医源性胆管狭窄的预防与处理

医源性胆管损伤所致的胆管狭窄是胆道外科中一个病变复杂、处理困难的问题。胆管损伤若未能及时发现，则可产生严重的并发症；胆管狭窄若处理不当，则可造成严重后果，甚至可危及生命。随着胆道外科手术的普及和腹腔镜胆囊切除术的开展，胆管损伤近几年有增多的趋势，约占0．1％～0．5％[1]。美国每年约有2250例医源性胆管损伤[2]。1胆管损伤及胆管狭窄的原因及预防1．1胆囊切除术中损伤胆管是胆管损伤的主要原因在医源性胆管损伤中，约90％见于胆囊切除术，5％为胆总管探查引流术，3％为胃切除术，2％为十二指肠慈室切除术、门腔静脉分流术…     

注意胆道解剖变异,减少医源性胆管损伤

注意胆道解剖变异，减少医源性胆管损伤第四军医大学西京医院肝胆外科（ｕ００３２）高志清医源性胆管损伤是胆囊切除术中最严重的并发症，轻者给患者造成多次手术痛苦和沉重经济负担，重者甚至死亡．为减少或避免胆管损伤，在胆囊切除或其他手术时应注意胆道的解剖变异。...     

医源性肝外胆管损伤的处理和预防

医源性肝外胆管损伤的处理和预防上海市第七人民医院（２００１３７）费学明随着胆囊结石病人的增多及胆囊手术的普及，在胆囊切除术中医源性胆道损伤时有发生，预防术中胆道损伤及损伤后处理的研究，已显得十分重要。本文总结近３０年来在我院发生的医源性胆道损伤１０例...     

支撑引流治疗胆管缺损性损伤的体会

医源性胆管缺损性损伤大多发生在胆囊切除术或胆道手术过程中 ,发生率为 0 .2 %～ 0 .6% [1,2 ] 。近十年来 ,随着腹腔镜胆囊切除术的普遍开展 ,胆道损伤的并发症似有增多趋势。胆管一旦损伤 ,若首次处理不当 ,则可引发一系列严重的并发症 ,导致胆管狭窄、慢性胆管炎反复发作 ,最终形成胆汁性肝硬化和门静脉高压症 ,甚至造成终身残疾 (胆道残废[1] )。我院采用支撑引流方法治疗一组胆道损伤 ,获得较好疗效 ,现报告如下。1　临床资料　　例 1,女 ,4 9岁 ,因慢性胆囊炎、胆囊结石于 1993年 11月行腹腔镜胆囊切除术。手术后第 13天确诊为胆汁性…     

腹腔镜胆囊切除术中胆道变异的处理

腹腔镜胆囊切除术中胆道变异的处理云南曲靖地区第二人民医院（６５５０００）荀祖武腹腔镜胆囊切除术和开腹胆囊切除术一样，需正确识别和处理先天性胆道变异，以减少医源性胆管损伤和胆漏这些严重的手术并发症。与胆囊切除术有关的胆道变异可分为三类：１．胆囊形态和位...     

胆囊切除术式的选择与医源性胆管损伤（附12例报告）

目的 分析胆囊切除术式的选择，对造成医源性胆管损伤的影响，探讨造成损伤的原冈及预防措施。方法 对我院1990年6月～2005年12月12例医源性胆管损伤进行回顾性分析。结果 传统开腹胆囊切除术1660例，发生医源性胆管损伤4例（0．24％），小切口胆囊切除术590例，发生医源性胆管损伤3例（0.51％），腹腔镜胆囊切除术415例，发生医源性胆管损伤5例（1．20％）。结论 医源性胆管损伤预防是关键，熟练掌握各种月日囊切除术式的适应证和禁忌证，医源性胆管损伤是可以尽量减少和避免的。     

术中胆道意外损伤的处理

随着胆囊切除术在各级基层医院的广泛开展，使得术中胆道意外损伤屡有发生。大量的临床实践表明，对损伤胆道的处理绝不可轻视，若处理不当将会给患者带来严重的后果甚至危及生命。尤其值得注意的是，近年来胆道损伤重建术后远期胆道狭窄的报道逐年增多。以我院为例，自１９９０年以来我们共诊治医源性胆管损伤４３例（本院２例，外院转入４１例）。其中，７例是基层医院行胆囊切除术后一周内出现黄疸或胆漏后立即转入我院；另３６例因术中胆道损伤而在各级医院施行“正确的”修复或重建术，“康复”一段时间后又出现梗阻性黄疸、肝内胆管结…     

医源性肝外胆管损伤14例分析

胆囊切除术是腹部外部最常见的手术之一 ,医源性胆管损伤是胆道手术中不常见的并发症 ,据文献 [1] 报道 ,开腹胆囊切除术致胆管损伤的发生率为0 .1 8%～ 2 .3 % ,平均 0 .44% ,如果发生胆管损伤后未能及时发现和正确修复 ,将造成严重后果 ,且处理极为困难 ,医源性胆管损伤的问题日益受到临床医师的重视 ,胆管损伤的预防及处理已成为胆道外科的突出问题。为此笔者就 1 998年以来本科收治的1 4例医源性胆管损伤患者的治疗体会 ,报告如下。1　临床资料1 .1　一般资料本组 1 4例 ,男性 8例 ,女性 6例 ,年龄 1 6～ 72岁 ,4例发生于本院 ,其余 1 0…     

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.     

