胆肠吻合术后再手术临床分析

Management of reoperation after cholangioenterostomy

目的探讨胆肠吻合术后再手术的原因、处理及预防措施。方法回顾性分析78例胆肠吻合术后再手术患者的临床资料。结果再手术的原因包括首次胆肠吻合术术式选择和处理不当17例；胆肠吻合口狭窄、肝胆管狭窄19例；胆肠吻合口结石堵塞、肝内外胆管继发结石24例；反复发作的返流性胆管炎13例和继发肝内胆管癌5例。再手术方式采用切除胆总管囊肿、胆管空肠Roux—en-Y吻合术5例：胆肠吻合口扩大、整形或盆式吻合19例；经Y臂空肠胆管镜辅助下取石15例；左肝外叶或左半肝切除6例；右肝段切除3例；拆除原胆总管十二指肠吻合口或原肠肠吻合口，改为规范的胆管空肠ROUX—en-Y吻合术18例；恢复胆总管结构，T管引流7例；肝内胆管癌切除3例；剖腹探查、癌灶活检术2例。56例随访3个月-13年，7例仍有间歇性畏寒发热和右上腹不适等症状。结论严格把握胆肠吻合术手术指征和施行规范的胆肠吻合术可以降低再手术率。

Objective To investigate the cause, management and prevention of reoperation after cholangioenterostomy. Methods A retrospective clinical analysis was made in 78 cases between 1995 and 2008. Results The causes of reoperation included improper management of first operation in 17 cases ; anastomotic stricture or hepatic duct stricture in 19 ; stones recurrence in 24 ;cholangitis recurrence in 13 and intrahepatic cholangiocarcinoma in 5. Of all cases,5 were subjected to choledocho-cystectomy and cholangioenterostomy, 19 to reanastomosis after enlarging the primary anastomosis, 15 to stones extraction by choledochoscope,6 to left hepatolobectomy,3 to right segmentectomy, 18 to dismantling the primary anastomosis and performing proper operations,7 to recovering normal bile path with T tube drainage,3 to excision of intrahepatic cholangiocarcinoma and 2 to abdominal laparotomy. The follow-up of 56 cases for 3 months to 13 years showed that 7 cases still had cholangitis. Conclusion The rate of reoperation can be reduced by strictly selecting surgical indications and performing proper cholangioenterostomy.