Cắt gan và xẻ gan điều trị sỏi trong gan: Đặc điểm, chỉ định và kết quả

Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> 61 CAÉT GAN VAØ XEÛ GAN ÑIEÀU TRÒ SOÛI TRONG GAN:<br /> ÑAËC ÑIEÅM, CHÆ ÑÒNH VAØ KEÁT QUAÛ<br /> Vaên Taàn*, Nguyeãn Cao Cöông* vaø coäng söï<br /> <br /> TOÙM TAÉT<br /> Ñaët vaán ñeà: Soûi trong gan laø beänh thöôøng gaëp ôû caùc nöôùc Ñoâng Nam AÙ. ÔÛ Vieät Nam, taïi beänh vieän VieätÑöùc, trong 22 naêm (1976-1998), coù 536 tröôøng hôïp soûi trong gan ñôn thuaàn, chieám 10% trong toång soá soûi maät<br /> trong cuøng thôøi gian. Taïi beänh vieän Bình Daân, trong 8 naêm (1995-2002), chuùng toâi ñaõ ñieàu trò noäi truù cho 1052<br /> tröôøng hôïp soûi trong gan, chieám tæ leä 13%.Ñieàu trò trieät ñeå soûi trong gan raát khoù, nhaát laø ngöøa taùi phaùt.<br /> Muïc tieâu: Nghieân cöùu cuûa chuùng toâi nhaèm: 1- Khaûo saùt nhöõng ñaëc ñieåm cuûa nhoùm beänh caét gan hay xeû<br /> gan ñeå laáy soûi. 2- Ñöa ra nhöõng chæ ñònh caét gan hay xeû gan phoái hôïp ñeå laáy soûi, 3- Bieát ñöôïc keát quaû ñieàu trò.<br /> Ñoái töôïng vaø Phöông phaùp: Hoài cöùu caùc beänh nhaân bò soûi trong gan phaûi caét gan hay xeû gan hay phoái<br /> hôïp caû hai, ñeå laáy soûi trieät ñeå töø ñaàu naêm 1995 ñeán heát naêm 2002 taïi beänh vieän Bình Daân. Ñònh beänh soûi gan<br /> tröôùc moå cuûa chuùng toâi haâu heát döïa treân sieâu aâm sau khi beänh nhaân coù trieäu chöùng taéc maät-nhieãm truøng.<br /> Chuùng toâi truy taàm soûi trong luùc moå vaø kieåm tra ñöôøng maät trong vaø sau moå nhôø thaùm saùt ñöôøng maät qua OMC<br /> baèng ngoùn tay, baèng duïng cuï, baèng chuïp hình coù caûn quang, baèng soi ñöôøng maät vaø baèng sieâu aâm tröïc tieáp.<br /> Keát quaû: Chuùng toâi hoài cöùu ñöôïc 236 tröôøng hôïp, goàm 189 tröôøng hôïp caét gan vaø 47 tröôøng hôïp xeû gan<br /> trong ñoù coù 31 tröôøng hôïp vöøa caét gan vöøa xeû gan keát hôïp vôùi taùn soûi qua noäi soi ñeå laáy soûi. 1- Ñaëc ñieåm: 64<br /> nam vaø 125 nöõ, tuoåi trung bình cuûa nhoùm caét gan laø 41, cuûa nhoùm xeû gan laø 48. 40% tröôøng hôïp cö truù taïi<br /> thaønh phoá Hoà Chí Minh. Ña soá laøm ngheà noâng-ngö hay thôï thuû coâng vôùi ñôøi soáng töông ñoái thaáp. Haàu heát nhaäp<br /> vieän vì ñau haï söôøn phaûi hay thöôïng vò maø ña soá coù keøm soát-ôùn laïnh vaø oùi. Tam chöùng Charcot ñaày ñuû khi<br /> nhaäp vieän chæ coù 1/3 vaø coù 2 tröôøng hôïp bò soác nhieãm truøng khi nhaäp vieän. Hôn 2/3 tröôøng hôïp coù tieàn caên ñau<br /> haï söôøn phaûi, soát-ôùn laïnh töøng ñôït trong nhieàu thaùng hay thaäm chí trong nhieàu naêm maø 52 tröôøng hôïp ñaõ moå<br /> soûi ñöôøng maät töø 1 ñeán 6 laàn. 81% coù soûi phoái hôïp vôùi soûi ñöôøng maät ngoaøi gan vaø 13% coù phoái vôùi soûi tuùi maät.<br /> Chæ coù soûi trong gan traùi laø 15%, chæ soûi trong gan phaûi laø 1% vaøø chæ coù soûi trong caû gan phaûi laãn traùi laø 3%. Soûi<br /> trong gan traùi thöôøng naèm trong nhöõng ñöôøng maät giaûn lôùn, coù dòch maät nhieãm truøng, coù khi laø muû thaät söï maø<br /> chuùng toâi xem nhö nhöõng apxe, nhoùm naày chieám 20%. Moâ gan thöôøng bò toån thöông naëng, xô hoùa vaø laøm thuøy<br /> gan co ruùt thaønh nhöõng tuùi soûi. Nhöõng caây soûi ñi töø ñöôøng maät ngoaøi gan vaøo taän caùc nhaùnh gan haï phaân thuøy<br /> hay nhöõng xaùc laûi cuõng ñöôïc tìm thaáy ôû 4 tröôøng hôïp. ÔÛ 4 tröôøng hôïp khaùc, coù nang ñöôøng maät trong gan vôùi<br /> soûi vaø muû, 2 tröôøng hôïp coù nhöõng khoái u aùc tính cuûa ñöôøng maät trong gan, 1 tröôøng hôïp coù u teá baøo gan vaø 2<br /> tröôøng hôïp coù u ñöôøng maät ngoaøi gan maø 1 laø cuûa tuùi maät vaø 1 laø cuûa oáng gan chung. 