37例肝囊型包虫破入胆道诊治分析

目的： 探讨肝囊型包虫破入胆道的诊断和治疗经验.方法： 对37例肝囊型包虫破入胆道患者的临床资料进行回顾性分析,采用腹部超声（SUG）、CT、核磁共振胆胰管造影（MRCP）、内镜逆行胰胆管造影（ERCP）分别检查37、22、12、4例,36例患者施行肝包虫内囊摘除及残腔引流术,其中31例行胆总管探查“T”型管引流术,4例经胆囊管置引流管胆总管减压,1例行Roux-en-y胆总管空肠吻合术, 1例内囊摘除术后患者内镜十二指肠乳头切开清理胆道引流术.结果：SUG、CT、MRCP均能准确诊断包虫囊肿,对胆道扩张的诊断率分别为67.6%、77.3%、100.0%,ERCP对胆道扩张、胆总管内包虫内囊和（或）子囊碎片及包虫囊肿与胆管相交通的诊断率均为100.0%.术中胆瘘口缝合的19例患者中2例出现术后残腔胆瘘,而未缝合的17例中8例出现胆瘘, 缝合者平均住院10.9 d, 未缝合者平均住院18 d （P＜0.05）.结论： MRCP检查对高度可疑肝囊型包虫破入胆道患者具有诊断准确和无创等优点,ERCP不仅对该病有确诊意义,而且可对该病术后并发症实施有效的治疗.缝合胆瘘、胆道减压是治疗肝囊型包虫破入胆道的简单、安全、有效且并发症少的方法,而术中胆道造影和胆道注射亚甲蓝是发现胆瘘口的有效的手段.

Diagnosis and treatment of 37 patients with intrabiliary rupture of hepatic hydatid cyst

Objective: To evaluate the diagnosis and treatment of the rupture of hepatic hydatid cyst into bilary duct.Methods: Thirty-seven patients with intrabiliary rupture of hepatic hydatid cysts were retrospectively reviewed.Results: The diagnosis of intrabiliary rupture may be difficult on ultrasounography(USG) and CT,sensitivity rates of USG and CT were 67.6% and 77.3% respectively.MRCP is an effective,noninvasive and useful diagnostic tool in difficult cases;ERCP is the gold standard in confirming diagnosis.Partial cystectomy and cholecystectomy in 36 patients,common bile duct exploration were performed in 31 patients.In 19 patients,the biliary duct within the cyst cavity was sutured.Intraoperative cholangiography was performed in 8 patients and diluted methylene blue was delivered through bile duct into the biliary system in 5 patients.T-tube was inserted after the biliary tract content was thought to have been totally cleaned out in 31 patients,inserted a Foley catheter into the biliary tree through the choledochotomy in 4 patients and a Roux-en-y choledochojejunostomy was performed in one patient.External biliary fistula developed in two patients in sutured group and in eight patients in non-sutured group.Hospitalization time was 10.9 days(ranging from 9 to 13 days) in the sutured group,but it was 18 days(ranging from 14 to 27 days) in the non-sutured group(P<0.05).One postoperative patient with high-output biliary fistulae was successfully treated by ERCP and sphincterotomy.There was no mortality.Conclusions: MRCP is an effective,noninvasive and useful diagnostic tool;ERCP is not only the gold standard in confirming intrabiliary rupture of liver cystic hydatid disease,but also an effective technique for treating postoperative extended external biliary fistula.This study indicates that suture of the communication and biliary decompression are effective procedures with low morbidity and mortality rate.Intraoperative cholangiography or deliver methylene blue through bile duct into the biliary system is very useful for finding the biliary fistula.