265例胆道再次或多次手术的临床分析

Clinical analysis of repeated operations in 265 patients with biliary diseases

目的探讨导致胆道再次或多次手术的原因。方法回顾性分析2005年1月至2011年6月上海市第六人民医院金山分院收治的265例行胆道再次或多次手术患者的临床资料。第1次胆道再次手术主要以取尽结石、修补胆管损伤、治疗恶性肿瘤为主要目的。手术方式主要包括胆总管切开取石＋T管引流术或胆管空肠Roux-en-Y吻合术，经胆道镜或ERCP＋EST取石术，胆总管切开取石＋肝段或肝叶切除＋T管引流术或胆管空肠Roux-en-Y吻合术，胆管狭窄切开成形＋胆肠内引流术，肝外胆管对端吻合＋T管支撑引流术，肿瘤根治性或姑息性手术，单纯胆肠内引流术或内镜下置胆道内支架引流术，剖腹探查术，胆瘘或出血部位缝扎、止血、腹腔冲洗和置管引流术等。第2次或多次胆道再次手术以解除胆管狭窄，建立通畅的胆汁引流途径为目的。组间率的比较采用X^2检验。结果胆道第1次再次手术的主要原因为结石残留或复发，占69．8％（120／172），明显高于胆道第2次或多次再次手术患者的31．2％（29／93），两者比较，差异有统计学意义（X^2=36．51，P〈0．05）。第2次或多次再次手术的主要原因是胆管或胆肠吻合口狭窄，占58．1％（54／93），明显高于第1次再次手术的4．1％（7／172），两者比较，差异有统计学意义（X^2=99．32，P〈0．05）。265例患者中46例围手术期发生并发症，其中第1次胆道再次手术患者的并发症发生率为10．5％（18／172），明显低于第2次或多次胆道再次手术患者的30．1％（28／93），两者比较，差异有统计学意义（X^2=13．61，P〈0．05）。围手术期死亡6例，死因为失血性休克或MODS；第1次胆道再次手术患者和第2次或多次胆道再次手术患者的病死率分别为1．7％（3／172）和3．2％（3／93），两者比较，差异无统计学意义（X^2=0．59，P〉0．05）。结论导致胆道再次或多次手术的原因包括疾病本身和手术操作。术前对病情充分评估，术中谨慎操作，选择合理的手术方式是降低再次手术及围术期并发症发生率的关键。

Objective To investigate the causes of repeated operations in patients with biliary diseases.Methods The clinical data of 265 patients who received repeated operations at the Jinshan Branch of Shanghai Sixth People＇s Hospital from January 2005 to June 2011 were retrospectively analyzed. The causes of repeated operations were analyzed. The first reoperation aimed at removing the calculi completely, repairing the injured biliary ducts and managing malignant tumors. The primary surgical procesures of the first reoperation included choledochotomy ＋ T tube drainage, choledochotomy ＋ Roux-en-Y choledochojejunostomy, endoscopic retrograde cholangiopancreatography ＋ endoscopic sphincterotomy, choledochotomy ＋ hepateetomy ＋ T tube drainage or Roux- en-Y choledochojejunostomy, choledochotomy ＋ biliary-endo-drainage, end-to-end anastomosis of bile duct ＋ T tube drainage, radical or palliative resection of tumor, endoscopic biliary stent drainage or exploratory laparotomy. The second and multiple reoperations aimed at reconstructing the passage for biliary drainage. All data were analyzed using the chi-square test. Results A total of 69.8% （120/172） of patients who had recurrent or retained calculi received first reoperation, which was significantly higher than 31.2% （29/93） of those who received second or multiple reoperations X^2 = 36.51, P 〈 0.05 ）. A total of 58.1% （54/93） of patients who had benign stenosis of bilioenteric anastomosis received multiple reoperations, which was significantly higher than 4.1% （7/172） than those who received first reoperation （X^2 = 99.32, P 〈 0.05）. Of the 265 patients, 46 had complications. The incidence of complications of patients who receive first reoperation was 10.5% （ 18/172 ） ,which was significantly lower than 30.1% （28/93） of patients who received second or multiple reoperations （X^2 = 13.61, P 〈 0. 05 ）. Six patients died of hemorrhagic shock or multiple organ syndrome dysfunction postoperatively. The mortality rates for patients who received first reoperation and second or multiple reoperations were 1.7% （3/172） and 3.2% （3/93） , respectively, with no significant difference （ X^2 = 0.59, P 〉 0. 05 ）. Conclusions The causes for reoperation of biliary disease are multifaetorial. Full assessment of the status of biliary diseases and ample preperation preoperatively, careful operation and precise and rational selection of operative procedures are keys to decrease the reoperative rates and perioperative complications.