2- Phaãu thuaät vaø keát<br /> quaû: Trong soá caét gan traùi phoái hôïp vôùi xeû gan giöõa ñeå laáy soûi coù 1 tröôøng hôïp bò suy gan, gaây töû vong ôû ngaøy<br /> thöù 30. Töû vong phaãu thuaät laø 0.53% vaø bieán chöùng phaãu thuaät laø 17%. Caùc bieán chöùng thöôøng gaëp laø nhieãm<br /> truøng veát moå, doø maät, xuaát huyeát maët caét gan, apxe toàn löu döôùi gan. Thôøi gian naèm vieän trung bình sau moå laø<br /> 12 ngaøy. Vôùi nhöõng kyõ thuaät truy taàm treân, tæ leä soûi toàn löu vì khoâng laáy ñöôïc laø 6% vaø soûi soùt laø 3%. Ña soá soûi<br /> coøn laïi ñeàu döôùi 5 ly vaø naèm saâu trong gan phaûi hoaëc gan giöõa. chuùng toâi ñaõ noái maät ruoät vaø taïo hình cô voøng<br /> Oddi cho 14 tröôøng hôïp soûi khoâng laáy heát hay ñöôøng maät heïp. Trong theo doõi trung haïn (12 thaùng), coù 3 tröôøng<br /> hôïp vieâm ñöôøng maät do soûi töø gan di chuyeån xuoáng maø moät nhôø ERCP laáy ñöôïc, coøn 2, phaûi moå ñeå laáy soûi<br /> trong oáng gan.<br /> * Beänh vieän Bình Daân TP. Hoà Chí Minh<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> 403<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> Baøn luaän: Tæ leä soûi trong gan ôû nöôùc ta khaù cao maø ña soá coù keát hôïp vôùi soûi ñöôøng maät ngoaøi gan. Soûi trong<br /> gan traùi chieám tæ leä cao hôn gan phaûi raát nhieàu. Ñieàu trò trieät ñeå soûi trong gan thöôøng raát khoù vôùi nhöõng phöông<br /> phaùp coå ñieån. Ngay caû vôùi nhöõng phöông tieän hieän ñaïi nhö phaãu thuaät hay thuû thuaät keát hôïp vôùi taùn soûi, laáy soûi<br /> baèng roï cuõng coøn ñeå soùt soûi vôùi moät tæ leä khaù cao. Xeû gan ñeå laáy soûi vaø taïo hình ñöôøng maät trong gan keát hôïp<br /> vôùi caùc thuû thuaät khaùc laø nhöõng bieän phaùp tích cöïc ñeå laáy soûi trieät ñeã, chæ ñònh cho caùc tröôøng hôïp soûi lôùn, soûi<br /> nhieàu naèm trong caùc oáng maät ôû moät haï phaân thuøy hay 1 thuøy gan khoâng theå naøo laáy saïch ñöôïc qua OMC, ñaëc<br /> bieät laø trong caùc oáng gan giaûn töøng ñoaïn maø moâ gan coøn toát. Caét boû moät phaàn gan ñöôïc chæ ñònh tuyeät ñoái cho<br /> caùc tröôøng hôïp soûi naèm laâu trong ñöôøng maät trong gan ñaõ gaây nhieãm truøng kinh nieân, phaù huõy moâ gan vôùi<br /> ñöôøng maät giaûn roäng ñaõ bieán thaønh nhöõng tuùi soûi naèm trong muû vaø caùc tröôøng hôïp soûi trong caùc oáng maät raát<br /> nhoû hay trong nhu moâ gan cuõng nhö trong caùc tröôøng hôïp coù nang ñöôøng maät hay nghi ngôø ung thö ñöôøng<br /> maät trong gan. Caét gan cuõng coù theå phoái hôïp vôùi xeû gan, maø ñöôøng xeû hoaëc theo oáng gan hôû ra sau khi caét,<br /> hoaëc qua moät hay nhieàu ñöôøng tröïc tieáp khaùc ñeå laáy soûi trieät ñeã. Tuy ñaõ coá gaéng moå ñeå laáy soûi trong gan nhö<br /> vaäy, tæ leä soûi khoâng laáy ñöôïc vaø soûi soùt cuûa chuùng toâi vaãn