医源性胆管损伤再手术原因分析及防治

目的：探讨医源性胆管损伤再手术的原因及防治。方法：对19年中129例胆管损伤108例再手术病人的损伤部位和再手术时机进行回顾性分析。结果：再手术率83．1％（108／129）；病人性别、年龄与再手术率无显著关系（P＞0．05）；再手术率与损伤原因、首次手术方式、损伤部位、再手术时机、再手术术式和手术操作等因素有关；LC胆管损伤再手术率（93．3％）高于OC手术胆管损伤（82．5％），相差显著（P＜0．05）；LC胆管损伤再手术率最高（92．3％），OC次之（84％）、OC＋胆管探查术最低（75％），三组间相差显著（P＜0．05）；损伤部位再手术率：肝总管、肝门部胆管、高位胆管分别为92．3％、88．5％、89．6％，三者无显著差异（P＞0．05），而胆总管损伤再手术率最低36．9％，与前三个部位再手术率相差非常显著（P＜0．01）。结论：胆管损伤力争手术中、术后早期（＜24h）确诊并处理，术后被迫急诊手术只能作为急救措施进行胆汁外引流术。LC术中及其术后和OC手术术后胆管损伤短期内（＜4周）修复应慎用，4周后行损伤近端胆管与空肠Roux-Y端侧一侧吻合较合适，并内置于T管支撑半年以上，可降低术后胆管再狭窄及返流性胆管炎的发生率，从而降低再手术率。

Cause analysis and prevention of re-operation due to iatrogenic biliary tract injury

Objective To investigate the causes and prevention of re operation due to iatrogenic bile duct injury. Methods A total of 129 cases of iatrogenic biliary tract injury, in which 108 cases were treated by surgical procedures, were reviewed and analyzed in this paper. Results The re operation rate (83 1%) was related to injury causes, injury site and the pattern of the first operation but not to sex and age. Injury rates of laparoscopy, open abdominal operation and cholecystectomy with exploration of common bile duct were 93 3%, 84% and 75%, respectively. Injury rates of common hepatic duct, porta hepatis duct, high bile duct and common bile duct were 92 3%, 88 5%, 89 6% and 36 9%, respectively. Conclusions Only bile drainage should be done in patients with iatrogenic injury of the bile duct within 24 hours. Bile duct repair operation is not suggested within 4 weeks. Cholangio jejunostomy is the best method in dealing with iatrogenic bile duct injury after 4 weeks.