医源性胆管损伤的外科治疗

目的探讨医源性胆管损伤的外科处理方法及其疗效。方法 1992年1月至2011年12月期间共行胆囊切除术3 714例,发生医源性胆管损伤39例,发生率1.05%。其中术中发现胆总管或肝管部分损伤6例,胆总管或肝管被横断1例,左右肝管汇合部以上损伤2例,右侧副肝管损伤1例;术后发现胆囊管漏14例,胆囊床小胆管漏7例,胆总管或肝管部分损伤2例,胆总管或肝管被横断2例,左右肝管汇合部以上损伤1例,胆管严重狭窄2例,右侧副肝管损伤1例。行胆管修补+T管支撑引流术4例,胆管空肠Roux-en-Y吻合术12例,副肝管空肠Roux-en-Y吻合术1例,B超引导下腹腔穿刺置管引流7例,保留腹腔引流管引流14例,右侧副肝管缝扎1例。结果对术中解剖异常或操作困难的病例行术中胆道造影前后,医源性胆管损伤的发生率分别为2.37%(25/1 054)和0.53%(14/2 660),差异显著(P<0.05)。39例患者经外科治疗后均好转。术后出现的主要并发症为吻合口狭窄,共发生6例,其中术中发现损伤组3例,术后发现损伤组3例,两组比较无统计学差异(P>0.05);其他并发症还包括:切口感染4例(术中发现损伤组2例,术后发现损伤组2例),腹腔脓肿3例(术中发现损伤组1例,术后发现损伤组2例)。术后发现组低于术中发现组,为24.1%(7/29)vs.60%(6/10),有统计学差异(P<0.05)。结论医源性胆管损伤可防可治,具体外科治疗方法因病情而异,但总体来讲,胆管空肠Roux-en-Y吻合术的预后较好。

Surgical Treatments of Iatrogenic Bile Duct Injuries

Objective To discuss the methods of surgical managements of iatrogenic bile duct injury and their effects. Methods From January 1992 to December 2011, there were 39 cases （ 1.05% ） suf- fered from the iatrogenic bile duct injuries in 3 714 cholecystectomy, of which 10 （25.6%） found in the sur- gery, and the other 29 cases （74.4%） found postoperatively. There were 6 cases of partial injury to common bile duct or hepatic duct, 1 of transection of common bile duct, 2 of lesions above hepatic duct confluence, and 1 of right accessory hepatic duct injury in the intraoperative detected patients, while 14 cases of cystic duct leakage, 7 of leakage from small ducts in the liver bed, 2 of partial injury to common bile duct or hepatic duct, 2 of transection of common bile duct or hepatic duct, 1 of lesions above hepatic duct confluence, 2 of postoperative major stricture, and 1 of right accessory hepatic duct injury in the postoperative detected pa- tients. The main treatments included 4 of bile duct repair plus T-tube supporting drainage, 12 of Roux-en-Y hepaticojejunostomy, 1 of accessory hepatic duct-jejunum Roux-en-Y anastomosis, 7 of abdominal cavity drainage under B ultra guidance, 14 of the abdominal cavity drainage, and 1 of the right hepatic duct liga- tion. Results The rate of the iatrogenic bile duct injury was 2.37 % （25/1 054） and 0.53% （ 14/2 660） before and after the intraoperative cholangiography used in the difficulty operation. All the patients got cured af- ter operation, except 6 complicated with stoma stenosis, 4 cases incision infection, and 3 cases abdominal abscess. There was significant difference of the reoperation ~s complication rate between the intraoperative and postoperative detected patients, 60% （6/10） vs. 24. 1% （7/29） （P 〈 0.05）. Conclusions Iatrogenic bile duct injury is preventable and curable with specific surgical methods depending on the specific conditions. But overall, the prognosis is better for hepaticojejunum Roux-en-Y anastomosis.