医源性胆管损伤的诊断和治疗

Diagnosis and treatment of iatrogenic biliary duct injury

目的:探讨医源性胆管损伤的原因、诊治及预防。方法:回顾性分析41例医源性胆管损伤患者的临床资料。结果:本组41例均为胆道手术所致。21例术中发现胆管损伤,随即进行修复,其中7例裂口小行单纯胆总管修补术,10例行胆管端端吻合加T管引流术,4例行胆管空肠Roux-en-Y吻合术。5例迷走胆管损伤和1例缝针刺伤肝总管,导致漏胆,仅进行腹腔引流。4例胆囊切除胆总管探查术后发生腹膜后感染,进行引流。10例因胆汁性腹膜炎,经近端胆管引流和腹腔引流,术后3～6个月后再次手术行胆管空肠Roux-en-Y吻合术,7例效果良好,1例术后吻合口狭窄,术后14个月再次手术切除狭窄行胆管空肠Roux-en-Y吻合。生存36例中31例获随访,随访时间1～7年,随访率86.1%。本组死亡5例,2例胆管空肠Roux-en-Y吻合术和1例右肝管吻合T管引流术后因严重肝功能衰竭死亡,2例胆囊切除胆总管探查术后死于腹膜后感染。结论:认识胆道损伤的危险因素,胆囊切除前辨清三管关系和规范操作是预防医源性胆管损伤的关键。损伤类型决定手术方式,其中以胆管空肠Roux-en-Y吻合术疗效最佳。

Objective： To study the causes, diagnosis and management of iatrogenic bile duct injury. Methods zA retrospective study was made on a clinical data of forty-one patients with iatrogenic bile duct injury from Jan 1990 to Dec 2010. Results：The cause of 41 cases were bile duct surgery. 21 cases were founded during the sur- gery, direct repair in 7cases, end-to-end anastomosis with T-tube stent in 10 of the cases and Roux-en-Y hepaticojeju- nostomy in 4cases were done,7 patients were only performed drainage procedure （2 patients were aberrant duct inju- ries, 1 patient was a needle stick injury,4 patients were retroperitoneal infection ） ;10 patients were performed Roux- en-Y procedure after a previous abdominal drainage procedure 3-6months （1 patient undergone a secondary recon- struction procedure because of anastomotic stenosis） ;31 patients were followed up for 1 to 7 years,the follow-up rate was 86 % （31/36） ; among 5 dead patients, the death of causes were liver function failure（3/5） and severe retroperito- neal infection（2/5）. Conclusion：The key of prevention to iatrogenic bile duct injury was recognizing the risk factors, identifying the anatomy of＂3-tube＂of extrahepatic bile ducts,doing manupition. Normatively. Surgical managements depended on the types of injury,Roux en-Y hepatico jejunostomy is the most effective method of iatrogenic bile duct injury.