王 超， 徐 鋒， 劉曉琳， 戴朝六

(中國(guó)醫(yī)科大學(xué)附屬盛京醫(yī)院 肝膽脾外科， 沈陽(yáng) 110004)

隱匿性膽總管結(jié)石診斷與治療的新進(jìn)展

王 超， 徐 鋒， 劉曉琳， 戴朝六

(中國(guó)醫(yī)科大學(xué)附屬盛京醫(yī)院 肝膽脾外科， 沈陽(yáng) 110004)

隱匿性膽總管結(jié)石臨床上無(wú)癥狀，如不及時(shí)診斷和處理，可誘發(fā)膽囊切除術(shù)后不明原因腹痛，或是膽源性胰腺炎、急性膽管炎等嚴(yán)重并發(fā)癥而危及生命。選擇合適的診斷及治療方式可降低術(shù)后并發(fā)癥、節(jié)約醫(yī)療資源并可能減少醫(yī)患糾紛。簡(jiǎn)述了隱匿性膽總管結(jié)石的診斷與治療新進(jìn)展，包括影像學(xué)檢查(腹部超聲、CT、磁共振胰膽管造影、超聲內(nèi)鏡、經(jīng)內(nèi)鏡逆行胰膽管造影、術(shù)中膽道造影、術(shù)中腹腔鏡超聲、膽管腔內(nèi)超聲及術(shù)中膽道鏡)的基本特點(diǎn)和診斷效能，不同治療方式(十二指腸乳頭括約肌切開(kāi)術(shù)、腹腔鏡膽總管探查術(shù)、開(kāi)腹膽總管探查、內(nèi)鏡下球囊擴(kuò)張術(shù)、液電碎石法、體外沖擊波碎石法、結(jié)石溶解法及激光碎石法)的治療效果。指出隱匿性膽總管結(jié)石的診療應(yīng)根據(jù)風(fēng)險(xiǎn)分層區(qū)別對(duì)待。中層以上風(fēng)險(xiǎn)者應(yīng)盡可能完善超聲內(nèi)鏡或磁共振胰膽管造影檢查，其結(jié)果對(duì)術(shù)式的選擇至關(guān)重要。治療方式上應(yīng)根據(jù)實(shí)際條件酌情選擇腹腔鏡膽總管探查術(shù)或經(jīng)內(nèi)鏡逆行胰膽管造影/十二指腸乳頭括約肌切開(kāi)術(shù)。

膽總管結(jié)石； 診斷； 治療； 綜述

膽總管結(jié)石是常見(jiàn)的膽道疾病，約占膽石癥的10%～15%[1]。其中約1/3膽總管結(jié)石臨床上無(wú)癥狀，稱(chēng)之為隱匿性膽總管結(jié)石。隱匿性膽總管結(jié)石如不及時(shí)診斷和處理，可誘發(fā)膽囊切除術(shù)后不明原因腹痛，或是膽源性胰腺炎、急性膽管炎等嚴(yán)重并發(fā)癥而危及生命[2]。目前臨床上常用的影像學(xué)檢查方法包括無(wú)創(chuàng)檢查[如CT、磁共振胰膽管造影(MRCP)、超聲內(nèi)鏡(EUS)]和有創(chuàng)檢查[如經(jīng)內(nèi)鏡逆行胰膽管造影(ERCP)、經(jīng)皮經(jīng)肝膽道造影、術(shù)中膽道造影(intraoperative cholangiography，IOC)]，對(duì)診斷膽總管結(jié)石的敏感度和特異度均有所差異。正確選擇影像學(xué)檢查可以快速準(zhǔn)確地明確診斷，進(jìn)而指導(dǎo)外科醫(yī)生合理地選擇治療手段，避免不必要的創(chuàng)傷。目前臨床實(shí)踐中尚存在因選擇影像學(xué)檢查不規(guī)范而未能及時(shí)發(fā)現(xiàn)隱匿性膽總管結(jié)石，導(dǎo)致術(shù)后發(fā)生并發(fā)癥或醫(yī)療糾紛。本文將就隱匿性膽總管結(jié)石的診斷和治療方案的新進(jìn)展作一簡(jiǎn)要綜述。

