What are the treatment methods of common bile duct stones?

Patients with choledocholithiasis often go to see a doctor when they have acute cholangitis such as pain, fever or jaundice. It is difficult to determine the location and quantity of stones and the pathological changes of biliary system during acute inflammation surgery, which is not suitable for complex surgical treatment and has more chances for reoperation. However, if the obstruction and inflammation are serious, conservative treatment is often difficult to work. Therefore, in an emergency, it is very important to correctly grasp the relationship between surgical and non-surgical treatment.

In general, emergency surgery should be avoided as much as possible. Non-surgical measures should be taken to control the acute inflammatory stage, and surgery should be chosen after the symptoms are relieved. After strong anti-inflammatory, anti-shock, intravenous infusion to maintain water, electrolyte and acid-base balance, nutritional support and symptomatic treatment, PTCD or endoscopic papillary incision and nasobiliary drainage and decompression can be effective. After 65,438+0.2 ~ 24 hours of non-surgical conservative treatment, if there is no improvement or aggravation, such as persistent typical Charcot triad or severe acute obstructive suppurative cholangitis such as shock and mental disorder, biliary tract exploration and decompression should be carried out in time. The principle and purpose of surgical treatment of common bile duct stones are mainly to remove stones, relieve obstruction, unblock bile and prevent infection.

1. Endoscopic Oddi Sphincterotomy or Endoscopic Papillary Incision, Endoscopic Oddi Sphincterotomy (EST) or Endoscopic Papillary Incision (EPT) are suitable for stones with less number and smaller diameter in the lower segment of the common bile duct. In particular, secondary stones are often embedded in the lower segment of common bile duct, ampulla or nipple because of their small size and small quantity. Stones with a diameter less than 1cm can be removed by EPT or EST. This method has the advantages of less trauma and quick effect, and is more suitable for elderly and weak patients or patients who have undergone biliary surgery. In choledochoscopy under fiberscope, EST should be done first, then put into choledochoscope and stone basket should be used to take stones. If the stone is big, it should be crushed before it can be taken out. This method can remove high bile duct stones, but the operation is complicated.

2. Choledocholithotomy is still the main method to treat choledocholithiasis. The right upper abdomen can expose the common bile duct satisfactorily through rectus abdominis incision or right costal oblique incision. After laparotomy, the liver, gallbladder, pancreas, stomach and duodenum should be explored by routine palpation. For elective surgery, if possible, it is best to perform intraoperative cholangiography or intraoperative B-ultrasound examination before cutting the common bile duct to further clarify the pathological state of stones and biliary system. In particular, primary common bile duct stones are mostly accompanied by intrahepatic bile duct stones or bile duct strictures, which need to be solved simultaneously during operation. After cutting the common bile duct and taking out the stones, it is best to routinely put the choledochoscope into the internal and external bile ducts of the liver for examination and stone removal. Observe whether the hepatobiliary system has left stones, strictures and other diseases under direct vision, and take out stones as much as possible. Then use the catheter of F 10 ~ 12. If the catheter can smoothly enter the duodenum through the nipple and inject about 10ml of normal saline from the catheter, it means that the nipple has no obvious stenosis. If the F 10 catheter can't enter the duodenum, we can use a Becks bile duct dilator with a diameter of 2 ~ 3 mm for exploration. Normal Oddi nipple can pass through the dilator with a diameter of more than 3 ~ 4 mm, and the metal biliary tract dilator should be used from the small dilator with a diameter of 2 ~ 3~4mm, and gradually increase the 1 dilator after passing smoothly. With the bending of the common bile duct, put it gently and slowly, and don't insert it forcibly, so as not to break through the lower end of the common bile duct and form a false road, which will cause serious consequences. If the common bile duct is obviously dilated, you can put your finger into the common bile duct for exploration. Sometimes soft and turbid stones can attach to the dilated bile duct wall or ampulla, which does not hinder the passage of bile duct probe and catheter, and the hand feel is more accurate at this time. It needs to be emphasized again that it is impossible to accurately know whether there are residual stones or strictures in the bile duct, especially in the intrahepatic bile duct, whether using catheter, Becks dilator or finger exploration. Intraoperative choledochoscopy observation and stone removal can make up for this deficiency and effectively reduce or avoid residual stones. After common bile duct exploration, there are different opinions on whether to place bile duct drainage. It is considered that bile duct drainage is only suitable for simple common bile duct stones (mainly secondary stones), and the bile duct system is basically normal. It is proved that there are few cases such as no stone residue, no bile duct stenosis (especially no lower common bile duct or nipple stenosis) and no obvious cholangitis, which can shorten the hospitalization time and avoid complications related to bile duct drainage. Suture the common bile duct immediately under the condition of strict indication. In suture technology, it is best to use non-invasive fine thread with needle to suture the incision of common bile duct accurately and tightly to prevent bile from overflowing. However, in order to understand and extract the possible bile overflow, it is necessary to place a drainage tube for the sub-hepatic abdominal cavity.

