医源性胆管损伤后肝硬化伴肝肺综合征的外科治疗

Surgical treatment of iatrogenic bile duct injury associated with hepatopulmonary syndrome

目的 通过对医源性胆管损伤（IBDI）后肝硬化伴肝肺综合征（HPS）患者诊疗过程的总结,探讨对该类患者外科再次胆道修复手术的方式选择与疗效.方法 总结2011年3月至2012年9月期间所收治的6例IBDI患者经初次或再次胆道修复手术治疗后仍发生胆道狭窄、肝内胆管结石、胆汁淤积性肝硬化伴HPS的诊疗经过.结果 对6例IBDI患者均成功施行胆道修复手术,术式没有统一的定式,手术时间（4.9±3.6）h,术后发生呼吸衰竭3例、胆漏伴腹腔局部感染1例,呼吸功能衰竭后死亡1例,余患者治愈出院.术后随访0.5~2年,优良率为100%.结论 IBDI后肝硬化伴HPS患者在施行胆道再次修复手术时选择个体化胆道修复术式,胆道修复手术并未改善肺泡动脉氧分压差（A-aDO2）的升高,IBDI后伴HPS患者术后发生呼吸功能不全或衰竭的概率比较大,而且有较高病死率.

Objective Through the investigation and summarization to surgical treatment of iat rogenic bile duct injury（IBDI） patients associated with hepatopulmonary syndrome（HPS）, we aim to provide some experiences for selection indication and therapeutic efficacy for secondary construction of bile duct in them. Methods From March 2011 to September 2012, total 6 IBDI patients underwent primary and secondary bile duct construction in our center, in post-surgery period they were complicated with biliary stricture, calculus of intrahepatic duct, hepatic cirrhosis combined with HPS. Their clinical data was summarized respectively. Results 6 cases underwent bile duct re-construction without uniform procedure selection successfully. The Operating time was averagely 4. 9 ± 3. 6 hours. In postsurgery, 3 patients complicated with respiratory failure, in which I of them died from it. Furthermore, 1 patient was found to be complicated with bile lead and local abdominal infection. Other patients were treated successfully and no recurrence was found in follow-up time （ranging from 0. 5 to 2 years）. Conclusion The individual bile duct re-construction is a better selection for patients who suf- fered from IBDI associated with HIPS, and no uniform procedure can be referred to or as standard pro- tocols. The individual bile duct re-construction has some advantages, including easy operating, fast time and better efficacy. Although these, alveolo-arterial oxygen partial pressure difference （A-aDO2） is not easily to be improved. High incidences of respiratory failure and mortality rate in post-surgery can be seen in such cases.