术中胆总管下段医源性损伤处理的系统评价

Systematic review on management of perioperative iatrogenic injury of distal common bile duct

目的比较术中胆总管下段损伤不同处理方式的疗效。方法以“胆总管（胆道）下（远、末）段（端）损伤”为检索词，检索中文医学全文数据库。纳入1990年以后发表的所有关于胆道手术术中医源性胆总管下段及周围组织损伤的临床研究。收集相关临床数据及不同处理方式的病死率和再次手术率。结果共34篇文章233例患者纳入本研究。排除14例单纯十二指肠损伤患者后，余219例患者总体病死率为9．6％，再次手术率为17．4％。有21篇文章对胆总管下段损伤的术中发现与术后发现进行了区分，共有145例患者。术中发现并治疗的106例患者，病死率为1．9％，再次手术率为1．9％；术后发现者39例，病死率为43．6％，再次手术率为84．6％。有9篇文章对46例患者术中修补及术中引流的治疗效果做了评估。术中修补21例，加强引流25例，手术病死率及再手术率均为0。结论及时发现并一期处理是治疗术中胆总管下段医源性损伤的关键，加强胆汁引流与穿孔修补的治疗效果无明显差异。

Objective To study the effectiveness of different treatment modalities for iatrogenic in- jury of distal common bile duct during operation. Methods We browsed Chinese Medical Full-text Data- base with the term of ＂distal common bile duct injury＂. All the clinical studies associated with perioperative latrogenic injury of distal common bile duct and adjacent tissue published after 1990 were enrolled, and we collected the clinical data, mortality and reoperation rate with different treatments for analysis. Results Thirty-four case series and case reports with 233 patients were included. 14 patients with isolated duodenal injury were excluded. The overall mortality of the remaining 219 patients was 9.6% , and the reoperation rate was 17.4%. A total of 145 patients who were diagnosed with distal common bile duct injury during and after operation from 21 articles were compared. The mortality and reoperation rate were both 1.9% among 106 patients who were diagnosed during operation. The figures were 43.6%, and 84.6% among 39 patients who were diagnosed after operation, respectively. In 9 articles with 46 patients, the clinical outcomes of 21 patients who were treated by intraoperative suture was compared with 25 patients who underwent enhanced biliary and retroperitoneal drainage. The mortality and reoperation rates were 0 in both groups. Conclusions Early detection and management are crucial to perioperative common bile duct injury. Furthermore, no sig- nificant difference of clinical outcomes observed between bile drainage and perforation suture groups.