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重症肝內結石症의 治驗

Succesfully Treated Cases of Severe Intrahepatic Lithiasis

대한외과학회지 1966년 8권 8호 p.433 ~ 438
김수태,
소속 상세정보
김수태 (  ) - 서울대학교 의과대학 외과학교실

Abstract


During the preceding one year from March 1965 to April 1966, three patients with severe intrahepatic lithiasis were successfully cured by various surgical procedures.
Case 1. (B.S. Lee, SNUH No. 257943.) Sex: F.; Age: 28.(Fig. 1 and 7).
This poor patient had numerous stones in the left lobe of the liver, for which a left lateral segmentectomy was done and a sphincterotomy was added. Drainage from the cut surface of the liver continued until up to three weeks postoperatively. On the eighteenth postoperative day, a T-tube cholangiogram revealed that the right hepatic duct was free from stones and no visualization of the left hepatic duct due to hepatectomy; the liver function was within normal limits. Meanwhile, because of schizcphrenic symptoms, she was transfered to the department of psychiatry, where she she was treated for twenty days and completely recovered and discharged. Since then she has not been complaining of preperative symptoms and signs, and is now in good health.
Case 2. (W.H. Chung, SNUH No. 287358.) Sex: F.; Age: 28.(Fig. 2,8-15).
This poor patient was operated on three times for her biliary trouble; the first operation was cholecystectom, the second transhepatic lithotomy, and the third left lateral segmentectomy with end-to-end choleduchojejunostomy in Roux-en-Y type, for over a period of three months. At the time of hepatectomy, the left portal vein and left hepatic artery were ligated respectively, but the left hepatic duct was ligated at the cut surface cf the liver. A postoperative cholangiogram through a Nelaton catheter which was introduced into the left hepatic duct passing the jejunum from a stab wound as a splint for the choledochojejunostomy revealed no retained stone in the biliary system and clearly showed the patent stoma of the choledochojejunostomy. Until that time the liver function was improving, but a biliary fistula developed, and close care was inevitable to overcome the complication. A fistulogram through the biliary fistula showed the partial outline of the both hepatic ducts through the left hepatic duct, which was opened at the cut surface of left the lobe. Afterwards, laparotomy was performed again for the ligation of the left hepatic duct, and two middle-finger-tip sized stones were found in the cistern-like cavity of the left hepatic duct between its bifurcation from the common hepatic duct and its opening on the cut surface of the left lobe. The stoma of the choledochojejunostomy was more than two cm. in diameter, whereupon it was probed through the opening of the left hepatic duct. Before the ligation of the left hepatic duct, a cholangiogram performed through its opening revealed no stone in the biliary system. The ligation was done just distal to the stricture of the left hepatic duct. After the operation jaundice was gradually decreased and biliver function tests returned to normal values but cephalin-cholesterol floculation and thymol turbidity remained relatively higher until four and a half months after the third operation. The fistula was completely healed six months following the operation. A few sinuses of stitch abscesses on the incision line were curretted and infected cartilage of the left weventh rib was resected, then the operative wound was completely healed. Actually about five months after the third operation, she recovered from her complaints and was discharged. She is now considered to be free from intrahepetic stones.
Case 3.(U.R. Chu, SNUH No. 320054.) Sex; M.; Age: 52. (Fig. 3-6, 16-17)
His preoperative percutaneous transhepatic cholangiogrm revealed numerous intrahepatic stones in the left lobe of the liver and probably a stricture of the right hepatic duct. Left lateral segmentectomy with a transduodenal partial papillectomy was done. Biopsy of the superior pericholedochal lymphnode and operative findings suggested that this patient possibly had primary adenocarcinoma elsewhere in the biliary system rather than the removed left lobe, in which the pathologist failed to find any carcinomatous change except marked biliary cirrhosis with intrahepatic stone. Postoperative T-tube cholangiogram revealed the visualization fo the right hepaic duct and the flow of the contrast media into the duodenum. This patient had no complications during postoperative course. On the sixteenth day following operation the total serum bilirubin dropped from 30.82 to 12.17 mg/100ml. The patient was considered to have recovered from his intrahepatic stone, except for harbouring the primary adenocarcinoma possibly in the biliary system. The left lobe was atrophic and cirrhotic at the time of operation.
The author thus reviewed three cases of severe intrahephtic stones treated succesfully.
The location of the stones and types and types of operation performed are as follows;
Case 1. left lateral segmentectomy with sphincterotomy for intrahepatic stones in the left lobe.
case 2. Left lateral segmentectomy with choledochojejunostomy in Roux-en-Y for intrahepatic stones in the left and right lobes.
Case 3. Left lateral segmentectomy with transduodenal papilectomy for intrahepatic stones in the left lobe and primary adenocarcinoma in the biliary system elsewhere than the removed left lobe and gall bladder.

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