【Abstract】 Objective To discuss the factors associated with residual stones after biliary lithotripsy. Methods To retrospectively analyze the data of patients admitted to the hospital from 2004 to 2008. Conclusion Early detection and rational treatment of residual stones is the key to treating residual stones. The prevention of residual stones can be achieved by preoperative examination, intraoperative exploration and so on to improve the success rate of surgery. 【Keywords】 Residual stone;Related factors Guangxin Wang, Department of General Surgery, Wuhan Third Hospital Bile duct stone is a common disease of the biliary tract, but the treatment is quite difficult. Most patients have not been completely cured after several surgeries. Although surgery has reached a high level, the incidence of postoperative biliary tract residual stones is still high. Now, we analyze 85 patients admitted to the Department of Hospital Surgery II, analyze the main causes of residual biliary tract stones, and propose corresponding preventive and therapeutic measures. 1 Clinical data 1.1 General data From January 2002 to December 2007, 98 cases of residual bile duct stones were admitted to Xuchang County People’s Hospital of Henan Province. Among them, 47 cases were male and 51 cases were female, aged between 21 and 85 years old, with an average of 53 years old. 49 cases (50%) had a disease duration of less than 10 years, 25 cases (26%) had a disease duration of 10 to 20 years, and 23 cases (24%) had a disease duration of more than 20 years. Epigastric distension was felt in 20 cases, recurrent biliary colic in 37 cases, biliary colic with pancreatitis in 17 cases, and the rest of the patients were asymptomatic. 1.2 Diagnosis of residual stones Residual stones should include:①stones that had been found in biliary surgery but could not be removed;②stones found by biliary drain imaging or choledochoscopy after surgery;③repeated pain, fever and jaundice within 3 months after biliary surgery and confirmed by choledochography;④simple cholecystocleisisography. The diagnosis of residual stones was based on: ① patients with recurrent cholelithiasis after surgical removal of the gallbladder and incision of the common bile duct for stone extraction; ② those who had stones detected by T-tube imaging or ultrasound or CT; and ③ those who had stones in the bile ducts proved by reoperation [1]. For patients with intrahepatic bile duct stones after choledochotomy, trans-T-tube cholangiography was routinely performed 9~31 d after the operation, and if no residual stones were found, the T-tube was removed according to the principle and method of T-tube removal, and the ultrasound examination was repeated within 3 months. 1.3 Residual stones in the biliary tract occur most often in the following cases Gallbladder stones fall into the biliary tract during cholecystectomy and are not found in time, and the stones can not enter the intestine. The patient’s condition is complex, not suitable for extensive exploration and other complex surgical procedures, only the choledochotomy to remove the stone T-tube drainage, the preoperative condition does not have a sufficient understanding of the disease, and so on. Biliary tract infection plays an important role in the formation of biliary stones. The role of infection should also be emphasized in recurrent stones after biliary lithotripsy. Therefore, the removal of stones does not mean that biliary stones are cured. Biliary obstruction also plays an important role in stone formation. 2 The causes of residual stones The causes of residual stones after biliary tract surgery are many, mainly: ① emergency admissions do not do a comprehensive preoperative examination, the preoperative history of incomplete understanding; ② preoperative examination is imperfect, intraoperative cholangiography, choledochoscopy, blind stone removal. The patient’s condition is not good, poor nutritional status: ④ no corresponding means of inspection during the operation, can not detect the problem in time to solve the problem immediately during the operation; ⑤ the stone is located in a special location, making it difficult to remove the stone. Inexperience of the operator is also an important reason, the omission of surgical exploration, only satisfied with the discovery of an obvious lesion, but neglected to further search for other coexisting lesions, or did not strictly grasp the indications of the common bile duct exploration or improper operation, the stone will be pushed into the right and left hepatic ducts; improper selection of the surgical style is also easy to cause the residual stone left in the lower end of the common bile duct, resulting in recurrent infections. 