处理医源性胆管损伤的若干体会

医源性胆管损伤在各级医院屡有发生,在胆囊切除术中胆管损伤是最严重的并发症,轻者给患者造成多次手术痛苦和沉重的经济负担,重者造成胆道残废,甚至造成患者死亡;同时医源性胆管损伤还常引起医疗纠纷,给医院造成不良影响.因此,在胆囊切除中要特别警惕医源性胆管损伤,在术中预防胆管损伤是十分重要的.     

超声刀腹腔镜胆囊切除术胆管损伤的特点和处理

目的 探讨超声刀无钛夹法腹腔镜胆囊切除术(UHS-LC)胆管损伤的特点、处理方法及预防措施.方法 回顾性分析近5年行UHS-LC1863例的临床资料,11例发生胆管损伤,全部经手术修复,随访1～5年.结果 11例胆管损伤分别为:右肝管损伤3例,肝总管损伤2例,胆总管横断3例,胆总管穿孔2例,胆总管横断合并左、右肝管同时损伤1例;损伤于手术中发现9例,手术后发现2例.11例患者共施行再手术13次,无胆管狭窄,无死亡病例.结论 手术时一定要弄清肝总管、胆总管与胆囊管三者的关系,采用顺逆相结合的方法,遵循"辨-切-辨"原则,腹腔镜下打结技术对术者要求较高,尤其是三孔法LC,过分牵拉Calot三角易造成出血和副损伤,在靠近胆总管的地方尽量使超声刀刀头的背面朝上,并且其背面绝对不能直接接触胆总管,术中及术后早期发现胆管损伤者,应即刻妥善处理.     

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。     

医源性胆总管远段损伤的临床分析

目的探讨医源性胆总管远段损伤早期诊断及腹膜后严重感染的预防。方法 回顾分析1990年至2004年间处理的17例医源性胆总管远段损伤患者的临床资料。结果 17例患者中,15例为术中损伤,2例为ERCP切开取石所致。术中发现胆管损伤14例,术中未及时发现者1例。胆管损伤前行B超检查16例,MRCP检查2例,6例在胆道探查后行胆道镜检查。10例行胆总管穿孔修补加T管引流,2例行Oddi括约肌切开成形术,2例行胆肠吻合术,1例行十二指肠及胆管修补腹膜后引流术。胆管损伤后术中表现为胆道探子异位于胆管壁外,胆道镜见到胆管远段有2个或多个孔隙,经T管注水见腹膜后水肿和积液,注入美蓝出现腹膜后蓝染。损伤后临床表现为腹胀、发热、腰背胀痛、休克等。治愈13例,术后并发症包括十二指肠瘘1例,切口感染1例,死亡4例,其中3例死于感染性休克,1例死于胃切除术后再出血。结论 胆道远段损伤术后表现缺乏特异性,对可疑患者应作CT检查,早期诊断胆总管下段损伤并进行及时治疗可以取得较好效果。术前完善的影像学检查及在胆道探查前进行胆道镜检查有可能减少胆总管远段损伤。     

Postoperative management of noniatrogenic traumatic bile duct injuries: role of endoscopic retrograde cholangiopancreaticography

BACKGROUND: Endoscopic therapy for iatrogenic bile duct injuries is well established. Abdominal trauma-related biliary injuries, however, are complex in nature. The role of endoscopic therapy for these patients needs further evaluation. METHODS: A retrospective study investigated nine patients who had surgery for abdominal trauma (4 gunshot, 4 crush, and 1 stab injury), presented postoperatively with noniatrogenic biliary injuries, and underwent endoscopic retrograde cholangiopancreaticography (ERCP). RESULTS: The ERCP was successful for all the patients. Eight patients had significant bile leak at intra- or extra-hepatic sites, and one patient was discovered to have complete cutoff of the common hepatic duct. All bile leaks were treated successfully using biliary sphincterotomy with or without transpapillary stenting. No complications of ERCP were observed. CONCLUSIONS: In this case series, ERCP was found to be useful as a diagnostic and therapeutic method for managing noniatrogenic traumatic biliary injuries in patients who had undergone previous surgery for abdominal trauma. The ERCP results were similar to those for iatrogenic bile duct injuries.     

