腹腔镜胆囊切除术后胆管损伤围手术期处理

目的探讨腹腔镜胆囊切除术后胆管损伤围手术期的处理方法。方法分析我院1989年1月至2005年6月收治的38例腹腔镜胆囊切除术后胆管损伤的临床资料，结合随访结果总结有关围手术期处理方面的经验。结果38例胆道重建包括胆肠吻合术29例和对端吻合及胆管修补术9例，术后均放置胆道支撑管；术后发生胆瘘5例（13．15％），切口感染4例（10．52％），腹腔积液3例（7．89％）。胆道引流管3～4周内拔除31例；5～6周拔除7例。随诊6个月～15年，平均93个月，33例（86．84％）手术效果良好，5例（13．16％）术后吻合口狭窄，其中3例再次手术治愈，2例经十二指肠镜介入球囊扩张好转。结论胆管损伤宜术中及时发现和合理的处理；胆管损伤导致严重腹腔感染应尽早探查引流择期再行胆道重建术；胆道重建术后吻合口再狭窄处理前须获得满意的影像学检查结果；是否胆管重建术后常规放置支撑管和通过介入方法行胆管扩张治疗胆道狭窄的疗效有待进一步研究。

The perioperative management of bile duct injuries after laparoscopic cholecystectomy

Objective To investigate the perioperative management of bile duct injuries after cholecystectomy. Methods From January 1989 to June 2005, 38 patients with bile duct injuries after cholecystectomy were treated in our hospital. Patients' follow-up results were retrospectively reviewed to analyze perioperative surgical management. Results 38 patients were treated for bile duct injuries following cholecystectomy including 29 Roux-en-Y hepaticojejunostomies and 8 end-to-end ductal repairs. The transanastomotic stents were placed in all cases. The stents were removed in postoperative 3 to 4 weeks in 31 cases and 5 to 6 weeks in 7 cases. The postoperative complications were biliary leak (13. 15%), wound infection (10. 52%) and subhepatic collection (7. 89%). All the 38 patients were followed up for 6 months to 15 years and 33 patiensts (86. 84%) recovered well and biliary stricture occurred in 5 cases. Conclusions Proper diagnosis and appropriate treatment of Bile duct inj ury during cholecystectomy are important to prevent postoperative complications. The control of sepsis and the ongoing bile leak is the primary goal of the initial management of an unrecognized bile duct injury after cholecystectomy and surgical reconstruction is not urgent. The preoperative cholangiography to delineate the anatomy is important for the management in patients with an anastomotic stricture after previous repaire. The further prospective studies are still needed to define whether transanastomotic biliary stents should be placed routinely and interventional balloon dilatation is a useful method in management of patient with a failure of initial surgical reconstruction.