医源性损伤性胆管狭窄的外科治疗

Iatrogenic traumatic biliary stricture is one of the difficult points in the biliary surgery,and operation is the only definitive treatment. The operative opportunity,surgical procedure and techniques ...     

术中胆管损伤和继发胆管狭窄的外科治疗

由于各种手术引起胆管损伤的发生率在０．０５％～０．２％之间［１］,随着腹腔镜胆囊切除技术的广泛应用,其胆管损伤的发生率也有增高的趋势［２］。损伤后继发性的胆管狭窄,若不及时正确处理,将会带来严重的后果［３］。我院１９８８年以来,共收治外院２２例损伤后胆管狭窄病例,结合国内外的相关文献,总结我们对胆管损伤和继发胆管狭窄的治疗体会。１　临床资料１．１　一般资料本组２２例,男性６例,女性１６例,年龄３６岁至６９岁,平均年龄４３．２岁。在最初手术中：择期手术２１例,急诊手术１例,１６例为单纯胆囊切除术,…     

损伤性胆管狭窄42例的外科治疗

本文总结近5年来收治的42例医源性胆管损伤病例，其中行胆囊切除术致伤者27例，占65.85％，经腹腔镜胆囊切除术致伤者4例，胆总管探查术9例，行胃大部切除术和肝血管瘤行术中肝动脉栓塞术致伤各1例。损伤的处理多属后期，21例胆管损伤后因出现胆汁性腹膜炎、黄疸和腹痛等症状在外院曾施行再手术治疗29次。42例病人在我院进行了胆肠通路的重建手术或胆管狭窄的修复手术。其中37例随访，随访率为88．10％。疗效优良，优良率为90％。本文分析了胆管损伤的原因，讨论了腰管狭窄的的早期发现和处理，以及后期处理的原则，镍钛记忆合金行胆管内支撑治疗取得了明显的效果，为损伤性胆管狭窄的治疗提供了新的手段。     

损伤性肝外胆管狭窄的原因和治疗

报告损伤性肝外胆管狭窄45例。着重分析胆管损份后狭窄的原因、初次手术修复后远期狭窄的有关因素和胆系手术中隐性损伤与胆管狭窄的关系。诊断方法以B超、PTC、ERCP为主，全组均手术治疗，随访39例，优良87.2％。活疗方法以肌管空肠Y型吻合较好。     

复杂损伤性胆管狭窄的治疗

Biliary stricture after cholecystectomy poses difficult management problems to surgeons because of high and stable incidence.In contrast to malignant stricture,benign stricture requires durable repair....     

损伤性高位胆管狭窄41例报告

目的 总结损伤性高位胆管狭窄外科治疗的经民教训。方法 性调查４１例损伤性高位胆管狭窄患者的治疗方法，并发症及远期疗效。结果 采用胆肠吻主３８例，无手术死亡。其中肝管空肠Ｒｏｕｘ－Ｙ吻合术２６例，随访２～１０年，优良率８３．３％；肝管十二指肠吻合１２例，随访３年以上，优良率７０％。结论 肝管空肠Ｒｏｕｘ－Ｙ吻合术是治疗损伤性高位胆管狭窄的最佳方式，肝管十二指肠吻合术对高危胆管狭窄患者仍然是有效方法之     

损伤性胆管狭窄的手术时机

医源性胆管损伤是伴随着胆道外科及邻近器官手术的发展而出现的 ,自 1882年Ｌａｎｇｅｎｂｕｃｈ施行首例胆囊切除术至今已 12 0余年 ,经几代普外医生的不懈努力 ,开腹胆囊切除的病死率和胆道损伤发生率均保持在很低水平。 1987年法国Ｍｏｕｒｅｔ开创了腹腔镜胆囊切除术 ,以其损伤小、恢复快的特点 ,而使胆囊切除术进入微创时代 ,仅几年便迅速在全世界普及 ,胆囊切除再也不是一个难于进行的手术 ,或者说是在很多中青年医生眼中只要初步掌握腹腔镜技术即可尝试的“小手术”。但随之也出现许多胆道并发症 ,其发生率高达1% ,病死率是 0 .1%。…     

