拔T管后胆漏的治疗和预防

目的　探讨拔T管后胆漏的治疗和预防策略。方法　回顾性总结我院 1996年 2月～2 0 0 2年 6月治疗的 9例拔T管后胆漏的治疗方法和效果。结果　拔T管后出现胆漏的时间为拔管后 10min～ 4h ,8例首选非手术治疗 ,7例治愈 ,1例无缓解形成弥漫性胆汁性腹膜炎同另 1例手术治疗病例行窦道结扎或重置T管 ,均治愈。结论　拔T管后胆漏的治疗绝大部分首选非手术治疗 ,如无效或病情加重开腹引流 ,窦道结扎或重置T管。适当延长拔管时间 ,注重术中操作同时加强内科疾病的治疗     

拔T管后胆漏的防治

目的探讨拔T管后胆漏的预防和治疗方法。方法对1994年1月至2005年12月间胆道手术拔T管后发生的19例胆漏进行回顾性分析,并结合文献对该症的预防和治疗进行讨论。结果19例胆漏,14例经非手术治疗痊愈,占73．7％;5例经再次手术治愈,占26．3％。结论拔T管后胆漏重在预防。各项基本措施到位,将窦道造影显示的T管窦道状况作为拔T管的客观依据是预防胆漏的根本性措施。一旦发生胆漏应积极处理,应用各种非手术方法充分引流胆汁,无效者应立即手术。     

T管拔除后胆漏的预防

目的　探讨拔T管后出现胆漏并发症的预防。方法　胆总管探查、T管引流术的连续病例 2 4 3例。A组 114例术后 3周拔T管 ,若出现有症状胆漏和 /或胆汁性腹膜炎 ,立即用红橡皮导尿管置入窦道作引流 1～ 6d(平均 3.5d)。B组 12 9例术后 2周拔T管后常规立即用红橡皮导尿管置入窦道作引流 1～ 4d(平均 1.5d)。结果　A组拔T管后发生胆漏 9例 ,B组无胆漏发生。所有病例均获治愈出院。两组胆漏发生率有显著性差异 (χ2 =8.4 9,P <0 .0 0 5 )。结论　拔管后再引流法可有效预防拔T管后胆漏的发生。对已发生的局限性胆汁性腹膜炎 ,及时用导尿管置入窦道作引流 ,亦是有效的处理方法     

拔T管致胆漏经腹腔镜手术治疗6例

采用腹腔镜手术治疗6例常规拔T管致胆漏的患者，均为腹膜炎体征较严重非手术治疗无效者。6例均治愈。提示经腹腔镜手术治疗拔T管所致胆漏是安全、有效的，并体现了微创治疗的优点。     

胆总管探查术后拔T管致胆漏病因分析和防治（附12例报告）

目的　探讨常规拔T管后胆漏致胆汁性腹膜炎发生的原因和防治方法。方法　对本院近 8年来胆总管探查术后常规拔T管胆漏致胆汁性腹膜炎 12例病例进行回顾性分析。结果　 12例病例中 5例再次手术、7例保守治疗 ,均痊愈出院 ,无再次手术并发症。结论　常规拔T管后出现胆漏胆汁性腹膜炎 ,原因是多方面的 ,预防是关键。症状严重者应及时手术 ,症状轻者可行非手术治疗。     

胆总管探查术后发生胆漏的原因及防治

目的：探讨胆总管探查术后发生胆漏的原因及其预防措施和治疗方法。方法：对8例胆管切开探查术后胆漏的临床资料作回顾性分析。结果：8例中胆总管T管周围漏4例，拔T管后胆漏4例。本组保守治疗6例，手术治疗2例(其中1例手术后复发时采用非手术治疗)。本组病人均治愈出院。结论：胆漏发生主要原因与胆管切口缝合不当、高龄、营养差、组织愈合不良致T管周围胆管切缘扩大、T管窦道形成缓慢等有关。胆漏发生后应根据漏出量及腹膜炎的程度选择手术治疗和非手术治疗。     

老年患者延迟拔T管后胆瘘8例临床分析

目的 总结延迟拔T管后胆瘘的临床特点和治疗.方法 回顾性分析2000年1月至2011年1月我院8例延迟拔T管后胆瘘的临床表现和治疗过程.结果 8例均治愈.其中3例拔T管后重插引流管持续引流,1例行开腹续行胆总管T管引流,3例行开腹漏口修补腹腔引流,1例行ERCP+鼻胆总管引流(ENBD)引流术.结论 延迟拔T管后胆瘘多数症状出现较晚且以腹部胀痛为主,若胆瘘后立即重置引流能取得良好的效果,如重置引流无效开腹首选漏口修补腹腔引流可加快术后恢复,避免二次拔T管.     

