胆管宽口径端端吻合术在胆管损伤修复中的应用

胆管损伤临床并不鲜见,开腹胆囊切除术及腹腔镜下胆囊切除术致胆管损伤的实际发生率远较报道的高。随着腹腔镜胆囊切除术在基层医院的开展和普及,胆管损伤的发生率有升高趋势。胆管吻合口发生缩窄性病理改变是术后必然事件,如处理不当,致残、致死率高。且损伤的部位、程度及发现损伤的时间不同,伤后修复手术时机和手术方式的选择一直存在争议。我们设计的一种胆管宽口径端端吻合法即时修复22例胆管损伤,现报道如下。     

医源性胆管损伤及狭窄的防治（附54例报告）

1980～1996年，作者共收治医源性胆管损伤及狭窄病人54例。其中发生于胆囊切除术47例，发生于胃大部切除术7例。10例行胆管端端吻合术．37例行胆管空肠Roux-Y吻合术。17例行3次以上修复手术。结果51例痊愈，3例死亡。讨论了医源性胆管损伤的预防和不同时期的损伤处理.     

医源性肝外胆管损伤一期修复手术方式选择体会

医源性肝外胆管损伤尤其是腹腔镜胆囊切除术（1aparoscopic cholecystectomy,LC）所致的胆管损伤已成为现代肝胆外科疑难问题。肝外胆管损伤的一期修复,目前主要有胆总管空肠端端吻合术与胆肠侧侧Roux-en-Y吻合术。回顾性分析我院1998年7月至2009年3月收治的医源性肝外胆管损伤27例的临床资料,对两种术式进行分析比较,现报告如下。     

医源性胆管损伤27例分析

目的 探讨医源性胆管损伤的原因、诊治及预防。方法 回顾性分析２７例医源性胆管损伤。结果 医源性胆管损伤多发生于胆囊切除术，原因主要有人为因素及客观原因，包括胆道解剖异常、局部病理因素、术中出血及手术麻醉情况等。对术后黄疸的病人，ＰＴＣ及核磁共振胆道成像（ＭＲＣＰ）检查可明确诊断并能确定梗阻部位，各种类型的胆管损伤应采取不同方法及早处理，对胆漏先行胆道及腹腔引流术，３个月后再作胆道重建术，手术方法以     

胆囊切除术致胆管损伤29例分析

目的 探讨胆囊切除术致胆管损伤的原因、诊断方法及处理原则。方法 回顾性分析29例胆囊切除术致胆管损伤的临床资料。结果 29例行胆管修补术或胆管空肠Roux—en—Y吻合术，3例术后再次出现胆管狭窄，经再次手术后痊愈。结论 预防损伤是关键。胆管损伤的及时发现，及时处理是治疗成功的关键。应根据损伤的情况和术后发现的时间选择不同的处理方法。     

腹腔镜胆囊切除胆管损伤一期修复22例

回顾性分析腹腔镜胆囊切除术（LC）并发胆管损伤22例的相关临床资料。瞪管空肠Roux-en-Y吻合加胆管内支撑引流12例,胆管缝合放置T型管内支撑引流6例,胆管直接缝合未置T型管内支撑引流1例,用肝圆韧带修补置T型管内支撑引流2例,用带蒂胆囊壁修补置T型管内支撑引流1例。术后随访6个月～5年（平均36个月）,效果优良21例（95．45％）;效果差1例。结合文献分析,医源性胆管损伤早期发现、早期处理效果较满意。胆管缝合修补加T型管内支撑引流和胆肠Roux-en-Y吻合加胆管内支撑引流为早期疗效较好的方式。     

胆管变异及胆管损伤的处理分析

病例资料1997年10月至2010年8月期间我们收治处理8例胆管变异及胆管损伤的患者,其中男5例,女3例;年龄29～64岁,平均43.1岁。其中开放性胆囊切除术(OC)4例,腹腔镜胆囊切除术(LC术)4例。3例为OC术中发现,其中1例为OC术中胆总管横断伤,术中行胆总管     

医源性胆管损伤的原因及处理

目的:探讨医源性胆管损伤的原因及处理方法。方法:对21例医源性胆管损伤的临床资料进行回顾性分析。结果:本组21例病人,20例痊愈出院,1例死亡。2例因术后胆管狭窄再手术治愈;胆管空肠Roux-en-Y吻合术为最佳手术方式。结论:胆管损伤的根本原因是没辨清胆总管、肝总管及胆囊管。胆管损伤的处理根据发现时间、部位、程度,选择不同的方法。     

Kasai肝门空肠吻合术在医源性高位胆管损伤手术中的应用

目的总结Kasai术(肝门空肠吻合术)治疗医源性高位胆管损伤的临床价值。方法回顾性分析1994年3月～2006年1月18例因医源性高位胆管损伤而采用Kasai肝门空肠吻合加胆管外引流术的临床资料。结果术后随访15例,平均时间3.5年(3个月～11年),优良率为86.7%(13/15)。差2例,分别于术后1年和拔管后2年内多次胆道感染。结论Kasai肝门空肠吻合加胆管外引流术是治疗医源性高位复杂胆管损伤的简单而有效的方法。     

