肝移植术变异胆管胆漏的预防与处理

目的 探讨肝移植术中变异肝管胆漏的预防及治疗.方法 回顾性分析我院3例肝移植术后发生变异肝管胆漏的诊断及预防、治疗方法.3例供肝切取均采用肝肾联合切取的方法,胆管重建方式为胆总管端端吻合.结果 1例右后叶副肝管汇入胆囊管患者在胆管吻合后发现肝门处胆囊管残端胆汁漏出,立即拆除原胆管吻合口,成型后一期吻合,术后痊愈.1例Luschka胆管漏患者术后胆漏经过充分引流漏口自行闭合痊愈,但最后终因肝内外感染而于术后7个月再次肝移植.另一例右后叶副肝管汇入胆总管患者,术中遗漏断端导致术后胆漏.该患者因严重并发症行二次肝移植.结论 了解肝内外胆管的解剖和常见变异形式,供肝修整时仔细辨认肝门组织,提高对存在副肝管及迷走胆管变异的警惕性,对预防肝移植术后胆管断端胆漏的发生非常重要.     

Bile leak from the accessory biliary duct following laparascopic cholecystectomy

Anatomists and surgeons have described the presence of accessory biliary ducts between the liver and gallbladder. Bile leakage from accessory duct following laparoscopic cholecystectomy (LC) is an unusual post-operative complication. Aim of the study was to assess its incidence, the intraoperative methods helpful for notice the anatomical anomaly and the impact of endoscopic procedure as a suitable treatment. From January 1997 to September 2002, 185 patients underwent LC for symptomatic cholelithiasis in our surgical department. Post-operative bile leakage from accessory biliary duct occurred in two patients (1%): one case from the liver bed of gallbladder (duct of Luschka) and one case from an aberrant cholecystohepatic duct entering Hartmann's pouch. One patient underwent open celiotomy because of unavailability of endoscopic retrograde cholangiopancreatography. The other patient was successfully treated by endoscopic sphincterotomy and nasobiliary tube placement. By careful dissection, accessory ducts were noticed and clipped in three other patients with overall incidence of 2.7%. Meticulous laparoscopic technique aimed to careful recognize all structures during LC is the main policy to contain biliary injury within its nadir incidence. Depending of availability, endoscopic sphincterotomy and nasobiliary drainage allow diagnosis and treatment of bile leakage, preserving the effectiveness of laparoscopic procedure.     

Preoperative evaluation of the extrahepatic bile duct structure for laparoscopic cholecystectomy

Background The incidence of aberrant bile duct injury associated with laparoscopic cholecystectomy (LC) has not yet been adequately examined. This study aimed to clarify the types of normal cystic ducts and the incidence of aberrant extrahepatic bile ducts, and to search for a method of avoiding injuries during LC. Methods Aberrant hepatic ducts were retrospectively categorized into five types according to the pattern of the cystic ducts and the accessory hepatic ducts by preoperative endoscopic retrograde cholangiography or multidetector three-dimensional computed tomography using drip infusion cholangiography. The aberrant bile ducts were classified as type A (merging at the right side of the common bile duct), type B (merging at the anterior side), or type C (merging at the posterior left side). Results The intrahepatic bile ducts and cystic duct were clearly shown for 1,044 of the 1,278 patients who underwent LC. Secondary branches of aberrant cystic ducts were observed in 37 cases (3.5%), and accessory hepatic ducts were observed in 30 cases (2.9%). A comparison of the difficulties encountered with LC for each type based on the merging patterns of cystic ducts showed that type C needed a much longer operation time for LC than the other types. Conclusions A preoperative evaluation of the bile duct tract and the accessory hepatic duct before LC is important. Patients with a cystic duct merging normally into the posterior left side of the common hepatic duct (type C) experienced difficulty when undergoing LC. The authors have safely performed LC with the use of an endoscopic nasobiliary drainage tube in type D cases (cystic duct merging with the right hepatic duct), in type IV cases (cystic duct merging with an accessory hepatic duct).     