1 隱匿性膽總管結(jié)石的診斷

1.1 肝功能指標(biāo) 懷疑隱匿性膽總管結(jié)石者應(yīng)首選血清肝功能檢測(cè)[3]。GGT是診斷膽總管結(jié)石最具敏感性的指標(biāo)[4]，但GGT水平受酒精或藥物影響[5]。在診斷膽總管結(jié)石時(shí)需要排除其他情況導(dǎo)致的化驗(yàn)結(jié)果異常。ALP升高對(duì)診斷膽總管結(jié)石也具有很強(qiáng)的提示性[6]。當(dāng)GGT、血清膽紅素(結(jié)合膽紅素為主)以及ALP升高時(shí)要高度懷疑存在膽總管梗阻[7]。如果出現(xiàn)持續(xù)的肝功能異常需要進(jìn)一步的影像學(xué)檢查。

1.2 腹部超聲 普通的腹部超聲是將高頻聲波轉(zhuǎn)化為圖像的影像學(xué)檢查方法，具有便捷、經(jīng)濟(jì)、無(wú)創(chuàng)、易獲得等優(yōu)點(diǎn)。張皞等[8]報(bào)道，腹部超聲診斷膽總管結(jié)石的敏感度為66.4%，特異度為75%，陽(yáng)性預(yù)測(cè)值為89.2%，陰性預(yù)測(cè)值為41.7%，準(zhǔn)確度為68.5%。Gurusamy等[7]對(duì)5項(xiàng)研究進(jìn)行了Meta分析，發(fā)現(xiàn)腹部超聲診斷膽總管結(jié)石的敏感度為73%，特異度為91%。當(dāng)受胃腸氣體、肥胖等原因干擾時(shí)腹部超聲診斷膽總管結(jié)石的效果不佳，對(duì)于膽總管擴(kuò)張的敏感度為87%[6]。

1.3 計(jì)算機(jī)斷層掃描(CT) CT為診斷腹部疾病的最主要檢查手段，平掃CT診斷膽總管結(jié)石的敏感度為50%～88%[9-10]，特異度為84%～98%[11]。結(jié)石能否于CT顯像取決于結(jié)石的大小及化學(xué)成分。如果結(jié)石直徑小于CT螺距則難以顯像[12]。而膽色素結(jié)石及鈣鹽沉積較多的結(jié)石CT值高，容易顯像[13]。當(dāng)結(jié)石直徑<5 mm時(shí)CT的診斷率會(huì)明顯下降甚至出現(xiàn)假陰性[9-10]。Tseng等[9]認(rèn)為，CT三維構(gòu)建并不能提高膽總管結(jié)石的診斷效能。周占文[14]則認(rèn)為，CT三維構(gòu)建有助于鑒別膽總管下端占位，定性診斷結(jié)石或是腫瘤，其準(zhǔn)確率為89.74%。

1.4 磁共振胰膽管造影(MRCP) MRCP是利用膽汁和胰液中含有的大量自由水，采用重T2加權(quán)技術(shù)成像，獲得膽胰管圖像，具有非侵入性的特點(diǎn)。Polistina等[15]報(bào)道，MRCP診斷膽總管結(jié)石的敏感度為77.4%，特異度為100%，準(zhǔn)確度為80.5%，陽(yáng)性預(yù)測(cè)值為100%，陰性預(yù)測(cè)值為85%。Chen等[16]對(duì)25項(xiàng)研究進(jìn)行了Meta分析，發(fā)現(xiàn)MRCP診斷膽總管結(jié)石的敏感度為90%，特異度為95%。有報(bào)道[17]認(rèn)為使用釓塞酸二鈉可以提高其敏感度和特異度。然而Choi等[18]認(rèn)為，是否使用對(duì)比劑對(duì)其敏感度和特異度沒(méi)有影響。當(dāng)結(jié)石直徑<5 mm，時(shí)MRCP可能難以發(fā)現(xiàn)而出現(xiàn)假陰性結(jié)果，故應(yīng)進(jìn)一步行EUS檢查以明確診斷[10]。