For many years, the traditional method is to explore the common bile duct, take out the stones and place a "T" tube for drainage. It can effectively prevent bile extravasation, avoid postoperative biliary peritonitis and local cholestasis infection, and is safe and reliable. After operation, we can understand and deal with complex problems such as residual stones in biliary tract through "T" tube. Especially in China, the incidence of primary bile duct stones is high, and there are many complicated diseases such as intrahepatic bile duct stones, dilatation and stenosis of intrahepatic and extrahepatic bile ducts, so it is difficult to ensure perfect treatment during common bile duct exploration. Therefore, in most cases, it is still appropriate to place a "T" tube for drainage. The material of T-tube should be latex tube, which is easy to cause tissue reaction. Usually in 2 ~ 3 weeks, sinus can be formed due to surrounding adhesion. T-tube made of silicone tube or polyethylene material has light tissue reaction, is not easy to form sinus, and has more chances of biliary peritonitis after extubation, so it is not suitable for use. The thickness of "T" tube should be adapted to the lumen of common bile duct. The diameter of the short arm placed in the common bile duct after pruning should not exceed the inner diameter of the bile duct to avoid tension when suturing the bile duct. Because the tension is too large and too tight, the blood supply of the bile duct wall is insufficient or cracked, bile overflows, and bile duct stenosis occurs in the future. If the common bile duct is dilated to a certain extent, it is best to choose a "T" tube of 22 ~ 24f, so as to take stones through the sinus with fiber choledochoscope after operation. It is better to suture the common bile duct incision with 2-0 or 3-0 absorbable thread. Because knots that do not absorb silk threads, such as silk threads, may enter the common bile duct and become the core of stone recurrence. After the suture of common bile duct is completed, a proper amount of normal saline can be injected gently and slowly through the long arm of T-tube to test whether the suture is tight. If there is water leakage, it should be sutured tightly with needles to avoid bile leakage after operation. Before closing the abdomen, the long arm of the "T" tube and the other puncture hole of the sub-hepatic peritoneal drainage tube were led out of the body to avoid affecting the primary healing of the abdominal incision.

3. Laparoscopic choledocholithotomy is mainly suitable for simple choledocholithiasis. Before or during cholangiography, there is no bile duct stenosis and multiple stones in intrahepatic bile duct. Therefore, this method mostly explores the common bile duct during laparoscopic cholecystectomy to treat secondary common bile duct stones. After common bile duct incision, most of them need to put a fiber choledochoscope through the abdominal wall and take stones with a stone basket, which is difficult and requires skilled laparoscopic surgery. After stone removal, it can be decided to directly suture the common bile duct incision or place a "T" tube for drainage according to the specific situation.

4. Treatment of stenosis and obstruction of the lower common bile duct Whether it is primary or secondary choledocholithiasis with obvious dilatation of the common bile duct, there may always be stenosis and obstruction of the lower common bile duct. If the lower end of the common bile duct is obviously narrowed and obstructed during intraoperative exploration, biliary and intestinal drainage should be carried out at the same time to establish a smooth biliary and intestinal channel.