医源性胆管损伤的外科治疗

目的探讨医源性胆管损伤的外科处理方法及其疗效。方法 1992年1月至2011年12月期间共行胆囊切除术3 714例,发生医源性胆管损伤39例,发生率1.05%。其中术中发现胆总管或肝管部分损伤6例,胆总管或肝管被横断1例,左右肝管汇合部以上损伤2例,右侧副肝管损伤1例;术后发现胆囊管漏14例,胆囊床小胆管漏7例,胆总管或肝管部分损伤2例,胆总管或肝管被横断2例,左右肝管汇合部以上损伤1例,胆管严重狭窄2例,右侧副肝管损伤1例。行胆管修补+T管支撑引流术4例,胆管空肠Roux-en-Y吻合术12例,副肝管空肠Roux-en-Y吻合术1例,B超引导下腹腔穿刺置管引流7例,保留腹腔引流管引流14例,右侧副肝管缝扎1例。结果对术中解剖异常或操作困难的病例行术中胆道造影前后,医源性胆管损伤的发生率分别为2.37%(25/1 054)和0.53%(14/2 660),差异显著(P<0.05)。39例患者经外科治疗后均好转。术后出现的主要并发症为吻合口狭窄,共发生6例,其中术中发现损伤组3例,术后发现损伤组3例,两组比较无统计学差异(P>0.05);其他并发症还包括:切口感染4例(术中发现损伤组2例,术后发现损伤组2例),腹腔脓肿3例(术中发现损伤组1例,术后发现损伤组2例)。术后发现组低于术中发现组,为24.1%(7/29)vs.60%(6/10),有统计学差异(P<0.05)。结论医源性胆管损伤可防可治,具体外科治疗方法因病情而异,但总体来讲,胆管空肠Roux-en-Y吻合术的预后较好。     

Complications of laparoscopic cholecystectomy.

As laparoscopic cholecystectomy has become more widely practiced, the full spectrum of complications associated with this technique is being realized. We have performed 283 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 5.3% (15 of 283 patients; six major complications, nine minor complications). Major complications included one bile duct injury requiring laparotomy and t-tube insertion and two patients with retained stones. Symptomatic bile leakage occurred in three patients (1%). Two of these bile leaks were from accessory ducts entering the gallbladder bed; the third leak was secondary to a cystic duct leak. Eight patients (2.8%) required conversion to open cholecystectomy. Minor complications included three patients with subumbilical wound infections, two patients with urinary tract infections, one patient with costochondritis after operation, and three patients with prolonged hospital stays (more than 48 hrs) caused by ileus or fever. Several patients with life-threatening complications, including two patients who ultimately died, were transferred to our care from other centers. These included two patients with common duct injuries combined with duodenal perforations (one of whom died), one patient with a complete common duct transection, one patient with major common hepatic duct injury, and two patients with further instances of bile leakage. Laparoscopic cholecystectomy can be performed safely, and it can be associated with life-threatening complications. Prevention of complications is dependent on proper patient selection, meticulous technique, and an accepting attitude toward conversion to "open" cholecystectomy.     

Management of Bile Leakage After Laparoscopic Cholecystectomy Based on Etiological Classification

Purpose To analyze and classify bile leakage after laparoscopic cholecystectomy (LC) according to its etiology. This classification will help to determine the most appropriate management strategy, whereby unnecessary intervention can be avoided.Methods We examined the medical records of 16 patients in whom bile leakage occurred as a complication of LC.Results Bile leakage was classified according to its cause into the following groups: insecure closure of the cystic duct stump (n = 3); retention of a common bile duct (CBD) stone (n = 1); CBD injury (n = 10); unsuspected accessory bile ducts (n = 1); and unknown origin (n = 1). The management strategies included observation (n = 3), laparoscopic intervention with drainage (n = 4), laparotomy with drainage (n = 3), and laparotomy with Roux-en-Y choledochojejunostomy for CBD transection (n = 6). All 16 patients recovered uneventfully with similar hospitalization.Conclusions Bile leakage is not always caused by bile duct injury, and it would be inappropriate to attribute leakage to bile duct injury if there is a retained CBD stone, an unsuspected accessory duct, or an unsecured cystic duct stump. Thus, the management of each condition should vary accordingly. Reviewing a videotape of the surgery and early cholangiogram can help to establish the etiological diagnosis and select the most appropriate course of action.     