医源性肝外胆管损伤的原因及处理

目的 探讨医源性胆管损伤的原因及处理。方法 综合国内４家医院收治的１８２例医源性肝外胆管损伤的临床资料,进行回顾性分析。结果 １７２例经行胆管对端吻合或胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术恢复良好,病死率５．５％（１０／１８２）。结论 胆囊切除术时应认清胆囊三角解剖关系,单纯胆囊切除时,应行逆行胆囊切除术。胆管损伤应尽早发现,及时处理。根据损伤的情况和术后时间选择不同的处理方法。     

胆囊切除术胆管损伤的原因分析与处理

目的探讨胆囊切除术导致胆管损伤的原因及损伤后的处理方式。方法对21例胆囊切除术引起胆管损伤的损伤原因及处理方式的临床资料进行回顾性分析。结果损伤原因主要有：（1）胆囊急性炎症期进行手术8例,（2）经验不足5例,（3）Calot三角结构不清3例和解剖变异3例,（4）术中出血导致损伤2例。在处理方式上,本组有3例在术中发现胆管损伤后即时进行修复,12例在术后14d内修复,均取得良好的效果。另外6例在损伤后15d-95d之间进行修复,其中4例恢复良好,1例术后存在慢性胆管炎,死亡1例。绝大部分17例的病例采用胆管空肠Roux-en-Y吻合术,恢复良好15例。结论胆囊切除术导致的胆管损伤应由有经验的肝胆外科专科医生进行修复．早期修复是可行的,胆管空肠吻合术是首选的手术方式。     

Repair of bile duct injuries with gore-tex vascular grafts: Experimental study in dogs

Bile duct injury is the most feared complication related to biliary tract operations. The goal of this investigation was to offer an alternative treatment that might prevent this complication. Twelve mongrel dogs, thin-walled FEP-ringed Gore-Tex vascular grafts, and Gore-Tex sutures were used in this study. The dogs were randomized into three groups of four according to the length of time of graft implantation: group 1 = 1 month; group 2 = 2 months; and group 3 = 3 months. During the first part of the study, a biliary injury was induced by ligating the middle choledocus after performing a conventional cholecystectomy. During the second part of the study, biliodigestive and biliobiliary anastomosis were performed using Gore-Tex vascular grafts prior to resection of the stenotic area. Initially, an increase in serum bilirubin and alkaline phosphatase levels was noted. Two weeks later, after implantation of the grafts, these values returned to normal. Thin-walled FEP-ringed Gore-Tex vascular grafts were found to be useful in the repair of bile duct injuries, especially in complete transections of the common bile duct. The ductility and flexibility of the material allows any type of anastomosis to be performed, especially when bile duct-gut anastomosis is technically difficult. Presented at the Third Americas Congress of the American Hepato-Pancreato-Biliary Association, Miami, Fla., Feb. 22–25, 2001.     

Acute bile duct injury

Background: An immediate repair is considered optimal in acute biliary duct injuries; however, it may prove to be a challenge, because such repairs are usually performed on small ducts whose viability cannot always be determined. Methods: We performed a retrospective review of the charts of patients with acute bile duct injury who underwent repair at a tertiary care academic university hospital. A total of 204 patients with acute bile duct injury were seen between 1989 and 2002. Of these, 30 were repaired within minutes to hours after the injury. These patients were divided into two groups. Group I patients had a Roux-en-Y hepatojejunostomy below the hepatic junction; Group II patients had a Roux-en-Y hepatojejunostomy at the junction level. We then performed a long-term evaluation of anastomosis function in these patients, using clinical, radiological, and laboratory. Results: Twenty-eight injuries were secondary to a laparoscopy; the other two resulted from open cholecystectomies. All of the patients suffered complex injuries with complete section of the duct and substance loss (Strasberg E). There were 12 patients in group I and 18 in group II. Three cases in group I (25%) and one in group II (5%) developed anastomosis dysfunction. Mean follow-up was 56 months (range, 12–80) in group I and 52 months (range, 10–76) in group II. Two cases in group I (16%) and none in group II (0) required reoperation (p < 0.05). Conclusions: In the acute setting, complex lesions should be treated with a high bilioenteric anastomosis (at the junction level) in the first attempt at repair. Lower-level anastomoses are associated with a higher dysfunction rate and the need for radiological manipulation and reoperation. Also, stenosis of the anastomosis secondary to undetected duct ischemia in the acute repair is more frequent in low bilioenteric anastomoses.     

胆肠Roux-en-Y吻合术在胆道再次手术中的应用

目的 探讨胆肠Roux-en-Y吻合术在再次胆道手术中的应用.方法 对2005年1月～2012年5月我院再次胆道手术中行胆肠Roux-en-Y吻合的临床病例资料做回顾性分析.结果 130例围手术期无死亡病例,术后并发伤口感染2例,胆漏、肠瘘、胰瘘各l例,经保守治疗后,均治愈.结论 胆肠Roux-en-Y吻合是复杂、再次胆道手术重要的手术方式,但应该严格掌握其适应症及注意事项.     