1.5 超聲內(nèi)鏡(EUS) EUS是將超聲傳感器置于十二指腸鏡前端，利用超聲傳感器靠近目標(biāo)器官獲取圖像，能夠最大限度避免腹壁脂肪及胃腸氣體的干擾[19]，其圖像要比普通超聲更加準(zhǔn)確和精細(xì)。EUS目前被認(rèn)為是優(yōu)于MRCP的一種無(wú)創(chuàng)性檢查手段。Giljaca等[20]對(duì)18項(xiàng)研究進(jìn)行了Meta分析，發(fā)現(xiàn)EUS診斷膽總管結(jié)石的敏感度為75%～100%，特異度為85%～100%，總體敏感度為95%，特異度為97%。Lin等[21]報(bào)道，EUS診斷隱匿性膽總管結(jié)石的敏感度為100%，特異度為94.7%，陽(yáng)性預(yù)測(cè)值為91.7%，陰性預(yù)測(cè)值為100%，準(zhǔn)確度為96.7%。EUS對(duì)于診斷直徑<5 mm的結(jié)石依然可以保持較高敏感度，其診斷效能不隨結(jié)石直徑的減小而降低[10]。Petrov等[22]研究認(rèn)為，EUS檢查可減少約2/3不必要的ERCP檢查，從而減小ERCP并發(fā)癥。

1.6 經(jīng)內(nèi)鏡逆行胰膽管造影(ERCP) ERCP是通過(guò)十二指腸鏡將造影劑注入膽總管而成像，目前被譽(yù)為診斷膽總管結(jié)石的金標(biāo)準(zhǔn)[23]。一項(xiàng)Meta分析[24]表明，ERCP診斷膽總管結(jié)石的敏感度為67%～94%，特異度為92%～100%，總體的敏感度為83%，特異度為99%。但是ERCP屬于有創(chuàng)操作，可能發(fā)生急性胰腺炎、急性膽管炎、出血、穿孔等并發(fā)癥，并發(fā)癥發(fā)生率為4%～6%，ERCP相關(guān)病死率為0.1%～0.5%[25]。因此，ERCP現(xiàn)已很少用于診斷目的，多用于內(nèi)鏡下括約肌切開(kāi)取石術(shù)中膽道造影。

1.7 術(shù)中膽道造影(IOC) IOC是指將造影劑通過(guò)膽囊管插入的導(dǎo)管注入膽總管中行術(shù)中透視。Gurusamy等[24]Meta分析顯示，IOC診斷膽總管結(jié)石的敏感度為75%～100%，特異度為96%～100%，總體敏感度和特異度均為99%。IOC無(wú)明確并發(fā)癥，總體來(lái)說(shuō)是安全、可靠的。在腹腔鏡膽囊切除術(shù)(LC)術(shù)中常規(guī)使用IOC可以提高患者的安全性和遠(yuǎn)期療效[26]。由于目前MRCP、EUS和CT應(yīng)用越來(lái)越普及，術(shù)前檢查趨于完善，對(duì)于上述檢查未懷疑膽總管結(jié)石的患者，不常規(guī)行IOC并沒(méi)有發(fā)生因遺漏結(jié)石所導(dǎo)致的并發(fā)癥，且IOC檢查還會(huì)延長(zhǎng)手術(shù)時(shí)間，所以是否應(yīng)常規(guī)行IOC仍然存在爭(zhēng)議。但是對(duì)于既往存在黃疸、胰腺炎病史，肝功能異常，術(shù)前檢查提示膽總管擴(kuò)張，不能除外隱匿性膽總管結(jié)石的患者，應(yīng)行IOC檢查[27]。在偏遠(yuǎn)地區(qū)的醫(yī)療機(jī)構(gòu)，如無(wú)法行ERCP和MRCP檢查，IOC可以作為替代檢查。