医源性胆道损伤的预防及治疗措施

目的探讨医源性胆道损伤的预防和治疗措施。方法对36例医源性胆道损伤的临床资料进行回顾性分析。结果36例共施行手术41次,其中2次手术者5例。最后1次手术方式为胆管端端吻合2例,胆管壁缺损修补4例,单纯缝线拆除3例,胆管空肠R oux-en-Y吻合27例。28例随访1~8年,优良率90%。结论胆囊切除术是医源性胆道损伤的主要原因,是可以避免的。胆管空肠R oux-en-Y吻合术是医源性胆道损伤或损伤性狭窄修复重建的首选方法。     

医源性胆道损伤的外科治疗

目的：探讨医源性胆道损伤的原因、诊断、手术时机和手术方式的选择。方法：对28例胆道损伤进行分析总结：分别施行了胆管修补术3例、胆管端端吻合术2例和胆肠吻合术23例。结果：全组无围手术期死亡，4例术后出现胆管狭窄而再次手术，其余愈后良好。结论：尽早发现、及早正确处理对提高疗效和预防术后胆管狭窄起着决定性的作用。术中发现胆管损伤立即行端端吻合或修复加T管引流；术后数天发现或多次重建术失败，则宜行规范的胆肠Roux-en-Y吻合术。     

Is there a place for laparoscopy in management of postcholecystectomy biliary injuries?

Despite its minimal invasiveness, laparoscopic cholecystectomy (LC) carries unquestionably higher morbidity and mortality rates when compared with the open counterpart (OC). Among the iatrogenic injuries, biliary tract lesions are the most clinically relevant because of their potential for patient's disability and long-term sequelae. No universal agreement exists for classifying these lesions, but numerous authors have advocated a distinction between bile leaks and bile injuries. Even if not entirely correct, bile leaks refer to fistulas from minor ducts in continuity with the major ductal system or from accessory ducts (as the duct of Luschka). Biliary injuries are major complications consisting of leaks, strictures, transection, or ligation of major bile ducts. While bile leaks are typically treated by percutaneous and/or endoscopic drainage and stenting, biliary injuries often require a combined radiology-assisted and endoscopic approach or even conventional surgery. The role of laparoscopy in the management algorithm of biliary lesions is still anecdotal. To date, a total of 25 cases of laparoscopic drainage of post-cholecystectomy bilomas have been reported in the literature, whereas there is no mention of laparoscopic primary repair of biliary injuries detected at or after cholecystectomy. The main reasons depend on the excellent results achieved by the ancillary techniques; the emergency settings that accompany more complex biliary lesions; the technical challenges posed by the presence of inflammation, collections, and obscured anatomy; and the potential for malpractice litigation. However, a sound laparoscopic technique and a strict adherence to basic surgical tenets are crucial in order to avoid the incidence of iatrogenic biliary injuries and reduce their still unknown impact on long-term patient disability.     

Surgical management of bile duct injuries following laparoscopic cholecystectomy: analysis and follow-up of 28 cases

BACKGROUND: Biliary tract lesions pose a dreaded complication of laparoscopic cholecystectomy. In a retrospective study we analyzed the clinical presentation, diagnostic and therapeutic management and outcome of 28 patients presenting with iatrogenic bile duct injuries. PATIENTS AND METHODS: Between 1994 and 2001 we treated 28 patients with bile duct lesions following laparoscopic cholecystectomy at our center. Operation notes and charts of all patients were reviewed systematically. A follow-up examination of each patient was performed after a median of 12 months (range 1-90). RESULTS: Twenty-two patients presented with major circumferential bile duct defect lesions. Less severe injuries (n=6) were two minor bile leaks, one bile duct stricture and three tangential lesions. Twenty-six patients were referred to our institution within 16 days (range 0-226 days). Six patients were treated by nonsurgical procedures: endoscopic stenting in four and percutaneous intervention in two. In one of the remaining patients a cystic duct leak was closed via laparotomy, and in 21 a hepaticojejunostomy was performed. Reconstruction of a hepaticojenunostomy was performed in two of these patients. Patients were dismissed from the hospital after a median of 13 days (range 4-156). Four patients presenting with generalized biliary peritonitis required prolonged intensive care. One or more episodes of cholangitis were seen in five patients during follow-up examinations. CONCLUSIONS: Major iatrogenic bile duct injuries are associated with high morbidity and prolonged hospitalization. Interdisciplinary cooperation and early referral to an experienced center is crucial in the management of patients suffering from this affliction. Cholangitis is a marked problem in the follow-up.     

医源性胆道损伤52例报告

目的:总结医源性胆道损伤的经验教训。方法:对过去33年间5 2例医源性胆道损伤进行回顾性分析。结果:肝外胆道手术所致4 8例,胃大部切除术及肝脏手术所致各2例。损伤部位在肝总管与胆总管交界处34例,肝总管6例,胆总管6例,左右肝管汇合部4例,左、右肝管各1例。胆管完全性损伤30例,部分性损伤2 2例。结论:要警惕医源性胆道损伤的发生,及早诊断并修复胆道的连续性是提高疗效的关键     

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。