李 強(qiáng)， 汪志偉， 柴 琛

蘭州大學(xué)第一醫(yī)院普外三科，甘肅 蘭州 730000

膽總管結(jié)石治療方法的研究進(jìn)展

李 強(qiáng)， 汪志偉， 柴 琛

蘭州大學(xué)第一醫(yī)院普外三科，甘肅 蘭州 730000

膽總管結(jié)石是臨床常見病及多發(fā)病，主要治療方法有內(nèi)鏡及手術(shù)治療，隨著內(nèi)鏡及腹腔鏡技術(shù)的發(fā)展，其治療趨于微創(chuàng)化。本文就膽總管結(jié)石的治療方法進(jìn)展作一概述。

膽總管結(jié)石；治療

膽總管結(jié)石是臨床較常見的疾病之一，其發(fā)生與多種因素有關(guān)，在我國約10%的成人患有膽囊結(jié)石而其中有20%的患者并發(fā)膽總管結(jié)石[1-2]。膽總管結(jié)石可分為原發(fā)性和繼發(fā)性。65%以上的膽總管結(jié)石患者有暴飲暴食、嗜煙酒的表現(xiàn)，50%以上的患者缺乏鍛煉[3]。患者主要表現(xiàn)為發(fā)熱、上腹部疼痛、黃疸、惡心嘔吐等癥狀, 嚴(yán)重影響患者的生活質(zhì)量[4]。腹腔鏡膽囊切除術(shù)、術(shù)中膽道造影(intaoperative cholangiography,IOC)是目前膽總管結(jié)石檢測的金標(biāo)準(zhǔn),腹腔鏡超聲(laparoscopic ultrasonography,LUS)因其無輻射、操作迅速、成功率高、可重復(fù)檢查而越來越受到重視[5]。還可通過B超、CT、ERCP、MRCP等檢查并結(jié)合病史及臨床表現(xiàn)即可做出診斷。隨著手術(shù)、內(nèi)鏡治療等各種治療技術(shù)的不斷發(fā)展，對其治療的方法也越來越多。

1 保守治療

保守治療可作為患者的術(shù)前準(zhǔn)備，膽總管結(jié)石患者一般都有膽管炎，這種情況應(yīng)避免急診手術(shù)，應(yīng)進(jìn)行保肝、抗炎、補(bǔ)液、營養(yǎng)及對癥治療，待患者病情平穩(wěn)可進(jìn)行手術(shù)治療。較小的膽總管結(jié)石(直徑≤0.5 cm)可以自行排入腸道[6],從而避免手術(shù)。

2 手術(shù)治療

2.1腹腔鏡膽總管探查術(shù)放置T管引流膽總管探查T管引流是膽總管結(jié)石的常規(guī)術(shù)式。當(dāng)膽總管結(jié)石取石時造成膽管重大創(chuàng)傷、膽總管多發(fā)結(jié)石或泥沙樣結(jié)石、膽管壁炎癥水腫較重、十二指腸乳頭舒縮功能差時可行T管引流[7]。膽總管切開術(shù)后T管引流可引流膽汁、膽道減壓,通過其觀察膽道發(fā)現(xiàn)潛在的疾病及了解膽道的病理生理變化；行膽道造影、搜集膽汁行細(xì)菌學(xué)檢查；還可通過其處理殘余的結(jié)石；但易并發(fā)水電解質(zhì)紊亂、T管扭轉(zhuǎn)或脫落、膿毒癥、局部疼痛、持續(xù)性的膽瘺、膽道狹窄等并發(fā)癥[8]。因此，術(shù)后是否需要常規(guī)放置T管引流存在爭議。

2.2腹腔鏡膽總管探查術(shù)(LCBDE)一期縫合膽總管探查一期縫合已成為膽總管結(jié)石的一種可行手術(shù)方式。主要適合于膽總管的直徑>7 mm、無膽道狹窄、膽道內(nèi)的結(jié)石已取凈、不合并重度膽管炎等情況[9]。然而隨著其他技術(shù)的發(fā)展，原先不適宜行一期縫合術(shù)的患者，若在其他技術(shù)的配合下，如球囊擴(kuò)張、膽道支架，也可行一期縫合術(shù)。有學(xué)者[10]認(rèn)為，一期縫合膽管壁縫合更為密閉，不易發(fā)生膽汁漏。膽漏與是否行一期縫合無關(guān)，與結(jié)石是否取凈和膽總管直徑有關(guān)[11]。一期縫合術(shù)后恢復(fù)都較好，與T管引流相比，可縮短手術(shù)時間和住院時間；長期隨訪資料表明，一期縫合可降低結(jié)石的復(fù)發(fā)率及膽道狹窄率；因此，LCBDE一期縫合被認(rèn)為是一種安全有效的替代T管引流的方法[12]。

