胆管损伤早期发现的重要意义

胆囊切除术一旦发生胆管损伤,就改变了原发病的治疗效果,从而造成难以估计的预后.胆管损伤发生后,胆汁不断流入腹腔,将带来严重的病理生理变化,而且随着时间的延长愈发严重.由于胆管损伤没有及时处理造成病人死亡的教训并非罕见.百余年累积的经验和教训已经使我们认识到,胆管损伤发生后的早期发现对处理的成败有着极其重要的意义.     

胆管损伤的诊断和治疗指南(2013版)

胆管损伤的诊断和治疗仍然是当前腹部外科中的难题之一.为最大限度降低胆管损伤的发生率,规范胆管损伤的诊断与治疗,改善胆管损伤患者的预后,中华医学会外科学分会胆道外科学组于2008年组织相关领域的专家制订了“胆管损伤的预防与治疗指南(2008版)”.该指南首刊于《中华消化外科杂志》,并多次在全国学术会议上向国内胆道外科医师解读和推广.此后,在广泛征集同行意见的基础上,基于循证医学的原则,指南编审委员会对有关胆管损伤的诊断和治疗关键问题进行循证评价,结合当前最佳证据和专家经验给予推荐意见,形成“胆管损伤的诊断和治疗指南(2013版)”.该版指南针对2008版共识做出以下重要修订:(1)针对胆管损伤诊断和治疗的关键问题提出推荐意见;(2)强化胆管损伤的诊断和治疗,删除原共识中胆管损伤的预防部分;(3)优化胆管损伤的分型系统;(4)补充内镜治疗胆管损伤的循证评价;(5)提出胆管损伤分期和分型施治原则.     

良性胆管狭窄的治疗现状

90%以上的良性胆管狭窄为医源性损伤所致,所以良性胆管狭窄亦被称为损伤性胆管狭窄.由于胆管狭窄的部位、程度、狭窄近远侧胆管的口径变化、管壁组织的病理改变各不相同以及术前并发症程度轻重不一,给治疗带来了许多的困难,故笔者就其治疗现状作一综述以引起临床重视.     

医源性胆管狭窄:胆道外科之痛

损伤性胆管狭窄多是涉及胆道外科时医源性引起.其导致的严重后果仍然是胆道外科之痛.随着肝脏外科与移植外科的发展和LC的广泛诮,损伤性胆管狭窄的模式正在改变.将胆道系统作为一个整体器官来对待和更多地保存其生理功能的完整性,可能是治疗损伤性胆管狭窄的发展方向.文中介绍了我们简化胆管损伤和胆管狭窄分类的建议.     

胆管空肠Roux-en-Y吻合术后上消化道大出血八例报告

胆管空肠Roux-en-Y吻合术(BJRoux-en-y)近年被广泛应用于治疗胆管结石、肿瘤及胆管损伤的修复.尽管该手术有许多优点,但术后并发症也不少见.本文报告BJRoux-en-Y 术后8例上消化道出血的有关临床资料,并探讨其原因和防治.     

胆管损伤的治疗

胆管损伤是肝胆手术的严重并发症.由于胆囊切除术的普及与腹腔镜胆囊切除术的广泛开展,使胆管损伤的发生率有增无减,胆管损伤后的处理较为困难,其在治疗上的复杂性、严重的并发症和后期的肝功能损害,是难治性胆道疾病,外科手术治疗是最为有效的方法之一.     

医源性胆管损伤分型及优化处理规范探讨

目的 研讨一种科学的胆管损伤分型标准,用以规范胆管损伤的诊断并指导临床治疗.方法 回顾分析52例胆管损伤的临床资料,研究其损伤特点、处理方式及治疗效果,并总结复习相关文献.结果 本组病例根据不同的胆管损伤类型,指导治疗方案,对术中及术后不同时期发现的胆管损伤,分别行一期胆道修复、外引流或胆肠吻合等不同方法合理处理,术后随访,发生胆道狭窄8例,11例常伴有右上腹不适,33例随访期恢复良好.结论 胆管损伤的疗效受损伤类型和恰当的处理方案等因素的影响.科学合理的胆管损伤分型和基于该分型而采取的处置原则,能减少并发症及提高治疗效果,可以作为胆管损伤后规范治疗的参考.     

