医源性胆管损伤18例个体化处理经验及教训

Experience and lessons of individualized treatment on 18 cases with iatrogenic bile duct injury

目的总结医源性胆管损伤个体化治疗的临床疗效、经验及教训。方法收集我院2005年1月至2013年12月收治的18例医源性胆道损伤患者的病例资料,对其临床特点、损伤类型、手术时机及方式、手术疗效进行回顾性分析分析。结果 18例患者参照Bismuthi-Strasberg分型标准。A型2例、C型1例均行局部缝扎或修补。D型4例,分别行胆管修补、或T管引流、ERCP+ENBD术。E1型3例,2例行胆管端端吻合术,其中1例术后出现胆漏、腹水,PTC提示吻合口断裂,经腹腔引流3个月后行肝肠吻合术;另1例行胆肠吻合术。其余E2型5例,E3型2例,E4型1例均行胆肠吻合术。结论明确病理损伤的类型是医源性胆管损伤修复的前提,根据患者的表现及身体状况制定个体化的修复方案,注重手术方法及细节,可提高手术疗效。

Objective To summarize the clinical effect,experience and lessons in individualized treatment of iatrogenic bile duct injury（IBDI）.Methods Clinical data of 18 patients with IBDI in our hospital during Jan.2005 to Dec.2013 were collected.The clinical characteristics,classification of bile duct injuries,timing and type of repair and treatment effect were analyzed.Results Patients were classified according to Bismuth-Strasberg classification methold.Two cases of type A and 1 case of type C were subjected to bile duct sew and mend.Four cases of type D underwent bile duct sew,or over T tube,and ERCP＋ENBD.In 3 cases of type E1,ductto-duct anastomosis was performed in 2 cases,but 1 case with ascites and bile leakage postoperatively was diagnosed as anastomotic rupture,underwent Roux-en-Y hepaticojejunostomy 3 months after peritoneal drainage;the other one was subjected to hepaticojejunostomy.The procedure for repair of other patients including 5cases of E2 type,2 cases of E3 type and 1 case of E4 type were hepaticojejunostomy.Conclusion Identification of the classification of injuries is essential before surgery,and individual repair procedure should be made according to the clinical features and physical status of the patients.The long-term outcome can be improved by individualized repair procedure and good operative technique.