胆道手术中副肝管损伤的防治体会：附26例报告

目的: 总结胆道手术中防治副肝管损伤的经验。方法: 回顾分析近10年间发现的26例副肝管病例资料。结果: 26例病例中I型10例，占38.5％，均被切断、结扎，术后无胆汁漏、胆系感染或梗黄发生;II型7例，占26.9％，损伤3例,经相应处理，未发生并发症;III型6例，占23.1％，损伤2例,1例术后发生胆漏,经再次手术治愈。IV型2例，占7.7％，2例均得以保护，未损伤。V型1例，占3.8％，术前得以确诊，未损伤。结论: 为防止副肝管损伤，应加强术前、术中副肝管诊断，尤其是术中胆道造影。不同类型副肝管损伤，处理上应分别对待。对于I型胆囊胆管可切断结扎，II型汇入胆囊管的副肝管应尽量保护，如损伤，根据管径大小，采取不同处理方法。III型、IV型副肝管均应保护，防止损伤，如损伤，采用修补或内引流术，防止术后发生严重并发症。     

Development of intrahepatic biliary stones after excision of choledochal cysts

Background: The incidence of intrahepatic cholelithiasis and cholangitis has not yet been well studied postoperatively in patients with choledochal cysts. Methods: One hundred three patients with choledochal cysts had operative cholangiography, underwent standard excision of a choledochal cyst with Roux-en-Y hepatico-jejunal anastomosis, and were at a mean follow-up of 12[frac12] years. The incidence of intrahepatic bile duct stones was analyzed according to the 3 morphologic types of intrahepatic bile duct observed at initial operative cholangiography: type 1, no dilatation of the intrahepatic bile ducts; type 2, dilatation of the intrahepatic bile ducts but without any downstream stenosis; and type 3, dilatation of the intrahepatic bile ducts associated with downstream stenosis. Initially, there was no evidence of intrahepatic bile duct stones in any of the 103 patients. Results: Among 50 type 1 patients, intrahepatic cholelithiasis developed in only 1 patient (2%). Among 43 type 2 patients, 1 patient (2%) had intrahepatic cholelithiasis, and 2 (5%) had postoperative cholangitis. Among 10 type 3 patients, 4 (40%) had intrahepatic cholelithiasis (P [lt ] .01), and 3 (30%) had postoperative cholangitis. Time intervals between the initial surgery and the first identification of intrahepatic stones ranged from 3 to 22 years. Conclusions: One of the major causes of formation of intrahepatic cholelithiasis has been clarified; patients with intrahepatic biliary dilatation with downstream stenosis can get intrahepatic bile duct stones long after excision of a choledochal cyst.     

Voluntary and Involuntary Ligature of the Bile Duct in Iatrogenic Injuries: A Nonadvisable Approach

Background Bile duct injuries related to laparoscopic and/or open cholecystectomy are a frequent finding and require surgical treatment. Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to “facilitate identification of the duct by bile duct dilation.” Considering that we are a national referral center for such injuries, we decided to analyze our cases of voluntary and involuntary duct ligation after iatrogenic bile duct injury. Methods We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts, operative treatment, and postoperative results were analyzed. Results A total of 413 patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. Bile duct dilation (>10 mm) was demonstrated in one case of voluntary (6%) and three cases of involuntary ligations (10%). The remaining cases in both groups had no duct dilation and developed necrosis at the blinded duct and leakage proximal to the ligature, with different degrees of bilioperitoneum and/or biloma. In all cases, a Roux-en-Y hepatojejunostomy was performed. Conclusion Bile duct ligature produces dilation in a very small number of patients (less than 10%) and usually produces necrosis of the blinded stump with subsequent bile leakage. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.     