1.8 術(shù)中腹腔鏡超聲(intraoperative laparoscopic ultrasonography，IOUS) 目前認(rèn)為，IOUS在某些方面要優(yōu)于IOC。Jamal等[28]Meta分析顯示，IOUS診斷膽總管結(jié)石的敏感度可達(dá)90%，特異度可達(dá)99%，而且IOUS操作時(shí)間短，無(wú)電離輻射，失敗率低，并可根據(jù)術(shù)者需要進(jìn)行反復(fù)操作。行LC尤其是炎癥反復(fù)發(fā)作的患者使用IOUS可以顯著降低術(shù)中因解剖困難所致膽總管損傷和膽汁漏發(fā)生[29]。但其探查胰腺段膽總管結(jié)石的成功率不如IOC(73.8% vs 97.3%)[30]。聯(lián)合使用IOUS和IOC可以彌補(bǔ)各自的不足，提高膽總管結(jié)石診斷的敏感度(92.9%)，最大限度地排查潛在的隱匿性膽總管結(jié)石[30]。

1.9 膽管腔內(nèi)超聲(intraductal ultrasonography，IDUS) IDUS是指通過(guò)十二指腸鏡將微型超聲探頭置于膽總管腔內(nèi)實(shí)施掃查，以獲得高質(zhì)量、實(shí)時(shí)的橫截面圖像，可用于膽總管結(jié)石的診斷，常與十二指腸乳頭括約肌切開(kāi)術(shù)(endoscopic sphincterotomy，EST)聯(lián)合使用[31]。Kim等[32]研究顯示，對(duì)ERCP陰性的可疑膽總管結(jié)石患者行IDUS檢查，其診斷結(jié)石的敏感度、特異度、陽(yáng)性預(yù)測(cè)值和陰性預(yù)測(cè)值分別為100%、93.0%、94.6%和100%，準(zhǔn)確度為96.8%。與傳統(tǒng)ERCP相比，其優(yōu)勢(shì)在于避免了X射線下膽管造影，避免其可能導(dǎo)致的膽管炎或化學(xué)性胰腺炎[31]。

1.10 術(shù)中膽道鏡 術(shù)中膽道鏡有診斷與治療兩種應(yīng)用。應(yīng)用術(shù)中膽道鏡可以直視膽道內(nèi)結(jié)構(gòu)，對(duì)結(jié)石的大小、數(shù)量、位置進(jìn)行明確診斷，也可以對(duì)膽道內(nèi)占位性質(zhì)加以鑒別，必要時(shí)可以留取活組織檢查標(biāo)本。開(kāi)腹或腹腔鏡膽道探查術(shù)中可同時(shí)應(yīng)用膽道鏡進(jìn)行取石。使用術(shù)中膽道鏡探查可將殘余結(jié)石率從30%降至5.7%[33]。膽囊結(jié)石患者合并下列情況應(yīng)注意可能存在隱匿性膽總管結(jié)石，應(yīng)行術(shù)中膽道鏡檢查[34]：(1)既往有高熱、寒戰(zhàn)、黃疸、胰腺炎等病史；(2)肝功能肝酶輕度異常者；(3)膽囊多發(fā)細(xì)小結(jié)石，且術(shù)中發(fā)現(xiàn)膽囊管擴(kuò)張；(4)術(shù)前B超提示膽總管直徑>0.8 cm；(5)術(shù)中發(fā)現(xiàn)膽總管輕度擴(kuò)張。但是對(duì)于合并膽管狹窄和膽管解剖變異者，術(shù)中膽道鏡使用受到限制。

