Nonoperative management of bile leaks following liver transplantation

The biliary anastomosis has been called ‘the Achilles heel’ of liver transplantation (Rabkin JM, Orloff SL, Reed MH . Transplantation 1998: 65 [2]: 193; Davidson BR, Rai R, Kurzawinski TR . Br J Surg 1999: 86 [4]: 447). Biliary complications after liver transplantation reportedly occur at an incidence of 20–30%, 10–15% as bile leaks. The management of bile leaks, especially early bile leaks, is controversial. In the present study, we report our experience with the management of bile leaks after liver transplantation.
In this retrospective study, we reviewed 85 liver transplants over a 3‐yr period. In 79, the biliary anastomosis was choledochocholedochostomy (CDCD) over a small‐caliber T‐tube, while choledochojejunostomy (CDJ) was used in 7. Over a mean follow up period of 13.5 months (median 10 months), 10 patients (12%) experienced a clinically significant bile leak within the first 3 months after liver transplantation.
The early leaks, occurring within 1 month of transplant, were successfully managed by observation (Davidson BR, Rai R, Kurzawinski TR . Br J Surg 1999: 86 [4]: 447) or endoscopic retrograde cholangiopancreatography (ERCP) and the placement of a biliary stent for a duration of 6–12 wk (Randall HB, Wachs ME, Somberg KA . Transplantation 1996: 61 [2]: 258). One of these resulted from accidental dislodgement of the T‐tube on postoperative day 1; one resulted from necrosis at the CDCD anastomosis and required CDJ; the remaining four resulted from leaks along the T‐tube track.
One of the late leaks occurred following the planned removal of the T‐tube at 3 months after liver transplantation; the other two were leaks along the T‐tube track. All were successfully treated by ERCP and stent placement, though in one case, ERCP was initially unsuccessful because of the inability to advance a guidewire, necessitating a fluoroscopically aided guide wire placement during a mini laparotomy. ERCP was then successfully performed with the placement of a stent. Table 1 Conclusions: Our experience indicates that most bile leaks after liver transplantation, including early leaks, can be successfully managed nonoperatively. Most will require intervention, but ERCP and stent placement are usually sufficient.

大网膜人工窦道预防胆管引流管拔出后胆漏的动物实验研究

目的探讨采用带蒂大网膜在胆管引流管周围做成人工窦道的方法及效果。方法建立实验兔胆管引流动物模型。100只新西兰大白兔随机分为2组,即实验组及对照组。每组再随机分成5个亚组,每亚组10只,在手术后3、6、9、12、15d分别剖腹了解5亚组中一亚组胆管引流管窦道形成情况,并取部分窦道壁送病理检查。结果实验组在不同时间点,窦道完全形成动物数分别为:3d8只,6d10只,9d10只,12d10只,15d10只;对照组分别为:3d1只,6d1只,9d2只,12d3只,15d4只。两组比较差异有统计学意义(P<0.01)。结论采用带蒂大网膜在胆管引流管周围形成人工窦道的方法简单、实用,不仅可缩短留置T管的时间,而且可有效防止拔T管后胆漏的发生,值得临床推广使用。     

肝外胆管结石取石术后一期缝合与置T管引流的疗效分析

目的探讨肝外胆管结石取石后胆管一期缝合术的安全性。方法选择我院2007年1月～2012年1月因肝外胆管结石行胆总管切开取石术患者111例,其中行胆总管一期缝合50例（缝合组）,行T管引流61例（引流组）,对两组的临床疗效进行比较分析。结果两组患者在手术时间、腹腔引流时间、术后胆漏、结石残留和结石复发等方面差异均无统计学意义（均P〉0.05）;缝合组在住院时间、补液量、电解质紊乱发生率等项均少于引流组,差异均有高度统计学意义（均P〈0.01）。结论肝外胆管结石行胆总管取石后一期缝合,能明显缩短住院时间、减轻患者经济负担,而且不存在T管引起的各种弊端,只要掌握适应症该术式是可靠、安全的治疗方法。     

Detection of Tract Formation for Prevention of Bile Peritonitis after T-Tube Removal. Case Report

Bile leakage after removal of T-tube is a relatively rare complication caused by inadequate tract formation around the tube. We report a case of bile peritonitis after removal of a latex T-tube. The patient underwent reoperation and a new T-tube was introduced. The T-tube was removed six weeks later. Immediately after removal of the tube, the cutaneous ostium of the tube was catheterized with a thin Nelaton catheter. The administration of gastrographin showed the presence of an intact tract. The removal of the t-tube was uneventful. We would propose this method for detecting the tract after removal of the T-tube in order to prevent severe bile leakage after inadequate tract formation.     

