医源性胆管损伤28例诊治分析

探讨医源性胆管损伤的诊治。回顾性分析1998年3月-2013年2月我院28例医源性胆管损伤患者临床资料。术中发现胆管损伤9例,2例行胆管对端吻合、T管支撑引流,7例行胆管空肠Roux-en-Y吻合;术后发现胆管损伤19例,2例行胆管对端吻合、T管支撑引流,16例行胆管空肠Rouxelly吻合术,1例后期}亍肝门胆管整形申胆肠ROUX-en-Y吻合术03例患者发生胆瘘、6例反复发作狭窄性胆管炎、1例术后死于肝功能衰竭。胆道手术过程中应预防医源性胆管损伤,一旦发生应尽早诊断并给予正确处理。     

医源性胆管损伤的治疗分析

目的探讨胆道损伤的外科处理方法。方法回顾分析10年中7例医源性胆管损伤的外科处理。结果胆总管修复+T管支撑引流2例,胆总管对端吻合+T管支撑引流2例,胆肠Roux-en-Y吻合+引流管支撑2例,胆肠Roux-en-Y吻合1例。结论胆管修补、胆管对端吻合及胆肠Roux-en-Y吻合,放置胆管支撑引流管6个月以上是治疗胆管损伤防治胆管狭窄的一个重要方法。胆管空肠Roux-en-Y吻合术是修复高位胆管损伤或二期修复胆管损伤的首选方法。     

医源性胆管狭窄的手术治疗

目的 探讨医源性胆管狭窄的手术治疗方法.方法 回顾性总结1989年1月至2006年12月收治的235例医源性胆管损伤及胆管狭窄患者的临床资料.对损伤或狭窄患者采用胆肠通路重建术、保留和利用乳头括约肌的修复术、肝移植术等进行修复.结果 本组182例患者行胆肠Roux-en-Y吻合术,12例行胆总管对端吻合术,34例行自体带蒂组织瓣吻合术,6例行胆总管切开成形T管引流术,1例行肝移植术.随访时间1～10年,189例获随访.手术优良率为94.7%(179/189).狭窄复发率为5.3%(10/189),复发原因主要为合并结石、硬化性胆管炎、胆汁性肝硬化等.1例因严重胆汁性肝硬化、门静脉高压症,术后死于肝功能衰竭.结论 胆肠Roux-en-Y吻合术是可靠的治疗方法.利用自体带蒂组织瓣修复胆管能保留胆管下端Oddi括约肌的功能,效果良好,但远期疗效有待进一步评估.胆管内不需要常规放置支撑管.肝移植是治疗胆管狭窄引起的终末期胆病的有效方法.     

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。     

医源性胆道损伤治疗效果分析

目的总结医源性胆道损伤的临床治疗经验。方法回顾性分析我院外科自1989年1月至2005年1月收治的医源性胆道损伤患者38例，其中胆总管横断伤3例，行胆管端端吻合T管引流术1例，胆总管十二指肠吻合2例；肝总管横断伤6例，行胆管端端吻合T管引流术2例，胆肠Roux-en-Y吻合术4例；胆总管部损伤5例，行胆管壁缺损修补T管引流术2例，胆肠Roux-en-Y吻合术3例；肝总管部分损伤9例，行胆管壁缺损修补T管引流术3例，胆肠Roux-en-Y吻合术6例；胆总管、肝总管、左肝管缝扎各3、8、4例，均行Roux-en-Y吻合术。结果失访2例，36例获随访，时间1—14年，痊愈30例(78．9％)。胆道狭窄并结石形成3例，再次行Roux-en-Y吻合，术后反复发作胆道感染2例，死亡1例。结论医源性胆道损伤一经确诊，应有计划、有步骤地采取合理的治疗程序，术式要视损伤后时间、部位、程度及类型而定。     

医源性胆管损伤64例临床分析

目的 分析总结医源性胆管损伤诊治经验。方法 回顾性分析2005年1月至2009年12月中国医科大学附属盛京医院收治的64例医源性胆管损伤病人的临床资料。结果 64例中发生于开腹胆道手术41例,腹腔镜胆囊切除术16例,其他手术7例。4例损伤较轻,术后出现胆汁瘘,行鼻胆管引流术;5例首次术中发现行损伤处T管引流术;55例行胆管空肠Roux-en-Y吻合术。1例死亡,2例吻合口狭窄再次手术,1例术后支架管脱落后吻合口狭窄再次手术,63例痊愈。结论 术中发现胆管较小损伤（<3mm）慎用单纯缝合修补,应积极实施T管引流。术中发现胆管横断,术后数天发现胆管损伤或重建术失败者,胆肠Roux-en-Y吻合术为首选术式;胆肠吻合应慎用环型吻合器。     