胆道手术后胆漏的原因及治疗体会

目的 探讨胆漏形成的原因与防治.方法 回顾性分析1996年1月-2007年12月治疗的18例胆漏患者的胆漏原因、治疗方法和结果.结果 本组18例中,11例于拔T管后并发胆漏(占61%),是胆道手术后胆漏的主要原因;胆囊切除术中被疏漏的轻微胆管壁损伤,是胆漏的另一重要原因,本组2例最终均再次手术.所有拔T管后胆漏均首选非手术治疗,成功9例,2例中转手术;本组18例患者全部治愈.结论 及时、正确的早期处理,拔管后胆漏多可非手术治愈;胆管轻微损伤引起的胆漏,不易早期发现,多需再次手术.腹痛、腹腔积液范围扩大、肠麻痹是中转手术的指征,手术方式以双套管持续引流为主.预防应从术前、术中、术后三个环节着手.     

肝移植术后胆漏的诊断治疗

目的：探讨肝移植术后胆漏的诊断及治疗方法。方法：回顾分析我院6例肝移植并发胆漏病人（男4例,女2例）的诊断及治疗。胆管重建方式为胆总管端端吻合术。1例为肝脏移植术后第3天T管脱落．1例术后3个月拔除T管后出现胆漏,4例为吻合121漏,其中2例合并胆管狭窄。5例非手术治疗,1例手术治疗。结果：6例胆漏中5例治愈,1例并发感染死亡。结论：术后及时诊断并阻止胆漏．感染恶性循环是治疗胆漏的关键。胆漏多可经非手术治愈。经非手术治疗失败者,应予积极手术治疗。     

T管拔除后胆漏腹膜炎16例分析

回顾性总结1991年1月－2001年2月拔除T管后发生胆、胆汁性腹膜炎16例的诊治经验。由于早期诊断，11例经及时引流等非手术疗法治愈；5例非手术治疗未缓解，经再次手术重新放置T管治愈。无死亡病例。提示拔T管后造成胆、腹膜炎原因很多，预防其发生非常重要：手术和拔管应操作规范；术中应注意T管的选择和正确置放，不用硅胶T管；拔T管的时间应“个体化”，对年老体弱、营养状况不佳、贫血、合并肝硬化、低蛋白血症、糖尿病长期或大量使用激素的患者应延长拔管时间。一旦发生胆漏，应立即经窦道口置入粗尿管引流。若引流不畅，应及时剖腹探查，重置T管引流。     

Consequences of intraperitoneal bile: bile ascites versus bile peritonitis

Recent experience with patients with bile ascites and bile peritonitis prompted a review of other case histories in the medical literature of these conditions. The clinical courses of 24 patients with bile ascites and 34 with bile peritonitis were reviewed. Bile ascites occurred most often as a postoperative complication of biliary tract operations and also occasionally after trauma. Clinical signs were minimal except for abdominal distention, and operations were delayed for an average of 30 days. Peritoneal fluid was sterile in the 11 patients studied. In contrast, bile peritonitis occurred most commonly after spontaneous perforation of the gallbladder or hepatic ducts but also after trauma. All patients had severe signs of peritoneal irritation, and operation was performed earlier, at a mean of 4 days after onset of symptoms. Of 11 patients with specimens of their peritoneal fluid cultured, 6 had sterile fluid and 5 had bacteria. Although both bile salt concentration and bacteria have been implicated in the development of bile peritonitis rather than bile ascites, our understanding of the mechanisms involved is still incomplete.     