coøn 9%, ñaëc bieät laø soûi nhoû döôùi 5 ly, naêm saâu trong<br /> gan phaûi. Tæ leä naày töông ñoái thaáp so vôùi toaøn nhoùm moå chöông trình vôùi nhieàu phöông phaùp khaùc nhau laø<br /> 20%, Chuùng toâi chöa theo doõi ñuû thôøi gian ñeå bieát tæ leä soûi taùi phaùt trong gan thaät söï laø bao nhieâu. Ngoaøi vaán ñeà<br /> soùi soûi, soûi taùi phaùt laø vaán ñeà maø nhieàu taùc giaû raát quan taâm vaø ñaõ ñeà nghò nhieàu phöông phaùp phaãu thuaät<br /> phoøng ngöøa cuõng nhö ñieàu trò, nhaát laø ôû caùc tröôøng hôïp coù giaõn vaø heïp ñöôøng maät trong gan.<br /> Keát luaän: Soûi trong gan laø moät beänh lyù ñaëc thuø cuûa nöôùc Vieät Nam, ñieàu trò trieät ñeå khoù. Caét boû moät phaàn<br /> gan hay xeû gan ñeå laáy soûi vaø taïo hình ñöôøng maät ñöôïc chæ ñònh cho gaàn 1/4 tröôøng hôïp trong nhoùm beänh soûi<br /> trong gan cuûa chuùng toâi. Nhôø phoái hôïp caét gan hay xeû gan ñeå laáy soûi, tæ leä coøn soûi trong gan trong nhoùm beänh<br /> naày ñaõ haï thaáp, ñaëc bieät chæ coøn soûi nhoû.<br /> <br /> ABSTRACT<br /> PARTIAL HEPATECTOMIES OR HEPATOTOMIES TO TREAT THE INTRAHEPATIC<br /> STONES (IHS): PATIENTS CHARACTERISTICS, INDICATIONS AND RESULTS<br /> Van Tan, Nguyen Cao Cuong et al * Y Hoc TP. Ho Chi Minh * Vol. 8 * Supplement of No 1 * 2004:<br /> 403 - 411<br /> <br /> Background: IHS are a special pathology of the Asian countries. It ‘s a disease difficult to cure. The rate of<br /> residual or retained stones after operation are over 20% in many studies. Many researches have focused on<br /> the etiology, the treatment and the recurrence of IHS. In Viet Nam, in 1970’s decade, Ton That Tung had a<br /> report dealing about the treatment of this disease with partial hepatectomies, illustrated in the French surgical<br /> paper before 1979. Dang Kim Son, his succedor have also a new report, appeared in French surgical paper on<br /> 1998. Many other studies are aiming to treat radically and to prevent the IHS appeared in the medical papers<br /> since 1995. On 2000, we have had a report of 628 IHS in the Vietnamese Surgical Association Annual<br /> Congress.<br /> Purpose and Method: We study the IHS patients treated at Binh Dan hospital with partial hepatectomies<br /> or with hepatotomies or combined both procedures from 1995 to 2002 to show and to discuss about the patients<br /> characteristics, the surgical indications, and the results. From 1995 to 2002, there are 1052 cases of IHS<br /> admitted in our hospital. Among them, we have performed 189 partial hepatectomies, 46 hepatotomies and in<br /> 41 both procedures are applied, in some cases an endoscopic lithotripsy is required. The preoperative<br /> diagnosis based on the clinical picture, ie bile stasis and infections, and on the ultrasound. Per-operatively, at<br /> <br /> 404<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> first by the choledochotomy we use the finger and the bile duct instruments to extract and to control the<br /> residual stones. For difficult cases, a cholangiography, a choledoscopy or an US are required. In postoperative<br /> period for affirming the BD is free of stones, a cholangiogram (in cases that T tube presented) or an US are<br /> used and an ERCP are required now and then.