医源性胆管损伤的严重后果

目的探讨胆囊切除术中严重医源性胆管损伤的原因、处理方法、经验教训与预防对策。方法回顾性分析本院1992年10月至2005年4月共处理的202例医源性胆管损伤中9例（4．45％）致严重后果者的临床资料，以致死致残（胆道残废），处理棘手，引发医疗纠纷及耗资巨大，判定为严重后果。结果严重医源性胆管损伤中5例死亡；4例为胆道残废，赔款或继续医疗费用巨大。结论胆囊切除术或胆道探查术中注意规范性、轻柔操作、认真细致、谨慎的作风、熟悉解剖等能有效避免胆管损伤；胆管损伤后及时发现并处理效果良好；防重于治。     

腹腔镜胆囊切除术胆管损伤术后胆漏的处理

目的:总结腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)胆管损伤术后胆漏的预防与处理。方法:回顾分析2000年1月至2008年6月我院9例LC胆管损伤术后胆漏患者的临床资料,总结胆漏的原因、预防措施及处理。结果:9例全部痊愈出院。随访3~60个月无黄疸、发热等胆管炎症状。结论:LC胆管损伤后胆漏重在预防。肝内胆管分支损伤及肝外胆管侧壁损伤可采取保守治疗,腹腔引流联合内镜治疗明显缩短病程。肝外胆管横断伤需腹腔引流4周,周围炎症基本消退再行肝门胆管盆式空肠内引流术。     

开腹胆囊切除术致胆管损伤的防治(附58例分析)

目的探讨开腹胆囊切除术致胆管损伤的预防和处理。方法回顾近３０年北京３家医院开腹胆囊切除术致胆管损伤５８例,分析损伤的部位、类型、发现时间、手术方法和治疗效果。结果本组５８例,痊愈出院５５例,治愈率达９４９％,手术死亡率５１％,随访４４例,随访率８０％,随访平均时间７３年。２例因再次狭窄手术治愈。结论预防损伤是关键。胆囊炎手术处理原则、切除胆囊的方法以及规范手术操作是值得重视的。胆管损伤的处理应根据发现的时间、部位、类型等选择不同的方法。     

腹腔镜胆囊切除术中胆管损伤的预防

目的总结腹腔镜胆囊切除术中胆管损伤的原因及其防治方法. 方法回顾分析1 000例腹腔镜胆囊切除术临床资料. 结果中转开腹手术15例(1.5%);并发症6例(0.6%),其中胆总管损伤3例,胃穿刺损伤1例,腹壁刺口出血1例,胆漏1例.无远期并发症. 结论胆道牵拉成角是胆管损伤最常见原因.     

医源性胆管损伤的原因及处理(附66例报告)

目的探讨胆管损伤和狭窄的防治方法。方法回顾性分析６６例胆囊切除（或伴）胆总管探查术发生胆管损伤及狭窄的原因和治疗。结果１３例胆管损伤在术中发现并立即修复,其中１２例手术治愈,１例术后发生胆管狭窄。５３例胆管狭窄或胆漏在术后被诊断,其中４例行胆管对端吻合（术后均复发狭窄）;４４例行胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合,３６例治愈;５例吻合口狭窄经再手术治愈。８例死亡（死于胆漏感染５例,胆汁性肝硬化３例）。结论胆管损伤若能术中发现并妥善修复常可避免发生狭窄。胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合治疗胆管狭窄可取得较好疗效。     

Early versus late repair of bile duct injuries

Biliary injuries associated with laparoscopic cholecystectomy occur at a constant rate of 0.3% to 0.6%. The spectrum of injures ranges from small leaks of bile to complete section of the main ducts requiring bilioenteric reconstruction. The goal of biliary reconstruction is to obtain a high-quality bilioenteric anastomosis that will not malfunction for a long time. No prospective, controlled, randomized trial (evidence level 1) has been conducted that shows whether an early repair is better than a late one. The timing of the operative procedure should be individualized. A complete examination of the patient should be performed to identify the type of injury and coexistent comorbidities. For septic patients and those with multiple organ dysfunction syndrome, the repair should be delayed. Maneuvers to drain the bile ducts can be performed to relieve jaundice and cholangitis in these patients. For these cases, the surgery should be delayed. If a stable patient is found, without comorbidities, the operation can be scheduled earlier. Subhepatic drains should not be left for a long period because of the risk for intestinal fistulization. If needed, they should be changed for transhepatic stents. High-quality bilioenteric anastomoses are performed with fine absorbable sutures for healthy ducts (nonscarred, noninflamed, nonischemic) in a wide opening, with anastomosis of a (tension-free) defunctionalized jejunal limb. Individualization of the patient is the best rule.