2.3傳統(tǒng)開腹手術(shù)傳統(tǒng)開腹手術(shù)是以開腹切開膽總管取石為主，是腹腔鏡手術(shù)出現(xiàn)前經(jīng)典的手術(shù)方式。其手術(shù)切口較大、創(chuàng)傷較重，手術(shù)時間及住院時間較長，術(shù)后恢復(fù)慢，易并發(fā)切口感染及出血等并發(fā)癥，因此限制了其發(fā)展。但開放手術(shù)可作為其他方式失敗后的最終選擇[13]。

3 內(nèi)鏡治療

3.1內(nèi)鏡下十二指腸乳頭括約肌切開取石術(shù)(endoscopicsphincterotomy,EST) EST是近年來廣泛開展的一項(xiàng)微創(chuàng)技術(shù)，十二指腸乳頭括約肌切開后，大部分膽總管結(jié)石可通過球囊或網(wǎng)籃取出。對于直徑<10 mm的膽總管結(jié)石效果較好[14]。本方法術(shù)后患者創(chuàng)傷小、術(shù)后恢復(fù)迅速、重復(fù)性較好,有效率達(dá)90%[15]。然而,EST 不僅破壞了Oddis 括約肌的功能，還會出現(xiàn)肝膿腫、膽管炎、膽總管結(jié)石復(fù)發(fā)、穿孔性急腹癥、出血、誘發(fā)胰腺炎、乳頭瘢痕狹窄等并發(fā)癥[16-17]。

3.2內(nèi)鏡下乳頭球囊擴(kuò)張術(shù)(endoscopocpapillaryballoondilatation,EPBD) 為了避免EST中的并發(fā)癥，EPBD是一種替代療法。EPBD治療膽總管結(jié)石的成功率與EST接近，術(shù)后膽道并發(fā)癥及結(jié)石殘留率顯著低于EST[18-20]。EPBD保留了十二指腸乳頭括約肌的功能，然而EPBD 所致的胰腺炎及高淀粉酶血癥發(fā)生率比EST高，這仍然是一個潛在的危險[21]。EPBD適用于膽總管結(jié)石直徑<10 mm的治療，年輕患者需要保留Oddis括約肌功能、有出血傾向、十二指腸乳頭旁憩室及畢Ⅱ式胃大部切除術(shù)后[22]。但是對于直徑>10 mm較大的膽總管結(jié)石, EPBD常需要多次取石和機(jī)械碎石, 增加了操作時間和操作難度。

3.3內(nèi)鏡下乳頭大球囊擴(kuò)張術(shù)(endoscopocpapillarylargeballoondilation,EPLBD) EPLBD與EST聯(lián)合治療，EST采用小切口，盡可能地保留了Oddis括約肌功能[23]。對于大的膽總管結(jié)石，特別是復(fù)雜性膽總管結(jié)石是安全有效的[24]?？擅黠@減少碎石取石的頻次，操作時間也明顯縮短，術(shù)后胰腺炎、出血、穿孔等早期并發(fā)癥發(fā)生率較EST 低[25-26]?？勺鳛镋PBD或EST的一種替代療法[27-29]。然而,EPLBD技術(shù)在國內(nèi)開展的比較少，技術(shù)還不是很成熟,限制了它的運(yùn)用。

3.4內(nèi)鏡下鼻膽管引流術(shù)(endoscopocNasobiliarydrainage,ENBD) ENBD是一種暫時性的膽汁引流措施，具有迅速解除膽道梗阻、降低膽道壓力、通暢引流的作用，通過鼻膽管還可進(jìn)行沖洗、注射藥物、造影及膽汁細(xì)菌培養(yǎng)。當(dāng)內(nèi)鏡取石困難仍有結(jié)石殘留、膽管結(jié)石并發(fā)急性膽管炎、復(fù)雜結(jié)石及患者不能耐受手術(shù)時，臨時置入鼻膽管可使膽道減壓，緩解膽管感染的癥狀,通過鼻膽管沖洗可使結(jié)石縮小,為以后內(nèi)鏡取石創(chuàng)造條件。此外，EPBD 后使用ENBD 可以降低胰腺炎的發(fā)生率[30]。但ENBD作為一種外引流措施，長期引流導(dǎo)致膽汁流失、水電解質(zhì)紊亂及營養(yǎng)障礙，還可增加感染的風(fēng)險。一般引流管不宜放置時間過長，1～2周為宜。

