医源性胆道损伤致胆汁渗漏74例诊治分析

目的探讨医源性胆道损伤致胆漏的常见原因、预防和早期诊治方法。方法对74例医源性胆道损伤致胆漏病例的手术方式、损伤类型以及损伤时间进行回顾性分析，并采用手术治疗。手术方式：腹腔引流18例（24．3％），胆管修补并T管支撑引流22例（29．7％），胆总管端端吻合合并T管支撑引流14例（18．9％），胆管空肠Roux-en—Y吻合18例（24．3％），胆总管十二指肠吻合2例（2．7％）。结果全组术后无近期并发症，21例获3个月～3年随访，无远期并发症。结论医源性胆道损伤致胆漏以胆囊切除术多见，多发生于胆囊三角区，主要原因为缺乏胆管影像学诊断，局部组织水肿坏死或粘连，手术器械缺乏或设备不规范，照明等条件差，暴露欠佳，术后经验缺乏等。早发现、早诊断的有效治疗是术中常规手术视野敷白纱布，疑有胆道损伤时即行胆道造影、胆总管探查术；常规手术区低住置引流管，术后1周严密观察腹腔引流液性状及量、胆汁性腹膜炎体征、巩膜、皮肤黄染情况，B超动态监测胆管直径及腹腔游离液体变化；术后2周常规T管胆管造影或ERCP等。适当进行结扎、引流胆管修补、胆肠吻合、胆管支撑等手术方式是有效的治疗措施。

Diagnosis and treatment of iatrogenic biliary tract damage

Objective To evaluate the pathogeny precaution, early diagnosis and treatment of iatrogenic biliary tract damage. Methods The clinical data of 74 cases of iatrogenic biliary tract damage were retrospectively analyzed including the modus operandi the clinical manifestation and the final diagnosis time. The modus operandi of iatrogenic biliary tract damage included belly cavity drainage in 18 cases（24.3%）, biliary tract repair and T tube drainage in 22 cases （29.7%） ,end-to-end bile duct anastomosis and T tube drainage in 14 cases（18.9%）,Roux-en-Y choledochojejunostomy in 18 cases（24.3%） ,biliary pore-duodenum anastomosis in 2 cases（2.7N）. Results No complication in the near future or long-term. Conclusion The iatrogenic biliary tract damage mainly appears in cholecystectormy,also mainly Calot＇s triangle. The causes are mainly lake of imageology diagnose of biliary tract,appearance of dropsy and necrosis or accretion of part tissue,lack of Surgical instruments and imnormal equipment, bad illumine, And experience and so on. The utility measure of early discovery and diagnostic include., white bandage is paved on. Visual field of operation; when biliary tract damage is suspected,biliary tract opacification and exploration of the common bile duct are executed at once;low-set drainage tube is usually placed in field of operation; peritoneal cavity. Drainage charcter and quantum,bile peritonitis objective sign and albuginea occult and skin stained are exactly observed during lweek after operation moreover dynamicstate of biliary ducts diameter is monitored with B ultrasound; routine biliary tract opacification or ERCP is carned out during 2weeks after operation and so on, proper Choice of deligating, drainaging,restoring,choledochojejunos-tomy pedestal is effective