Mirizzi综合征手术致胆管损伤随访近16年报告并文献复习

Biliary Duct Injury Induced by Surgery for Mirizzi Syndrome with Follow-up for 16 Years: a Report and Literature Review

目的探讨复杂医源性胆管损伤的纠治策略及预防措施。方法回顾性分析1例随访近16年的Mirizzi综合征手术致胆管损伤患者的临床诊治经过,并复习相关文献,分析胆管损伤发生原因、修复治疗时机和方式及疗效判定标准。结果本例因胆囊结石伴慢性萎缩性胆囊炎,行开腹胆囊切除术,术中确诊Mirizzi综合征(Ⅰ型),因术野区粘连严重、发现胆汁,仔细查找发现左右肝管汇合部以下约0.5 cm处胆管横断,行确定性修复手术,随访5年效果良好。术后第6年出现胆道狭窄,继行病变胆管切除、胆管整形、胆肠吻合术。3年后出现胆肠吻合口狭窄及左肝萎缩,行胆肠吻合口拆除、左肝切除、右肝管整形、胆肠再吻合术。随访3年,无明显不适。结论医源性胆管损伤的主要原因为手术医师麻痹大意和患者病变的复杂性。建议在患者全身状况能耐受手术和损伤胆管局部情况良好的情况下,由经验丰富的胆道专科医师积极实施确定性手术,且随访时间至少20年。

Objective To investigate treatment strategies and preventive measures of complex iatrogenic bile duct injury.Methods Process of clinical diagnosis and treatment for a Mirizzi syndrome patient with bile duct injury induced by surgery, who was followed for 186 months, was retrospective analyzed, and related literature was reviewed.Pathogenesy reasons, prosthodontic treatment timing and methods and the criteria of judging curative effect were analyzed.Results The patient underwent open cholecystectomy for gallstone accompanied with chronic atrophic cholecystitis, and Mirizzi syndrome （type I） was confirmed during surgery.Definitive reconstructive surgery was implemented because of serious adhesion and bile were found in the operative visual fields, and bile duct transection was found at 0.5 cm below the junction point of the left and right hepatic ducts after careful observation, and the surgery achieved good effect with 5 years of follow-up.Biliary stricture was observed in postoperative 6th year, and then following excision of diseased bile duct, reconstruction of bile duct and choledochojejunostomy were conducted.Anastomotic stricture and left liver atrophy were found in 3 years later, and then removal of biliary-intestinal anastomosis, excision of left liver, reconstruction of the right hepatic duct and second choledochojejunostomy were conducted.No obviously uncomfortable symptoms were found during followed up for 3 years.Conclusion The main causes of iatrogenic bile duct injury are the carelessness of surgical physicians and the complexity of patients＆#39; pathological changes.It＆#39;s suggested that definitive surgeries should be implemented positively by experienced specialists after considering generally physical conditions and the well local circumstance of the diseased bile duct of patients, and follow-up visit time should be at least 20 years.