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Title: [Endoscopy-assisted transoral removal of deep hilar and intraparenchymal stones in the Wharton's duct].
Author: Zhao YN, Zhang YQ, Ye X, Meng Y, Xie XY, Liu DG.
Journal: Zhonghua Kou Qiang Yi Xue Za Zhi; 2018 Dec 09; 53(12):826-831. PubMed ID: 30522206.
Abstract:
Objective: To investigate the different surgical approaches and long-term outcomes of endoscopy-assisted transoral removal of deep hilar and intraparenchymal stones in the Wharton's duct. Methods: From January 2008 to March 2018, 481 consecutive patients with deep hilar and intraparenchymal calculi in the Wharton's duct underwent endoscopy-assisted transoral removal at Deparment of Oral and Maxillofacial Radiology, Peking University School and Hospital of Stomatology. There were 250 males and 231 females. Their ages ranged from 9-86 years. We operated 476 patients under local anesthesia on an outpatient basis, and the remaining 5 were operated under general anesthesia. On the basis of ultrasonography, spiral CT, sialography and endoscopy, the calculi were classified into 4 types: hilum stones (located at the hilum or proximally with a distance <5 mm from the hilum), infra-hilum stones (intra-glandular stones with a distance of 5-10 mm from the hilum), intraparenchymal stones (with a distance ≥10 mm from the hilum), and multiple stones (concomitant hilum and intra-glandular stones). The treatment approaches included: hilum duct slitting, intraparenchymal duct slitting, submandibulotomy and intraductal retrieval. The success rate, immediate safety and effectiveness of different types of stones were evaluated. After surgery, the patients were followed up, and gland function was analyzed on the basis of clinical symptoms and signs. Results: The calculi sizes varied from 3 to 25 mm, with a mean of 7.8 mm. The calculi were located in the right submandibular gland in 259 patients, in the left submandibular gland in 219 patients and in bilateral glands in 3 patients. The calculi were successfully removed in 446 glands, with a success rate of 92.1% (446/484). The success rate varied according to the stone sites: 97.8% (363/371) for hilum stones, 64.4% (29/45) for infra-hilum stones, 4/16 for intraparenchymal stones and 96.2% (50/52) for multiple stones. The main treatment methods applied included hilum duct slitting in 347 glands, intraparenchymal duct slitting in 13, submandibulotomy in 4, intraductal retrieval in 73, and hilum duct slitting accompanied by intraductal retrieval in 9. Ductal breakage occurred in 2 glands. All patients complained of mild to moderate pain with a duration of 3-7 days. Nine had temporal lingual nerve injury. During 3-120 months' follow-up (mean 36 months) of the total 484 glands, 1.6% (7/446) developed ranula, 1.3% (6/446) experienced obturation of the main duct and 2.0% (9/446) had recurrent stones. The remaining 95.1% (424/446) glands were symptom-free with good function. Conclusions: Endoscopy-assisted transoral removal of deep hilar and intraparenchymal submandibular calculi is a safe and effective gland-preserving procedure. According to the depth, size and number of the calculi, variant surgical approaches should be attempted to maximize the success rate and to minimize the side effects. 目的： 探讨唾液腺内镜辅助下颌下腺腺门和腺内不同深度结石的取石方法及术后疗效。 方法： 收集2008年1月至2018年3月于北京大学口腔医学院·口腔医院医学影像科就诊、采用内镜辅助口内途径取石的481例（484侧）下颌下腺腺门或腺内结石病例（男性250例，女性231例，年龄9~86岁），根据超声、螺旋CT、造影及内镜所见将结石分为腺门型、腺门下型、腺内型及多发型。采用4种取石方法，方法Ⅰ：腺门部切开取石；方法Ⅱ：腺内追踪主导管取石；方法Ⅲ：腺体切开取石；方法Ⅳ：导管内抓取。分析不同类型结石的取石成功率、并发症以及中长期疗效。 结果： 481例患者中3例为双侧腺门结石。484侧病变中446侧取石成功，取石成功率为92.1%；腺门型、腺门下型、腺内型、多发型结石的取石成功率分别为97.8%（363/371）、64.4%（29/45）、4/16和96.2%（50/52）。取石方法包括方法Ⅰ347侧，方法Ⅱ13侧，方法Ⅲ 4侧，方法Ⅳ73侧，方法Ⅰ+Ⅳ 9侧。2侧术中导管腺门部断裂，所有病例术后腺体及口底肿痛3~7 d，9侧出现暂时性舌神经损伤。取石成功病例平均随访36个月，1.6%（7/446）发生舌下腺囊肿，1.3%（6/446）导管闭锁，2.0%（9/446）结石复发，95.1%（424/446）腺体功能良好。 结论： 对于下颌下腺腺门和腺内不同深度的结石，应在内镜辅助下采用不同方法取石，以最大程度提高取石成功率，减少并发症。.

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