医源性胆胰肠结合部损伤诊治和预防

Diagnosis,management and prevention of iatrogenic injury in choledocho-pancreatico-duodenal junction

医源性胆胰肠结合部损伤涉及范围包括胆总管下段、Vater壶腹、胰管终末段及围绕他们的括约肌复合体,损伤的常见原因是胆管探查时不恰当地使用手术器具。胆胰肠结合部损伤会造成严重的腹腔、腹膜后感染,甚或会导致死亡。损伤发生后,从胆总管T管注水可见腹膜水肿,注入美兰则可见十二指肠旁后蓝染。如术中发现损伤处,可用细线仔细缝合,并安放T管和有效引流,如未能明确损伤部位,可置放T管和腹腔引流,术后密切观察。晚诊并出现腹腔、腹膜后脓肿及蜂窝织炎者,应充分清创引流,必要时加行胆胰液分流和十二指肠憩室化手术。胆胰肠结合部损伤的预防:熟悉该区域的解剖特点;胆管探查切忌暴力;术末仔细检查防止漏诊。

Iatrogenic injury of choledocho-pancreatico-duodenaljunetion refers to the penetrating injury in the terminal bile duet, pancreatic duct or duodenal wall in the region of ampulla of Vater. It is often caused by improper operation of surgical instruments.It results in severe peritonealand retroperito- neal space infection and a poor prognosis. The early manifes- tations of bile duct perforation include peritoneal swelling caused by detained water after trans T-tube injection, blue staining of the field of operation and contrast medium leaking outside the bale duct system.If the perforation is discovered during the operation, it should be sutured and choledocal T-tube drainage should be performed. If the perforation is not discovered during the operation, choledocal T-tube and peritoneal drainage should be conducted. For patients with delayed diagnosis, thorough drainage of the region, separation of bile and pancreatic juice, duodenal divenicularization and jejunostomy should be considered. The key point in preventing the injury lies on full knowledge of the anatomy of the region, delicate practice without forceful exploration and detailed examination after the operation to avoid missing diagnosis.