<br /> Results:.The male/female ratio is 0.56; the middle age is 40 for male and 48 for female. 60% of patients<br /> came to hospital from the provinces and almost of them are poor farmers. 72% of cases, admitted because of<br /> RUQ or epigastric pain, chill-fever and nausea. 25% have had Charcot triad with 1% in shock state. 50% have<br /> had a past history of a biliary infection now and then and 26% have been operated for biliary stones at least<br /> one time. 81% of IHS were associated with EHS and 13% of them, there are also gallbladder stones. 66% of<br /> stones are found in the left liver, 2.5%, in the right liver and 32%, in the left and right liver. Almost of the IHS<br /> are brown pigment stones. Intrahepatic BD dilatations were observed in almost of cases with infected bile even<br /> with pus that we consider as abscesses in 20% of cases. Another lesions are intrahepatic biliary cysts with<br /> stones in 4 cases, neoplasic biliary duct with stones in 3 cases. Operative complications are 20% that wound<br /> infections, bile leakage, bleeding and subhepatic abscesses are often seen. Operative death is 0.42%, in only 1<br /> case due to liver failure. The median operative time is 90 minutes, the median blood loss, 200 ml and there are<br /> only 3 cases that must be transfused. The median time of hospital stay in post-op is 12 days. 6% retained<br /> stones and 3% residual stones were observed before discharging. Almost of these stones were small (< 5 mm<br /> in diameter). In cases of the stones known but couldn’t be removed because difficult to avoid severe liver<br /> injuries, we use endoscopic lithotrisy or perform a biliary-digestive anastomosis or a sphincteroplasty. In<br /> median term follow-up (12 months), there are 3 cases: in 1 case the stones stuck in the Oddi, then removed<br /> successfully by ERCP and 2 cases, in the hepatic duct, must be reoperated.<br /> Discussion: The rate of IHS in our country is high, more than 50% in the North and 15% in the South.<br /> Almost of them are in the left liver. It is very difficult to remove all IHS, even with the advanced techniques as<br /> direct intraductal lithotripsy. It is also more difficult to prevent recurrent stones, especially in cases there are<br /> segmental dilatation and stenosis of intrahepatic BD. Hepatotomies for removing the stones and for repairing<br /> the abnormal bile ducts can keep the patency of the BD and can prevent the stones to recur. Partial<br /> hepatectomies for removing a segment or a lobe of sclerotic liver, shrinked around the diltated bile ducts with<br /> multiple stones, with hepatic abscess or in cases of neoplasic duct beeing suggested. Partial hepatectomies are<br /> also indicated in cases of multiple cysts of the intrahepatic duct as in Caroli disease.<br /> Conclusion: Intrahepatic stones are a special disease of our country that the treatment and the prevention<br /> are big problems. Partial hepatectomies, hepatotomies or both are applied in almost 22% of cases, in our study<br /> we have the good results in 91% in middle term followed-up.