腹腔镜胆总管切开纤维胆道镜取石术260例报告

以260例肝内外胆管结石患者在腹腔镜下切开胆总管用纤维胆道镜取石,胆总管内置入T管。腹腔镜手术全部成功,手术时间为70－230分钟,术后发生胆漏6例,十二指肠损伤1例,腹腔残石致引流管口形成脓肿1例,胆道残石10例,经T管窦纤维胆道镜取石后治愈。从T管引流出钛夹2例,术后第二天进流质饮食并下床活动,平均住院5天,带T管出院,认为该手术扩大了腹腔镜胆囊切除术适应证,具有创伤小、恢复快、这短等优点,是治疗胆囊结石并胆总管结石龙共是胆总管大结石的有效方法。     

纤维胆道镜经T管窦道治疗胆道残石

目的探讨纤维胆道镜治疗胆道术后胆道残石的价值、方法和技巧。方法回顾分析了纤维胆道镜经T管窦道治疗胆道残石386例,应用网篮套取、冲洗,并配合经皮胆囊镜、冲击波胆道碎石仪等取出结石。结果386例患者中371例取净结石,取净率96.11%,最多取石次数5次,平均1.8次。并发胆道出血4例,发热8例,腹泻10例均经保守治疗后好转。结论利用纤维胆道镜经T管窦道取石安全有效,并发症少,是治疗胆道残石最有效的方法。熟练的胆道镜操作技术有利于提高取石的成功率。     

肝移植术中不留置T型管指征的探讨

目的 探讨肝移植术中不留置T型管,以降低与T管相关胆道并发症的发生率.方法 对2004年1月至2006年10月的肝移植患者进行前瞻性临床研究.在此期间内符合指征未留置T管的患者102例,观察本组患者胆道并发症的发生率.结果 本组患者均随访6个月以上.胆道并发症的发生率是4.9%(5/102),其中3例为肝内胆管多发性狭窄,均行再次肝移植;2例为肝总管非吻合口狭窄,经ERCP行球囊扩张并放置胆道内支撑管3个月后治愈.结论 对符合指征的肝移植患者术中不留置T管是安全的,可避免T管相关并发症,降低胆道总体并发症的发生率.     

Metallic Clip Migration to T-tube Sinus Tract after Laparoscopic Choledochotomy

Migration and translocation of metallic clips in the abdominal cavity after laparoscopic bile duct surgery have been reported to occur in the common bile duct (CBD), hepatic duct, duodenum, and even the ovarium, which could cause severe complications. Here we present three cases of metallic clip migration to the T-tube sinus tract after laparo-scopic choledochotomy. Metallic clips were discharged from the sinus tract of the T-tube into the drainage bag in two cases. In another case, clips were found to translocate into the sinus tract during choledochoscopic examination for residual stones in CBD.     

Percutaneous video choledochoscopic treatment of retained biliary stones via dilated T-tube tract

Background: Retained biliary stones is a common clinical problem in patients after surgery for complicated gallstone disease. When postoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy are unsuccessful, several percutaneous procedures for stone removal can be applied as alternatives to relaparotomy. These procedures are performed either under fluoroscopic control or with the use of choledochoscopy, but it is also possible to combine these methods. Methods: Since 1994, we have used the percutaneous video choledochoscopic technique for the removal of difficult retained biliary stones via dilated T-tube tract in 17 patients, applying the technique of percutaneous stone extraction used in urology. While waiting for the T-tube tract to mature and after the removal of the T-tube, the dilatation of its tract was 26--30 Fr. Stone removal was carried out using a flexible video choledochoscope and a rigid renoscope under fluoroscopic control, with the aid of Dormia baskets, rigid forceps, and high-pressure irrigation. Results: We performed 23 operative procedures, and the clearance of the biliary ducts was successful in all cases. There were no major complications or deaths. Conclusion: Percutaneous video choledochoscopic--assisted removal of large retained biliary stones via the T-tube tract is a highly effective and safe procedure. Its advantages over other procedures include the ability to visualize the stones and noncalculous filling defects; it also guarantees that the stones can be removed under visual video endoscopic control. It has no problems related to tract or stone size. apd: 21 December 2000     

3D腹腔镜在胆道手术中应用的初步探索

目的初步探索3D腹腔镜在胆道手术中的临床效果。方法回顾性分析2015年1月-2016年6月在该院接受腹腔镜胆囊切除+胆总管探查手术治疗的胆道结石患者38例,其中3D腹腔镜手术16例,2D腹腔镜22例,比较分析两组患者手术时间、出血量、术后腹腔引流量,术后引流时间、术后住院时间、住院费用和并发症等的差异。结果 3D组患者手术时间及出血量均优于2D组(P0.05),两组患者术后引流量、术后引流时间、术后住院时间、住院费用和并发症差异无统计学意义(P0.05)。2D组有1例患者出现结石残留,术后2个月行经T管窦道胆道镜取石术后痊愈;3D组无结石残留病例。随访2~18个月,两组患者均无结石复发。结论 3D腹腔镜技术使胆道手术更精准、微创,有着广阔的应用前景。