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。

Clinical analysis for iatrogenic injuries in the distal part of common bile duct

OBJECTIVE: To investigate the early diagnosis on iatrogenic injuries in distal part of common bile duct and the prevention of severe retroperitoneal infection. METHODS: From 1990 to 2004, 17 patients with bile duct injures in the distal part of common biliary tract were admitted. And the clinical data of the 17 cases were retrospectively analyzed. RESULTS: Of the 17 cases, the injuries of 15 cases were caused by the operation, and the injuries of the other 2 cases were caused in the process of removing the stone by endoscopic retrograde cholangiopancreatography (ERCP). The injuries of 14 cases were found during the operation, but the other one was not found in time. Before the operation, 16 cases were examined by B-type ultrasonography, 2 by MRCP and 6 by intraoperative choledocho-endoscope after the biliary tract exploration. Ten cases underwent perforating suture repair and T-tube drainage; 2 with Odd's sphincter incision and shaping; 2 with choledochojejunostomy; 1 with duodenum wall and bile duct repair and drainage. When the bile duct injured, the major findings during operation were bile duct explorer located out of the duodenum wall and bile duct, two or more than cleft in the distal part of common biliary tract found by choledocho-endoscopic examination, retroperitoneal edema and liquid accumulation found by irrigating water through T-tube, and/or retroperitoneal tissues stained blue by irrigating methylthioninium chloride through T-tube. The clinical manifestations after injuries were abdominal distention, abdominal pain, pain in the waist and back, fever and shock, et al. Thirteen cases were cured. And the syndromes included 1 case with intestinal fistula, 1 with incisional infection, 4 dead (3 died from infectious shock; 1 from bleeding in gastrectomy). CONCLUSIONS: The postoperative clinical manifestations for iatrogenic injuries in the distal part of common biliary tract lack specificity, CT examinations are necessary to doubtful patients. Early diagnosis and timely management can obtain better results, and can effectively lower severe retroperitoneal infection. The perfect preoperative imaging examinations and intraoperative choledocho-endoscopic examinations before the biliary tract exploration maybe reduce iatrogenic injuries in the distal part of common biliary tract.