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간내 담석증의 임상적 고찰 A clinical study of the intrahepatic calculi

대한외과학회지 1972년 14권 4호 p.17 ~ 27
조범구, 허경발, 박용범, 김순일,
소속 상세정보
조범구 (  ) 
연세대학교 의과대학 외과학교실

허경발 (  ) 
고려병원 외과
박용범 (  ) 
연세대학교 의과대학 외과학교실
김순일 (  ) 
연세대학교 의과대학 외과학교실

Abstract


The late professor Ludlow (1930) of Severance Union Medical College suggested that there may be
many differences between the type of cholelithiasis seen Korean patients and that noted in orientals.
In the subsequent studies that have followed his initial impressions clinical and pathological investig
ations have confirmed his statement. It is suggested that the high incidence of intrahepatic calculi may
be a significant factor contributing to the unique clinical picture of cholelithiasis in Korea.
However, to day there have not been any well decumented studies of intrahepatic calculi in Koreans.
This study is an observation of 462 cases of patients with cholelithiasis seen in the Department of
Surgery at Yonsei University College of Medicine and at Korea General Hospital over the last 12
years; (Jan. 1958-June 1967, 68 cases at Yonsei and NOv. 1968-April 1971, 17 cases at Korea General
Hospital). Special reference was made to 85 of the 462 cases. These had proven intrehepatic calculi.
An evaluation and review has been made for the clinical incidence, the symptomatology, the location
of the stones, the mothod of treatment, and the changes in operative treatment over the past twelve
years.
18.4% of all gallstone patients were found to have intrahepatic calculi. The youngest patient was
17 and the oldest was 74 with a peak incidence occuring in the 5th decade. There is no significant
sex differences.
The most prominent symptoms and signs were pain (89%) and tenderness(93%) in the right upper
quardrant and epigastric region.
Two thirds of all intrahepatic calculi were in the common hepatic or the intrahepatic bilary ducts,
and one third of these were associated with cholecystolithiasis.
The calculi were found in the left intrahepatic duct in 76 (89.4%) cases in the right intrahepatic
duct in 55(64.7%) cases. In 6 cases (7.1%), calculi were limited only to the left intrahepatic duct
but in no case were right intrahepatic calculi seen without associated calculi.
The classification of the intrahepatic calculi based upon our clinical experiences is as follows,
A type : Simple intrahepatic calculi
B type : Complicated intrahepatic calculi
Ⅰ : intrahepatic calculi with stenosis at the bifurcation of both intrahepatic duct
Ⅱ : intrahepatic calculi with stenosis in the left intrahepatic duct with or without contralateral
intrahepatic calculi
Ⅲ : intrahepatic calculi with stenosis in the right intrahepatic duct with or without contralateral
intrahepatic calculi
Ⅳ : intrahepatic calculi with multiple stenosis in the both intrahepatic ducts.
Most of the intrahepatic calculi are of the Simple type (34.8%) but the Complicated B-Ⅳ type is
the next most common (28.9%).
In the first 5 years (1958. Jan-1962. Dec) 22 out of 25 cases had no by-pass procedures. The recu
rrent rate of biliary colic and the other symptoms was 81.8% (18 out of 22) and the most of them
had to undergo another operations.
In the second (1963. Jan-1967. June) 21 out of 43 had a by-pass operation and the rest of 43(22
cases) had no by-pass operation. The recurrence rate was 72.7%.
During the 3rd period from 1968. Nov. to 1971. April, 11(64.7%) out of 17 cases had by-pass
procedures without recurrence, and only 6 (35.3%) out of 11 had no by-pass procedure. Among the
six, 2 cases had recurrence.
Throughout the three periods, of observations, there was an increased tendency or indication for
by-pass procedures at the time of primary surgery.
The following surgical procedures for each type of intrahepatic calculi is considered as a choice of
proper approach to conquer the problems of the intrahepatic calculi.
A Type : Simple by-pass procedure (preferably Roux-en-Y type)
B-Ⅰ Type : Templeton Dodd´s procedure with Roux-en-Y type
B-Ⅱ Type : Longmire´s procedure.
B-Ⅲ Type : Roux-en-Y choledocho-jejunostomy and right intrahepaticojejunostomy.
B-Ⅳ Type : No definite treatment but a simple by-pass procedure may be helpful.

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