腹腔镜胆囊切除术中医源性胆道损伤的处理策略

目的:探讨腹腔镜胆囊切除术(LC)中医源性胆管损伤的诊断及处理策略。方法:回顾分析2009年1月至2018年12月19例LC导致的医源性胆管损伤患者的临床资料。按Strasberg-Bismuth胆管损伤分型,胆囊管残端漏或胆囊床小胆管漏(A型)3例(15.8%);副右肝管损伤导致胆漏(C型)2例(10.5%);肝外胆管侧壁损伤导致胆漏(D型)7例(36.8%);肝外胆管横断损伤导致胆管梗阻(E型)7例(36.8%)。术后发现并处理7例,其中行胆管空肠Roux-en-Y吻合治疗4例,行内镜鼻胆管引流、腹腔引流3例。术中发现并处理12例,其中腹腔镜胆管修补1例,腹腔镜胆管修补+T管引流3例,腹腔镜胆囊床小胆管夹闭处理2例,中转开腹行胆管空肠Roux-en-Y吻合3例,胆管端-端吻合+T管引流1例,副右肝管空肠Roux-en-Y吻合2例。结果:19例患者失访2例,随访率89.5%,术后中位随访时间49个月。1例患者经过内镜鼻胆管引流、腹腔引流后胆漏消失,但拔管后出现胆管狭窄、黄疸,于术后5个月再次行胆管空肠Roux-en-Y吻合治愈。全组均无严重并发症及死亡病例。结论:LC相关医源性胆管损伤应根据损伤发现时间、原因、部位及程度等因素进行个体化治疗,及时诊断并由经验丰富的专科医师进行确定性修复手术是改善预后的关键。     

腹腔镜胆囊切除术中医源性胆管损伤的原因及防治

目的总结腹腔镜胆囊切除术中医源性胆管损伤的原因,探讨防治措施。方法本研究采用回顾性分析,纳入2010年05月~2017年05月于我院行腹腔镜胆囊切除术的1800例患者,将其中发生医源性胆管损伤的6例患者作为研究对象。分析损伤原因、治疗措施及预后。结果医源性胆管损伤患者6例,其中2例因胆囊管汇入异常损伤肝右管,2例因胆囊管过短手术医生盲目自信而误将胆总管横断,1例因急性胆囊炎三角结构不清致肝总管部份切断,还有1例是术中电钩使用不精细误伤胆总管引起迟发性胆瘘。6例患者除迟发性损伤1例外其余5例均是术中发现并及时处理,其中3例行胆肠Roux-en-Y吻合术;2例行胆管端端吻合术,吻合口远端留置T管支撑引流;对迟发性损伤的1例患者于术后第6天行开腹胆道切开探查、行T管引流。1例胆管端端吻合术的患者于术后11个月出现胆总管狭窄,行球囊扩张后好转,余5例患者均顺利康复。结论医源性胆管损伤重在"防",术中精准解剖"三管一壶腹",早期发现并处理胆管损伤尤为重要,重建方式主要采用胆肠Roux-en-Y吻合术,条件允许可行胆管端端吻合术,胆管损伤后应该提倡以肝胆外科为主导的多学科诊疗模式。     

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。     

手术治疗医源性胆管损伤的临床体会

目的总结医源性胆管损伤的诊治方法及再手术要点。方法回顾性分析2008年1月至2013年12月收治的医源性胆管损伤病人的临床资料。结果总计32例医源性胆管损伤:发生于胆囊切除手术19例,胆管探查手术8例,肝切除手术5例。治疗方法:4例病人行非手术治疗,28例病人行手术治疗。手术方式:胆管修补术7例,胆管端端吻合术1例,胆管结扎线松解1例,胆管空肠Roux-en-Y吻合术13例,肝叶切除+胆管空肠Roux-en-Y吻合术4例,肝叶切除术2例。32例病人中:术后1例反复发作胆管炎,1例胆肠吻合口狭窄再次手术,2例死亡,其余28例随访期内恢复良好。结论医源性胆管损伤再手术的成功,有赖于丰富的胆道外科经验和精准的胆道外科技术,对于吻合口狭窄或重建手术失败者,胆管空肠Roux-en-Y吻合术为推荐术式。     

