在一般人群中,约有0.45%至1.20%的人发生结石病。典型的临床症状表现为餐后或唾液刺激后受影响的腺体疼痛肿胀,这极大地影响了患者的生活质量。随着鼻内镜和碎石术的发展,大多数唾液石可以通过保存腺体成功去除。然而,深肺门-实质下颌下导管中的唾液酸盐和位于近端导管中的腮腺结石继续构成巨大挑战。我们的唾液腺疾病研究中心(北京大学口腔医院)已经使用唾液腺内窥镜检查17年,治疗了>2000例唾液腺结石患者。颌下腺结石的成功率约为92%,腮腺结石的成功率约为95%。各种微创外科技术得到了应用和发展,这在难治性唾液酸结石的治疗中增加了实质性的改善。Further,针对这些顽固性结石提出了影像学定位标准和治疗策略.通过经口入路成功切除了大多数肝门实质下颌下结石,包括经口导管分切和导管内篮抓,而小部分浅表结石可以通过下颌下区域的小切口去除。位于腮腺导管远端三分之一处的结石通过“窦周切口”切除,用于避免直接口切口的瘢痕性狭窄。位于Stensen导管中部和近端三分之一处的阻生腮腺结石可通过直接小切口或耳周皮瓣移除。直接经皮小切口通常在局部麻醉下进行,并带有难以察觉的疤痕,并表示位于中间三分之一的大部分受影响的石头,肺门和腺内导管。相比之下,耳周皮瓣是在全身麻醉下进行的,腺体实质的手术损伤相对较大,最好保留更深的颗粒内结石。在过去的十年中,激光碎石术已被用于治疗胆管结石,据报道,钬∶YAG激光具有最佳的治疗效果。在过去的3年里,我们的研究小组对少数顽固性唾液结石患者进行了激光碎石术.根据我们的经验,将内窥镜尖端从激光纤维的末端撤回0.5-1.0厘米,一致的盐水灌溉,仔细监测腺体肿胀对于避免碎石术中导管壁和易损内窥镜晶状体的损伤至关重要。较大的结石需要多个治疗程序。导管狭窄的风险可以通过内窥镜扩张来减轻。总之,在大多数难治性唾液管结石患者中,适当使用各种内镜辅助取石术有助于保留腺体功能.需要在以下方面进行进一步的研究:经颈切除腺内颌下结石,嵌顿性腮腺结石和下颌下深部结石的导管内激光碎石术,评估受影响腺体的长期术后功能,etal.
Sialolithiasis occurs in approximately 0.45% to 1.20% of the general population. The typical clinical symptom manifests as a painful swelling of the affected glands after a meal or upon salivary stimulation, which extremely affects the life quality of the patients. With the development of sialendoscopy and lithotripsy, most sialoliths can be successfully removed with preservation of the gland. However, sialoliths in the deep hilar-parenchymal submandibular ducts and impacted parotid stones located in the proximal ducts continue to pose great challenges. Our research center for salivary gland diseases (in Peking University School and Hospital of Stomatology) has used sialendoscopy for 17 years and treated >2 000 patients with salivary gland calculi. The success rate was approximately 92% for submandibular gland calculi and 95% for parotid calculi. A variety of minimally invasive surgical techniques have been applied and developed, which add substantial improvements in the treatment of refractory sialolithiasis. Further, the radiographic positioning criteria and treatment strategy are proposed for these intractable stones. Most of the hilar-parenchymal submandibular stones are successfully removed by a transoral approach, including transoral duct slitting and intraductal basket grasping, while a small portion of superficial stones can be removed by a mini-incision in submandibular area. Impacted stones located in the distal third of parotid gland ducts are removed via \"peri-ostium incision\", which is applied to avoid a cicatricial stenosis from a direct ostium incision. Impacted parotid stones located in the middle and proximal third of the Stensen\'s duct are removed via a direct mini-incision or a peri-auricular flap. A direct transcutaneous mini-incision is commonly performed under local anesthesia with an imperceptible scar, and is indicated for most of impacted stones located in the middle third, hilum and intraglandular ducts. By contrast, a peri-auricular flap is performed under general anesthesia with relatively larger operational injury of the gland parenchyma, and should be best reserved for deeper intraglandular stones. Laser lithotripsy has been applied in the treatment of sialolithiasis in the past decade, and holmium ∶YAG laser is reported to have the best therapeutic effects. During the past 3 years, our research group has performed laser lithotripsy for a few cases with intractable salivary stones. From our experiences, withdrawal of the endoscopic tip 0.5-1.0 cm away from the extremity of the laser fiber, consistent saline irrigation, and careful monitoring of gland swelling are of vital importance for avoidance of injuries of the ductal wall and the vulnerable endoscope lens during lithotripsy. Larger calculi require multiple treatment procedures. The risk of ductal stenosis can be alleviated by endoscopic dilation. In summary, appropriate use of various endoscopy-assisted lithotomy helps preserve the gland function in most of the patients with refractory sialolithiasis. Further studies are needed in the following aspects: Transcervical removal of intraglandular submandibular stones, intraductal laser lithotripsy of impacted parotid stones and deep submandibular stones, evaluation of long-term postoperative function of the affected gland, et al.