医源性胆管损伤37例诊治分析

Diagnosis and treatment of iatrogenic biliary tract damage:a report of 37 cases

目的:探讨医源性胆管损伤的原因、预防措施、早期诊断和治疗方法。方法:对37例医源性胆管损伤病例的手术方式、损伤类型以及明确损伤时间进行回顾性分析。并采用手术进行治疗,手术方式:腹腔引流9例(24.3%),胆管修补并T型管支撑引流11例(29.7%),胆总管端端吻合并T型管支撑引流7例(18.9%),胆管空肠Roux-en-Y吻合9例(24.3%),胆总管十二指肠吻合1例(2.7%)。结果:全组术后无近期及远期并发症。结论:医源性胆管损伤以胆囊切除术多见,多发生于胆囊三角区,主要原因为缺乏胆管影像学诊断,局部组织水肿坏死或粘连,手术器械缺乏或配备不规范,照明等条件差,暴露欠佳,术者经验缺乏等。早发现早诊断的有效措施是术中常规手术视野敷白纱布,疑有胆管损伤时即行胆管造影、胆总管探查;常规手术区低位置引流管,术后1周严密观察腹腔引流液性状及量、胆汁性腹膜炎体征、巩膜皮肤黄染情况,B超动态监测胆管直径及腹腔游离液体;术后2周常规T型管胆管造影或ERCP等。适当选择结扎、引流、胆管修补、胆肠吻合、胆管支撑等手术方式是有效的治疗措施。

Objective：To evaluate the pathogeny,precaution,early diagnosis and treatment of iatrogenic biliary tract damage.Methods：The clinical data of 37 cases of iatrogenic biliary tract damage were analyzed retrospectively including the modus operandi,the clinical manifestation and the final diagnosis time.The modus operandi of iatrogenic biliary tract damage included belly cavity drainage in 9 cases（24.3%）,biliary tract repairand Ttube drainage in 11 cases（29.7%）,end-to-end bile duct anastomosis and Ttube drainage in 7 cases （18.9%）,Roux-en-Y choledochojejunostomy in 9 cases（24.3%）,biliary pore-duodenum anastomosis in 1 case（2.7%）.Results：No complication in the near future or long-term.Conclusions：The iatrogenic biliary tract damage mainly appears in cholecystectomy,also mainly Calot＇s triangle,The causes are mainly lake of imageology di-agnose of biliary tract,appearance of dropsy and necrosis or accretion of part tissue,lack of surgical instruments and imnormal equipment,bad illumination and exposure,lack of operater＇s experience and so on.The utility measure of early discovery and diagnostic include：white bandage is paved on visual field of operation;when biliary tract damage is suspected,biliary tract opacification and exploration of the common bile duct are executed at once;low-set drainage tube is usually placed in field of operation;peritoneal cavity drainage character and quantum,bile peritonitis objective sign and albuginea oculi and skin stained are exactly observed during 1 week after operation,moreover dynamic state of biliary ducts diameteris monitored with B ultrasound;routine biliary tract opacification orERCP is carried out during 2 weeks after operation and so on.Proper choice of deligating,drainaging,restoring,choledochojejunostomy,pedestal is effective measures.