术中胆道损伤143例的原因及处理

Causes and management of intraoperative injuries of bile duct

目的讨论术中胆道损伤的原因及处理方法。方法分析我院1970年1月至2003年12月治疗的术中胆道损伤143例,占同期胆道手术的2.83%。男59例(41.26%),女84例(58.74%),平均年龄为44.7岁。导致胆道损伤的手术类型为胆道手术129例(90.21%),胃切除5例(3.5%),其他手术9例(6.29%)。损伤类型以胆管横断和部分切除等为多,术中发现并当即处理者69例(48.25%),3d内二次手术者28例(19.58%),1个月内手术者13例(9.09%),半年以后再次手术者33例(23.08%)。结果死亡7例(4.90%)(死亡原因为肝功能衰竭及严重感染),治愈136例,治愈率为95.1%,随访1～30年,平均9.4年,随访期间胆道狭窄19例(13.29%),均经再次手术治愈。结论术中胆道损伤的发生率为0.1%～3%,以胆囊切除术多见。术者缺乏训练,暴露欠佳,照明差,局部粘连为主要原因。疑有损伤者应行术中胆道造影及胆总管探查,确认后当即行修补或胆肠吻合,置管支撑、引流。术中胆道损伤多需再次手术,死亡率明显增加。

Objective To investigate the causes and management of intraoperative injuries of the bile duct. Methods A total of 143 patients with intraoperative injuries of the bile duct were surgically treated in our hospital from January 1970 to December 2003. Of the 143 patients, 59 were male and 84 female. The mean age was 44.7 years old. The causes for biliary injuries were biliary operation in 129 (90.21%), gastrectomy in 5 (3.5%) and other operations in 9 (6.29%). Most of the patients suffered from transverse amputation or partial resection of the bile duct. The injuries were found and managed during the operation in 69 patients (48.25%), 3 d after operation in 28 (19.58%), one months postoperatively in 13 (9.09%) and 6 months postoperatively in 33 (23.08%). Results After the management, 7 patients (4.9%) died and 136 (95.1%) cured. The follow-up study for 1-30 years showed that 19 patients had biliary stricture and they all were treated by reoperation. Conclusions The incidence of the intraoperative injuries of bile duct is 0.1%-3%. These injuries are mainly caused by cholecystectomy. Most of the patients suffer from the injuries of the hepatic duct and common bile duct. Transverse injuries are more common than others. Insufficient basic technology and training of the operators and inadequate illumination during the operation are the major causes for the injuries. If the injuries are suspected, operative cholangiography and incision of the common bile duct for exploration should be performed. Meanwhile, repair of the bile duct or cholangioenterostomy should be conducted.