3.5內(nèi)鏡下膽道支架放置術(shù)(endoscopicbiliarystentplacement) 內(nèi)鏡下膽道支架放置術(shù)適用于普通內(nèi)鏡無法取出的結(jié)石、結(jié)石取出困難、難治性結(jié)石、巨大的結(jié)石[31-33]。支架對結(jié)石進(jìn)行不斷摩擦，結(jié)石逐漸變小、碎裂甚至消失，結(jié)石本身脆弱及十二指腸乳頭功能的完整都有助于結(jié)石的排出[21]。支架置入還可以預(yù)防膽管炎、解除梗阻、減黃，特別在老年患者中不能耐受長時間手術(shù)時可以作為一種姑息性療法。也有報道[34-35]稱，放置膽道支架的同時,口服熊去氧膽酸治療膽總管巨大結(jié)石,可使結(jié)石顯著縮小。內(nèi)鏡下膽道支架放置術(shù)會出現(xiàn)支架移位或阻塞，此時可更換引流好、內(nèi)徑大的支架。

3.6膽道鏡、腹腔鏡、十二指腸鏡三鏡聯(lián)合治療三鏡聯(lián)合治療適用于膽囊結(jié)石合并膽總管結(jié)石、急性膽源性胰腺炎者、膽總管有不同程度的擴(kuò)張、內(nèi)鏡取石失敗先行ENBD 再行腹腔鏡和膽道鏡聯(lián)合手術(shù)、膽總管結(jié)石合并Oddis 括約肌狹窄者。三鏡聯(lián)合治療膽總管結(jié)石克服了腹腔鏡手術(shù)取石盲區(qū)的缺點(diǎn)，提高治療效果，避免再次手術(shù)的發(fā)生率[36]。具有恢復(fù)快、并發(fā)癥少、微創(chuàng)、縮短術(shù)后康復(fù)時間及住院時間短等特點(diǎn)。但術(shù)后可能也會出現(xiàn)胰腺炎、膽瘺、出血等并發(fā)癥。所以應(yīng)嚴(yán)格把握其適應(yīng)證，由有經(jīng)驗(yàn)的醫(yī)師執(zhí)行此操作，不能一味追求微創(chuàng)而導(dǎo)致嚴(yán)重后果。

3.7內(nèi)鏡下機(jī)械碎石術(shù)(endoscopicmechanicallithotripsy,EML) 當(dāng)膽總管結(jié)石直徑>10 mm，結(jié)石遠(yuǎn)端膽管狹窄、乳頭周圍憩室等原因行EPBD及EST時會導(dǎo)致取石失敗[37]。此種情況可先在內(nèi)鏡下行碎石后再取出結(jié)石。EML簡單易行，取石成功率高。但對于結(jié)石直徑>20 mm、質(zhì)地堅硬者行EML，易并發(fā)網(wǎng)籃斷裂或網(wǎng)籃嵌頓等情況。出現(xiàn)此種情況可行采用體外碎石、液電碎石術(shù)、激光碎石術(shù)、外科手術(shù)等方法進(jìn)行處理[38-39]?？稍谀懙雷幽哥R或SpyGlass直視系統(tǒng)下進(jìn)行液電碎石或激光碎石可避免損傷膽管壁。

4 中西醫(yī)結(jié)合治療

利膽排石湯聯(lián)合纖維十二指腸鏡治療膽總管結(jié)石可以排出十二指腸鏡無法根治的細(xì)小結(jié)石；膽總管結(jié)石通過手術(shù)治療后，由于部分患者術(shù)前肝功能受損術(shù)后可能會出現(xiàn)肝功能恢復(fù)緩慢及黃疸加重，而利膽消黃湯在改善肝功能異常及降膽紅素方面效果顯著。

綜上所述，膽總管結(jié)石的治療方法多種多樣，應(yīng)根據(jù)不同的患者、不同的病因、病程的不同階段采取個體化治療。然而，隨著內(nèi)鏡技術(shù)的不斷發(fā)展，膽總管結(jié)石的治療將趨于微創(chuàng)、低并發(fā)癥、低死亡率及復(fù)發(fā)率。

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Advancesinthetreatmentofcholedocholithiasis

LI Qiang, WANG Zhiwei, CHAI Chen

Department of General Surgery, the First Hospital of Lanzhou University, Lanzhou 730000, China

Choledocholithiasis is a common and frequently occurring disease in clinic. The main treatment methods are endoscopic and surgical treatment. With the development of endoscopic and laparoscopic techniques, the treatment tends to be minimally invasive. The advance in the treatment of chole docholithiasis was reviewed in this article.

Choledocholithiasis； Treatment

李強(qiáng)，主治醫(yī)師，碩士，研究方向：普外科疾病的研究。E-mail: 413857155@qq.com

10.3969/j.issn.1006-5709.2017.12.028

R575

A

1006-5709(2017)12-1436-03

2016-12-19

李 健)