘ＝Ｙ吻合术２例。结果：２１例均痊愈，无死亡，随访１年以上１６例，疗效优良率１５／１６例。     

胆肠吻合术治疗肝内外胆管结石并狭窄的术式选择及疗效分析

目的:分析胆肠吻合术治疗肝内外胆管结石并狭窄的术式选择的疗效。方法:对62例行胆肠吻合术的肝内外胆管结石并狭窄的病例进行总结,包括临床表现、结石部位、狭窄情况、手术方式和治疗效果等。结果:胆管狭窄主要位于1～2级胆管内,39例(62.9％)行肝胆管空肠Roux-Y吻合术,23例(37.1％)采用肝胆管十二指肠吻合术。随访结果表明:肝胆管空肠Roux-Y吻合术优良率为82.5％,胆总管十二指肠吻合术优良率为73.9％(P<0.05)。结论:对肝内外胆管结石并胆道狭窄的病人应首选Roux-Y吻合术。十二指肠吻合术应用于下级胆管狭窄、狭窄胆管切开整形、肝胆管大口径吻合。     

肝门胆管盆式空肠吻合术治疗肝内胆管结石并狭窄

目的 研究肝门胆管盆式空肠吻合术在肝内胆管结石狭窄治疗中的临床应用及效果。方法 对１９８６年８月－１９９８年８月２３例经肝门胆管盆式空肠吻合术的肝内胆管结石并狭窄的病例资料进行了回顾性分析。手术方法有肝门胆管盆式空肠Ｒｏｕｘ－Ｙ吻合术和肝门胆管盆式间空肠十二指肠吻合术。术中根据胆客狭窄部位不同持不同的肝门区胆管盆式整形,旷置空肠或间置空肠肠段长约５０ｃｍ,吻合口大小８－１０ｃｍ。结果 本组病病例１     

肝胆管残余结石外科治疗的展望

近 5 0年来 ,我国肝胆管结石的外科治疗已有了长足的进步 ,但肝胆管结石的发病率仍高 ,复杂困难的病例仍多 ,手术后残石率复发率仍高 ,因而肝胆管结石的外科治疗仍然是我国胆道外科的热门课题。本文拟从以下几方面谈谈肝胆管残余结石外科治疗方面的一些进展及展望。一、关于胆肠吻合术胆肠吻合术长期以来作为胆石症治疗的一种重要手术方式。早年的胆总管十二指肠吻合 ,胆总管空肠Ｒｏｕｘ Ｙ吻合 ,后来的肝门胆管切开取石后肝门胆管空肠盆式吻合以及皮下盲袢型Ｒｏｕｘ Ｙ吻合等 ,以及针对胆肠吻合后不可避免的逆行感染所设计的各种抗返流措…     

右肝后叶结石的手术治疗

近来，我们应用经右肝后叶胆管联合切开右肝后叶上、下段胆管．原位整形．胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术治疗右肝后叶结石１２例．获满意疗效．无胆道出血及手术死亡。文中讨论了右肝内胆管的正确辨认、手术适应症及手术操作要点。     

胆肠吻合术后肝内胆管结石、狭窄的防治

目的 探索利用胆道镜技术解决胆肠吻合治疗术后肝内胆管狭窄、结石复发的策略,探讨胆肠吻合术、胆肠吻合输出肠袢防胆肠返流人工瓣膜的可行性和有效性。方法 总结行胆肠Roux—en—Y吻合术的47例肝胆管结石患者的资料,患者全部采取输出肠袢人工防返流瓣。其中19例在空肠输入出袢处放置银夹标志。术后观察胆肠返流、复发、吻合口狭窄及其处理情况。结果 术后32例发生胆肠返流（32／47,68．1％）,说明Roux—en—Y吻合术式中的人工瓣并没有很好的防返流作用;2例肝内胆管结石患者术后复发通过金属标记物穿刺置管建立窦道,避免了再手术。6例胆肠吻合术后胆肠吻合口狭窄,5例通过经皮经肝胆道镜（PTCS）进行取石和吻合口狭窄扩张处理获得成功,1例死亡。结论 胆肠吻合术的银夹标志应用为胆道镜的治疗提供了简捷进入胆道内的路径,使复发的狭窄、结石治疗简捷化和安全化,充分发挥了胆道镜技术治疗肝胆管狭窄及残余结石的作用;PTCS微创、安全、有效,值得临床应用。     

