医源性胆胰肠结合部损伤的诊治体会

目的总结医源性胆胰肠结合部（CPDJ）损伤的诊治体会。方法回顾性分析2000年3月至2011年9月期间我院收治的9例CPDJ损伤患者的临床资料。结果 9例CPDJ损伤患者术中均放置双套管引流,术后均给予营养支持及抑制胰腺分泌治疗。①有6例术中即时发现,其中单纯胆总管下端后壁穿孔2例、单纯十二指肠壁穿孔者2例,均给予修补、胆总管T管支撑引流、腹腔引流;胆管或十二指肠损伤合并胰腺挫伤者2例,均行端侧胆肠吻合术＋毕Ⅱ氏胃空肠吻合术。该6例CPDJ损伤患者无一例死亡。②有3例术后发现,其中2例胆总管下端、十二指肠穿透伤合并胰腺挫伤,1例行全胆汁改道术后发生腹腔感染、十二指肠瘘、伤口裂开、腹腔和上消化道出血、多器官功能衰竭而死亡,另1例行全胆汁改道同时加做十二指肠憩室化手术后治愈;1例行十二指肠巨大间质细胞瘤手术致胆总管下端梗阻,先行经皮经肝胆管引流术,再行胆肠吻合术后治愈。结论 CPDJ损伤是一种发生于胆道手术、内镜下括约肌切开术、十二指肠手术中的损伤,术中易漏诊,可产生严重后果,应根据术中损伤的单纯性或复合性及术后发现的具体情况作相应的治疗。

Diagnosis and Treatment for Iatrogenic Injury of Cholodocho-Pancreatico-Duodenal Junction

Objective To summarize the experiences in diagnosis and treatment for iatrogenic injury of cholodochopancreatico-duodenal junction（CPDJ）.Method The clinical data of 9 patients with CPDJ injury were analyzed retrospectively.Results Double lumen tube drainage was emplaced in all the operations.Nutrition support and inhibitor of pancreatic secretion were applied in all the patients.① CPDJ injuries were observed intraoperatively for 6 out of 9 patients with CPDJ injury.Two patients with simple perforation of posterior wall of common bile duct inferior segment and 2 patients with simple duodenal perforation who were treated by perforation repair,common bile duct T tube drainage,and peritoneal drainage.Two cases of bile duct or duodenal injury with pancreatic injury were treated by choledochojejunostomy and Billroth Ⅱ gastrojejunostomy.These 6 patients with CPDJ injury were cured and none of case was death.② Injuries of CPDJ were observed postoperatively for 3 out of 9 patients with CPDJ injury.Total bile diversion or total bile diversion with duodenal diverticulum were performed in 2 cases of bile duct or duodenal injury with pancreatic injury,respectively.The one with total bile diversion only was died of abdominal infection,duodenal fistula,wound dehiscence,abdominal and upper gastrointestinal tract bleeding,and multiple organ failure;the one with total bile diversion with duodenal diverticulum and the one with sequent PTCD and choledochojejunostomy for biliary obstruction caused by operation of gigantic duodenal interstitialoma were cured.Conclusions CPDJ injury usually occurs in biliary duct exploration,endoscopic sphincterectomy or duodenal operation.It is easily misdiagnosed and serious consequences may happen from this.Timely and correct treatment should be taken according to the specific injury observed during or after the operation.