The postoperative concentration of bile salts in human bile

The postoperative changes in the concentration of bile salts in the bile have been studied in a series of surgical patients following drainage of the common bile duct through a T-tube. When the patient has had no evidence of hepatic disease or the latter is minimal, there is a temporary reduction in the concentration of bile salts in the bile, followed after two to three days by a progressive return to normal levels. This drop is interpreted as due to such factors as the type and duration of anesthesia, the local and constitutional effects of operative trauma, the degree of preoperative biliary obstruction with hydrohepatosis, and the like.The rapidity of the postoperative return toward a normal concentration of the bile salts in the bile and the maximal concentration attained during the period of observation in general are inversely proportional to the degree of hepatic damage. Evidence is presented that such factors as systemic infection, cholangitis, depletion of bile salts from prolonged drainage, and an inadequate supply of carbohydrate will reduce the concentration of bile salts in the bile, presumably as a result of functional as contrasted to structural changes.The multiplicity of factors which apparently affect the functional ability of the liver and so the concentration of bile salts in the bile correspondingly increase the difficulty in determining the factors responsible for the changes in any individual case.Evidence was obtained suggesting that in some instances the common bile duct may concentrate the bile passing through it in the same manner as is done in a normal gall-bladder.The continued failure of the liver to secrete bile salts in the bile is evidence of severe functional disturbance and so of serious prognostic import.     

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。     

腹腔镜再次胆道探查术治疗胆管结石

目的：探讨腹腔镜再次胆道探查术治疗胆管结石的方法和临床应用价值。方法：回顾分析为31例复发性胆管结石患者施行腹腔镜胆道探查取石术的临床资料。结果：31例中2例因腹腔粘连致密,胆道周围组织充血水肿严重而中转开腹。29例完成腹腔镜手术,其中1例因胆总管结石大,1例胆总管下端结石嵌顿,1例肝内胆管结石较多,胆道镜和取石钳取石困难,剑突下切口延长至3~4 cm,直视下用取石钳联合胆道镜取石。行胆总管一期缝合5例,24例行胆总管T管引流术。手术时间平均170 min。术后均无腹腔出血和肠漏等并发症发生。3例出现少量胆漏,未出现腹膜炎和腹内感染征象,腹腔引流管分别于术后第6,9,10天拔除。2例剑突下切口感染均是切口延长者,通过局部换药愈合。胆总管一期缝合5例,术后5~7 d出院。24例行胆总管T管引流的患者中,10例于术后7 d带T管出院,14例于术后14 d夹闭T管后带管出院。术中19例结石取净,10例胆道残余结石患者于术后2个月经胆道镜取出。结论：腹腔镜再次胆道探查术安全,患者创伤小,康复快。胆管炎症严重及肝内外结石较多、胆总管下端结石嵌顿者需慎重选择腹腔镜手术。     

腹腔镜胆总管切开取石方法探讨

目的 :探讨腹腔镜下胆总管探查胆道取石的方法。方法 :于腹腔镜下对胆总管结石 4 5例按由简单到复杂 ,由损伤轻到损伤重的原则应用冲洗、挤压及分离钳、胆道镜、改良取石钳取石。结果 :用冲吸法取净结石 3例 ,占 6 .6 % ;挤压和分离钳取净结石 13例 ,占 2 8 9% ;胆道镜取净结石 11例 ,占 2 4 % ;取石钳取净结石 18例 ,占 4 0 %。结论 :腹腔镜下胆总管取石应遵循由简到繁的原则 ,用取石钳取石较为可靠     

An unusual bile collection after postcholecystectomy bile leakage

Leakage from the cystic duct stumps accounts for the majority of postlaparoscopic cholecystectomy leaks. It commonly presents with a localized bile collection in the gallbladder fossa and endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is a common method of treatment. However, bile may collect in other intra-abdominal locations away from the gallbladder fossa. We present here a case of a patient who developed upper abdominal pain with distension, anorexia, and vomiting a week after laparoscopic cholecystectomy. Ultrasonography and computed tomography scans showed an intra-abdominal collection and ERCP showed a cystic duct stump leak. A biliary stent was inserted and the collection was percutaneously drained. His symptoms, however, recurred 2 weeks later, with fever, anorexia, and weight loss. Abdominal computed tomography scan showed 9.3x8.5 cm cystic mass in the left hypochondriac area and ERCP showed persistent leakage from the cystic duct stump. The stent was changed to a larger size Fr12 and the collection was again drained percutaneously. His clinical condition improved dramatically. The biliary stent was removed after 8 weeks and remained well at 9-month follow-up.     

腹腔镜下胆总管切开探查在胆管结石中的应用

目的 :总结腹腔镜下胆总管切开探查取石术的临床应用经验 ,探讨其手术方法 ,术中注意事项及临床应用的优缺点。方法 :腹腔镜下胆总管切开取石 ,T管引流或一期缝合。结果 :2 3例胆总管结石手术2 1例成功 ,2例中转开腹。结论 :腹腔镜下胆总管切开取石术应掌握适应证 ,才能使创伤减小 ,康复快且安全。