ĐIỀU TRỊ PHẪU THUẬT SỎI TRONG GAN ỐNG MẬT CHỦ KHÔNG GIÃN CÓ SỬ DỤNG NỘI SOI ĐƯỜNG MẬT BẰNG ỐNG SOI MỀM VÀ TÁN SỎI ĐIỆN THỦY LỰC TRONG MỔ

Abstract

Study aim: 1. Evaluate the clinic  and para clinic feature of  hepatholithiasis assocated with non dilated common bile duct. 2. The result of surgical management of hepatolithiasis using intraoperative flexible choledochoscopy and electrohydraulic lythotripsy. Patient and method: +Prospective study. +Time: 2007-2012. -Result: There were 47 patients, female 66,0%, male 34,0%, mean age:44,8 ± 13,7 year (18-70 Y), 70,2% were famer. 38,3% had previous biliary surgery; 19,1% had cholecystectomy; 27,7% had  history of parasitic infestation  and biliary arcariasis. Symptoms: 31,9% had triad of charcot  abdominal pain in right uper quadrant, fever, jaundice; 21,3% had abdominal pain and fever; 17% had  abdominal pain and jaundice, 29,8% had abdominal pain only; 100% had elevation of VSS; Leucocite elevation > 8000/mm3 was 63,9%. Bilirubilemie elevated in 44,7%, GOT elevated in 40,4% and GPT elevated  in 44,55%. Culture of bile fluid positive in 68%. Primary intrahepatic stones  in 85,1%, common bile duct stones and intrahepatic stones in 14,9%. The diameter of common bile duct £ 10mm in 100% (£8mm in 51,0%). Intraoperative choledochscopy via choledochostomy revealed intra hepatic duct stricture in 70,2%, cholangio abscess in 6 patients among them 3 patient had cholangio abscess and hemobilia. Operation performed: 100% choledocholithotomy under flexible cholangioscopy and T tube drainage, partial hepatectomy performed in 25,5% (left lateral segmentectomy in 9 patients, anterior segmentectomy in 1 patient, subsementectomy in 2 patients (SS III, SSVIII). Stones fragmentation by Electrohydrolic lithostripsy (EHL) in 61,7%. + There was no death per and postoperation.  +Complications in 6 patients (12,9%) (one patient had urgent operation due to splenic rupture,portal hypertension), 2 others patients had subphrenic abscess due to biliary fistulas treated by aspiration. one had pancreatitis treated by medicament, 2 others patients had medical treatment. + Cholagiography post operation revealed stones clearances in 51,0%, Residual stones in 49,0%, No residual stones in common bile duct and common hepatic duct. –Conclusion: We conclude that the surgical management of hepatolithiasis with non dilated common bile duct was a challence for biliary surgeon because of difficulty in detection and stones removal that left behind intra hepatic duct stricture associated with cholangio abscess and hemobilia. The combination of hepatic resection and stones fragmentaton by EHL is a effective surgical procedure to obtained satisfactory result.The stone clearance was 51,0%, retained stones was 49,0%.In order to lower the retained stones, it is recommended to  use post operative transhepatic cholangioscopic lithotomy  and Electrohydraulic lithostripsy (EHL)  or via T tube tunnel.