胆道损伤经手术修复后再次胆道狭窄的外科处理

Surgical management in biliary re-stricture after operation for bile duct injury

目的胆道损伤经修复手术后发生再次胆道狭窄是外科处理的难点，该文探讨此类病例的手术时机和手术方法．方法回顾性分析了自2005年11月至2007年10月间。上海交通大学医学院附属瑞金医院收治的胆道损伤经一次或二次修复手术后发生再次胆道狭窄的病例16例，对这些病例的临床资料进行分析。结果胆道损伤绝大多数是由胆囊切除所造成．其中14例为腹腔镜胆囊切除术．1例为小切口胆囊切除术，另1例为腹部外伤。初次胆道损伤按Strasberg分型．E1 例、E2 7例、E3 5例和e4 3例．其中2例E4类型的病人合并动脉损伤。术次修复手术方式分别为11例胆肠Roux-en—Y吻合，3例胆总管端端吻合并放置T管，1例左肝管T管引流．另1例胆道外引流术。该次入院12例病人接受了胆肠Roux-en-Y吻合，其中1例接受了二期右半肝切除术（E4类型合并右肝动脉损伤）：1例病人接受了胆总管端端吻合；1例病人（E1类型合并肝固有动脉损伤）接受了尸肝移植；1例病人（腹部外伤所致）接受了活体右半肝移植；另1例病人接受了胆道外引流水。经初步随访，病人恢复基本良好。结论尽管再次手术时因炎症瘢痕等因素使得胆道狭窄平面高于初次损伤平面，但胆肠Roux-en-Y吻合依然是修复胆道损伤的主要治疗方法。术前评估应尤其重视是否合并血管损伤，并根据情况考虑是否需要行半肝切除或肝移植术；而对于全身条件较差者，可先行胆道外引流治疗。

Objective It is a considerable surgical challenge to handle biliary re stricture after reparation for bile duct injury. This paper is aimed to discuss the operation timing and method for such cases. Methyls From November 2005 to October 2007. 16 cases of bili^ry re stricture after repara tions for bile duct injury were admitted into our hospital. Their clinical data were analyzed retrospec- tively. Results The bile duct injury was caused by cbolecystectomy and laparoscopic cholecystectomy in 14 cases, mini incision choleystectomy in 1 and abdominal injury in the remaining 1. According to the classification of Strasberg, type E1 injury was found in 1 patient, type E2 injury in 7, type E3 injury in 5 and type E4 injury in 3. Twoofthe patients with type E injury had also a vascular injury of the hepatic artery. For the last reparation operation, eleven patients received Roux en Y hepaticojejunostomy, 3 patients duct to duct reconstruction with T tube stent, 1 patient T tube drainage in the left hepatic duct and 1 patient external biliary drainage. For this time in our hospital, 12 patients underwent Roux-en-Y hepaticojejunostomy, and one of them received right hepatectomy afterward. One patient received duct to duct re-anastomosis, one of the type E, injury received corpse liver transplanta- tion, one patient caused by abdominal injury received living related liver transplantation and the remai ning one patient received external biliary drainage. All ~hese patients recovered fairly well. Conclusion Although the level of scarred biliary stricture could be much higher than that of the primary bile duct injury, Roux en-Y hepaticojejunostomy is still the main approach for bile duct injury reparation. We should pay special attention to concomitant vascular injury in preoperative assessment. It may be ap propriate to consider a hemihepatectomy or liver transplantation based on different circumstances. In case of poor general condition, external biliary drainage might be the unique choice upon emergency.