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损伤性胆管狭窄 ,包括胆管的直接损伤与肝、胆、胃、胰术后不同时间发生的胆管狭窄 ,后者也多因前次手术损害了胆管的血运及胆管壁的完整性所致 ,是胆道外科的重要课题。　　随着胆囊切除术的普及 ,尤其是腹腔镜胆囊切除的开展 ,胆管损伤的发生率有明显增高趋势 ,一旦发生胆管损伤 ,尤其是术后延迟发生者 ,使治疗增加了复杂性与难度 ,由于多因素的影响 ,胆管狭窄的 (2年内 )复发率很高 ,由于反复进行的狭窄修复手术及反复发作的胆管炎 ,不仅使病人陷于痛苦之中 ,且可导致胆汁性肝硬化的发生 ,从而大大影响其确定性治疗的远期效果。　　因此 …     

高位胆管损伤及其处理

目的 探讨高位胆管损伤的原因、类型和处理方法.方法 回顾性总结分析了1998-2005年间对38例胆管损伤的诊治过程,其中腹腔镜胆囊切除术（LC）术中损伤24例,开腹胆囊切除术（OC）术中胆管损伤14例;高位胆管损伤21例.结果 所有胆管损伤病人均行手术治疗,分别行胆管对端吻合、胆管修补、肝管空肠吻合及胆管空肠吻合术.结论 LC手术发生胆管损伤多为高位胆管损伤,以行肝胆管空肠吻合术作为主要治疗手段,胆管损伤经手术修复后仍有一定术后并发症发生率.     

胆管端端吻合术在医源性胆管损伤中的临床应用探讨

目的 分析医源性胆管损伤胆管缺损较大的病例采用胆管端端吻合术的可行性、有效性和重要性.方法 回顾分析2006年3月至2012年10月期间共收治医源性胆管损伤胆管缺损较大的患者17例,其中BismuthⅡ型16例,BismuthⅢ型1例.均以7号丝线缝合十二指肠球部浆肌层和肝门板坚韧组织各一针,同时拉拢结扎,使二胆管断端在无张力下吻合重建.结果 17例胆管损伤患者经胆管端端吻合术均获痊愈,无再手术病例.结论 胆管端端吻合术对胆管缺损较大的医源性胆管损伤的治疗效果确切,能减少胆管损伤行端端吻合术后再手术的机会,可作为一种主要术式在临床上推广应用.     

LC 术胆管损伤的危险因素及术后分析

目的 分析LC 术胆管损伤的危险因素,并对胆管损伤术后进行分析.方法 回顾性分析本院1999 年10 月至2010 年12 月行LC 术的4 531 例患者所出现的41 例胆管损伤,对胆管损伤的各影响因素进行χ2检验,分析胆管损伤的独立危险因素;同时分析胆管损伤是否能在术中及时发现.结果 单因素分析显示:患者性别、炎症分期、B 超示胆囊壁厚度、胆囊三角解剖和手术经验与胆总管损伤有关联(P<0.05).多因素非条件Lo-gistic 回归分析结果显示:胆囊三角解剖和手术经验是胆管损伤的独立危险因素(P<0.05).胆管损伤术中发现例数明显多于术后发现例数(χ2=12.868,P<0.05).结论 患者性别、炎症分期、B 超示胆囊壁厚度、胆囊三角解剖和手术经验与胆总管损伤密切相关.胆囊三角解剖和手术经验是胆管损伤的独立危险因素.胆管损伤一般能在术中及时发现及处理.     

Mechanism, management, and prevention of bile duct injury in laparoscopic cholecystectomy

Injury to the bile duct is one of the most serious complications of laparoscopic cholecystectomy. The incidence of bile duct injury during laparoscopic cholecystectomy may be higher than during open cholecystectomy. Most of these injuries occur early in a surgeon’s experience with the new technique. The classical laparoscopic bile duct injury occurs when the common duct is mistaken for the cystic duct; the common bile duct is transected and a part of the extrahepatic biliary system is resected. The bile duct may also be injured by excessive diathermy, resulting in a bile leak or a stricture. Insecure clipping of the cystic duct may also result in bile leakage. If these injuries are not recognized at the time of surgery, they present as bile collections or jaundice postoperatively. ERCP will delineate the exact injury accurately. These injuries are preventable by careful attention to technique and a willingness to convert to open surgery when difficulties are encountered. To minimize the risk to patients, programs of training, proctoring, and accreditation in laparoscopic surgery should be established.     

