胆总管结石治疗方法的研究进展

李 强， 汪志伟， 柴 琛

兰州大学第一医院普外三科，甘肃 兰州 730000

胆总管结石治疗方法的研究进展

李 强， 汪志伟， 柴 琛

兰州大学第一医院普外三科，甘肃 兰州 730000

胆总管结石是临床常见病及多发病，主要治疗方法有内镜及手术治疗，随着内镜及腹腔镜技术的发展，其治疗趋于微创化。本文就胆总管结石的治疗方法进展作一概述。

胆总管结石；治疗

胆总管结石是临床较常见的疾病之一，其发生与多种因素有关，在我国约10%的成人患有胆囊结石而其中有20%的患者并发胆总管结石[1-2]。胆总管结石可分为原发性和继发性。65%以上的胆总管结石患者有暴饮暴食、嗜烟酒的表现，50%以上的患者缺乏锻炼[3]。患者主要表现为发热、上腹部疼痛、黄疸、恶心呕吐等症状, 严重影响患者的生活质量[4]。腹腔镜胆囊切除术、术中胆道造影(intaoperative cholangiography,IOC)是目前胆总管结石检测的金标准,腹腔镜超声(laparoscopic ultrasonography,LUS)因其无辐射、操作迅速、成功率高、可重复检查而越来越受到重视[5]。还可通过B超、CT、ERCP、MRCP等检查并结合病史及临床表现即可做出诊断。随着手术、内镜治疗等各种治疗技术的不断发展，对其治疗的方法也越来越多。

1 保守治疗

保守治疗可作为患者的术前准备，胆总管结石患者一般都有胆管炎，这种情况应避免急诊手术，应进行保肝、抗炎、补液、营养及对症治疗，待患者病情平稳可进行手术治疗。较小的胆总管结石(直径≤0.5 cm)可以自行排入肠道[6],从而避免手术。

2 手术治疗

2.1腹腔镜胆总管探查术放置T管引流胆总管探查T管引流是胆总管结石的常规术式。当胆总管结石取石时造成胆管重大创伤、胆总管多发结石或泥沙样结石、胆管壁炎症水肿较重、十二指肠乳头舒缩功能差时可行T管引流[7]。胆总管切开术后T管引流可引流胆汁、胆道减压,通过其观察胆道发现潜在的疾病及了解胆道的病理生理变化；行胆道造影、搜集胆汁行细菌学检查；还可通过其处理残余的结石；但易并发水电解质紊乱、T管扭转或脱落、脓毒症、局部疼痛、持续性的胆瘘、胆道狭窄等并发症[8]。因此，术后是否需要常规放置T管引流存在争议。

2.2腹腔镜胆总管探查术(LCBDE)一期缝合胆总管探查一期缝合已成为胆总管结石的一种可行手术方式。主要适合于胆总管的直径>7 mm、无胆道狭窄、胆道内的结石已取净、不合并重度胆管炎等情况[9]。然而随着其他技术的发展，原先不适宜行一期缝合术的患者，若在其他技术的配合下，如球囊扩张、胆道支架，也可行一期缝合术。有学者[10]认为，一期缝合胆管壁缝合更为密闭，不易发生胆汁漏。胆漏与是否行一期缝合无关，与结石是否取净和胆总管直径有关[11]。一期缝合术后恢复都较好，与T管引流相比，可缩短手术时间和住院时间；长期随访资料表明，一期缝合可降低结石的复发率及胆道狭窄率；因此，LCBDE一期缝合被认为是一种安全有效的替代T管引流的方法[12]。

2.3传统开腹手术传统开腹手术是以开腹切开胆总管取石为主，是腹腔镜手术出现前经典的手术方式。其手术切口较大、创伤较重，手术时间及住院时间较长，术后恢复慢，易并发切口感染及出血等并发症，因此限制了其发展。但开放手术可作为其他方式失败后的最终选择[13]。

3 内镜治疗

3.1内镜下十二指肠乳头括约肌切开取石术(endoscopicsphincterotomy,EST) EST是近年来广泛开展的一项微创技术，十二指肠乳头括约肌切开后，大部分胆总管结石可通过球囊或网篮取出。对于直径<10 mm的胆总管结石效果较好[14]。本方法术后患者创伤小、术后恢复迅速、重复性较好,有效率达90%[15]。然而,EST 不仅破坏了Oddis 括约肌的功能，还会出现肝脓肿、胆管炎、胆总管结石复发、穿孔性急腹症、出血、诱发胰腺炎、乳头瘢痕狭窄等并发症[16-17]。

