外伤所致胆胰结合部损伤的诊治

Diagnosis and treatment of injury to choledocho-pancreatico-duodenal junction

胆胰结合部损伤是腹部外伤中最复杂的情况之一。因为常合并有其他脏器损伤,加上胆管、胰腺、十二指肠损伤的处理尚无统一的治疗方案,因而处理起来显得更为困难和复杂。结合部损伤的诊断有赖于临床症状、实验室检查、影像学检测乃至剖腹探查的联合应用。当病变累及单个器官、程度较轻时,主张进行止血、一期修补和通畅引流;当病变较重,累及两个或两个以上器官时,处理比较复杂,严重时需要行Whipple术。研究表明一期实施复杂手术(如Whipple术)危险性大,术后死亡率高,进而出现了损伤控制外科的治疗理念。简言之,胆胰结合部损伤围手术期并发症发生率和病死率高,准确、及时的诊断和有效处理该类损伤至关重要。熟练掌握胆胰结合部解剖和各部位病变的临床特征,注意结合应用包括CT、MRCP、ERCP在内的影像学技术或操作,并将损伤控制外科的理念纳入复合伤的治疗决策中去,对于改善胆胰结合部损伤病人的预后具有重要意义。

Injury to choledocho-pancreatico-duodenal junction is one of the most complicated situations in abdominal trauma. It is very difficult to deal with because of the common concomitant injuries to other organs and the absence of consensus regarding treatment of injuries to bile duct, pancreas, and duodenum. The diagnosis relies on the combined use of clinical symptoms, laboratory tests, imaging modalities and even exploratory laparotomy. For lesions involving a single organ or being very mild, stanch bleeding, primary repair .and drainage are advocated. As for lesions involving two or more organs, or being serious, treatments tend to be complicated, sometimes even panereatoduodenectomy （Whipple procedure）. Studies show that the implementation of complicated operations, such as Whipple procedure, in primary treatment of acute injury is very dangerous and correlated with high postoperative mortality rate leading to the occurrence of the concept of damage control surgery. In short, injury to chotedocho-pancreatico-duodenal junction is correlated with high perioperative complications and mortality rate. Accurate and timely diagnosis and effective treatment are very important. Proficiency in anatomy of choledocho-pancreatico-duodenal junction, clinical features of lesions, combined applications of imaging techniques （including CT, MRCP, ERCP）, and the concept of damage control surgery into the decision-making, are of great significance to improve the prognosis of patients with injuries to choledocho-pancreatico-duodenal junction.