医源性胆管损伤后的微创治疗

Minimally invasive therapy for iatrogenic bile duct injury

目的探讨医源性胆管损伤的类型、临床和影像学特征以及内镜和放射介入治疗的疗效和安全性。方法收集2013年1月1日至2016年6月30日因医源性胆管损伤行介入或内镜诊疗的48例患者临床资料，回顾性分析患者一般情况、导致胆管损伤的相关医疗操作、胆管损伤的类型及临床表现、治疗方式、疗效、并发症。结果胆管损伤发生的原因依次为胆囊切除（45．8％，22／48）、肝移植（35．4％，17／48）、经颈静脉肝内门体静脉分流术（8．3％，4／48）、胆肠吻合术（6．3％，3／48）和经内镜逆行胰胆管造影术（4．2％，2／48）。胆管损伤最常见的类型为肝内外胆管狭窄或梗阻（66．7％，32／48），其次为胆瘘（18．8％，9／48），胆道出血（10．4％，5／48）、胆肠吻合口狭窄（4．2％，2／48）。胆管损伤最常见的临床表现为黄疸（37．5％，18／48），其次为腹痛（29．2％，14／48），其余主要临床表现包括发热（14．6％，7／48）、呕血黑便（8．3％，4／48）、引流液异常（8．3％，4／48）等。x线下血管或胆管造影及内镜检查可明确胆管损伤诊断。内镜或血管栓塞介入治疗胆管损伤疗效总体优良率达91．7％（44／48）。治疗后最常见并发症为发热（16．7％，8／48），其次为胰腺炎（10．4％，5／48），还有个别患者出现胆道出血（2．1％，1／48）、贲门撕裂（2．1％，1／48）以及导管脱落导致胆瘘（2．1％，1／48），经内科药物治疗以及拔除鼻胆管处理后均好转。结论医源性胆管损伤在上腹部外科手术、消化内镜及血管介入操作后均可出现，早期诊断并及时采取内镜或血管介入治疗的疗效及安全性令人满意。

Objective To investigate the type, clinical and imaging features of iatrogenic bile duct injury and the efficacy and safety of endoscopic and interventional radiology therapy. Methods A total of 48 patients with iatrogenic bile duct injury who have undergone endoscopic and/or interventional therapy from January 1st 2013 to June 30th 2016 were enrolled. Patients＇ general information, causes of injury, clinical manifestations, treatment methods, efficacy and complications were retrospectively analyzed. Results The causes of iatrogenic bile duct injury were cholecystectomy （ 45.8%, 22/48 ）, liver transplantation （ 35.4%, 17/48） , transjugular intrahepatic portosystemic shunt （ 8.3%, 4/48） , Roux-en-Y anastomosis （ 6.3%, 3/48） and endoscopic retrograde cholangiopancreatography （4. 2%, 2/48 ）. The most common type of iatrogenic bile duct injury was stenosis of intra/extra bile ducts （66. 7%, 32/48 ）. Other types included biliary fistula（ 18.8%, 9/48 ） , hemobilia （ 10.4%, 5/48 ） and stenosis of anastomotic stoma （ 4.2%, 2/48 ）. The most common clinical manifestations were jaundice（ 37.5%, 18/48） and abdominal pain （29. 2%, 14/48）. Other clinical manifestations were fever （ 14. 6%, 7/48 ）, hematemesis or melena （ 8.3%, 4/48 ） and abnormal drainage fluid （8.3%, 4/48 ）. Diagnosis was confirmed by angiography, cholangiography or endoscopy. The overall effective rate of minimally invasive therapy was 91.7% （ 44/48 ） and the most common complications were fever （ 16. 7%, 8/48） and pancreatitis （ 10. 4%, 5/48）. Other complications were hemobilia （ 2. 1%, 1/48 ） , cardia dilaceration （ 2. 1%, 1/48 ） and biliary fistula caused by catheter shedding（2. 1%, 1/48）. Conclusion Iatrogenie bile duct injury could occur after upper abdominal surgeries, endoscopic or interventional proeeduros. Early diagnosis and treatment with endoscopic or vascular interventional methods can achieve satisfying efficacy and safety.