3.2内镜下乳头球囊扩张术(endoscopocpapillaryballoondilatation,EPBD) 为了避免EST中的并发症，EPBD是一种替代疗法。EPBD治疗胆总管结石的成功率与EST接近，术后胆道并发症及结石残留率显著低于EST[18-20]。EPBD保留了十二指肠乳头括约肌的功能，然而EPBD 所致的胰腺炎及高淀粉酶血症发生率比EST高，这仍然是一个潜在的危险[21]。EPBD适用于胆总管结石直径<10 mm的治疗，年轻患者需要保留Oddis括约肌功能、有出血倾向、十二指肠乳头旁憩室及毕Ⅱ式胃大部切除术后[22]。但是对于直径>10 mm较大的胆总管结石, EPBD常需要多次取石和机械碎石, 增加了操作时间和操作难度。

3.3内镜下乳头大球囊扩张术(endoscopocpapillarylargeballoondilation,EPLBD) EPLBD与EST联合治疗，EST采用小切口，尽可能地保留了Oddis括约肌功能[23]。对于大的胆总管结石，特别是复杂性胆总管结石是安全有效的[24]。可明显减少碎石取石的频次，操作时间也明显缩短，术后胰腺炎、出血、穿孔等早期并发症发生率较EST 低[25-26]。可作为EPBD或EST的一种替代疗法[27-29]。然而,EPLBD技术在国内开展的比较少，技术还不是很成熟,限制了它的运用。

3.4内镜下鼻胆管引流术(endoscopocNasobiliarydrainage,ENBD) ENBD是一种暂时性的胆汁引流措施，具有迅速解除胆道梗阻、降低胆道压力、通畅引流的作用，通过鼻胆管还可进行冲洗、注射药物、造影及胆汁细菌培养。当内镜取石困难仍有结石残留、胆管结石并发急性胆管炎、复杂结石及患者不能耐受手术时，临时置入鼻胆管可使胆道减压，缓解胆管感染的症状,通过鼻胆管冲洗可使结石缩小,为以后内镜取石创造条件。此外，EPBD 后使用ENBD 可以降低胰腺炎的发生率[30]。但ENBD作为一种外引流措施，长期引流导致胆汁流失、水电解质紊乱及营养障碍，还可增加感染的风险。一般引流管不宜放置时间过长，1～2周为宜。

3.5内镜下胆道支架放置术(endoscopicbiliarystentplacement) 内镜下胆道支架放置术适用于普通内镜无法取出的结石、结石取出困难、难治性结石、巨大的结石[31-33]。支架对结石进行不断摩擦，结石逐渐变小、碎裂甚至消失，结石本身脆弱及十二指肠乳头功能的完整都有助于结石的排出[21]。支架置入还可以预防胆管炎、解除梗阻、减黄，特别在老年患者中不能耐受长时间手术时可以作为一种姑息性疗法。也有报道[34-35]称，放置胆道支架的同时,口服熊去氧胆酸治疗胆总管巨大结石,可使结石显著缩小。内镜下胆道支架放置术会出现支架移位或阻塞，此时可更换引流好、内径大的支架。

3.6胆道镜、腹腔镜、十二指肠镜三镜联合治疗三镜联合治疗适用于胆囊结石合并胆总管结石、急性胆源性胰腺炎者、胆总管有不同程度的扩张、内镜取石失败先行ENBD 再行腹腔镜和胆道镜联合手术、胆总管结石合并Oddis 括约肌狭窄者。三镜联合治疗胆总管结石克服了腹腔镜手术取石盲区的缺点，提高治疗效果，避免再次手术的发生率[36]。具有恢复快、并发症少、微创、缩短术后康复时间及住院时间短等特点。但术后可能也会出现胰腺炎、胆瘘、出血等并发症。所以应严格把握其适应证，由有经验的医师执行此操作，不能一味追求微创而导致严重后果。

3.7内镜下机械碎石术(endoscopicmechanicallithotripsy,EML) 当胆总管结石直径>10 mm，结石远端胆管狭窄、乳头周围憩室等原因行EPBD及EST时会导致取石失败[37]。此种情况可先在内镜下行碎石后再取出结石。EML简单易行，取石成功率高。但对于结石直径>20 mm、质地坚硬者行EML，易并发网篮断裂或网篮嵌顿等情况。出现此种情况可行采用体外碎石、液电碎石术、激光碎石术、外科手术等方法进行处理[38-39]。可在胆道子母镜或SpyGlass直视系统下进行液电碎石或激光碎石可避免损伤胆管壁。

4 中西医结合治疗

利胆排石汤联合纤维十二指肠镜治疗胆总管结石可以排出十二指肠镜无法根治的细小结石；胆总管结石通过手术治疗后，由于部分患者术前肝功能受损术后可能会出现肝功能恢复缓慢及黄疸加重，而利胆消黄汤在改善肝功能异常及降胆红素方面效果显著。

综上所述，胆总管结石的治疗方法多种多样，应根据不同的患者、不同的病因、病程的不同阶段采取个体化治疗。然而，随着内镜技术的不断发展，胆总管结石的治疗将趋于微创、低并发症、低死亡率及复发率。

[1] ZHU L, AILI A, ZHANG C, et al. Prevalence of and risk factors for gallstones in Uighur and Han Chinese [J]. World J Gastroenterol, 2014, 20(40): 14942-14949.