Bile peritonitis from a cholecystohepatic bile ductule: an unusual complication of cholecystectomy

A case is presented of postoperative bile peritonitis from an accessory cholecystohepatic bile ductule after cholecystectomy for acute cholecystitis. Accessory bile ductules (ducts of Luschka) are occasionally encountered in the gallbladder fossa but do not drain directly into the gallbladder fundus. Nevertheless, they may be injured during surgery and may go unrecognized. When recognized intraoperatively, ligation is acceptable; however, when they are actively leaking bile and are greater than 2 mm in diameter, repair of injured cholecystohepatic ducts may be indicated. This case serves to reemphasize one argument for the routine placement of drains after cholecystectomy for acute cholecystitis.     

腹腔镜胆囊切除术并发症的防治

目的探讨腹腔镜胆囊切除术(LC)的并发症及预防、处理措施。方法回顾分析794例腹腔镜胆囊切除术并发症的临床资料。结果发生各类并发症11例(1.38%),其中腹腔内出血2例,胆管损伤1例,胆漏2例,胆总管残余结石2例,切口感染1例,皮下气肿1例,胃肠道损伤2例。死亡1例,病死率0.13%。结论胆管损伤、腹腔出血、胆漏是腹腔镜胆囊切除术的主要并发症,遵守操作规范,及时中转剖腹可预防并减少并发症的发生。     

Small Bile Duct Reconstruction of the Caudate Lobe in Living-Related Liver Transplantation

OBJECTIVE: To justify the technique of biliary reconstruction without mucosa-to-mucosa alignment for reconstructing the caudate lobe bile duct. SUMMARY BACKGROUND DATA: The use of a left hepatic lobe graft with the caudate lobe (LHGC) has been introduced to resolve the problem of small-for-size grafts in living-related liver transplantation. The authors have found that the LHGCs occasionally have independent openings of the bile duct of the caudate lobe. METHODS: The graft bile ducts were anastomosed to Roux-en-Y jejunal loops. The main left hepatic ducts were reconstructed in a standard manner. Small bile ducts of the caudate lobe were anastomosed to the intestine without mucosa-to-mucosa alignment, with an external biliary drainage tube, positioned transanastomotically. RESULTS: In 8 of the 19 patients who received LHGCs, nine bile ducts of the caudate lobe (median 1 mm) were reconstructed. After surgery there was no bile leakage. In five of the eight patients, the tubes were removed a median of 92 days after transplantation. Bile duct dilatation had not been observed at a median of 363 days after surgery. CONCLUSIONS: The authors consider their technique of biliary reconstruction without mucosa-to-mucosa alignment useful for the safe reconstruction of small bile ducts of the caudate lobe.     

Intraoperative Placement of External Biliary Drains for Prevention and Treatment of Bile Leaks After Extended Liver Resection Without Bilioenteric Anastomosis

Background

Improved surgical techniques, substantial preoperative diagnostics, and advanced perioperative management permit extensive and complex liver resection. Thus, hepatic malignancies that would have been considered inoperable some years ago may be curatively resected today. Despite all this progress, biliary leakage remains a clinically relevant issue, especially after extended liver resection. Intraoperative decompression of bile ducts by means of distinct biliary drains is controversial. Although drainage is rarely used as a routine procedure, it might be useful in selected patients at high risk for biliary leakage.

Methods

We describe surgical management of long-segment exposed or injured bile ducts after extended parenchymal resection with concomitant lymphadenectomy. Because blood supply to the bile duct may be impaired, the risk of biliary necrosis and/or leakage is significant. Internal splinting of the bile duct to ensure optimum decompression plus guidance might be helpful. Thus, in selected cases after trisectionectomy we inserted an external–internal or internal–external drain into long-segment exposed bile ducts. For internal–external drains the tube was diverted via the major duodenal papilla into the duodenum and then transfixed after the duodenojejunal flexure through the jejunal wall by means of a Witzel’s channel.

Results

Because the entire bile duct is splinted, this technique is superior to bile duct decompression with a T-tube. This is supported by the course of a patient suffering biliary leakage after extended right-sided hepatectomy for colorectal metastasis. Initially, a T-tube was inserted for decompression, but biliary leakage persisted. After inserting transhepatic external–internal drainage, bile leakage stopped immediately. The patient’s course was then uneventful. Five other patients (mostly with locally advanced hepatocellular or cholangiocellular carcinoma) treated similarly were discharged without complications. Drain removal 6 weeks postoperatively was uncomplicated in five of the 6 patients. In the sixth patient, external–internal drainage was replaced by a Yamakawa-type prosthesis for a biliary stricture. None of the patients suffered severe complications during long-term follow-up.

