肝囊型包虫病胆道并发症284例的诊治分析

Diagnosis and treatment for biliary complications of hepatic cystic echinococcosis

目的探讨肝囊型包虫病胆道并发症的诊断和治疗经验。方法对新疆医科大学第一附属医院自2002年1月至2009年1月手术治疗的284例肝囊型包虫病合并胆道并发症及胆道相关并发症患者的临床资料进行对比分析。结果（1）包虫破入胆道并梗阻性黄疸和（或）胆道感染组（51例）：腹部超声（SUG）、CT检查、核磁共振胰胆管造影（MRCP）、内镜逆行胰胆管造影（ERCP）分别检查51、42、27、7例，包虫囊肿破入胆道的诊断符合率分别为78．4％，85．7％，100％和100％。术中缝合胆瘘口的28例中3例（10．7％）出现术后残腔胆漏，而未缝合23例中17例出现残腔胆瘘（74％）（P〈0．01），其中3例是严重胆瘘（胆汁引流量〉250ml／d）；（2）包虫与胆道相通并胆道感染和（或）包虫囊肿感染组：经胆囊管探查减压组（A组）术后残腔并发症、术后带管时间与经胆总管探查T管减压组（B组）差异无统计学意义，且胆道并发症显著低于B组（P〈o．05），胆道探查并减压的两组（A组和B组）术后残腔并发症、术后带管时间显著低于未胆道探查减压组（c组）；（3）包虫破入胆道致过敏并发症8例，胆道狭窄7例，胆道结石3例，胆道出血1例，术后顽固性胆漏者12例，均实施手术包虫囊肿清除同时处理相应胆道并发症及相关并发症，恢复良好。结论（1）MRCP对肝囊型包虫合并胆道并发症的诊断具有准确率高和无创等优点，ERCP不仅对肝囊型包虫胆道并发症有确诊意义，而且又是一种有效的治疗方法；（2）缝合胆瘘、胆总管减压是治疗肝囊型包虫破人胆道的简单、安全、有效的方法；（3）术中经胆囊管探查减压可有效解决肝囊型包虫病术后残腔胆漏，且维系胆总管完整性，从而减少了T管相关并发症。

Objective To evaluate the diagnosis and treatment of hepatic cystic echinococcosis with biliary complications. Methods 284 patients with hepatic cystic echinococcosis （CE） with biliary complications were surgically treated from January 2002 to January 2009 in our hospital. A summary of the surgical procedures was categorized and compared in the current study. Results （1） Intrabiliary rupture of CE with obstructive jaundice and （or） inflammation of bile duct （51 patients）. The diagnosis of biliary complications of hepatic hydatid cyst was difficult on ultrasound and CT, with sensitivity rates of 78.4% and 85.7%, respectively. MRCP was an effective, noninvasive and useful diagnostic tool in difficult cases; ERCP was used as the gold standard in confirmation. Biliary fistulae were seen in 3 patients （10.7%） treated by suturing the rupture site. In the non-sutured group, 17 patients （74 %） developed biliary fistulae after surgery （P〈0.01）. In three patients the fistula was a high-out- put type （the fistula output was greater than 250 ml/d）. （2） CE communicated with the bile duct and （or） infection （210 patients） ： The cavity-related problems and draining time in group C （no bile duct exploration and decompression） were significantly higher than group A （biliary system explored and decompressed through the cystic duct） and group B （biliary system explored and decompressed through the common bile duct）, while cavity-related problems and draining time between the A and B groups showed no significant difference. Biliary tract-related problems in group A was significantly lower than group B （P〈0.05）. Conclusions （1） MRCP was an effective, noninvasive and useful diagnostic tool; ERCP was used only as the gold standard in confirming intrabiliary rupture of liver cyst ie hydatid disease, and also as an effective technique for treating extended postoperative external biliary fistula. （2） This study indicated that suturing the communication at the rupture site and biliary de compression were effective with low morbidity and mortality rates. （3） Cholangiography and common bile duct exploration through the cystic duet could solve the cavity-related problems while avoiding the T-tube related problems.