[2] HENRIKSEN N A, MORTENSEN J H, SORENSEN L T, et al. The collagen turnover profile is altered in patients with inguinal and incisional hernia [J]. Surgery, 2015, 157(2): 312-321.

[3] YU D W, HONG M Y, HONG S G. Endoscopic treatment of duodenal fistula after incomplete closure of ERCP-related duodenal perforation [J]. World J Gastrointest Endosc, 2014, 6(6): 260-265.

[4] TROENDLE D M, BARTH B A. ERCP can be safely and effectively performed by a pediatric gastroenterologist for choledocholithiasis in a pediatric facility [J]. J Pediatr Gastroenterol Nutr, 2013, 57(5): 655-658.

[5] JAMAL K N, SMITH H, RATNASINGHAM K, et al. Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones [J]. Ann R Coll Surg Engl, 2016, 98(4): 244-249.

[6] LEFEMINE V, MORGAN R J. Spontaneous passage of common bile duct stones in jaundiced patients [J]. Hepatobiliary Pancreat Dis Int, 2011, 10(2): 209-213.

[7] GURUSAMY K S, KOTI R, DAVIDSON B R. T-tube drainage versus primary closure after laparoscopic common bile duct exploration [J]. Cochrane Database Syst Rev, 2013(6): CD005641.

[8] PODDA M, POLIGNANO F M, LUHMANN A, et al. Systematic review with meta-analysis of studies comparing primary duct closure and T-tube drainage after laparoscopic common bile duct exploration for choledocholithiasis [J]. Surg Endosc, 2015, 30(3): 845-861.

[10] DONG Z T, WU G Z, LUO K, et al. Primary closure after laparoscopic common bile duct exploration versus T-tube [J]. J Surg Res, 2014, 189(2): 249-254.

[11] HUA J, LIN S, QIAN D, et al. Primary closure and rate of bile leak following laparoscopic common bile duct exploration via choledochotomy [J]. Dig Surg, 2015, 32(1): 1-8.

[12] DARKAHI B, LILIJEHOLM H, SANDBLOM G. Laparoscopic common bile duct exploration. Nine years’ experience from a single centre [J]. Front Surg, 2016, 3: 23.

[13] RAO V, REDDY M, CHANDRA A, et al. A study of open surgical approach for common bile duct stones [J]. Intern Surg J, 2016, 3(1): 90-95.

[14] JANG H W, LEE K J, JUNG M J, et al. Endoscopic papillary large balloon dilatation alone is safe and effective for the treatment of difficult choledocholithiasis in cases of Billroth Ⅱ gastrectomy: a single center experience [J]. Dig Dis Sci, 2013, 58(6): 1737-1743.

[15] GUPTA N, POREDDY V, AL-KAWAS F. Endoscopy in the management of choledocholithiasis [J]. Curr Gastroenterol Rep, 2008, 10(2): 169-176.

[16] 王蓉, 王富文, 华国安, 等. 内镜下乳头括约肌小切开联合气囊扩张术在胆总管结石治疗中的应用价值[J]. 胃肠病学和肝病学杂志, 2011, 20(2): 185-186.

WANG R, WANG F W, HUA G A, et al. Limited endoscopic sphincterotomy plus balloon dilatation for removing common bile duct stones [J]. Chin J Gastroenterol Hepatol, 2011, 20(2): 185-186.

[17] LANGERTH A, SANDBLOM G, KARLSON B M. Long-term risk for acute pancreatitis, cholangitis, and malignancy more than 15 years after endoscopic sphincterotomy: a population-based study [J]. Endoscopy, 2015, 47(12): 1132-1136.

[18] YASUDA I, FUJITA N, MAGUCHI H, et al. Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones [J]. Gastrointest Endosc, 2010, 72(6): 1185-1191.

[19] Doi S, Yasuda I, Mukai T, et al. Comparison of long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation: a propensity score-based cohort analysis [J]. J Gastroenterol, 2013, 48(9): 1090-1096.

