31例医源性胆管损伤临床分析

目的探讨如何减少医源性胆管损伤的发生及诊断与治疗。方法回顾性分析临床胆囊切除术中胆管损伤的原因、诊断和处理方法。结果胆囊切除术中发现14例、术后临床和影像学检查证实胆管损伤17例。损伤的临床分型；按损伤部位分为胆总管Ⅰ-型、肝总管Ⅱ-型、胆总管与肝总管汇合部Ⅲ-型、左右肝管Ⅳ-型。Ⅰ-型3例、Ⅱ-型2例、Ⅲ-型22例、Ⅳ-型4例。按损伤的严重程度分为线形1-亚型、横断形2-亚型、缺损形3-亚型，1-亚型4例、2-亚型5例、3-亚型22例。按病程分为术中至术后72h以内发现为A期，72h以后至术后3个月为B期，大于3个月为C期，A期21例、B期7列、C期3例。手术方式；胆肠内引流20例，胆管修复＋腹腔引流＋“T”管或胆管支架管引流术8例，胆管端端吻合3例。早期手术1次手术19例，中期2次手术10例，晚期2次手术2例。术后随访28例，失访3例，随访率28／31。1例术后2个月出现胆管吻合口狭窄黄疸再次手术改行胆肠内引流，2例偶有轻度的畏寒、发热，考虑为反流性胆管炎、经药物治疗可以缓解。其余病人均能胜任日常生活和工作。结论胆囊切除应重视胆管解剖变异、把握手术时机、尽量避免医源性胆管损伤；胆囊切除后检查胆囊管与肝总管、胆总管的交汇处的连续性，同时检查胆囊标本、有无双管开口，肝门有无异常胆管开口和胆汁流出，及时发现及时处理。对于术中发现1、2-亚型胆管损伤、应优先考虑胆管修复和支架引流，同时加以有效的腹腔引流。对于3-亚型胆管损伤无论损伤部位、损伤分期，以内引流为首选。医源性胆管损伤处理取决于其分期和损伤的严重程度。胆管损伤胆管狭窄的最佳处理时间尚无定论。我们认为早期手术有利于胆管重建和肝功能的恢复。

Clinical analysis of 31 cases iatrogenic bile duct injury

Objective To explore how to reduce the occurrence of iatrogenic bile duct injury and to investigate its diagnoses and managements. Methods The clinical data of the causes, diagnosis and management of bile duct injury in cholecystectomy were retrospectively analyzed.Results 14patients of bile duct injury were found in cholecystectomy, and 17 patients were confirmed by clinical and imaging inspectation succedently. The clinical type of injury: common bile duct type-Ⅰ, common hepatic duct type-Ⅱ, the joint of common bile duct and common hepatic ducttype-Ⅲ,left and right hepatic duct type-Ⅳ. Of the 31patients, 3 were type-Ⅰ, 2 were type-Ⅱ, 22 were type-Ⅲ and 4 were type-Ⅳ. By the severity of the injury, they were divided into: linetype-1 subtype, traversetype-2 subtype and default-3 subtype. 4 patients were subtype-1, 5 patients were subtype-2 and 22 patients were subtype-3. By the course of disease, they were divided into: phase A were found during the surgery and no more than 72 hours after the surgery, phase B were found between 72 hours and 3 months after surgery, phase C were over 3 months. Of the 31patients, 21 were phase A, 7 were phase B, 3 were phase C.The mode of surgery: 20patients were cholangioenterostomy; 8patients were bile duct repair and abdominal drainage and T tube or cholangiography and stenttube draining; 3 patients were end-to-end bile duct reconstruction. Among them, 19 cases were performed 1 time in early stage, 10 cases were performed 2 times at metaphase, and 2 cases were performed 2 times in late stage, Of the 31 patients, 28 were followed up with a follow-up rate of 28/31, 3 patients were lost to followed up. 1 patient was performed cholangioenterstomy again because of bile duct anastomosis stenosis and jaundice two months after surgery, 2 patients feared cold and had fever now and then. Both of them were considered reversion cholangitis and relieved after curation. All of the others were competent for daily living and work.Conclusions We should attach important to bile ductal anastomotic variations in cholecystectomy and the timing of the operation. Iatrogenic bile duct injury should be avoided as far as possible. We should check chstic duct and partmain of choledochus and common hepatic duct postcholecystectomy. checking in the meantime the gall bladder specimen whether containing double tube openings, discover in time to handle in time. checking hepatic portal whecher containing abnomal opening of bile duct or bile flowing, Type-Ⅰ,and type-Ⅱwas treated priorityly by biliary endoprosthesis and bile duct repair. combined with effective abdominal drains. as to type-Ⅲ, regardless to hurt part and hurt phase, internal drainnge should be selected firstly. management of iatrogenic bile duct injury be decided byhurt part and hurt degree. The best processing time of biliary-strcture still havn't hard conclusion. we think that surgical operation in early days was advantageous to bile duct rescution and instauration of the liver function