Surgical treatment of bile duct injuries following laparoscopic cholecystectomy. Does the concomitant hepatic arterial injury influence the long-term outcome?

BACKGROUND: Bile duct injuries are the most dreaded complication associated with laparoscopic cholecystectomy. Recent collective reviews have outlined the management of bile duct injuries, but only few have reported on the significance of concomitant injuries of the right hepatic artery. This study was conducted to compare the outcome of patients with isolated bile duct injuries and patients with additional vascular injuries. PATIENTS AND METHODS: From January 1990 to February 2002, a total of 54 patients with bile duct injuries during laparoscopic cholecystectomy were surgically treated in our institution. In 46 patients a Roux-Y hepaticojejunostomy was performed. Eight patients underwent other surgical procedures and were not included in the statistical analysis. 11 patients had a concomitant vascular injury. Multivariate analysis was performed to evaluate the impact of vascular injuries. RESULTS: The rate of postoperative biliary complications was 21.7 % for all patients. Patients with combined bile duct and hepatic arterial injuries had a higher risk for the development of a biliary complication (6 of 11 patients (54.5 %) versus 4 of 35 patients (11.4 %); p = 0.006). After a median follow-up time of 61 months (range, 2-164 months) a successful overall outcome was achieved in 42 of 46 patients (91.3 %), which included the patients who required additional endoscopic or surgical treatment after primary reconstruction. The long-term outcome was successful in 9 of 11 patients (81.8 %) with combined bile duct and hepatic arterial injuries and in 33 of 35 patients (94.3 %) with solitary bile duct injury. CONCLUSION: The outcome of patients with combined bile duct and arterial injuries is worse than in patients with isolated bile duct injuries. We therefore recommend the evaluation of patients with major bile duct injuries for additional vascular injuries. Vascular reconstruction should be performed when ever possible in early recognised injuries to prevent late complications.     

胆道损伤的处理

目的 探讨胆道损伤的分类和临床特点。方法 回顾性分析临床资料，72例胆道损伤中，医源性49例，外伤性23例(胆总管下段损伤5例，胆总管上段／肝总管损伤50例，肝内胆管损伤17例)，经局部缝合、组织修补、胆肠吻合等方式治疗。结果 全组发生胆漏2例，死于胆道感染、出血2例；随访66例，发现胆道狭窄4例，结石复发3例。结论 应努力避免和及时发现胆道损伤，根据损伤部位、类型、程度、特点分类，采取不同方式修复胆道损伤，并保证修复后胆道血供良好。     

Ruptured retroperitoneal bile duct cyst. An extremely rare injury after blunt abdominal trauma

Management of a retroperitoneal extrahepatic bile duct cystenteric tear at a cystenteric malformation of the intra- and extrahepatic ducts (Todani IV-A) discovered during an emergency surgical procedure following an accident is presented and the problems associated with bile duct cysts are discussed. It is pointed out that acute treatment with a simple and safe method (external Kehr-T drainage) can be successful when injuries are present, although most trauma surgeon are seldom, and many never, directly confronted with injuries attributable to these extremely rare malformations.     

应用循证医学理念处置小切口胆囊切除术中医源性胆管损伤

目的 探讨小切口胆囊切除术中医源性胆管损伤的预防及处理措施.方法 回顾性分析1991年1月至2010年12月间我院45 306例小切口胆囊切除术的年医源性胆管损伤数量、比率及阶段性比率差异变化.结果 20年来共发生医源性胆管损伤32例,平均发生率为0.071％,低于大宗病例发生率的下限（1％）;尤其是后10年的损伤率更趋下降,为0.026％,与前10年相比有统计学差异（P＜ 0.05）.结论 小切口胆囊切除术是传统开腹式胆囊切除术在技术上和方法上的一个大的改进和发展,预防医源性胆管损伤至关重要,具有特殊意义.术者只要做到思想重视、规范操作,可以减少胆管损伤或将严重胆管损伤降低到最低限度.     

