胆管扩张症诊断与治疗的难点与对策

Difficulties and countermeasures of diagnosis and treatment of biliary dilatation

胆管扩张症的发病机制尚不明确,胆胰管汇合方式术前评估依然困难,微创治疗的适应证有限。妊娠期胆管扩张症的诊断与治疗和胆管扩张症再手术是治疗的两个棘手问题。病变胆管切除的彻底性与脏器的保留以及与手术安全性之间的矛盾是胆管扩张症治疗面临的两大问题,应注意两者的平衡。中央型肝管扩张与胰腺段胆管扩张是诊断与治疗的两大难点区域。董氏分型在Todani分型的基础上将肝外胆管扩张的分型化繁为简,肝内胆管扩张的分型进一步细分,突出了治疗的难点,为分型论治提供了更精确的依据。“彻底切除病变胆管,去除继发病变,重建高质量的胆肠吻合”是胆管扩张症的治疗目标。分型论治是手术方式选择的原则,应在精确评估的基础上,采用“围肝门技术体系”与“胰门板降低技术”分别处理肝门部与胰腺段扩张的胆管,以提高病变胆管切除的彻底性与安全性。术后不仅应管控胆汁漏与胰液漏等近期并发症,更应关注病灶切除彻底性与患者的远期生命质量。

The pathogenesis of biliary dilatation is unclear and the preoperative evaluation of pancreaticobiliary junction type is still difficult. The indication of minimally invasive surgery is limited. Diagnosis and treatment of gestational biliary dilatation and reoperation of biliary dilatation are two tricky problems. There are two dilemmas in the treatment of biliary dilatation, including the balance between radical resection of pathological bile ducts and organ reservation, as well as balance between radical resection of pathological bile ducts and surgical safety. The most difficult regions of diagnosis and treatment lie in the hilar dilated bile duct and dilated bile duct in the pancreatic segment. Dong′s classification simplifies the classification of extrahepatic bile duct dilatation and subdivides the classification of intrahepatic bile duct dilatation on the basis of Todani classification.It highlights the difficulties of treatment and provides more accurate basis for choosing appropriate method according to the classification. The therapeutic goals of biliary dilatation are the radical excision of pathological bile duct, removal of the secondary lesions and reconstruction of excellent cholangiojejunostomy. The principle of surgical procedure choice is choosing appropriate method according to the classification. Perihilar surgery technique and pancreatic door plate descending technique can be used to deal with the dilated bile ducts at hilar and pancreatic segment on the basis of accurate evaluation in order to improve the thoroughness and security of pathological bile duct resection. Not only short-term complications such as postoperative bile leakage and pancreatic leakage require management, but radical resection of lesion and long-term life quality of patients should be paid more attention.