腹腔镜胆囊切除术后迟发性迷走胆管漏的预防及处理

Prevention and Management of Delayed Luschka Duct Leakage after Laparoscopic Cholecystectomy

目的探讨腹腔镜胆囊切除术后迟发性迷走胆管漏的诊断、治疗及经验教训。方法对1997年2月～2009年8月13例LC后迟发性迷走胆管漏,分别采用开腹胆总管切开、T管引流(1例),超声定位下腹腔置管引流术(2例)及超声定位下腹腔置管联合ERCP、ENBD(10例)3种方法进行治疗。结果 13例经腹部B超及腹腔穿刺后确诊为迟发性迷走胆管漏,1例因休克急诊行开腹胆总管切开、T管引流术,2例行腹部B超定位下腹腔置管引流术,10例行腹部B超定位下腹腔置管引流、ENBD。2例选择胆囊窝积液区穿刺腹腔置管及ENBD后腹部症状及体征未完全消失,复查腹部B超仍提示腹腔积液,在超声定位下取右下腹麦氏点穿刺置管引流后胆漏停止、腹部症状及体征完全消失。1例迷走胆管漏并发休克,纠正休克后急诊行腹腔探查、胆管切开引流术,术中出现呼吸、心跳骤停,心肺复苏成功,术中经胆总管注水发现胆囊床有直径约0.2mm胆管漏胆,放置T管缝合管壁后,T管缝线针眼渗胆,术后再次出现胆漏,经充分引流等治疗32 d后痊愈。腹部B超定位下腹腔置管引流术,治愈时间12、15 d,平均13.5 d。腹部B超定位下腹腔置管引流、ENBD,治愈时间2～5 d,平均2.8 d。12例随访12～24个月,平均15个月,无胆道狭窄、肠梗阻、胆管结石及其他并发症出现。结论 采用腹部B超定位下腹腔穿刺置管引流联合ENBD胆管减压治疗LC后迷走胆管漏,能达到开腹手术引流胆汁、胆道减压的效果,且具有创伤小,痛苦少,恢复快及住院时间短等优点,值得推广应用。

Objective To investigate the diagnosis,treatment of delayed Luschka duct leakage after laparoscopic cholecystectomy（LC）,as well as the lessons we learnt from our experience. Methods The clinical data of 13 cases of delayed Luschka duct leakage after LC in our hospital from February 1997 to August 2009 were collected in this study.The patients received T-tube drainage（1 case）,B-ultrasonography-guided drainage（2 cases） or B-ultrasonography-guided drainage combined with endoscopic nasobiliary drainage（ENBD,10 cases）,respectively. Results The delayed Luschka duct leakage was confirmed with B-ultrasonography and abdominal paracentesis in all the 13 cases.Among them,open choledocholithotomy and T-tube drainage were performed in emergency in one patient because of shock;B-ultrasonography-guided drainage via a lower abdominal tube was carried out in two cases;the other 10 patients received B-ultrasonography-guided drainage combined with ENBD.After the ENBD and B-ultrasonography-guided drainage,two patients still suffered from retroperitoneal symptoms,and their reexamination by B-ultrasonography showed abdominal fluid;they were then cured by B-ultrasonography-guided drainage at the McBurney point.One patient developed shock during the operation,and thus underwent abdominal exploration,choledocholithotomy and drainage in emergency after the shock was corrected;by using T-tube and suturing,however,biliary leakage occurred once again at the suture points on the T-tube after the operation.This patient was finally cured by complete drainage and conservative treatments after 32 days.The two patients who received B-ultrasonography-guided drainage were cured in 12 and 15 days respectively（mean,13 days）,and the 10 who underwent B-ultrasonography-guided drainage combined with ENBD were cured in a mean of 2.8 days（2-5 days）.Follow-up was achieved in 12 cases for 12-24 months（mean,15 months）,during which no bile duct stenosis or calculi,nor intestinal obstruction occurred. Conclusions B-ultrasonography-guided percutaneous drainage combined with ENBD is effective,less traumatic for patients with post-LC Luschka duct leakage with less pain and quick recovery.