探讨加速康复外科（ERAS）理念下经皮经肝胆道镜碎石术（PTCSL）治疗肝胆管结石病的安全性和疗效。

回顾性分析2016年1月至2020年12月在中山大学附属第三医院岭南医院行PTCSL的35例肝胆管结石患者临床资料。其中男11例，女24例；年龄39~89岁，中位年龄61岁。既往有胆道手术史32例，二次以上手术史13例。初发结石9例，复发结石26例。患者签署知情同意书，符合医学伦理学规定。围手术期应用ERAS措施管理，手术方法采用一步或二步法PTCSL。观察患者术后恢复和并发症发生情况，术后疼痛评估采用视觉模拟评分（VAS）。

患者均成功行PTCSL，其中一步法手术19例，二步法手术17例。行2次以上手术8例，3例术中联合T管取石。右侧入路26例，左侧入路10例。平均手术时间（2.3±1.1）h，用水量（6 300±575）ml，术中出血量中位数40（5~400）ml，术后VAS（2.9±1.0）分，住院时间12（6~27）d。围手术期无死亡。发生手术并发症9例，其中肝周积液3例，胸腔积液2例，胆道感染2例，胆漏1例，经治疗后好转；术中胆管出血1例，术后复查示肝Ⅲ段胆管门静脉瘘，保守治疗无效，予消融治疗后好转。结石完全清除率89%（31/35），CT示穿刺胆管所在二级分支内均无残留结石。

ERAS理念下采用PTCSL治疗肝胆管结石病微创、安全、可行，可加快术后康复，尤其适合胆道结石复发或残余结石。

To evaluate the safety and efficacy of percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) in the treatment of hepatolithiasis under the concept of enhanced recovery after surgery (ERAS).

Clinical data of 35 patients with hepatolithiasis undergoing PTCSL in Lingnan Hospital of the Third Affiliated Hospital of Sun Yat-sen University from January 2016 to December 2020 were retrospectively analyzed. Among them, 11 patients were male and24 female, aged from 39 to 89 years, with a median age of 61 years. 32 patients had a history of biliary tract surgery in which 13 cases had more than twice surgeries. 9 patients were initially diagnosed with stones and 26 cases of recurrent stones. The informed consents of all patients were obtained and the local ethical committee approval was received. ERAS management measures were delivered during perioperative period, and one-stage or two-stage PTCSL was employed. Postoperative recovery and incidence of complications were observed. Postoperative pain was assessed by visual analogue scale (VAS).

All patients underwent PTCSL successfully, including 19 cases of one-stage and 17 cases of two-stage PTCSL. 8 patients underwent more than twice PTCSL, and 3 cases received PTCSL combined with T-tube lithotomy. 26 cases underwent PTCSL via the right approach and 10 cases via the left approach. The average operation time was (2.3±1.1) h,the amount of water consumption was (6 300±575) ml, the median intraoperative blood loss was 40(5-400) ml,the postoperative VAS score was 2.9±1.0, and the length of hospital stay was 12(6-27) d. No intraoperative death was reported. Postoperative complications occurred in 9 cases, including 3 cases of perihepatic effusion,2 cases of pleural effusion, 2 cases of biliary tract infection and 1 case of bile leakage, and all were improved after corresponding treatments. Intraoperative bile duct bleeding occurred in 1 case, who was found with bile duct portal vein fistula in segment Ⅲ by postoperative reexamination. The patient was relieved by ablation after noneffective conservative interventions. The complete stone clearance rate was 89%(31/35). No residual stone was found in the secondary branch of bile duct by CT scan.

Under the concept of ERAS, PTCSL is a minimally invasive, safe and feasible treatment for hepatolithiasis, which can accelerate postoperative recovery, especially for patients with recurrent or residual biliary tract stones.