(1) Difficulties in surgical treatment of intrahepatic bile duct stones
Because the pathology of intrahepatic bile duct stones is very complicated, it is another disease different from gallbladder stones in thought and understanding, and intrahepatic bile duct stones can not be treated according to the principles and methods of treating gallbladder stones. Gallbladder stones can be treated by oral or puncture infusion of litholytic drugs, and have achieved certain results at present. At present, there is no ideal litholytic drug for intrahepatic bile duct stones. Gallbladder stones can be completely treated by cholecystectomy, but intrahepatic bile duct stones cannot be widely removed. Adding intrahepatic bile duct stones, the lesions inside and outside the liver are scattered, which often leads to stricture and dilatation of intrahepatic bile ducts. Technically, it is sometimes difficult to treat them completely in one operation. Sometimes patients are in a critical state such as acute cholangitis and shock, and the emergency operation and preoperative situation are unclear or only emergency measures are allowed, leaving liver lesions. Intrahepatic bile duct stones combined with cirrhosis and portal hypertension are very difficult to treat surgically, which often leads to postoperative residual stones and bile duct stenosis. According to domestic statistics, after the operation of intrahepatic bile duct stones, the incidence of residual stones is as high as 40% ~ 70%, and the proportion of residual intrahepatic bile duct stenosis is even greater, so that about 30% cases need bile duct surgery again. Seriously, with the increase of the number of operations, the pathological conditions of many patients are more complicated, and bile duct stenosis is more likely to occur, which requires reoperation. As a result, surgical complications and mortality increased.
(2) Principles of surgical treatment for intrahepatic bile duct stones.
With the improvement of medical practice and the progress of diagnosis and treatment technology, systematic method has improved the understanding of the principles of wholeness, comprehensiveness and dialectics in treating hepatolithiasis. The concepts of imaging examination and three-dimensional imaging of hilar anatomy make it possible to transform traditional extrahepatic surgery into intrahepatic surgery. For the treatment of intrahepatic bile duct stones, the hilum and intrahepatic bile duct are treated by liver surgery technology to achieve good exposure, which forms a relatively complete surgical treatment principle for intrahepatic bile duct stones, that is, removing stones, correcting bile duct stenosis, restoring and establishing the physiological function of bile duct and smooth bile flow, and avoiding and preventing bile duct infection and stone recurrence.
(3) Make preoperative preparations to avoid emergency surgery.
Systematic planning and overall design were carried out according to the treatment principle. For patients with intrahepatic bile duct stones, try not to operate in an emergency, especially if the pathological situation is unclear. We can adopt the method of combining traditional Chinese and western medicine, give appropriate antibiotics, decompress the bile duct through nose, or drain the bile duct through percutaneous liver puncture to correct the imbalance of water, electrolyte and acid-base balance and get through the critical period.
Actively treat all kinds of complications before operation, and clearly diagnose the location of gallstones, the location and degree of bile duct stenosis, the pathological state of bile ducts inside and outside the liver, liver function and general situation. According to the pathological changes and the actual possibility, make a treatment plan and strive for the first operation. If it is a case that has undergone multiple operations, it should be carefully considered and carefully designed as the last operation.
(4) Combined operation and follow-up treatment.
① Combined surgery. The surgical treatment requirements of hepatolithiasis are difficult to be completely solved in one operation with a certain surgical method, and multiple surgical methods must be combined and supplemented to meet the treatment needs. For example, left lobe calculus or left lobe liver fibrosis, liver tissue atrophy, feasible left lobe or left lateral lobe resection; If hilar bile duct stricture is complicated at the same time, hilar bile duct plasty should be performed; Such as bile duct tissue defect, can be repaired with gallbladder flap or round ligament; If the defect is large, it can also be repaired with gastric or jejunal flap with vascular pedicle. As long as there is no stenosis at the lower end of the extrahepatic bile duct, cholangioplasty should be used as far as possible to preserve the functions of the extrahepatic bile duct and the sphincter at the end of the common bile duct.
If there are extensive stones in the left and right lobes of the liver and bile duct stricture in the hilum of the liver, the hepatic duct can be cut upward to expose the 1 ~ 2 grade hepatic duct, so as to relieve the bile duct stricture and take out the stones in the liver.
At present, the ultrasonic lithotriptor directly enters the intrahepatic bile duct for lithotripsy. Because of the TV monitoring, you can reach the 3 ~ 4 grade bile duct for lithotripsy, and suck while crushing. In most cases, stones can be completely removed during operation, and combined with postoperative choledochoscopy treatment, the therapeutic effect of intrahepatic bile duct stones is improved.