(1) choledochoduodenectomy: simple and easy to operate, with good early results. It was often used in the past. However, bile duct reflux or reflux cholangitis will inevitably occur in this operation, and repeated inflammation will easily lead to anastomotic stenosis and stone recurrence, and the long-term effect is not good. In particular, patients with bile duct stenosis at the upper end of anastomosis or incomplete removal of residual stones in intrahepatic bile duct often have severe cholangitis or biliary liver abscess repeatedly. Therefore, choledochoduodenectomy is rarely used today. Most people claim that it is only applied to the elderly, the infirm, those who can't stand complicated operations and have made it clear that there is no residual stone, stenosis or obstruction in the bile duct above the anastomosis. The diameter of anastomosis should be greater than 2 ~ 3 cm to prevent retraction and stenosis in the future.

(2) Jejunostomy with interposition of common bile duct and duodenum: two ends of free jejunum with blood vessels were anastomosed with common bile duct and duodenum respectively, and a jejunum bridging anastomosis channel was formed between common bile duct and duodenum. Although the artificial nipple is made at the anastomosis with duodenum or the jejunum segment is extended by 50 ~ 60 cm, it is still difficult to effectively prevent bile reflux, which is easy to cause bile to stay in the interposition jejunum segment and increase infection factors. The operation process is also complicated, and the long-term effect and operation are not superior to that of common bile duct jejunostomy.

(3) Roux-en-Y anastomosis of common bile duct and jejunum: It is easy to achieve a wide anastomosis of more than 3 ~ 5 cm by using jejunum and common bile duct, which is beneficial to prevent anastomotic stenosis. The jejunum is free, easy to operate and flexible, especially suitable for patients with common hepatic duct, hepatobiliary duct stenosis above hepatic portal or hepatolithiasis. It can continuously cut hepatic hilum, left and right hepatic ducts and even grade III hepatic duct stricture, relieve stricture, remove intrahepatic bile duct stones, and establish worry-free stoma. Wide application range and good drainage effect. Combined with various forms of anti-reflux measures to prevent bile reflux and reflux cholangitis, it is the most commonly used type of biliary-intestinal drainage.

(4)Oddi Sphincterotomy: In the early years, it was mostly used for patients with common bile duct end and nipple stenosis, and the duodenum was cut for Oddi Sphincterotomy. In fact, it is similar to low choledochoduodenectomy, which is more complicated and prone to restenosis, and the long-term effect is not better than choledochoduodenectomy. Especially in recent years, EST has been successfully applied in clinic and gradually popularized, with no laparotomy, little trauma and strong popularization. Cases suitable for Oddi sphincterotomy can be replaced by EST, and the same effect can be achieved, so open Oddi sphincterotomy is rarely used.

(5) The new Japanese Fuji fiber choledochoscope minimally invasive gallbladder-preserving lithotomy: With the assistance of high-tech products laparoscopy and fiber choledochoscope, the position, shape and adhesion of the gallbladder were first explored by abdominal puncture with a pneumoperitoneum needle. After confirming that the outside of the gallbladder is normal, make a small incision of 2cm at the costal margin to pull the gallbladder, and make an incision of about 0.5cm at the bottom of the gallbladder to insert the choledochoscope. At the same time, the bile in the gallbladder is sucked out with a negative pressure aspirator, and the gallbladder is washed with normal saline. Finally, choledochoscope was used to repeatedly check whether there were small stones left in the gallbladder cavity, and to observe the situation of bile flowing into the gallbladder to rule out incarceration of cystic duct stones. After determining that there are no stones in the gallbladder, carefully suture the gallbladder with absorbable thread, and finally suture the surgical incision layer by layer.

(6) Non-surgical treatment of integrated traditional Chinese and western medicine: In the process of strong anti-inflammatory and conservative treatment, some traditional Chinese medicine prescriptions, such as soothing the liver and benefiting the gallbladder, relieving spasm and relieving pain, are used as auxiliary treatment, which has certain curative effect. For patients with small stones, few stones, no bile duct stenosis and normal Oddi sphincter function, it has been successfully reported that the method of combining traditional Chinese and western medicine is used to remove stones. However, larger stones cannot be discharged, and multiple stones are difficult to be discharged, which is easy to recur. Especially in the case that bile duct obstruction is obviously complicated with severe cholangitis, the number and size of stones are unknown, and whether there is bile duct stenosis or not, those who cannot be relieved or improved within a short period of time after non-surgical treatment should still undergo surgical drainage of common bile duct in time to avoid serious consequences such as biliary septic shock.