医源性胆道损伤的诊治

目的 总结医源性胆道损伤的诊治经验。方法 对解放军第153中心医院22年间医源性胆道损伤的20例患者进行回顾分析。结果 经腹胆囊切除术损伤6例,腹腔镜胆囊切除术损伤10例,胆总管探查术损伤4例。损害部位:肝总管6例,胆总管1例,本组病例最终均需手术治疗,手术方式根据损伤部位、类型、损伤后发现的具体时间决定,但以规范的胆肠Roux-en-y吻合术疗效最满意。结论 术者的责任心与技术因素是引起医源性胆道损伤的重要原因。     

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。     

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。     

Postoperative bile duct strictures: management and outcome in the 1990s

OBJECTIVE: To describe the management and outcome after surgical reconstruction of 156 patients with postoperative bile duct strictures managed in the 1990s. SUMMARY BACKGROUND DATA: The management of postoperative bile duct strictures and major bile duct injuries remains a challenge for even the most skilled biliary tract surgeon. The 1990s saw a dramatic increase in the incidence of bile duct strictures and injuries from the introduction and widespread use of laparoscopic cholecystectomy. Although the management of these injuries and short-term outcome have been reported, long-term follow-up is limited. METHODS: Data were collected prospectively on 156 patients treated at the Johns Hopkins Hospital with major bile duct injuries or postoperative bile duct strictures between January 1990 and December 1999. With the exception of bile duct injuries discovered and repaired during surgery, all patients underwent preoperative percutaneous transhepatic cholangiography and placement of transhepatic biliary catheters before surgical repair. Follow-up was conducted by medical record review or telephone interview during January 2000. RESULTS: Of the 156 patients undergoing surgical reconstruction, 142 had completed treatment with a mean follow-up of 57.5 months. Two patients died of reasons unrelated to biliary tract disease before the completion of treatment. Twelve patients (7.9%) had not completed treatment and still had biliary stents in place at the time of this report. Of patients who had completed treatment, 90. 8% were considered to have a successful outcome without the need for follow-up invasive, diagnos tic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture after laparoscopic cholecystectomy had a better overall outcome than patients whose postoperative stricture developed after other types of surgery. Presenting symptoms, number of stents, interval to referral, prior repair, and length of postoperative stenting were not significant predictors of outcome. Overall, a successful outcome, without the need for biliary stents, was obtained in 98% of patients, including those requiring a secondary procedure for recurrent stricture. CONCLUSIONS: Major bile duct injuries and postoperative bile duct strictures remain a considerable surgical challenge. Management with preoperative cholangiography to delineate the anatomy and placement of percutaneous biliary catheters, followed by surgical reconstruction with a Roux-en-Y hepaticojejunostomy, is associated with a successful outcome in up to 98% of patients.     

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     

Prognostic factors in the treatment of the bile duct injuries and strictures

To describe the prognostic factors after surgical reconstruction data. were collected prospectively on 60 patients treated at the Scientific Center of Surgery named after M.Topchubashov and N5 City Hospital with major bile duct injuries and postoperative bile duct strictures between 2000 and 2009. Of the 60 patients 21 had bile duct injuries, other 39 had postoperative strictures. In 15 of 53 patients with iatrogenic injury of bile ducts trauma was recognized and repaired intraoperatively. In 22 patients was early, in 16 patients delayed recognition of bile duct injury. Most of patients had undergone a choledocho (8) or hepaticojejunostomy (33) by Roux. External drainage of bile ducts was performed in 24 patients. Of the 60 patients undergoing surgical reconstruction, 47 hud completed treatment. Of patients who had completed treatment, 82,9% were considered to have a successful outcome (24 patients excellent, 15 patients - good results) without the need for follow-up invasive, diagnostic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture-without external drainage had a better overall outcome (92,9% successful outcome) than patients with drainage of bile ducts (68,4% successful outcome). Number of stents and length of postoperative stenting also were significant predictors of outcome. Type of operation (laparoscopic or open cholecystectomy) had nd significant influence on outcome. At the same time a successful outcome, without the need for biliary stents, was obtained in 87,5% of patients after laparoscopic cholecystectomy versus 71,8% after open cholecystectomy.     

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。     

胆道探查至胆总管下端损伤的临床分析

目的 讨论胆道探查术中探条所致胆总管下端损伤的原因及处理。方法 对胆道探查中探条所至的4例胆总管下端损伤，进行回顾性分析总结。结果 造成损伤原因主要是对胆总管下端的解剖认识不足，术中探查使用暴力所至，对2例胰腺管段未穿出胰腺的损伤，行T管充分引流，穿出胆管至腹膜后间隙的1例行局部修补加T管引流，另1例因术中遗漏，术后死于感染中毒性休克，结论 胆总管下端损伤重在预防，损伤后以局部修补，上方的充分引流为主。     

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。