医源性胆总管远段损伤的早期诊断及处理

Early diagnosis and treatment of iatrogenic injury in distal part of common bile duct

目的探讨医源性胆总管远段损伤早期诊断的方法及处理方式。方法对我院于1990至2004年间收治的15例医源性胆总管远段损伤病人的临床资料进行回顾分析。结果 15例中术中发现胆管损伤14例,1例术中未及时发现。术前 B 超检查14例,MRCP 检查2例,6例在胆道探查后行胆道镜检查。10例行胆总管穿孔修补加 T 管引流,2例行 Oddi 括约肌切开成形术,2例行胆肠吻合术。胆管损伤后术中表现为胆道探异位于胆管壁外,胆道镜见到胆管远段有2个或多个孔隙,经 T 管注水见腹膜后水肿和积液,注入美蓝出现腹膜后蓝染。治愈13例。术后并发症包括并发十二指肠瘘1例,切口感染1例,死亡2例:1例死于感染性休克,1例死于胃切除术后再出血。结论早期诊断胆总管下段损伤并进行及时治疗可以取得较好效果,应根据损伤的不同程度采用不同的手术方式,术前完善的影像学检查及在做胆道探查前胆道镜检查有可能减少胆总管远段损伤。

Objective To explore the measures for early diagnosis and treatment of iatrogenic injury in the distal part of common bile duct. Methods The clinical data of 15 patients with bile duct injury in the distal part of common bile duct treated in our hospital from 1990 to 2004 were retrospectively analyzed. Results The injury was found in 14 of the patients during operation. Thirteen patients were cured and 2 died. One died of septic shock and the other rebleeding after gastrectomy. The complications included duodenal fistula in 1 patient, incisional infection in 1. Preoperative examinations included B-mode ultrasonography in 14 and MRCP in 2. The intraoperative choledochoendoscopy was performed in 6 patients after the bile duct exploration. The perforated suture repair and T-tube drainage was performed in 10 patients, Oddi＇s sphincter incision and shaping in 2, choledochojejunostomy in 2. The major findings during operation were bile duct explorer being located out of the duodenal wall and bile duct, 2 or more clefts remaining in the distal part of common bile duct by choledochoendoscopy, retroperitoneal edema and liquid accumulation by irrigating water through T-tube and/or retroperitoneal tissues stained blue by irrigating methylithioninium chloride through T-tube. Conclusions Early diagnosis and timely management of iatrogenic injury in the distal part of common bile duct can obtain better results. Different procedures should be performed according to different degrees of the injury. The perfect preoperative imaging examination and intraoperative choledochoendoscopy before bile duct exploration may reduce the occurring rate of the injury.