延迟发现胆胰肠结合部损伤的诊断和治疗

目的 探讨延迟发现的胆胰肠结合部损伤的诊断和治疗方法.方法 回顾性分析2000年至2007年北京协和医院基本外科手术治疗5例胆胰肠结合部损伤患者的临床资料.5例均为延迟发现(损伤后24 h)的患者,其中4例为ERCP或EST+内支架植入术后造成胆胰肠结合部损伤,1例为车祸伤致十二指肠穿孔.结果 经保守治疗24～72 h,腹膜炎症状未减轻,急诊行手术.3例行胃、胆管和空肠三造瘘术,1例腹痛减轻,逐渐痊愈;2例因MODS于术后5～6周死亡.2例行十二指肠完全憩室化手术,术中结扎胆总管下段和幽门,修补十二指肠置T管和胃、空肠造瘘,腹膜后冲洗引流,6～7个月后再次重建消化道,行胆肠和胃空肠Roux-en-Y吻合,效果良好.结论 对于穿孔时间长、腹腔感染严重的患者,十二指肠完全憩室化是一种可考虑的选择.

Diagnosis and treatment of delayed-diagnosed injury in choledocho-pancreatico-duodenal junction

Objective To summarize the experience in prevention and management of delayed-diagnosed injury in choledocho-pancreatico-duodenal junction. Methods The clinical data of 5 patients with injury in chole-docho-pancreatico-duodenal junction who had received surgery from 2000 to 2007 in Peking Union Hospital was summarized and analyzed retrospectively. All the 5 patients were diagnosed 24 hours after the injury. The injury was caused after endoscopic retrograde cholangiopancreatography (or endoscopic sphincterotomy) +endovascular stent placement in 4 patients and by vehicle accident in 1 patient. Results All the patients were treated conserva-tively for 24-72 hours, and peritonitis was not alleviated, and were subsequently transferred to surgery. Three patients received gastrostomy +choledochostomy +jejunostomy. The abdominal pain was alleviated in 1 patient, and 2 died of multiple organ dysfunction syndrome 5-6 weeks later. Two patients received duodenal diverticulariza-tion + gastrostomy + jejunostomy + Roux-en-Y choledachojejunostomy + Roux-en-Y gastrojejunostomy, and had good prognosis. Conclusion Duodenal diverticularization is a proper choice for patients with perforation combined with severe intraabdominal infection.