3 Preventive measures Prevention of the factors of stone retention is of great significance to improve the long-term therapeutic effect. Choledochoscopy is currently an effective, safe and major method of treating residual stones after biliary surgery, and is also one of the methods of preventing residual stones. ①Patients in poor condition should be actively prepared for the operation, and the physical condition of the patients should be strengthened ②Pre-operative cholangiography and ultrasound should be fully applied to clarify the distribution and number of stones and pathological changes of the biliary tract, and to reduce the blindness of the operation. ③ To strictly grasp the indications of choledochal exploration, carefully explore the stones during the operation, gently remove the stones and pay attention to the integrity of the stones. ④ Necessary auxiliary examinations should be carried out during the operation to detect the residual stones and biliary strictures in a timely manner. Intraoperative cholangioscopy can make up for the insufficiency of preoperative examination, and directly find and remove the stone. 5 Surgical relief of bile duct stenosis. Intraoperative cholangiography is performed, but it should be noted that the concentration of contrast medium should not be more than 25%, and it should be injected slowly, not too fast, and to avoid air entering the bile duct. (6) Emphasize the treatment of biliary tract infection. (7) Strengthen the treatment of postoperative lithotripsy (8) For patients with T-tube drainage, routine T-tube imaging should be carried out before tube removal. ⑨ Strengthen nutrition, especially should increase the intake of protein and fiber, reduce the intake of cholesterol [2]. Postoperative choledochoscopy is an effective means of treating residual stones. Transcholedochoscopy with stone extraction mesh alone or additional comprehensive measures such as lithotripsy and laser lithotripsy can significantly improve the efficacy and reduce the rate of residual stones. Closely observing the condition of emergency patients with strong measures to control the deterioration of the condition, as far as possible, emergency surgery into elective surgery, can also reduce the occurrence of residual stones [3]. Postoperative application of anti-inflammatory and choleretic drugs can not only increase the flow of bile, but also relieve biliary spasm and control infection. 4 Discussion Not all residual stones in the biliary tract need to be reopened, but only those with jaundice should be operated if the conservative treatment is not effective. For those with T-tube drainage, the flow and nature of bile drainage should be observed after surgery. The presence of small stones or intermittent poor drainage suggests the possibility of residual stones. Before removing the T-tube, T-tube imaging should be performed again, and once residual stones are found, they can be removed through the T-tube sinus tract. For those who undergo surgery, preoperative preparations should be made first, using ultrasound, CT, PTC, ERCP examination, to learn as much as possible about the intrahepatic situation, bile duct anatomical variations, bile duct stenosis, obstruction site, and the size and number of stones. Nutritional status of patients should be improved, cardiac, hepatic and renal functions should be paid attention to, and infection should be controlled in order to enhance patients’ tolerance. Choose a good time for surgery and adopt appropriate surgical methods. During the operation, the stones should be removed, and after the operation, the biliary tract and biliary and intestinal drainage should be guaranteed to be smooth [4]. Residual stone obstruction leads to acute severe cholangitis, so for patients with bile duct residual stones, ultrasound, choledochoscopy, or partial hepatectomy should be used as much as possible during the operation, in an attempt to remove all the stones and prevent residual or recurrence. To summarize, the treatment of biliary tract residual stones is a tricky problem. The cure rate of biliary tract residual stones can be improved only if multiple methods of comprehensive treatment are used [5]. References [1] Liang Haohui, Wang Chengyou, Zhang Minjie, et al. Diagnosis and treatment of 57 cases of biliary tract residual stones. Journal of Guangdong Medical College, 2006 , 24(1): 24. ［2］ Ma Yugang,Wu Linfeng,Dai Wenjie,et al. Causes and prevention of postoperative recurrence and retention of biliary stones. Journal of Hepatobiliary and Pancreatic Surgery, 2008, 3(20):147-149. ［3］ Li Lichun,Zhu Hong,Li Xiao,et al. Comprehensive treatment of biliary tract residual stones. Journal of Hepatobiliary Surgery, 1997, 5(3):155-156. ［4］ Ji Qishun. Clinical analysis of 91 cases of reoperation for biliary tract residual stones. Central China Medical Journal, 2000, (24)3:165. ［5］ Liu Fengyen, Wang Xiaonong, Dong Da. Clinical analysis of 53 cases of biliary tract residual stones. Journal of Gannan Medical College, 1994, 2(6):129-131. reposted from China Essay Download Center http://www.studa.net