医源性胆管损伤的治疗及远期疗效

Management and long term efficacy of patients with iatrogenic bile duct injury

  • 摘要: 目的 探讨医源性胆管损伤的治疗方法并评价远期疗效。方法 回顾性分析 1982年 1月 至2012年4月北京协和医院收治的62例医源性胆管损伤患者的临床资料。LC致胆管损伤24例,开腹胆 囊切除术致胆管损伤38例。10例患者接受非手术治疗,其中8例行 PTCD治疗、2例行 ERCP+支架治疗。 52例患者接受手术治疗,其中47例行胆管空肠Roux-en-Y吻合、2例行肝胆管十二指肠吻合或重建、3例行 胆管缝合或端端吻合。术前36例患者行 PTCD治疗。术中42例患者放置胆管支架。为了预防术后腹腔 积液或包裹性胆汁积液,50例患者术中行腹腔引流。结果 接受手术治疗的52例患者中,13例出现1种 以上并发症,其中伤口感染1例、胆管炎4例、吻合口漏2例、吻合口出血 2例、吻合口不畅 1例、胆管支架 脱落1例、胃肠道相关疾病3例。18例患者术后早期进行胆道造影检查,其中2例提示胆汁漏。15例患者 术后行 PTCD+胆道支架植入,其中1例患者行经皮腹腔穿刺引流。2例患者因吻合口出血分别于术后1d 和术后2周行再次手术治疗。50例行术中腹腔引流术患者引流管平均放置时间为(7.7±2.6)d。全组患 者无围手术期死亡,术后平均住院时间为(18±12)d。本组62例患者中55例获得随访(非手术治疗10例、 手术治疗45例),中位随访时间为93个月。接受非手术治疗的 10例患者中,1例行 PTCD后因胆汁漏于 外院接受再次手术治疗,3例行 PTCD后因胆管炎反复发作伴结石形成多次行 PTCD。接受手术治疗的 45例患者中,6例出现远期并发症,其中发热6例、黄疸4例、胆管结石3例、胆管癌变1例;4例于术后2年 行再次手术。结论 尽早发现胆管损伤并由经验丰富的专科医师治疗是保证患者近期和远期疗效的最佳 方案。外科修复仍为治疗胆管损伤的首选。

     

    Abstract:

    Objective To investigate the management of iatrogenic bile duct injury and evaluate the long term efficacy.  Methods The clinical data of 62 patients with iatrogenic bile duct injury who were admitted to the Peking Union Hospital from January 1982 to April 2012 were retrospectively analyzed. Of the 62 cases of iatrogenic bile duct injuries, 24 were caused by laparoscopic cholecystectomy (LC) and 38 were caused by open cholecystectomy. Ten patients received non surgical treatment, including 8 patients received percutaneous transhepatic cholangiography and drainage (PTCD) and 2 received endoscopic retrograde cholangiopancreatography (ERCP)+stent implantation. Fifty two patients received surgical treatment, including 47 received cholecysto jejunostomy, 2 received cholecystoduodenostomy, 3 received biliary end to end anastomosis. Thirty six patients received PTCD preoperatively, and 42 received biliary stent implantation intraoperatively. Fifty patients received intraoperative peritoneal drainage to prevent postoperative peritoneal effusion or encapsulated bile collection.  Results Of the 52 patients who received surgery, 13 patients were complicated by more than 1 complication, including 1 case of wound infection, 4 cases of cholangitis, 2 cases of anastomotic leakage, 2 cases of anastomotic bleeding, 1 case of anastomotic occlusion, 1 case of biliary stent falling out and 3 cases of gastrointestinal diseases. Eighteen patients received cholangiography postoperatively, and 2 patients were diagnosed as with bile leakage. Fifteen patients received PTCD+biliary stent implantation, and 1 patient of them received percutaneous puncture drainage. Two patients received reoperation due to anastomotic bleeding. The mean time of peritoneal drainage for the 50 patients was (7.7±2.6)days. No perioperative death was observed, and the mean operation time was (18±12) days. Fifty five patients were followed up (10 patients received non surgical treatment, and 45 patients received surgical treatment), with a median time of 93 months. Of the 10 patients who received nonsurgical treatment, 1 received reoperation due to bile leakage, 3 received PTCD for the second time due to repeated cholangitis after PTCD. Of the 45 patients who received surgical treatment, 6 patients had long term complications, including 6 cases of fever, 4 cases of jaundice, 3 cases of choledocho lithiasis and 1 case of bile duct canceration; 4 received reoperation at the second year after operation.  Conclusions Early diagnosis of bile duct injury and operation carried out by experienced surgeons are important for a better short and long term prognosis. Surgical repair is the first line therapy for bile duct injury.

     

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