肝门部胆管癌根治性切除术后并发症的诊断与治疗

Diagnosis and treatment for postoperative complications after radical resection of hilar cholangiocarcinoma

目的探讨肝门部胆管癌患者根治性切除术后并发症的诊断与治疗。方法回顾性分析2011年7月至2014年2月在青岛大学附属医院收治的60例肝门部胆管癌根治性切除术后患者临床资料。其中男46例,女14例;年龄41~80岁,中位年龄65岁。所有患者均签署知情同意书,符合医学伦理学规定。患者均为R0切除,基本术式为胆管癌病灶及胆囊切除＋胆肠Roux-en-Y吻合。其中联合左半肝切除7例,右半肝切除1例,肝中叶部分切除2例,尾状叶切除4例。分析患者术后并发症的发生、诊断、治疗情况。结果肝门部胆管癌患者根治性切除术后并发症发生率为30%（18/60）,其中腹腔活动性出血2例,胆漏6例,腹腔积液合并感染4例,肺部感染4例,切口感染2例。2例腹腔活动性出血患者予加快输液速度、输血和应用止血药物等保守治疗无效后及时行手术探查止血。6例胆漏和4例腹腔积液合并感染患者在超声、CT引导下或介入穿刺置管引流,予有效的引流、抗感染及营养支持等治疗后治愈。4例肺部感染患者给予翻身、拍背、抗感染、祛痰等对症治疗后治愈。2例切口感染患者给予抗生素、及时更换敷料、补充白蛋白及新鲜血浆等治疗后治愈。结论肝门部胆管癌术后并发症发生率高,腹腔活动性出血发病凶险,应早期诊断、积极治疗,必要时手术止血。胆漏为常见并发症,加强引流和抗感染治疗至关重要。

Objective To investigate the diagnosis and treatment tor postoperative compllcanons after radical resection of hilar cholangiocarcinoma. Methods Clinical data of 60 patients with hilar cholangiocarcinoma undergoing radical resection in the Affiliated Hospital of Qingdao University between July 2011 and February 2014 were retrospectively studied. Among the 60 patients, 46 were males and 14 were females with the age ranging from 41 to 80 years old and the median of 65 years old. The informed consents of all patients were obtained and the local ethical committee approval had been received. All patients underwent R0 resection and the main surgery was resection of cholangiocarcinoma and cholecystectomy ＋ Roux-en-Y anastomosis. Seven cases underwent combined left hemihepatectomy, 1 combined right hemihepatectomy, 2 combined partial mesohepatectomy and 4 combined caudate lobectomy. The incidence of postoperative complications and the diagnosis and treatments were analyzed. Results The incidence of postoperative complications after radical resection for hilar cholangiocarcinoma was 30% （18/60）, in which, 2 cases developed active intra-abdominal hemorrhage, 6 bile leakage, 4 ascites complicated with infection, 4 pulmonary infection and 2 incision infection. The 2 cases who developed active intra-abdominal hemorrhage received treatments such as accelerating the infusion speed, blood transfusion and use of hemostatic. Surgical exploration was then performed to stop bleeding when conservative treatments failed. The 6 cases who developed bile leakage and 4 cases who developed ascites complicated with infection underwent percutaneous catheter drainage under the guide of ultrasound or CT or by interventional operation. These patients were cured after effective drainage, anti-infection treatment and nutritional support. The 4 patients who developed pulmonary infection were cured after symptomatic treatments such as body turning over, back slapping, anti-infection treatment and expectorant medication. The 2 patients who developed incision infection were cured after receiving treatments such as antibiotics, changing dressing timely and supplement of albumin and fresh plasma. Conclusions The incidence of postoperative complications after radical resection for hilar cholangiocareinoma is high. Active intraabdominal hemorrhage is extremely dangerous, which shall be diagnosed early and treated positively, and surgical hemostasis shall be performed when necessary. Bile leakage is the common complication. Strengthening the drainage and anti-infection is very important.