2 膽總管結(jié)石的危險(xiǎn)性分層

Maple等[3]認(rèn)為，多項(xiàng)因素可以預(yù)測(cè)膽總管結(jié)石的存在。極強(qiáng)預(yù)測(cè)因素包括：(1)超聲提示膽總管結(jié)石；(2)臨床出現(xiàn)膽管炎表現(xiàn)；(3)膽紅素>4 mg/dl。較強(qiáng)預(yù)測(cè)因素包括：(1)超聲提示膽總管擴(kuò)張(直徑>6 mm合并膽囊結(jié)石)；(2)膽紅素1.8～4 mg/dl。中等預(yù)測(cè)因素包括：(1)除膽紅素外的其他肝功能指標(biāo)異常；(2)年齡>55歲；(3)臨床表現(xiàn)為膽源性胰腺炎。如果患者存在1個(gè)極強(qiáng)因素或2個(gè)較強(qiáng)因素則認(rèn)為其罹患膽總管結(jié)石的風(fēng)險(xiǎn)較高(>50%)，如不存在上述任何一項(xiàng)預(yù)測(cè)因素，則為低風(fēng)險(xiǎn)(<10%)。其他情況則應(yīng)屬于中等風(fēng)險(xiǎn)(10%～50%)。

3 臨床處理方法

3.1 觀察 隱匿性膽總管結(jié)石往往是由超聲、MRCP等檢查發(fā)現(xiàn)，患者并沒(méi)有諸如腹痛、發(fā)熱、黃疸或肝功能異常等表現(xiàn)。Williams等[35]認(rèn)為，無(wú)論結(jié)石有無(wú)癥狀，均應(yīng)盡可能將結(jié)石取出。Almadi等[25]則認(rèn)為，<3 mm的隱匿性膽總管結(jié)石往往可自行排出，不會(huì)出現(xiàn)臨床癥狀。因此，不需要手術(shù)干預(yù)。Collins等[36]報(bào)道，LC術(shù)中發(fā)現(xiàn)的隱匿性膽總管結(jié)石一般不需要立即處理，可經(jīng)膽囊管留置造影管6周后進(jìn)一步行影像學(xué)評(píng)估, 約1/3的結(jié)石可自行排出。筆者認(rèn)為直徑<3 mm的隱匿性膽總管結(jié)石可暫不處置，定期復(fù)查即可；>3 mm者應(yīng)及時(shí)取出。

3.2 手術(shù)治療 目前臨床上治療隱匿性膽總管結(jié)石的常用方法包括：(1)腹腔鏡膽總管探查術(shù)(laparoscopic common bile duct exploration，LCBDE)；(2)開(kāi)腹膽總管探查術(shù)；(3)ERCP/EST；(4)內(nèi)鏡下球囊擴(kuò)張術(shù)(endoscopic papillary ballon dilation，EPBD)。

LCBDE與傳統(tǒng)開(kāi)腹膽總管探查術(shù)相比，存在如下優(yōu)勢(shì)：(1)手術(shù)創(chuàng)傷小，出血少，術(shù)后恢復(fù)快，胃腸道并發(fā)癥低[37]；(2)術(shù)后疼痛輕，患者可早日下床活動(dòng)，減少肺部感染機(jī)會(huì)[37-38]；(3)術(shù)后切口感染發(fā)生率低[37]；(4)住院時(shí)間短，住院費(fèi)用低[39]。其弊端在于手術(shù)時(shí)間長(zhǎng)，對(duì)手術(shù)技術(shù)要求高[37,39]。

