46例次医源性胆管损伤诊治中损伤控制应用分析

目的探讨医源性胆管损伤诊治中损伤控制应用的意义。方法回顾分析我们手术修复的46例次医源性胆管损伤病例，根据疗效情况分为优良组（n=41）及差组（n=5），分析其疗效与既往修复史及病理分型的关系，并进一步分析其既往修复技术正当性与疗效的关系。统计软件采用SPSS13．0软件包，方法采用χ^2检验Fisher确切概率法。结果共有5例次疗效差，病理分型均为Bismuth分型的Ⅲ型或Ⅳ型，其中4例次具有修复史，似乎疗效差组具有更高比例的修复史，但统计学分析差异无统计学意义（P=0．357，P〉0．05）。无修复史的21例均为直接接受本次专科修复，其中20例疗效优良。对有修复史的25例次的前次修复的专科属性与技术正当性的评判结果提示，多数的非专科修复技术运用不当（14／21），差异有统计学意义（P=0．026，P〈0．05）。结论规范内镜治疗，避免非专科确定性修复，防范修复过程中的新损伤，作为医源性胆管损伤诊治中损伤控制的重要内容，对改善预后具有重要价值。

Clinical application and analysis of damage control surgery in the treatment of 46 cases of iatrogenic bile-duct injury

Objective To discuss the clinical value of damage control surgery in the treatment of iatrogenic biliary injury. Methods The clinical data of 46 patients with iatrogenic biliary injury who had been undergone surgical reconstruction were analyzed retrospectively. These patients were divided into excellent group （n = 41 ） and poor group （n = 5 ） according to their clinical outcomes. The outcome and adequacy of their last repair were judged by two senior hepatobiliary surgeons. The chi-square test and Fisher g exact test were used and analyzed by SPSS 13.0 software. Results Four of the 5 patients with poor outcome received surgical restruction, with pathological results of Bismuth Ⅲor Ⅳ. In contrast, 20 of 21 patients without last repair had excellent outcome. Specialist judgement of the specialty and adequacy of last repair in 25 patients showed that most of the non-specialist repaired cases were managed inadequately （ 14/21, P = 0. 026,P 〈 0. 05 ）. Conclusion According to the principles of damage control surgery, standardization of therapeutic endoscopy, avoidance of non-specialized definitive repair and prevention of new injury in reconstruction are critical factors for successful repair of iatrogenic biliary injury.