Conclusions

The bile duct drainage technique presented in this study was useful for preventing and treating bile leakage after long-segment exposure of extrahepatic bile ducts during major hepatectomy. Transhepatic or internal–external drains are often used for bilioenteric anastomoses, but similar drainage techniques have not been reported for the native bile duct. T-tubes are generally used in this situation. In particular cases, however, inner splinting of the bile duct and appropriate movement of the bile via a tube can be helpful.     

The reliability and clinical limitations of sonographic scanning of the biliary ducts.

Sonographic scanning of the biliary ducts has been successfully used as a screening test to distinguish between patients with surgical and medical jaundice, with an accuracy of 90%. However, there is no consensus in the literature on what numerically defines a dilated biliary duct. To clarify this problem a prospective study of 102 consecutive patients was initiated to determine the sonographic size range of bile ducts in patients with and without extrahepatic ductal obstruction. The ultrasonic measurements were compared with direct measurements of the common bile duct, at surgery. The extrahepatic ductal system was visualized sonographically in 62% of the patients, while the intrahepatic ducts were found in 81% of the population. Direct measurements at operation agreed with the ultrasonic measurements in 84% of the patients. Analysis of the size range of the biliary ducts in patients with and without extrahepatic obstruction, by chi square analysis and the Student's t-test, allowed the following guidelines to be established. Extrahepatic bile duct obstruction was present if the extrahepatic bile ducts was 1 cm or wider (p less than 0.001) or if the intrahepatic bile duct was in excess of 0.5 cm (p less than 0.001). Similarly if the extrahepatic bile duct measured less than 0.8 cm sonographically, and the intrahepatic bile duct was 0.4 cm or less than bile duct, obstruction was not present (p less than 0.001).     

A new technique for biliary drainage in orthotopic liver transplantation utilizing the gall bladder as a pedicle graft conduit between the donor and recipient common bile ducts.

A technique for biliary drainage in orthotopic liver transplantation has been developed in which the gall bladder is used as a pedicle graft between the donor and recipient common bile ducts. In 7 patients this technique has produced encouraging results. There has been no incidence of bile leakage or stenosis of the anastomoses. The gall bladder permits the widest possible anastomoses for obliquely cut ends of the donor and recipient common ducts. It eliminates tension and retains the advantage of the sphincter of Oddi. Although the followup is short, the incidence of biliary complications using other techniques has been so high that the procedure described here would appear to have distinct advantages.     

Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors

BACKGROUND: Bile leakage is one of the frequent and disturbing complications of hepatic resection. STUDY DESIGN: Clinical records of the 363 patients who underwent hepatic resections without biliary reconstruction for hepatic cancers between January 1994 and June 2001 were reviewed. Postoperative bile leakage was defined as continuous drainage with a bilirubin concentration of 20 mg/dL or 1,500 mg/d lasting 2 days. Leakage that continued longer than 2 weeks or that required surgical intervention was defined as uncontrollable. Differences in incidence and frequency of uncontrollable leakage for the different types of hepatic resection, tumors, and underlying liver disease were investigated. Outcomes after treatment for uncontrollable bile leakage were also reviewed. RESULTS: Postoperative bile leakage occurred in 26 of 363 patients (7.2%). Although the incidence in patients with cholangiocellular carcinoma (3/9 [33%]) was higher (p = 0.03) than in patients with hepatocellular carcinoma, rates of occurrence were similar among the different types of hepatic resection and underlying liver disease. Eight of the 26 patients (31%) had uncontrollable leakage. Two patients required reoperation to control leakage; one of these developed hepatic failure and died 2 months after surgery. Four patients underwent endoscopic nasobiliary drainage 21 to 34 days after hepatectomy, and the leakage resolved within 3 to 21 days. Fibrin glue sealing was effective in two patients whose leaking bile ducts were not connected to the common bile duct. CONCLUSIONS: Although meticulous surgical technique can minimize the risk of postoperative bile leakage, some instances of leakage are unavoidable. Nonsurgical treatments, such as nasobiliary drainage or fibrin glue sealing, are preferable to reoperation.     

