医源性胆道损伤的诊治：附52例报告

目的:总结医源性胆道损伤的经验教训。 方法:对52例医源性胆道损伤患者的临床资料进行回顾性分析。 结果:胆道手术所致48例(92.3%)，胃大部切除术及肝脏手术所致各2例（共7.7%）。损伤部位在肝总管与胆总管交界处34例(65.4%)，肝总管6例(11.5%)，胆总管6例(11.5%)，左右肝管汇合部4例(7.7%)，左、右肝管各1例(共3.8%)。胆管完全性损伤30例(57.7%)，部分性损伤22例(42.3%)。所有病例均行手术处理。术中立即发现8例，采用直接修补或对端吻合、T管支撑引流术5例，直接置合适T管引流1例，肝总管与空肠Roux-en-Y吻合术1例，效果均满意；另1例行胆总管十二指肠吻合术，3年后因吻合口狭窄再次行肝管空肠Roux-en-Y吻合术治愈。术后发现的44例，行肝管空肠Roux-en-Y吻合术31例，肝总管与十二指肠吻合8例，胆总管置管引流2例，胆总管缺损用空肠瓣修补术1例，肝内胆管与空肠Longmire吻合术1例，拆除胆总管前后壁之间缝线1例。全组死亡4例，生存48例中41例获随访，疗效优良率为82.9%，疗效差的7例分别于术后2个月至5年再次作胆肠Roux-en-Y吻合术治愈。结论:要警惕医源性胆道损伤的发生，及早诊断、及早修复胆道的连续性是提高疗效的关键。手术方式根据损伤部位、类型、损伤后发现的时间具体决定，以胆管空肠Roux-en-Y吻合术的疗效最佳。

Diagnosis and treatment of iatrogenic bile duct injury:a report of 52 cases

Objective To summarize the experiences and lessons drawn from iatrogenic bile duct injury. Methods The clinical records of 52 patients with iatrogenic bile duct injuries were studied retrospectively. Results The injuries of 48 cases were resulted from extrahepatic bile duct operation,2 cases from partial gastrectomy and 2 cases from hepatectomy.The locations of injuries were at the juncture of common hepatic duct and common bile duct in 34 cases, the common hepatic duct in 6 cases ,the common bile duct in 6 cases ,the juncture of left and right hepatic duct in 4 cases,and the left and right hepatic duct each in 1 case respectively.Complete bile duct injuries were seen in 30 cases,and partial injuries in 22 cases .All patients were treated by operation. 8 cases were immediately discovered at the time of the initial operation and direct repair or end to end anastomosis with T tube stent was done in 5 of the cases,direct insertion of T tube drain in 1 case and Roux en Y hepaticojejunostomy in 1 case, all with good results;and in the another, a choledo choduodenostomy was performed,but re operation by Roux en Y hepaticojejunostomy was done 3 years later,due to stricture of the anastomosis.For the 44 cases in which the bile duct injury was detected after the initial operation, Roux en Y hepaticojunostomy was done in 31 cases,hepaticoduodenostomy in 8 cases, drainage of common bile duct in 2 cases,plastic repair of common bile duct defect with jejunal flap in 1 case, hepaticojejunostomy (Longmire) in 1 case,and removal of stitches between the anterior and posterior wall of the common bile duct in 1 case.In the whole series,4 patients died,and 41 of 48 surviving patients were followed up.The excellent result rate was 82.9%,and 7 cases with poor results were cured by reoperation with Roux en Y cholangiojejunal anastomosis 2 months to 5 years after operation. Conclusions The key to improvenment of treatment results of iatrogenic bile duct injury is awareness of its acurrence,early diagnosis , and eraly repair of the bile duct.The method of surgical therapy depends on the location and type of injury,and the time of detection after the injury.Roux en Y cholangiojejunal anastomosis gives the best results.