[20] SAKAI Y, TSUYUGUCHI T, SUGIYAMA H, et al. Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones [J]. World J Gastrointest Endosc, 2016, 8(10): 395-401.

[21] UEDA T, KIKUYAMA M, KODAMA Y, et al. Short-term biliary stent placement contributing common bile duct stone disappearance with preservation of duodenal papilla function [J]. Gastroenterol Res Pract, 2016, 2016: 6153893.

[22] CHUNG J W. Riview: Endoscopic papillary balloon dilation for removal of choledocholithiasis: indications, advantages, complications, and long-term follow-up results [J]. Gut Liver, 2011, 5(1): 1-14.

[23] 李鸿. 胆总管结石的内镜治疗进展[J]. 胃肠病学和肝病学杂志, 2014, 23(4): 385-387.

LI H. Progress of endoscopic treatment of choledocholithiasis [J]. Chin J Gastroenterol Hepatol, 2014, 23(4): 385-387.

[24] YANG X M, HU B, PAN Y M, et al. Endoscopic papillary large-balloon dilation following limited sphincterotomy for the removal of refractory bile duct stones: experience of 169 cases in a single Chinese center [J]. J Dig Dis, 2013, 14(3): 125-131.

[25] ROSA B, MOUTINHO RIBEIRO P, REBELO A, et al. Endoscopic papillary balloon dilation after sphincterotomy for difficult choledocholithiasis: A case-controlled study [J]. World J Gastrointest Endosc, 2013, 5(5): 211-218.

[26] YANG X M, HU B, PAN Y M, et al. Endoscopic papillary large-balloon dilation following limited sphincterotomy for the removal of refractory bile duct stones: experience of 169 cases in a single Chinese center [J]. J Dig Dis, 2013, 14(3): 125-131.

[27] HWANG J C, KIM J H, LIM S G, et al. Endoscopic large-balloon dilation alone versus endoscopic sphincterotomy plus large-balloon dilation for the treatment of large bile duct stones [J]. BMC Gastroenterol, 2013, 13: 15.

[28] MU H, GAO J, KONG Q, et al. Prognostic factors and postoperative recurrence of calculus following small-incision sphincterotomy with papillary balloon dilation for the treatment of intractable choledocholithiasis: a 72-month follow-up study [J]. Dig Dis Sci, 2015, 60(7): 2144-2149.

[29] MINAMI A, HIROSE S, NOMOTO T, et al. Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy [J]. World J Gastroenterol, 2007, 13(15): 2179-2182.

[30] SATO D, SHIBAHARA T, MIYAZALI K, et al. Efficacy of endoscopic nasobiliary drainage for the prevention of pancreatitis after papillary balloon dilatation: a pilot study [J]. Pancreas, 2005, 31(1): 93-97.

[31] HORIUCHI A, NAKAYAMA Y, KAJIYAMA M, et al. Biliary stenting in the management of large or multiple common bile duct stones [J]. Gastrointest Endosc, 2010, 71(7): 1200-1203, e2.

[32] FAN Z, HAWES R, LAWRENCE C, et al. Analysis of plastic stents in the treatment of large common bile duct stones in 45 patients [J]. Dig Endosc, 2011, 23(1): 86-90.

[33] SLATTERY E, KALE V, ANWAR W, et al. Role of long-term biliary stenting in choledocholithiasis [J]. Dig Endosc, 2013, 25(4): 440-443.

[34] HAN J, MOON J H, KOO H C, et al. Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study [J]. Am J Gastroenterol, 2009, 104(10): 2418-2421.

[35] CHENG C L, TSOU Y K, LIN C H, et al. Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography [J]. World J Gastroenterol, 2012, 18(19): 2396-2401.

[36] MATIN S F, GILL I S, WORLEY S, et al. Outcome of laparoscopic radical and open partial nephrectomy for the sporadic 4 cm. or less renal tumor with a normal contralateral kidney[J]. J Urol, 2002, 168(4): 1356-1360.

[37] ROSENKRANZ L, PATEL S N. Endoscopic retrograde cholangiopancreatography for stone burden in the bile and pancreatic ducts [J]. Gastrointest Endosc Clin N Am, 2012, 22(3): 435-450.

[38] TANAKA K, YASUDA K, UNO K, et al. Case report: trouble-shooting for difficult cases of common bile duct stones with endoscopictreatment [J]. Digestive Endoscopy, 2010, 22(Suppl 1): S114-S117.

[39] SHIM C S. How should biliary stones be managed? [J]. Gut Liver, 2010, 4(2): 161-172.

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

李强，主治医师，硕士，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)