医源性胆管损伤的诊治及预防

目的探讨医源性胆道损伤的原因及防治原则。方法对39例医源性胆道损伤患者的临床资料进行回顾性分析。结果胆道手术所致33例(84.6%),胃大部分切除术3例(7.7%),肝脏手术所致3例(7.7%)。损伤部位在胆总管24例(61.5%),肝总管4例(10.1%),肝总管与胆总管交界处7例(17.9%),左右肝管汇合部2例(5.1%),左右肝管各1例(共5.1%)。胆管完全性损伤19例(48.7%),部分性损伤20例(51.3%)。所有病例均行手术处理。术中立即发现7例,采取直接修补或对端吻合,T管支撑引流术5例,直接置合适T管引流1例,胆总管与空肠ROUX-EN-Y吻合术1例,效果满意。术后发现32例,行肝管空肠ROUX-EN-Y吻合术19例,肝总管与十二指肠吻合6例,胆总管置管引流4例,胆总管缺损用空肠瓣修补术1例,拆除胆总管前后壁缝线2例。全组死亡2例,生存37例,33例获随访,疗效优良率为90.9%,疗效差的4例分别于术后3个月至4年再次作胆肠ROUX-EN-Y吻合术治愈。结论要警惕医源性胆道损伤的发生,及早诊断,及早修复胆道的连续性是提高疗效的关键。

Prevenition and Diagnosis and Treatment of Iatrogenic Bile Duct Injury

Objective To discuss the prevention and diagnosis and treatment of iatro- genic bile duct injury. M e t h o d s The clinical recods of 39 patients with iatrogenic bile injuries were studied retrospectively. R e s u l t s The injuries of 33 cases were resulted from extrahepatic bile duct operation,3 cases from partial gastrectomy and 2 cases from hepatectomy.The locations of injuries were at the operation,3 cases from partial duct and common bile duct in 24 cases,the common hepatic duct in 4 cases , the juncture of left and right hepatic duct in 2 cases , and the left and right hepatic duct each in 1 case respectively . Complete bile duct injurest were seen in 19 cases , and partial injures in 20 cases .All patients were treated by operation . 7 cases were immediately discovered at the time of the initial operation and direct repair or end- to-end anastomosis with T-tube stent was done in 5 of the cases ,direct insertion of T- tube drain in 1 case and Roux-en-Y hepaticojejunostomy in 1 case ,all with good results. For the 32 cases in which the bile duct injury was detected after the initial operation , Roux-en-Y hepaticojunostomy was done in 19 cases , hepaticoduodenostomy in 6 cases , drainage of common bile duct in 2 cases , plastic repair of common bile duct defect with jejunal flap in 1 case , and removal of stitches between the anterior and posterior wall of the common bile duct in 1 case . In the whole series , 2 patients died , and 33 of 37 surviving patients were followed up . The excellent result rate was 90.9%, and 4cases with poor results were cured by reoperation with Roux-en-Y cholangiojejunal anastomosis 3 months to 4 years after operation.Conclusions The key to improvenment of treatment results of iatrogenic bile duct injury is awareness of its acurrence , early diagnosis , and eraly repair of the bile duct