医源性胆管损伤的手术时机与技术处理

目的: 分析医源性胆管损伤不同状态下的手术时机和手术技巧、方式对疗效的影响. 方法: 就28例病人的胆管损伤类型、修复时间、修复方法以及疗效评价,对手术时机及方式进行分析. 结果: 术后一次修复的成功率为46.4%.失败的主要原因:术式选择不当,支架放置的部位或时间不合理,延期修复的时间过长或过短. 结论: 胆管损伤的端端吻合术仅适用于术中发现的Ⅰ~Ⅱ型非热损伤的病人.凡是不适合于胆管端端吻合术者,应首选胆肠Roux-Y吻合术.除非有胆汁型腹膜炎或胆瘘存在,胆管损伤术中未能及时发现者,可以行延迟性手术.吻合口<10mm应放置内支架,取出支架的时间在1年左右为好.     

损伤性高位良性胆管狭窄的外科治疗策略

Iatrogenic bile duct injuries (BDIs) and subsequent benign biliary stricture is a medical catastrophe which is associated with significant perioperative morbidity and mortality,reduced long-term surviv...     

Repair of benign bile duct stricture

Cases of benign bile duct stricture treated during the past ten years were reviewed in reference to the location of the bile duct stricture, the method of repair and their long-term results. Common hepatic duct was the most frequent site of bile duct involved. Bilioenteric anastomosis in the form of retrocolic hepaticojejunostomy (Roux-Y) was the method of repair most frequently used. Brief survey was made on the current literatures concerning the methods of repair of benign bile duct stricture.     

胆总管探查并T管引流术后胆管狭窄再手术23例临床分析

目的探讨常规开腹胆总管探查、T管引流术后发生胆管狭窄的特点、原因以及再手术处理。方法回顾性分析中国人民解放军总医院肝胆外科1990-2005年间收治的因常规开腹胆总管探查、T管引流术后胆管狭窄并再手术的23例良性胆管狭窄的病例资料,对其既往手术史、此次就诊、再手术及疗效情况加以总结分析。结果23例胆管狭窄首次诊断均为胆囊结石、单纯胆总管结石,既往有1～3次手术史。狭窄分型以BismuthⅠ型和Ⅱ型为主,其中Ⅰ型7例（30.4%）;Ⅱ型8例（34.8%）,Ⅲ型4例（17.4%）;Ⅳ型4例（17.4%）。手术方式修复手术和胆肠吻合各11例（47.8%）,介入治疗1例（4.3%）。随访13例病人中胆道修复和胆肠吻合术疗效均为优良,1例介入治疗病人因长期胆道梗阻致肝功能衰竭死亡。结论肝门部胆管是极易受损的部位,不可轻视常规经典胆总管探查、T管引流手术不当所带来的严重并发症。     

胆管对端吻合治疗损伤性胆管狭窄的应用要点

目的总结胆管对端吻合术治疗损伤性胆管狭窄的技术要点。方法回顾性分析行狭窄段切除、胆管对端吻合治疗的14例BismuthⅠ、Ⅱ型损伤性胆管狭窄。结果患者均取得了较好的术后疗效,未见胆管炎、胆管狭窄或结石复发。结论对于损伤性胆管狭窄,行胆管对端吻合是较理想的手术方式,但治疗要取得成功则取决于精细的手术操作及正确的术后管理。     

A case of benign bile duct stricture causing difficulty in differential diagnosis from bile duct carcinoma

We report a patient with benign bile duct stricture causing difficulty in differential diagnosis from bile duct carcinoma. A 66-year-old woman consulted a local physician because of general fatigue. Blood biochemical tests showed increased levels of biliary tract enzymes. Abdominal ultrasonography (US) revealed tapering and blockage of the midportion of the bile duct and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography (MRCP) demonstrated obstruction of the midportion of the bile duct. Later, because a marked increase in biliary tract enzymes and jaundice appeared, percutaneous transhepatic biliary drainage (PTBD) was performed. Post-PTBD cytological examination of bile was negative for cancer. A third biopsy showed slight hyperplasia with no malignant findings. Recholangiography, performed through PTBD, suggested gradual improvement of bile duct stricture, but could not completely exclude the possibility of malignancy; thus, resection of the bile duct including the stricture site was performed, and the resected specimen was submitted for intraoperative frozen section examination. Histopathological diagnosis did not reveal malignant findings. After cholecystectomy and bile duct resection, hepaticojejunostomy (Roux-en-Y) was performed. Because only erosion and desquamation of the mucosal epithelium and mild submucosal inflammatory cell infiltration and fibrosis were observed, chronic cholangitis was diagnosed histopathologically. Surgical resection of the bile duct should be considered for potentially malignant stricture of the bile duct.     

