Department of General Surgery, Peking University Third Hospital, Beijing, China.
J Hepatobiliary Pancreat Sci. 2022 Sep;29(9):994-1003. doi: 10.1002/jhbp.1204. Epub 2022 Jul 6.
Bilateral hepatolithiasis is an intractable disease and repeated attacks of acute cholangitis seriously threaten patient health. The surgical approaches evolve along with gradually greater understanding of its pathophysiology.
This is a retrospective cohort study for bilateral hepatolithiasis from January 1958 to December 2018. Before May 1993 (Group A, n = 70), three surgical approaches were adopted: 37 patients with common bile duct exploration (CBDE), 29 with choledochoenterostomy (CE) and four with partial hepatectomy (PH). After June 1993 (Group B, n = 150), 101 patients underwent Oddi sphincter-preserved cholangioplasty with hepatico-subcutaneous stoma (OSPCHS), and 16 with CBDE, 21 with CE, 12 with PH. The perioperative and long-term outcomes were compared.
After 1993, the cholangitis recurrence rate significantly decreased from 49.2% to 20.9%, and the stone recurrence rate from 76.3% to 37.1% (both P < .001). Also, the stone-/cholangitis-free durations were prolonged significantly (median: 50.8 vs 26.4/49.6 vs 16.2 months, both P < .001). Preoperative cholangitis was an independent risk factor for stone recurrence (hazard ratio [HR] = 1.863, P = .018), and residual stone for cholangitis recurrence (HR = 2.838, P < .001). OSPCHS and PH were protective surgical approaches for recurrent stone (CBDE: reference; OSPCHS: HR = .469, P = .016, PH: HR = .219, P = .018) and cholangitis (CBDE: reference; OSPCHS: HR = .421, P = .010, PH: HR = .283, P = .093).
For bilateral hepatolithiasis, the management should focus on hepatobiliary lesion eradication and Oddi sphincter function preservation.
双侧肝胆管结石是一种难治性疾病，反复发作的急性胆管炎严重威胁患者健康。手术方式的演变是随着对其病理生理学认识的不断深入而发展的。
这是一项回顾性队列研究，纳入了 1958 年 1 月至 2018 年 12 月期间的双侧肝胆管结石患者。1993 年 5 月 1 日前（A 组，n=70），采用了三种手术方式：37 例行胆总管探查术（CBDE），29 例行胆肠吻合术（CE），4 例行部分肝切除术（PH）。1993 年 6 月后（B 组，n=150），101 例行Oddi 括约肌保留的胆管成形术联合肝皮下造口术（OSPCHS），16 例行 CBDE，21 例行 CE，12 例行 PH。比较两组患者的围手术期和长期疗效。
1993 年后，胆管炎复发率从 49.2%显著降至 20.9%，结石复发率从 76.3%显著降至 37.1%（均 P < .001）。同时，结石/胆管炎无复发时间显著延长（中位数：50.8 个月比 26.4/49.6 个月比 16.2 个月，均 P < .001）。术前胆管炎是结石复发的独立危险因素（风险比[HR] 1.863，P=0.018），残余结石是胆管炎复发的独立危险因素（HR 2.838，P < .001）。OSPCHS 和 PH 是预防结石复发的保护因素（CBDE 为参照；OSPCHS：HR 0.469，P=0.016，PH：HR 0.219，P=0.018）和胆管炎复发的保护因素（CBDE 为参照；OSPCHS：HR 0.421，P=0.010，PH：HR 0.283，P=0.093）。
对于双侧肝胆管结石，治疗重点应放在肝胆管病变的根治和Oddi 括约肌功能的保留上。