Rouxen-Y anastomosis between hilar bile duct or intrahepatic bile duct and jejunum should be performed after the treatment of intrahepatic stones and the relief of bile duct stricture, if extrahepatic bile duct stricture can no longer be used, or if the patient is operated again. It is very important that if the residual lesions in the liver, especially the intrahepatic bile duct stenosis, are not alleviated, cholangioenterostomy below the stenosis will not only not solve the postoperative bile drainage, but will increase the intestinal bile reflux, lead to biliary tract infection or severe cholangitis, or recurrence of stones, which is a common reason for reoperation in clinic.
② Follow-up treatment. That is, intrahepatic or extrahepatic bile duct catheter can be placed during operation, which can be simple catheter or balloon catheter. The location of catheter depends on whether there are residual stones inside and outside the liver, whether there is bile duct stenosis and the function of catheter. Some intrahepatic and extrahepatic bile duct strictures or supporting catheters and balloon catheters in anastomoses need to be preserved for a long time, generally 6 ~ 12 months. For patients who need long-term catheterization, U-tube can be used to reduce bile loss. Intrabiliary catheter can play a variety of roles after operation: drainage of infected bile; Support cholangioenterostomy; Support and dilate bile duct stenosis; Dropping medicine through catheter, diminishing inflammation, stopping bleeding and dissolving stones; Vibrating gravel with audio hydraulic pressure through the conduit; Residual stones or crushed stones were taken out through the catheter sinus with choledochoscope. Through cholangiography with catheter, the pathological situation of bile duct inside and outside the liver was observed, and the next treatment method and whether to remove the catheter were decided. These measures are the continuation and supplement of surgical treatment. Only the combination of combined surgery and follow-up treatment can improve the surgical treatment effect of intrahepatic bile duct stones.
(5) Treatment of several difficult problems of hepatolithiasis.
① Hepatolithiasis with cirrhosis and portal hypertension. Intrahepatic bile duct stones The pathological changes of the liver are mainly the liver tissue around the bile duct and the portal area. With the development of chronic inflammation, liver tissue fibrosis, portal vein cavity narrowing, wall thickening. The causes of portal hypertension are obvious dilatation of hepatic artery, thickening of inner diameter, compression of portal vein blood flow, reduction of reflux bleeding and atrophy of liver tissue. Coupled with recurrent cholangitis and cholangitis, cholestasis, liver cell injury and regeneration, biliary cirrhosis is formed, and portal hypertension develops with the aggravation of the disease. Therefore, portal hypertension in patients with intrahepatic bile duct stones is secondary, which is the result of long-term bile duct obstruction, severe jaundice and cirrhosis. In this kind of patients, in addition to the general portosystemic collateral circulation, there are a large number of venous networks and varicose veins in the extrahepatic biliary tract of the hepatic portal. The biggest difficulty of operation is uncontrollable bleeding during operation, which is also the main reason for the failure of operation. If it is a second operation, it will be more difficult. Treatment principle: For this complex case, we should first strengthen preoperative preparation, control infection, improve liver function, and then operate by stages.
Step 1 Splenectomy plus intestinal shunt to reduce portal vein pressure and prepare for reducing surgical bleeding. The second step is to perform a thorough operation on intrahepatic bile duct stones 3 ~ 6 months after operation according to the situation.
② Reoperation of hepatolithiasis after multiple operations. Cholelithiasis, due to its complicated pathology, high postoperative residual rate and recurrence rate, or improper previous surgical methods, often leads to recurrent suppurative cholangitis, which leads to repeated operations and makes the pathological situation more complicated. When a second operation is needed, it will undoubtedly increase the difficulty of the operation. Besides referring to the related problems of biliary reoperation, the treatment principles mainly pay attention to the following points: First, strengthen the improvement of general conditions before operation, comprehensively analyze the causes of reoperation, focus on solving residual stones and bile duct stenosis, establish or repair unobstructed bile flow, correct the defects of previous operations, improve or establish measures to prevent biliary-intestinal reflux, and reduce postoperative biliary tract infection and stone recurrence. Secondly, it is necessary to choose a suitable surgical approach, expose the deep bile duct of transverse hepatic fissure through the anatomy of hepatic capsule, and sometimes encounter uncontrollable bleeding. When the adhesion and thickening of the liver capsule and the increase of vascular plexus, it should be separated from the outside of the liver capsule as far as possible, electrocoagulation to stop bleeding, careful identification of tissues, avoiding blind clamping, and suture to stop bleeding if necessary. At the same time, it is necessary to consider the liver transposition and the displacement of hepatic portal structure in patients with intrahepatic bile duct stones, and we can separate and find extrahepatic bile duct while puncturing. Thirdly, with intraoperative B-ultrasound and intraoperative angiography, when the hilum is really difficult to dissect, the bile duct can be cut through the liver parenchyma to take stones or drain.