選擇LCBDE所致并發(fā)癥的發(fā)病率及病死率均低于ERCP/EST，分別為7% vs 13.5%與0.19% vs 0.5%[40]。對(duì)于合并膽囊結(jié)石者選擇先ERCP/EST再行LC的方案相對(duì)于LCBDE存在如下弊端[41]：(1)總體住院時(shí)間延長(zhǎng)；(2)膽總管結(jié)石復(fù)發(fā)率更高；(3)并發(fā)癥發(fā)生率更高；(4)成本效益低；(5)非必要的程序步驟過(guò)多；(6)結(jié)石較大時(shí)，EST失敗率高，可達(dá)20%[25]；(7)EST導(dǎo)致Oddi括約肌功能破壞，發(fā)生反流性膽管炎[42]；(8)在等待行LC期間或術(shù)中，膽囊結(jié)石有再次掉入膽總管的可能。而如果先行LC再行ERCP/EST，其并發(fā)癥的發(fā)生率與病死率理論上應(yīng)比先行ERCP/EST再行LC者低。因?yàn)橹挥蠭OC陽(yáng)性者才需要進(jìn)一步ERCP/EST治療。Chang等[43]認(rèn)為，術(shù)后選擇性行ERCP/EST者其平均住院日更短，費(fèi)用更低，能有效地減少ERCP/EST相關(guān)并發(fā)癥。但是一旦ERCP/EST失敗，患者有再次行開(kāi)腹膽道探查取石或LCBDE的風(fēng)險(xiǎn)。若能在LC術(shù)中行ERCP/EST可減少手術(shù)及住院時(shí)間，取得較好效果，但目前大多數(shù)醫(yī)院不具備此條件[44]。張智勇等[45]認(rèn)為，LCBDE治療膽總管結(jié)石的一期治愈率高于ERCP/EST，且并發(fā)癥低于ERCP/EST，既能保留十二指腸乳頭括約肌的生理功能，又可同時(shí)實(shí)施LC處理膽囊病變，在大多數(shù)情況下應(yīng)首先考慮LCBDE。對(duì)于膽源性胰腺炎(伴梗阻性黃疸)、膽道梗阻的患者，需要在48 h內(nèi)解除膽道梗阻，ERCP/EST可快速縮短膽道梗阻的時(shí)間。對(duì)于老年、身體條件較差，不能耐受手術(shù)者，可行ERCP/EST治療，出現(xiàn)遠(yuǎn)期并發(fā)癥如反流性膽管炎的可能性較低。對(duì)于某些微小結(jié)石病例，可直接通過(guò)ERCP取石，而不需要行EST，可以避免乳頭括約肌破壞相關(guān)的并發(fā)癥。

EPBD相對(duì)于EST具有降低術(shù)后出血，保留乳頭括約肌功能等優(yōu)點(diǎn)，更適用于肝硬化、凝血機(jī)制障礙及年輕患者[46]，但其術(shù)后并發(fā)胰腺炎的危險(xiǎn)性更高[47]。目前臨床上行EPBD聯(lián)合乳頭括約肌微切開(kāi)治療較大結(jié)石(直徑>12～15 mm)的病例已經(jīng)被多次報(bào)道[25,48]。

LCBDE分為腹腔鏡經(jīng)膽囊管膽道探查(1aparos-copictranscystic common bile duct exploration，LTCBDE)和膽總管切開(kāi)探查2種途徑。Feng等[49]認(rèn)為，LTCBDE的優(yōu)勢(shì)在于：(1)避免了T管相關(guān)并發(fā)癥；(2)避免膽汁漏相關(guān)并發(fā)癥；(3)避免了膽汁大量流失導(dǎo)致的水電解質(zhì)、酸堿失衡及消化功能紊亂；(4)避免術(shù)后膽道狹窄；(5)術(shù)后結(jié)石復(fù)發(fā)率更低；(6)避免術(shù)后長(zhǎng)期帶管生活不便。當(dāng)結(jié)石直徑<6 mm或膽總管直徑<6～10 mm時(shí)，因LTCBDE成功率高，并發(fā)癥少而應(yīng)優(yōu)先選擇[50]。LTCBDE能否成功受多種因素制約，包括膽管直徑，膽囊管與肝總管成角，結(jié)石的位置、大小、數(shù)量。韓威等[51]總結(jié)了LTCBDE的適應(yīng)證及禁忌證如下：(1)結(jié)石位于膽囊管匯入膽總管部位以下為其適應(yīng)證；(2)結(jié)石位于肝總管為禁忌證，但應(yīng)視實(shí)際情況而定；(3)肝內(nèi)膽管結(jié)石為其絕對(duì)禁忌證；(4)結(jié)石直徑<8～10 mm，數(shù)量<3～10枚為其適應(yīng)證；(5)多發(fā)，較大，鑄型結(jié)石為其絕對(duì)禁忌證；(6)膽囊管扭曲、纖細(xì)、脆弱、閉塞，匯入膽管位置異常為其相對(duì)禁忌證。El-Geidie等[52]報(bào)道，當(dāng)膽總管直徑>10 mm，結(jié)石直徑>10 mm，結(jié)石數(shù)量>4枚或經(jīng)膽囊管探查失敗后均可以嘗試進(jìn)行膽總管切開(kāi)探查。Grubnik等[53]報(bào)道，LCBDE膽總管結(jié)石清除率為94.2%。一項(xiàng)Meta分析[42]顯示，LCBDE對(duì)膽總管結(jié)石的清除率為90.2%。