Surgical treatment for carcinoma of the extrahepatic bile duct

Eighty-six patients with primary extrahepatic bile duct carcinoma operated on in the Second Department of Surgery at Nagasaki University Hospital during a recent 13.5-year period were reviewed. The patients were divided into five groups depending upon the site of the tumor. The operative mortality, resectability, postoperative survival period, and five-year survival rate in each group were studied. The lower third group had the highest resectability, lowest operative mortality and longest post operative survival period. The hepatic duct, the upper third and the extended groups, however, showed extremely poor results. The pathological features of these three groups are discussed here and an operative procedure for resection of the tumor is proposed. We emphasize that the development of methods of early diagnosis is necessary, and recommend aggressive surgical treatment for tumors of the hepatic duct, upper third, and extended groups.     

腹腔镜胆总管探查一期缝合术后胆瘘及胆总管狭窄的危险因素分析

目的 探讨腹腔镜胆总管探查（LCBDE）及一期缝合术后发生胆瘘及胆总管狭窄的临床危险因素。方法 收集自2017年1月至2019年6月湖州市中心医院收治的92例行LCBDE胆总管一期缝合术患者的临床资料,行回顾性对列研究及多因素回归分析。结果 全组患者术后胆瘘及胆总管狭窄发生率分别为11.9%（11/92）和18.5%（17/92）。合并糖尿病、胆总管直径＜1 cm、由胆总管一期缝合手术操作例数＜30例的主刀医师行手术治疗的患者术后胆瘘及胆总管狭窄的发生率明显升高（P＜0.05）。多因素回归分析发现,上述三个因素是LCBDE胆总管一期缝合术后胆瘘发生的独立危险因素[合并糖尿病：OR（95%CI）4.782（1.176～19.439）,P=0.029;胆总管直径＜1 cm：OR（95%CI）5.743（1.535～21.481）,P=0.009;胆总管一期缝合手术操作例数＜30例：OR（95%CI）4.693（1.251～17.612）,P=0.022],同时上述三个因素也是术后胆总管狭窄发生的独立危险因素[合并糖尿病：OR（95%CI）3.455（1.147～10.406）,P=0.028;胆总管直径＜1 cm：OR（95%CI）4.667（1.500～14.518）,P=0.008;胆总管一期缝合手术操作例数＜30：OR（95%CI）3.094（1.049～9.121）,P=0.041]。结论 合并糖尿病、胆总管直径＜1 cm、主刀医师经验不足（操作例数＜30例）是LCBDE胆总管一期缝合术后发生胆瘘及胆总管狭窄的独立危险因素。对存在糖尿病或胆总管直径＜1 cm的患者应避免行胆总管一期缝合术;在学习曲线内的主刀医师应采取合理的胆总管一期缝合方式以避免术后胆瘘及胆总管狭窄的发生。     

经验值得注意——再论胆管损伤与损伤性胆管狭窄

自腹腔镜胆囊切除术普遍开展之后,胆囊切除的病例很快增多,而胆管损伤发生率也随之升高,胆管损伤与胆管狭窄又重新成为本世纪的热门话题。医源性胆管损伤重在预防,预防手术中胆管损伤的基本点仍然是强调外科手术的基本要求,认真细致地施行手术,必要时中转开放手术。在专科中心及有经验的外科医生手中,修复手术结果优良者一般可达到90％,初期修复的效果优于再次修复。恢复胆道生理功能是修复手术的最终目的,当前广泛应用的仍然是肝管Roux-en-Y空肠吻合术。     

医源性胆管损伤27例诊治体会

目的分析医源性胆管损伤的发生原因、诊断及处理方法。方法回顾分析我院收治的27例医源性胆管损伤病例资料。结果在术中、术后早期和术后晚期发现胆管损伤,均予不同方法处理,27例经平均3年以上的随访,效果优良率达96．3％。结论思想上的重视及外科手术技术水平的提高是防治医源性胆管损伤的重要措施。