③ Treatment of residual stones in intrahepatic bile duct. There is still stone residue after hepatolithiasis surgery, which is a difficult problem in surgical treatment Despite the continuous improvement of surgical techniques, the incidence of residual stones after hepatolithiasis is still high. According to statistics, there are 4 197 cases of intrahepatic bile duct stones in 9 provinces and cities in China, and the incidence of residual stones is 30.36%. It is reported that the rate of residual stones after operation is as high as 90%.
Treatment principle: actively treat complications caused by residual stones, such as biliary tract infection, liver abscess, obstructive jaundice, etc.
If there is a bile duct catheter after operation, choledochoscope lithotripsy can be performed through the sinus of the catheter 4 ~ 6 weeks after operation. Methods: if there is bile duct stenosis, choledochoscope or balloon catheter dilatation is performed through sinus. Papillary sphincterotomy can also be used to solve the stenosis of the lower end of the common bile duct with duodenoscopy. Be careful and gentle when taking stones under choledochoscope. According to the preoperative diagnosis and bile duct conditions, such as bile duct inflammation, floc, etc., determine the location of residual stones, or enter the intrahepatic bile duct under the guidance of B-ultrasound. For larger stones, you can crush them with a stone crusher first and then clip them out. After removing the intrahepatic bile duct, check the extrahepatic bile duct until the lower end of the common bile duct is open. If you can't clean the stone at once, you can take it many times. Every time the interval is 3 ~ 5 days, in case of postoperative cholangitis, the stones should be removed after the inflammation is controlled. After each stone removal, the catheter should be put back into the bile duct to facilitate drainage and create conditions for stone removal again in the future. For intrahepatic bile duct above grade 4, if choledochoscope can't enter, audio-frequency hydraulic vibration lithotripsy can be used to loosen the surrounding bile duct stones to the thick pipe before lithotomy. Or go to the opening of the bile duct with choledochoscope and enter the distal bile duct with lithotomy forceps to take stones.
The residual stones that are difficult to treat are because the diameter of T tube or intrahepatic catheter is too thin, or the sinus disc of catheter is tortuous, so choledochoscope can't enter. In this case, the guide wire should be introduced into the catheter first, and the thicker catheter should be replaced and gradually expanded every 3 to 5 days, or the guide wire should be introduced into the choledochoscope to take stones. Secondly, the bile duct branch openings of residual stones are narrow, mostly relatively narrow or membranous, which can be directly dilated by choledochoscope. If the stenosis is serious and it is difficult for choledochoscope to expand, it is necessary to enter the guide wire to guide the expansion tube, expand it first, and then use choledochoscope to remove stones later. Furthermore, because the residual stones are located in the posterior branch or caudal branch of the right lobe of the liver, and the opening of the bile duct is angled, it is difficult for choledochoscope to find or enter. In this case, we should refer to B-ultrasound, CT, ERCP and other imaging examinations before operation to study the location of residual stones, enter choledochoscope from sinus, and find the opening of bile duct under B-ultrasound superconductivity. If the opening angle is too small, the choledochoscope can bend sideways and enter the stone extraction.
It is difficult to treat residual stones in patients without bile duct catheter after operation. Therefore, before pulling out the biliary drainage tube after operation, routine cholangiography or choledochoscopy should be performed to confirm that there are no residual stones and bile duct stenosis before pulling out the tube. If residual stones are found without biliary drainage tube, the treatment methods include: taking traditional Chinese medicine for removing stones, which is suitable for patients with cholelithiasis who have no stricture of bile ducts inside and outside the liver, and the stones are not too large (0.5 ~ 1.0 cm) and are located in the common bile duct or the common bile duct.
Shugan Lidan recipe was used, plus electrode tablets, jet vibrator, massage along meridians, acupoint pressing or acupuncture to remove stones. When the gallstones are located in the common bile duct, the gallstones can be taken out through the duodenoscope basket, and if necessary, endoscopic Oddi sphincterotomy (EST) should be performed first. Percutaneous selective bile duct catheterization (SPTCD), through which litholytic agents such as sodium 6- metaphosphate, disodium EDTA, cholic acid, heparin, orange oil and pig bile can be dripped. In this case, the effect of removing residual stones can be improved by combining audio-frequency hydraulic vibration lithotripsy. Percutaneous transhepatic choledochoscopy or oral choledochoscopy with internal support tube was used to treat biliary stricture.