對(duì)于LC術(shù)中發(fā)現(xiàn)的隱匿性膽總管結(jié)石如何處理，目前學(xué)術(shù)界尚存在爭(zhēng)議。鄧小明等[2]認(rèn)為，隱匿性膽總管結(jié)石患者膽總管往往無(wú)明顯擴(kuò)張，行膽總管切開(kāi)取石一期縫合或留置T管均增加術(shù)后膽漏及膽道狹窄風(fēng)險(xiǎn)。目前術(shù)中行ERCP/EST大多數(shù)醫(yī)院不具備設(shè)備條件。術(shù)后行ERCP/EST一旦失敗，患者存在二次手術(shù)風(fēng)險(xiǎn)。其經(jīng)驗(yàn)為，膽囊管內(nèi)徑>5 mm者，可經(jīng)膽囊管膽道鏡網(wǎng)籃取石。膽總管內(nèi)徑>6 mm、局部炎癥不重、膽囊管開(kāi)口于前壁或右側(cè)壁者，可腹腔鏡行縱向切開(kāi)膽囊管及膽總管2～3 mm，膽道鏡取石。取石順利，膽總管下段無(wú)明顯水腫者一期可吸收線縫合膽囊管及膽總管，否則經(jīng)膽囊管留置造影管后關(guān)閉。膽囊管內(nèi)徑≤5 mm，膽總管內(nèi)徑≤6 mm，術(shù)中一期取石困難者，直接經(jīng)膽囊管留置造影管，待術(shù)后二期行ERCP/EST取石。

3.3 其他治療手段 膽總管結(jié)石的治療方法還包括液電碎石法、體外沖擊波碎石法、結(jié)石溶解法以及激光碎石法。液電碎石法是指利用直流高電壓產(chǎn)生沖擊波通過(guò)液體介質(zhì)碎石，Aljebreen等[54]報(bào)道，液電碎石成功率可達(dá)100%，而且76%的患者只需1次ERCP即可完全清除結(jié)石，該方法我國(guó)臨床應(yīng)用較多。體外沖擊波碎石法是指聲波自體外經(jīng)皮直接作用于膽道，Tandan等[55]報(bào)道，體外沖擊波碎石法可使84.4%患者的膽總管結(jié)石完全清除，12.3%患者的膽總管結(jié)石部分清除，只有3.1%患者清除失敗。其目前多用于ERCP前將較大結(jié)石碎成小塊。溶解法的溶劑有多種，如醚、松節(jié)油、氯仿、肝素鹽水等，這些溶劑毒性副反應(yīng)較小，不會(huì)對(duì)膽道造成明顯刺激。有報(bào)道[56]稱(chēng)將溶解法作為腹腔鏡或內(nèi)鏡膽道手術(shù)的輔助治療可以提高治療效果。激光碎石法是指將激光束聚焦于膽管內(nèi)的結(jié)石，利用其能量碎石。Liu等[57]報(bào)道，激光碎石成功率為90%，可以在膽道鏡直視及X射線監(jiān)視兩種狀態(tài)下進(jìn)行[58]。

