腹腔镜胆总管一期缝合术后胆漏的多因素分析——血浆白蛋白水平是胆漏发生的独立危险因素

目的 探讨腹腔镜胆总管切开取石一期缝合术后胆漏的原因及防治策略.方法 2005年1月～2009年10月施行腹腔镜下胆总管切开取石一期缝合115例,全麻下四孔法建立气腹,腹腔镜下常规切除胆囊,腹腔镜下胆总管切开胆道镜取石,检查无残余结石、保证胆管通畅后行胆管一期缝合术.结果 一期缝合术后10例发生胆漏：6例经保守观察、通畅引流痊愈;2例行B超穿刺抽液;1例再手术探查为胆囊管残余结石;1例并发严重腹膜炎、多器官功能衰竭死亡.单因素分析显示,患者术前血浆白蛋白水平和术前总胆红素水平对一期缝合术后胆漏有显著影响,患者年龄、术前谷草转氨酶、胆总管缝合方式、术者及术后有无应用生长抑素、解痉药物无显著影响.logistic回归分析显示,患者术前低血浆白蛋白水平是胆漏发生的独立危险因素,β=-0.178,P=0.021,OR=0.837,95％ CI：0.719 ～0.974.结论 适应证把握不严格以及腔镜下缝合技术欠妥是术后胆漏的主要原因,保持通畅、有效的引流是处理胆漏的关键.术前低血浆白蛋白水平是胆漏发生的独立危险因素.

A Multivariate Analysis of Bile Leakage after Laparoscopic Common Bile Duct Exploration with Primary Duct Closure

Objective To explore the causes and preventive strategies of bile leakage atter primary closure following laparoscopic choledochotomy.Methods Laparoscopic common bile duct exploration with primary duct closure was performed on 115 cases between January 2005 to October 2009.Pneumoperitoneum was made through four-trocar method under general anesthesia.After routine laparoscopic cholecystectomy,choledocholithotomy were conducted,then primary closure of common bile duct was done when no residual stones were found and the bile duct was unobstructed.Results Bile leakage occurred in 10 cases （8.70％）：6 patients recovered by conservative treatment; 2 patients underwent paracentesis guided by B ultrasound; 1 case had residual stones in cystic duct through surgical reexploration; 1 case died of severe peritonitis and MODF.Single factor analysis showed that the level of preoperative plasma albumin and total bilirubin had significant effects on the occurrence of bile leakage,while patient age,glutamicoxalacetic transaminase,suture methods of common bile duct,operator,and postoperative application of somatostatin or antispasmodic drugs didn＇ t have significant effects on the occurrence of bile duct leakage.Logistic regression analysis revealed that low preoperative plasma albumin level was an independent risk factor for bile leakage（β =-0.178,P =0.021,OR =0.837,95％ CI：0.719-0.974.Conclusions The occurrence of postoperative bile leakage is largely due to insufficient supervision of operative indications and unqualified laparoscopic closure techniques.The key to handling bile duct leakage is to maintain unobstructed and efficient drainage.Low plasma albumin level is an independent risk factor.