<br /> IHS is a special disease of the South-East Asian<br /> countries. Its incidence varied from 15% to 50% of<br /> the BD stones according to the countries and to the<br /> regions of one country. In Viet Nam, Do Kim Son(2)<br /> have had a report of 536 patients of IHS at VietDuc<br /> hospital (North of VN) during 22 years (1976-1998),<br /> Van Tan(1), a same report of 628 cases at Bình Dân<br /> hospital (South of VN) during 5 years (1995-1999). It<br /> is a disease difficult to treat, although many<br /> therapeutic modalities were applied.<br /> <br /> Hepatectomy, hepatotomy or both are good<br /> radical ways to cure the IHS in selective cases. In Viet<br /> Nam, Do Kim Son(5), Van Tan(2,24,31,32), Tran Quyet<br /> Tien(3), Doan Thanh Tung(4) have had many studies<br /> aiming to treat and to prevent the IHS in the recent<br /> years. Many other new studies in the world aiming to<br /> treat radically the IHS and to prevent their recurrence<br /> appeared<br /> in<br /> the<br /> different<br /> medical<br /> (6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,23)<br /> .<br /> papers<br /> Purpose: The study is aim to analyse the patient<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> 405<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> <br /> charts of IHS in our hospital for finding the patients<br /> characteristics, the indications and the results of<br /> hepatectomies and of hepatotomies, then deducing a<br /> recommandation.<br /> <br /> MATERIALS AND METHOD<br /> A retrospective study of all patients having had a<br /> hepatectomy, a hepatotomy or combined procedures<br /> for radical treatment of the IHS from 1995 to 2002 in<br /> a hospital of the South of Viet Nam. 236 charts are<br /> found and studies. As surgical procedures, there are<br /> 189 hepatectomies, 46 hepatotomies, among them<br /> 41, both procedures are applied on the same time in a<br /> patient.<br /> In 95% of patients. a choledochotomy is needed.<br /> Peroperatively, the finger and the BD exploration<br /> equipment are used to break, to extract and to control<br /> the residual stones. For difficult cases, a<br /> cholangiography, an US or a choledoscope with an<br /> lithotryptor are required. In postoperative period for<br /> affirming the BD is free of stones, a cholangiogram<br /> (in cases that T tube presented) or an US are used<br /> and an ERCP are required to extract the suspected<br /> stones in the accessible BD. An endoscopic-lithotripsy<br /> is required to remove the retained stones either<br /> through the T tube tract or a new percutaneous<br /> transhepatic tract.<br /> <br /> Patient characteristics<br /> About age and sex, the male/female is 0.56 with<br /> middle age 40 for male and 46 for female<br /> Table 1<br /> Male<br /> 4<br /> 53<br /> 28<br /> 85<br /> <br /> Female<br /> 5<br /> 77<br /> 69<br /> 151<br /> <br /> Total<br /> 9<br /> 130<br /> 97<br /> 236<br /> <br /> For geographic distribution, majority of patients<br /> came to us from the provinces of the South and of the<br /> Center of Viet Nam<br /> <br /> 406<br /> <br /> Geographic distribution<br /> Ho Chi Minh city<br /> East and Center of