4 小結(jié)

目前臨床上對(duì)隱匿性膽總管結(jié)石的術(shù)前診斷主要依靠血液學(xué)結(jié)合腹部超聲、CT、MRCP、EUS等無(wú)創(chuàng)檢查，而MRCP與EUS均有較高的敏感度及特異度，因此，Williams等[35]認(rèn)為其對(duì)診斷膽總管結(jié)石具有高效性。根據(jù)風(fēng)險(xiǎn)分層，低風(fēng)險(xiǎn)患者若存在膽囊結(jié)石可單純行LC治療，術(shù)后注意隨訪患者有無(wú)再次腹痛等癥狀。中級(jí)以上風(fēng)險(xiǎn)患者若無(wú)法行MRCP或EUS檢查，可先行LC+IOC/IOUS，如IOC/IOUS為陽(yáng)性則行LCBDE；若醫(yī)療條件許可，應(yīng)進(jìn)一步行MRCP及 EUS檢查，如為陰性行LC，陽(yáng)性則行LCBDE。隱匿性膽總管結(jié)石的治療方案現(xiàn)無(wú)金標(biāo)準(zhǔn)可言，選擇內(nèi)鏡還是外科手術(shù)治療尚存在一定爭(zhēng)議。雖然目前很多文獻(xiàn)支持首選LCBDE治療，但此術(shù)式需要術(shù)者有較豐富的LC手術(shù)經(jīng)驗(yàn)與嫻熟的腔鏡下縫合技術(shù)，因此術(shù)式的選擇要依據(jù)實(shí)際醫(yī)療資源情況。

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引證本文：WANG C, XU F, LIU XL, et al. Latest advances in diagnosis and treatment of occult common bile duct stones[J]. J Clin Hepatol, 2017, 33(7): 1391-1396. (in Chinese) 王超， 徐鋒， 劉曉琳， 等. 隱匿性膽總管結(jié)石診斷與治療的新進(jìn)展[J]. 臨床肝膽病雜志, 2017, 33(7): 1391-1396.

(本文編輯：王亞南)

Latest advances in diagnosis and treatment of occult common bile duct stones

WANGChao,XUFeng,LIUXiaolin,etal.

(DepartmentofHepatobiliaryandSplenicSurgery,ShengjingHospitalofChinaMedicalUniversity,Shenyang110004,China)

Occult common bile duct stones have no clinical symptoms and if it is not diagnosed or treated in time, it can cause unexplained abdominal pain after cholecystectomy or serious complications such as biliary pancreatitis and acute cholangitis, which may threaten patients′ lives. Proper diagnosis and treatment modalities can reduce postoperative complications, save medical resources, and reduce medical disputes. This article introduces the latest advances in the diagnosis and treatment of occult common bile duct stones, including the features and diagnostic efficacy of imaging examinations (abdominal ultrasound, computed tomography, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, intraoperative laparoscopic ultrasonography, intraductal ultrasonography, and intraoperative choledochoscopy), as well as the effect of treatment modalities (endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE), open common bile duct exploration, endoscopic papillary balloon dilatation, electrohydaulic lithotripsy, extracorporeal shockwave lithotripsy, litholysis, and laser lithotripsy). It is pointed out that the diagnosis and treatment of occult common bile duct stones should be treated differently according to risk stratification. Endoscopic ultrasonography or MRCP should be performed for patients with moderate risks or above, and their results are critical to the choice of surgical procedure. For treatment modality, LCBDE or ERCP/EST should be selected according to patients′ actual conditions.

choledocholithiasis; diagnosis; therapy; review

10.3969/j.issn.1001-5256.2017.07.042

2016-11-21；

2017-02-24。

王超(1989-)，男，主要從事肝膽胰疾病基礎(chǔ)與臨床研究。

徐鋒，電子信箱：xufengsjh@126.com。

R657.42

A

1001-5256(2017)07-1391-06