肝胆胰术后胆汁漏21例处理体会

目的评估肝胆胰术后出现的各种胆汁漏的结局，分析其原因，提出预防和相应的治疗措施。方法回顾性分析我们治疗的肝胆胰术后胆汁漏21例，主要包括肝叶或半肝或多肝段切除后胆汁漏6例；各类开腹胆石病手术后7例；腹腔镜胆囊切除致右副肝管和迷走胆管损伤各1例；胆肠内引流术3例；胰十二指肠切除术后2例；ERCP和EST胆总管取石、胆总管十二指肠后段及胰腺段损伤1例。结果术后胆汁漏的主要原因是肝断面管道组织结扎不可靠，各种类型的肝外胆管损伤，胆囊管处理不满意，T管旁或针眼漏胆汁，胆肠吻合不完善等。21例术后胆汁漏病人中8例（38％）需要再次手术，术后8例均痊愈。21例术后胆汁漏病人中13例（62％）适合非手术治疗，其中12例痊愈；1例死于术后多器官功能衰竭，总体死亡率为5％（1／21）。结论肝胆胰手术中精细操作是预防术后胆汁漏的主要举措。当病人出现胆汁性腹膜炎、胆管损伤、肝下大量积液和经久不愈的胆汁漏时应及时手术，手术方式应根据具体情况决定，胆管修复、胆管支撑和腹腔引流是有效的治疗手段。

Management experiences of bile leakage after hepatobiliary and pancreatic surgery: a report of 21 cases

Objective To evaluate the outcomes of bile leakage after hepatobiliary and pancreatic surgery and analyze the causes and propose preventive and treatment measures. Methods Twenty-one cases of bile leakage after hepatobiliary and pancreatic surgery were analyzed retrospectively, including lobectomy or hemihepatectomy or multi-segmentectomy, accounting for 1.2%（6/510） over the same period in liver surgery and various types of open abdominal operation of cholelithiasis （n = 7）, accounting for 0. 5% over the same period of bile duct operation （7/1400）; right hepatic duct damage （n = 1） and vagus bile duct injury after laparoscopic choleeystectomy （n = 1 ）, accounting for 2. 0% over the same period of laparoscopic cholecystectomy （2/100） ; biliary enterostomy （n = 3）, accounting for 4% over the same period of enterostomy （3/75） ; panereaticoduodenectomy （n = 2）, accounting for 8% over the same operative period （2/25） ; common bile duct of pancreatic segment and duodenal injury af- ter ERCP and EST common bile duct stone removal （n = 1）. Results Eight cases of 21 postoperative bile leakage patients 38% （8/21） required reoperation and recovered. The remaining 13 cases （62 N） were treated conservatively. And 12 cases （92%） became cured. One case of pancreaticoduodenectomy died of multiple organ failure. Conclusions Most patients of bile leakage may be cured through abdominal bile drainage, anti-infection treatment and nutritional supports. Operation should be performed timely for peritonitis, bile duct injury, massive infrahepatic fluid and prolonged and unhealed bile leakage. Surgical approach decision should be based on specific patient circumstances. Bile duct repair, supporting care and abdominal bile drainage are effective measures.