VN<br /> West of VN<br /> North of VN<br /> Total<br /> <br /> %<br /> 40<br /> 34<br /> 23<br /> 3<br /> 100<br /> <br /> For occupations, 90% of them are farmers or<br /> workers that 71% lived in low socio-economic level<br /> and poor hygien conditions. The main clinical<br /> manifestations are cholangitis<br /> Table 3<br /> Clinical picture<br /> Subcostal or epigastric pain and fever<br /> Charcot triad<br /> Septic shock<br /> Prehistory of (R) subcostal or epigastric<br /> pain, shaking chill<br /> Past history of biliary surgery 1 to 6 times<br /> <br /> Cases<br /> 170<br /> 59<br /> 4<br /> 117<br /> <br /> %<br /> 72<br /> 25<br /> 1<br /> 50<br /> <br /> 61<br /> <br /> 26<br /> <br /> The blood type B seems higher than the others in<br /> normal range<br /> Table 4<br /> Blood type<br /> Cases<br /> %<br /> <br /> A<br /> .36<br /> 15<br /> <br /> B<br /> 72<br /> 30<br /> <br /> AB<br /> 17 111<br /> 7.2<br /> <br /> O<br /> 236<br /> 47<br /> <br /> Total<br /> 100<br /> <br /> 65 % of patients have had acute or subacute<br /> infection with WBC more than 8000/m3<br /> Table 5<br /> WBC<br /> Cases<br /> %<br /> <br /> RESULTS<br /> <br /> Age<br /> < 20<br /> 20 - 50<br /> > 50<br /> Total<br /> <br /> Table 2<br /> <br /> < 8000<br /> 84<br /> 35<br /> <br /> 8-10000<br /> 63<br /> 27<br /> <br /> >10000<br /> 89<br /> 38<br /> <br /> Total<br /> 236<br /> 100<br /> <br /> The liver function is more or less influenced by<br /> IHS and EHS: bile retention, hepatic cells necrosis so<br /> serum albumin dropped but coagulation function still<br /> normal.<br /> Table 6<br /> Bilirubine<br /> Cases<br /> %<br /> SGPT<br /> Cases<br /> %<br /> Albumin<br /> Cases<br /> %<br /> <br /> < 1.2<br /> 31<br /> 21<br /> < 50<br /> 58<br /> 40<br /> < 25<br /> 3<br /> 4<br /> <br /> 1.2-2.4<br /> 28<br /> 19<br /> 50-100<br /> 48<br /> 33<br /> 25-30<br /> 13<br /> 17<br /> <br /> > 2.4<br /> 87<br /> 60<br /> > 100<br /> 40<br /> 27<br /> > 30<br /> 61<br /> 79<br /> <br /> Total<br /> 146<br /> 100<br /> Total<br /> 146<br /> 100<br /> Total<br /> 77<br /> 100<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> Y Hoïc TP. Hoà Chí Minh * Taäp 8 * Phuï baûn cuûa Soá 1 * 2004<br /> TQ, TCK: No abnormal In majority of cases.<br /> HBsAg + in 10% of patients.<br /> The renal and the endocrinologic pancreatic<br /> functions seem not altered.<br /> Table 7<br /> Blood urea<br /> Cases<br /> %<br /> Glycemia g/l<br /> Cases<br /> %<br /> <br /> < 0.25<br /> 47<br /> 29<br /> < 1.4<br /> 140<br /> 98<br /> <br /> 0.25 - 0.50<br /> 109<br /> 68<br /> 1.4-2<br /> 3<br /> 2<br /> <br /> > 0.50<br /> 4<br /> 3<br /> >2<br /> 0<br /> 0<br /> <br /> TS<br /> 160<br /> 100<br /> Total<br /> 143<br /> 100<br /> <br /> The majority of patients having had a hematocrit<br /> over 30%<br /> Table 8<br /> Hematocrit %<br /> Cases<br /> %<br /> <br /> < 25<br /> 1<br /> 0,5<br /> <br /> 25-30<br /> 8<br /> 4.3<br /> <br /> > 30<br /> 177<br /> 95<br /> <br /> Total<br /> 186<br /> 100<br /> <br /> 66% of the IHS are found in the left liver and in<br /> 81% of cases (190), there are an association with an<br /> EHS, usually in the CBD and hepatic duct.