姑息性手术治疗不能切除的胰头癌

本文报告我院１０年间姑息性手术治疗不能切除的胰头癌１００例。最常见的症状为黄疸（８１％），腹痛或背痛（５２％），体重减轻（４３％）。手术方法：肝总管空肠Ｒｏｕｘ－Ｙ形吻合术４７例，肝总管空肠Ｒｏｕｘ－Ｙ形吻合和胃空肠吻合术３７例，胆囊空肠Ｒｏｕｘ－Ｙ形吻合术８例，肝内或肝外胆管置管外引流术８例。手术死亡率为６％，胆肠吻合和预防性胃空肠吻合术的手术死亡率为５．４％。近期并发症为３９％，其中伤口感染多见。远期并发症为２３％，其中以胆囊空肠吻合术后的胆管炎和黄疸多见。我们认为姑息性手术治疗不能切除的胰头癌应尽量选择肝总管空肠Ｒｏｕｘ－Ｙ形吻合术，同时作预防性胃空肠吻合。     

胆管空肠Roux—en—Y一层外翻吻合：附158例报告

我院自１９８５年１０月～１９９６年１２月共施行胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ（以下简称胆肠Ｙ吻合）一层外翻吻合１５８例，效果满意。现报道如下。１临床资料本组１５８例，其中男９６例，女６２例。年龄２４～７１岁。肝内外胆管结石１５３例，肝外胆管癌１例，硬化性...     

胆总管十二指肠吻合和胆管空肠吻合术式选择的临床意义分析—附120例

目的:探讨胆总管十二指肠侧侧吻合术与胆管空肠Roux-en-Y吻合术的术式选择及远期疗效。方法:总结行胆肠吻合术的120例胆道梗阻病例。原发疾病包括:复发性胆管结石并胆管狭窄65例、先天性胆管囊性扩张症22例、晚期胆道与胰腺肿瘤28例、医源性胆管损伤5例。其中行胆总管十二指肠侧侧吻合术30例(25%),胆管空肠Roux-en-Y吻合术90例(75%)。结果:术后全部病人恢复良好,术后随访98例,随访率81.7%,随访时间为6个月～4年,所有患者术后近期黄疸消退,肝功能恢复,能正常工作生活。远期生存质量评估:胆总管十二指肠吻合术后生存质量优良与良好91.3%(21/23),不良8.7%(2/23);胆管空肠Roux-en-Y吻合术后生存质量优良与良好92.0%(69/75),不良8.0%(6/75)。结论:胆总管十二指肠侧侧吻合术和胆管空肠Roux-en-Y吻合术都能很好起到引流胆汁的效果,严格掌握适应证和精细的手术操作是有效引流、缓解胆道梗阻的保证。     

胆道良性病变内引流术式与胆管癌变

目的探讨胆肠引流术后发生的胆管癌的原因。方法回顾分析我院1982年～2000年因胆道良性疾病作胆肠引流术后75例病人的病历和随访记录,按照胆肠吻合术将病人分为胆管空肠．Roux—y吻合术48例。胆管间置空肠吻合术4例,胆总管十二指肠吻合术16例,经十二指肠乳头切开术7例,随访期最长10年。结果胆管空肠Roux—y吻合术后发生吻合口癌2例,胆总管十二指肠吻合术后发生原发性胆管癌1例。发生癌变的病人中为肝内胆管结石及术后反复发生胆管炎者。结论长期胆肠引流和胆管恶性肿瘤存在相关性,可能与术后胆道结石、排石、反复胆管炎有关。     

胆道损伤修复术后再狭窄的治疗：附22例报告

目的:探讨医原性胆道损伤修复术后再狭窄的治疗.方法:回顾分析2001年1月-2011年12月期间收治的胆道损伤经外院修复后再狭窄的22例临床资料.22例胆道损伤均由胆囊切除所造成,其中8例为腹腔镜胆囊切除术,14例为开腹胆囊切除术.结果:22例患者均再次手术,21例行胆管空肠Roux-en-Y吻合术(1例因胆管损伤位置较高,肝方叶切除后行左右肝管空肠吻合),1例行U管引流术.所有患者经1～11年随访,除l例因胆道感染继发肝功能衰竭死亡外,其他21例患者近远期疗效尚可.结论:胆管损伤发生后应及早修复,注重手术操作的细节,选择合理修复方法;胆管空肠Roux-en-Y吻合术是治疗修复术后再狭窄的可靠术式.     

