胆总管远端穿通伤(肝外胆管医源性损伤的特殊类型)

Perforating injury of distal choledoch: a special type of iatrogenic injury of extrahepatic bile duct

目的 探讨胆道手术时采用胆道探条致胆总管远端穿通伤(PIDC)的病理特点及术时诊治方法。方法 回顾分析术时并发PIDC 5例的临床资料。结果 术时PIDC漏诊的2 例、术后在并发前肾旁间隙感染后均行引流术,该2例中1例最后死于脓毒血症,另1例在续发十二指肠瘘后死于MOF;在获PIDC确诊的3例中伴壶腹部嵌顿结石及Oddi括约肌狭窄分别为1例及2例。该3例均行Oddi括约肌成形术(OSP)、经壶腹内部直视下缝闭胆总管远端戮孔(SHDC)、及胆总管T管引流(DBT)。该3例包括术时行胆道造影外漏的造影剂引发急性胰腺炎1 例均获治愈。结论 PIDC是肝外胆管医源性损伤(IIEB)的一种特殊类型,术时正确诊断与治疗是治愈病人的关键。综合行OSP、SHDC及DBT手术等对具有壶腹部嵌顿结石或Oddi括约肌狭窄病人是一种适宜的选择。

Objective To investigate the pathologic features of perforating injury of distal choledoch (PIDC) complicated by using biliary probe during operation and explore methods for its immediate diagnosis and management. Methods The clinical data of 5 patients with PIDC were retrospectively analyzed. Results Two cases were not diagnosed during the primary operation. They had severe infection in the anterior pararenel space (APRS) and were treated by drainage. One of the 2 patients died of septicemia and another died of duodenal fistula and MOF ultimately. The other 3 patients who were diagnosed to suffer from PIDC during the primary operation received the reoperation composed of Oddi’s sphinceroplasty (OSP), suturing the small hole on the distal choledoch (SHDC) through the inner ampulla and T-tube drainage. One of the 3 patients was complicated with acute pancreatitis due to escaping opaque preparation during operative cholangiography. All the 3 patients were cured. Conclusions the PIDC is a special type of iatrogenic injury of the extrahepatic biliary tract. The exact diagnosis and immediate treatment of PIDC during the primary operation is very important for curing the patients. The operation composed of OSP, SPDC and DBT is an appropriate choice for the patients with ampulla impacted stone or stenosis of Oddi’s sphincter.