<br /> Table 9:<br /> Sites of stones<br /> (R) liver<br /> (L) liver<br /> (R) and (L) liver<br /> Total<br /> <br /> Cases<br /> 6<br /> 155<br /> 75<br /> 236<br /> <br /> %<br /> 2.5<br /> 66<br /> 32<br /> 100<br /> <br /> Almost of the bacteries in the infected biles<br /> culture during operation are sensible to 3rd generation<br /> cephalosporidine and 3rd generation aminoglycoside.<br /> Table 10<br /> Bacteries<br /> E coli<br /> <br /> Cases<br /> 10<br /> <br /> Enterobacter<br /> Proteus<br /> Klebsiella<br /> Pseudomonas<br /> Strept A hemolysis<br /> 1<br /> <br /> 6<br /> 5<br /> 1<br /> 1<br /> Cephalospor<br /> idine 3rd ge.<br /> <br /> Sensibilities<br /> Cephalosporidine 3rd<br /> ge., Aminosides<br /> same<br /> same<br /> same<br /> Aminosides, Quinolone<br /> <br /> Multiple intrahepatic BD and liver disorders are<br /> found.<br /> Table 11<br /> <br /> Nghieân cöùu Y hoïc<br /> <br /> Macroscopic lesions<br /> Alternative BD dilatation-stenosis, good liver<br /> Alternative BD dilatation-stenosis regional<br /> liver sclerosis<br /> Abscesses and purulent cholangitis<br /> Stones and ascaris (living or death)<br /> Intrahepatic BD cysts + Stones + Pus<br /> Bile duct carcinoma + stones<br /> HCC, GB carcinoma, cholangiocarcinoma<br /> Total<br /> <br /> Cases<br /> 73<br /> 102<br /> <br /> %<br /> 31<br /> 43<br /> <br /> 42<br /> 10<br /> 4<br /> 2<br /> 3<br /> 236<br /> <br /> 17.8<br /> 4.2<br /> 1.7<br /> 0.8<br /> 1.3<br /> 100<br /> <br /> As prehistory, 26% of patients having had at least<br /> 1 or more previous operations for biliary stones.<br /> Table 12<br /> Diseases<br /> Biliary stones treated ≥ 1 times<br /> Acute pancreatitis<br /> Liver abcesses<br /> Necrotic pancreatitis<br /> Whipple operation/ pancreatic carcinoma<br /> GB carcinoma<br /> HCC<br /> CBD carcinoma<br /> Concommitent medical disorders<br /> <br /> Cases<br /> 61<br /> 4<br /> 2<br /> 1<br /> 1<br /> 1<br /> 1<br /> 1<br /> 58<br /> <br /> Surgical indications and techniques:<br /> 189 cases<br /> hepatectomy<br /> <br /> having<br /> <br /> had<br /> <br /> indications<br /> <br /> for<br /> <br /> Table 13<br /> Indications<br /> Cases<br /> Segmental BD dilatation with abscesses and<br /> 51<br /> stones<br /> Segmental BD dilatation-stenosis, stones,<br /> 70<br /> sclerotic liver<br /> Segmental BD stenosis, recurrent stones.<br /> 61<br /> infected bile<br /> Intrahepatic BD cysts, stones and infected bile<br /> 4<br /> Intrahepatic BD carcinoma and stones<br /> 3<br /> Total<br /> 189<br /> <br /> %<br /> 27<br /> 37<br /> 32<br /> 2.3<br /> 1.7<br /> 100<br /> <br /> 46 cases having indications for hepatotomies and<br /> cases for intrahepatic BD repair (Table 14):<br /> Table 14<br /> Indications<br /> BD dilatation-stenosis with stones, good liver<br /> parenchyme<br /> Huge and multiple stones, good liver<br /> parenchyme<br /> Total<br /> Intrahepatic BD repair<br /> <br /> Chuyeân ñeà Hoäi nghò Khoa hoïc Kyõ thuaät BV. Bình Daân 2004<br /> <br /> Cases<br /> 34<br /> <br /> %<br /> 74<br /> <br /> 12<br /> <br /> 26<br /> <br /> 46<br /> 15<br /> <br /> 100<br /> 33<br /> <br /> 407<br /> <br />