梗阻性黄疸肝内增生胆管上皮细胞凋亡的实验研究

目的：研究梗阻性黄疸肝内胆管上皮细胞凋亡对增生胆管的影响。方法：应用末端脱氧苷酸转移酶介导的脱氧三磷酸尿苷（dUTP）缺口末端标记技术（TUNEL）观察大鼠胆道梗阻及胆肠内引流术后肝内胆管上皮细胞凋亡与胆管增生的关系。结果：胆道梗阻后，肝内胆管明显增生，胆管上皮细胞凋亡明显增加；早期胆肠内引流术后，增生的胆管及胆管上皮细胞凋亡明显减少。结论：胆道梗阻胆管上皮细胞凋亡增加可能与清除过度增生的胆管有关，是机体维持自身组织稳定的一种重要机制；早期胆肠内引流术后，随着增生的胆管减少，胆管上皮细胞凋亡明显减少。     

Development of intrahepatic biliary stones after excision of choledochal cysts

Background: The incidence of intrahepatic cholelithiasis and cholangitis has not yet been well studied postoperatively in patients with choledochal cysts. Methods: One hundred three patients with choledochal cysts had operative cholangiography, underwent standard excision of a choledochal cyst with Roux-en-Y hepatico-jejunal anastomosis, and were at a mean follow-up of 12[frac12] years. The incidence of intrahepatic bile duct stones was analyzed according to the 3 morphologic types of intrahepatic bile duct observed at initial operative cholangiography: type 1, no dilatation of the intrahepatic bile ducts; type 2, dilatation of the intrahepatic bile ducts but without any downstream stenosis; and type 3, dilatation of the intrahepatic bile ducts associated with downstream stenosis. Initially, there was no evidence of intrahepatic bile duct stones in any of the 103 patients. Results: Among 50 type 1 patients, intrahepatic cholelithiasis developed in only 1 patient (2%). Among 43 type 2 patients, 1 patient (2%) had intrahepatic cholelithiasis, and 2 (5%) had postoperative cholangitis. Among 10 type 3 patients, 4 (40%) had intrahepatic cholelithiasis (P [lt ] .01), and 3 (30%) had postoperative cholangitis. Time intervals between the initial surgery and the first identification of intrahepatic stones ranged from 3 to 22 years. Conclusions: One of the major causes of formation of intrahepatic cholelithiasis has been clarified; patients with intrahepatic biliary dilatation with downstream stenosis can get intrahepatic bile duct stones long after excision of a choledochal cyst.     

逆行经肝胆道引流在胆管结石手术中的应用

目的：探索可代替T管引流的手术方法。方法：对49例肝内外胆管结现人术中实施逆行经肝胆道引流术。其中37例逆行穿刺经右肝置管外引流;12例从肝胆管残端置管逆地引流。总胆管切口原位缝合关闭。结果：逆行穿刺引流术术后并发气胸及引流管出血各1例（5．4％）,术后平均第8天拔管。逆行经肝胆管残端置管引流乾术后残余结石4例,均经引流窦道取净。保留胆囊19例,术后造影,胆囊显影良好。术后随访6月－9年,B超检查无胆管狭窄及复发结石,保留的胆囊未形成结石。结果：逆行穿刺经肝胆道引流术后带管时间短,逆行经肝管残端引流对术后残余结石的处理较方便。两种引流术式对肝外胆管及保留的胆囊无不良影响。     

Intrahepatic B3 cholangiojejunostomy in the palliative surgery of high unresectable malignant biliary obstruction