Treatment of bile leaks from the cystohepatic ducts after laparoscopic cholecystectomy

The cystohepatic ducts represent accessory bile ducts of variable size which frequently travel within the gallbladder fossa or in the posterior wall of the gallbladder. These ducts can be injured during laparoscopic cholecystectomy and can result in bile collections if transected. Successful treatment by operative means or radiologically guided percutaneous drainage is possible, but endoscopic management has several advantages. We describe cases managed by endoscopic retrograde cholangiopancreatography (ERCP) with stent placement and discuss the advantages of this method. Also discussed is the anatomy of these accessory bile ducts, additional management options, and techniques for avoiding this injury during open or closed cholecystectomy.     

肝方叶切除联合肝门胆管高位劈开整形在肝门胆管狭窄合并结石中的应用

背景与目的:对于肝胆管结石多次手术后复发患者,如何安全取尽结石,最大限度解除肝门甚至是肝内胆管的狭窄,并建立或修复通畅的胆流通道,一直是胆道外科治疗领域中的难点。本研究探讨肝方叶切除联合肝门胆管高位劈开整形在肝门胆管狭窄合并结石中的治疗效果及应用价值。方法:回顾性分析2015年7月—2019年6月湖南省人民医院收治的36例复杂肝胆管结石患者的临床资料,36例患者既往平均手术2.4次,均存在不同程度的肝门部胆管狭窄,其中肝门胆管汇合部狭窄18例,合并右肝管狭窄8例,合并左肝管狭窄10例。结果:所有患者均行肝方叶切除、肝门胆管高位劈开整形、胆肠内引流手术,术中采用取石钳取石、塑形管冲洗、胆道镜探查等多种方式取尽结石。平均手术时间354.4 min,平均失血量230.5 mL。术后平均结石清除率在90%以上。术后2例患者出现胆汁漏,经积极引流治疗后好转,3例患者出现切口脂肪液化、感染,1例患者不完全性肠梗阻,均保守治疗后好转。术后采用门诊、电话随访12～48个月,4例患者出现反流性胆管炎,无胆肠吻合口再发狭窄病例。结论:肝方叶切除联合肝门胆管高位劈开整形能有效解除肝门胆管高位狭窄,达到取尽结石、通畅引流的目的,同时能避免大范围的肝切除,因此具有一定的临床应用价值。     

Endoscopic management of postoperative bile leaks.

Thirty-two patients aged 15-89 years developed postoperative bile leakage. Twenty-eight had undergone cholecystectomy, with choledocholithotomy in 11, and four had had miscellaneous operations. Endoscopic retrograde cholangiopancreatography (ERCP) was performed 2-75 days after operation and revealed leakage from the cystic duct stump in 19 cases, from a T tube track in five, from the gallbladder and liver abscess cavity in two and from the major bile ducts in six. Major bile duct lesions were not generally amenable to endoscopic treatment, but the remaining 26 patients were treated successfully with internal stenting (22) or endoscopic sphincterotomy (four); bile secretion in all cases stopped within 1 week. One patient with cholangitis after an ERCP procedure was managed by antibiotics; no other complication occurred and there were no deaths related to the procedure. ERCP procedures are well tolerated in the postoperative period and may be performed under sedation. ERCP is the method of choice for dealing with bile leakage and ERCP procedures are effective for the most common causes of postoperative bile leakage; complications are rare.     

Bile leak from the liver bed following laparoscopic cholecystectomy

Intraperitoneal accumulation of bile from accessory bile ducts following cholecystectomy is an uncommon, but well-described, occurrence. It is not unique to laparoscopic cholecystectomy. The presence of accessory channels between the liver and gallbladder has long been recognized by anatomists and surgeons. They are commonly known as the ducts of Luschka. Recognition and treatment of liver bed bile leaks vary. Usually the surgeon can treat this problem without an exploratory celiotomy depending on availability of ERCP or interventional radiology. This article will review clinical diagnosis, radiologic confirmation, and treatment for this complication.