医源性胆管损伤的治疗及疗效分析

目的探讨医源性胆管损伤的防治方法及疗效。方法回顾性分析30例医源性胆管损伤病人的临床资料。结果术中发现胆管损伤并及时修复9例,其中1例术后发生狭窄而再次手术治愈;另21例术后因胆管狭窄或胆漏确诊,2例行副肝管缝扎术,3例行胆管端端吻合T管引流术,16例行胆肠Roux-en-Y吻合。疗效优者22例、良5例、差1例、死亡2例(1例死于胆漏感染,1例死于胆汁性肝硬化)。结论医源性胆管损伤重要在于术中及时发现和及时处理,采取胆肠Roux-en-Y吻合治疗可取得较好疗效。     

Simple laparoscopic ultrasound technique for prevention of bile duct injuries

BACKGROUND: Bile duct injuries are serious complications of laparoscopic cholecystectomy. Laparoscopic ultrasonography (LUS) has been utilized over the last several years to screen for bile duct calculi and to delineate biliary anatomy. We have found a simple LUS scanning technique that can be useful for preventing bile duct injuries. METHOD: After initial scanning for screening, laparoscopic dissection is continued, isolating the cystic duct. If necessary, scanning can be performed to assure the location of the cystic duct before clipping. After clips are applied to the cystic duct, prior to its incision or transection, LUS is repeated to examine the cystic and bile ducts. RESULTS: This postclipping study can confirm that the clips are applied to the cystic duct and that the hepatic and common bile ducts are intact without occlusion. CONCLUSION: This additional LUS scanning maneuver is simple and quick and may help prevent bile duct injuries.     

腹腔镜下处理腹腔镜胆囊切除术胆道和胃肠道损伤

目的评价腹腔镜下处理腹腔镜胆囊切除术后胆道和胃肠道损伤. 方法 1991年10月～2002年12月,完成连续无选择腹腔镜胆囊切除术和腹腔镜胆囊切除联合胆道探查9 016例,其中发生胆道损伤14例(0.15%),胃肠道损伤3例(0.03%).其中1例胆管横断伤、10例胆管部分损伤、1例胃损伤、2例十二指肠损伤均在腹腔镜下修补. 结果 1例胆道损伤腹腔镜下修补术后胆漏,1年后发生胆道狭窄,其余均痊愈出院. 结论胆道部分损伤及胃肠道损伤可在腹腔镜下处理,对于胆道横断伤的腹腔镜处理,需进一步探讨.     

医源性总胆管远段损伤的术中诊治与预防

目的 探讨医源性总胆管远段损伤的术中诊治及预防.方法 回顾性复习1990年2月至2005年2月湖南省人民医院收治的22例医源性总胆管远段损伤的病例.结果 取石钳入腹膜腔(95.5%),注水试验阳性(100%).长臂T管支撑总胆管是有效的手段.全组18例获得随访,平均20.8个月,效果满意.结论 术中胆扩裸露征、注水试验是总胆管远段损伤的有效诊断手段.遵循浅、通、撑、抑四字外科原则,可获满意效果.满意的术野显露是有效的预防措施.

Abstract：

Objective To review the diagnosis and causes of iatrogenic injury to the distal choledochus at operation. Method The case notes of the patients with bile duct injuries that were treated in my Department from 1990.2-2005.2 were reviewed. Results To detect distal bile duct injuries, a sound in the bile duct had an accuracy rate of 95 % while injection of water into the bile duct to detect leakage had an accuracy rate of 100%. Using a long arm T tube in the common bile duct was an effective method to treat the injury. In 18 patients with an average follow-up time of 20. 8 months, the results were satisfactory. Conclusions Injecting water into the bile duct to diagnose distal common bile duct injury at operation was an effective way to detect distal bile duct injury. Adequate exposure of the opeative field is the best method to prevent bile duct injury.