Palliating the effects of biliary obstruction is a major goal of therapy in patients with unresectable cancer at the hepatic duct confluence. We reviewed our expirience with intrahepatic holangioenteric bypass to the segmental bile duct B3 as a palliative therapy in patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Since March 2001, we have performed intrahepatic segmental bile duct B3 cholangiojejunostomy by Roux-en-Y fashion utilizing a round ligament approach in 13 patients with malignant obstructive jaundice due to unresectable hilar holangiocarcinoma (8 cases) and gallbladder cancer (5 cases). Mean hospital stay was 123 days and mean blood loss was 25060 mL. Postoperative complications occurred in 3 patients (23%), but there was no surgical complications such as postoperative bleeding, bile leakage or abscess formation. 30-day mortality was 7.7% (1 patient). Late complications (37.5%) were observed in 3 of the 8 patients who survived for more than 5 months after the surgery. Median survival after B3 cholangiojejunostomy was 9 months (range, 10 days-22 months). Median survival time was significantly greater in patients with hilar cholangio-carcinoma (11.8 months; range: 2-22 months) compared with those with gallbladder cancer (4.6 months; range: 10 days-11.5 months) (P-0.032 log rank test; P-0.049 Tarone-Ware test). Intrahepatic B3 cholangiojejunostomy when combined with careful patient selection, can provide useful palliation from jaundice, pruritus and cholangitis with acceptable mortality and morbidity rates.     

医源性胆管狭窄的手术治疗

目的 探讨医源性胆管狭窄的手术治疗方法.方法 回顾性总结1989年1月至2006年12月收治的235例医源性胆管损伤及胆管狭窄患者的临床资料.对损伤或狭窄患者采用胆肠通路重建术、保留和利用乳头括约肌的修复术、肝移植术等进行修复.结果 本组182例患者行胆肠Roux-en-Y吻合术,12例行胆总管对端吻合术,34例行自体带蒂组织瓣吻合术,6例行胆总管切开成形T管引流术,1例行肝移植术.随访时间1～10年,189例获随访.手术优良率为94.7%(179/189).狭窄复发率为5.3%(10/189),复发原因主要为合并结石、硬化性胆管炎、胆汁性肝硬化等.1例因严重胆汁性肝硬化、门静脉高压症,术后死于肝功能衰竭.结论 胆肠Roux-en-Y吻合术是可靠的治疗方法.利用自体带蒂组织瓣修复胆管能保留胆管下端Oddi括约肌的功能,效果良好,但远期疗效有待进一步评估.胆管内不需要常规放置支撑管.肝移植是治疗胆管狭窄引起的终末期胆病的有效方法.     

The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures.

OBJECTIVE: The authors review the treatment and outcome of patients with benign bile duct strictures who underwent biliary enteric repair. SUMMARY BACKGROUND DATA: The authors conducted a retrospective review of all clinical records of patients referred for treatment of benign bile duct strictures caused by surgery, trauma, or common bile duct lithiasis or choledochal cyst. The authors performed univariate and multivariate analyses of clinical and pathologic factors in relation to patient outcome and survivals. METHODS: Eighty-four patients with documented benign bile duct strictures underwent hepaticojejunostomy, choledochojejunostomy, and intrahepatic cholangiojejunostomy during a 15-year period (January 1975 to December 1989). Morbidity, mortality, and patient survival rates were measured. RESULTS: Early and late outcomes correlated neither with demographic and clinical features at presentation nor with etiologic or pathologic characteristics of the stricture. Best results correlated with high biliary enteric anastomoses and degree of common bile duct dilatation independently of bile duct stricture location. CONCLUSIONS: High biliary enteric anastomosis provides a safe, durable, and highly effective solution to the problem of benign strictures of the bile duct. Transanastomotic tube stenting is unnecessary. Endoscopic and percutaneous transhepatic dilatation seems more appropriate for the treatment of patients in poor condition and those with anastomotic strictures.     

规则性肝段(叶)切除治疗肝内胆管结石并狭窄

目的探讨规则性肝段(叶)切除治疗肝内胆管结石并狭窄的临床疗效。方法48例肝胆管结石并狭窄患者,行左外叶切除19例,左半肝切除2例,左外叶+右后叶(或单纯Ⅵ、Ⅶ段)切除7例,右半肝(或单纯Ⅵ、Ⅶ段)切除20例;均行胆总管探查、T管引流术;行胆管空肠Roux-en-Y吻合术13例。结果术后胆管残石5例(10.4%),切口感染3例(6.2%),胆漏2例(4.2%)。随访41例(85.4%),2例肝内胆管结石复发,1例右上腹隐痛,其余随访结果优良。结论根据患者结石及狭窄的具体情况采用以肝段切除为主的手术方式是治疗肝内胆管结石并狭窄的有效手段。