摘要
胆总管结石是外科最常见的良性疾病之一,随着科技的进步、医疗技术的提升以及医院硬件设施的完善,经内镜逆行性胰胆管造影术(ERCP)及腹腔镜胆总管探查术(LCBDE)已经成为胆总管结石的主要治疗手段,且具创伤小、恢复快的临床优势。但是,临床多中心研究数据显示,胆总管结石术后复发率为4%~24%,因此,胆总管结石术后复发是外科医生必须面对的挑战和亟待解决的问题。胆总管结石的形成是一个复杂的遗传和环境因素相互作用的过程,其具体机制尚未完全阐明,术后复发机制及相关因素亦成为临床研究的难点和热点。笔者通过整理归纳相关文献,从十二指肠乳头括约肌功能、胆道微生态、胆道解剖三个维度,阐述胆总管结石术后复发的相关机制与研究进展,为预防胆总管结石术后复发提供新的策略和研究方向。
胆总管结石是全世界范围内的常见病、多发病,在消化系统疾病中占到了很大的比重,其在西方影响了超过10%的人
十二指肠乳头括约肌即Oddi括约肌,指包绕在胆总管末端、胰管末端及壶腹部周围的环形括约肌,包括胆总管括约肌、胰腺管括约肌、壶腹括约肌,扮演着胆汁和胰液排泄的“开关”角色,其对维持胆道系统流体压力、防止十二指肠液反流、防止胆汁和胰液之间的相互交通等发挥着重要作
随着临床探索的深入,胆总管结石手术的改进,腹腔镜及内镜的普及,LCBDE和ERCP已成为目前胆总管结石的临床一线治疗手
普遍认为相较EPBD利用球囊来放松十二指肠乳头括约肌达到取石目的来说,EST对十二指肠乳头括约肌的功能有着更大的伤
虽然EPBD相较EST更有利于保留尽量多的十二指肠乳头括约肌功能,但这种保护的效果极大程度上取决于术中使用的球囊大小。有学
人类体内存在大量的微生物,即使是健康个体不同身体部位的微生物群都存在着差异,这种微生态的差异已经被证明与饮食、宿主遗传、环境及微生物接触史有关,但这些原因还远远不足以解释人体微生态的多样
胆道由于其强碱环境的存在,在以前被认为是无菌的相对封闭结
相较于初发胆结石疾病,复发性胆总管结石患者的胆道微生态中的微生物多样性降
上述研究结果均能直接或间接地证实胆道微生态的存在,且胆道微生态与胆总管结石的复发关系密切,改善胆道微生态可降低胆总管结石复发的风险亦得到证实,但是,如何恢复胆道微生态平衡,应提高或降低何种细菌的丰度,使用何种抗生素或微生态制剂,目前都缺少相应的基础及临床研究的证据,因此,通过改善胆道微生态平衡来预防结石的产生和术后复发还有很多问题亟待揭示,这些薄弱区或盲区都应是我们未来关注的热点和研究方向
在胆总管结石手术后,结石复发的危险因素尚未明确,但学者们都普遍认为结石的复发与胆汁淤积相
由于胆总管下端向十二指肠开口,所以其形态上会形成一个向右偏移的解剖位置,这个偏移角度通常被称为胆总管成
除了尖锐的胆总管成角外,存在壶腹周围憩室也是胆总管结石复发的危险因素之一,壶腹周围憩室指的是邻近或包含壶腹的十二指肠黏膜和黏膜肌层的腔外突出
也有学者表示胆总管的远端直径与胆总管结石的短期复发有关,胆总管的远端直径越大,短期复发胆总管结石的风险也越大,虽然不同研究者对于复发患者胆总管直径的随访数据稍有差距,但他们的数据都表明了随着远端胆总管直径的增大,患者复发胆总管结石的风险也随之上升这一趋
胆总管结石是一种常见的胆道良性疾病,它的复发常常被认为是多因素共同作用的结果,目前所取得的研究结果表明这些因素多与胆总管结石术式选择、术中操作、十二指肠乳头括约肌功能的保留、胆道微生态紊乱、尖锐的胆总管成角、远端胆总管直径、壶腹周围憩室、胆总管结石的大小和数量等因素有关。上述这些因素共同导致了肠内容物经由功能减弱的十二指肠乳头括约肌反流至胆道,从而影响胆道微生物群的构成,破坏了稳定的胆道环境,造成胆总管结石复发。遗憾的是,关于多种胆道因素影响胆总管结石复发的研究多停留在回顾性研究阶段,更多的详细机制还有待于进一步的实验结果来证明。但目前已知的研究结果已经为围术期管理提供了新的思路,是否可以通过长期随访高复发风险患者、围术期运用抗生素、ERCP术中进行胆道冲洗等措施来改善胆总管结石患者预后,降低复发风险呢?具体证据还有赖于更多的临床试验来进行挖掘。
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