胆管损伤修复术后狭窄再手术16例疗效分析

Surgical therapy of biliary restenosis after repair for bile duct injury in 16 cases

目的探讨胆管损伤修复后再狭窄的原因、修复技术要点及疗效评判标准。方法回顾性分析2000年1月至2016年12月上海交通大学医学院附属仁济医院收治的60例胆管损伤，其中16例为修复术后狭窄再手术患者的临床资料。结果损伤修复后狭窄再手术16例患者分型为Ⅱ1d型3例，Ⅱ2d型10例，Ⅱ3d型2例，Ⅱ4d型1例。再手术方式包括肝门胆管整形＋胆肠吻合15例，右半肝切除＋左肝管空肠吻合1例。术后胆漏3例，右侧胸腔积液10例，均治愈。16例患者均获得随访，平均随访时间5．2年，8例患者随访至今无胆管炎发作及肝酶升高；6例患者有γ-GT及ALP升高．无胆管炎症状，MRCP提示有吻合口狭窄：2例患者有反复发作胆管炎，并经历再次手术。结论胆管损伤修复后狭窄再手术需要精准的术前评估，选择合理的手术入路和坚持“黏膜对黏膜”的胆肠吻合方式，术后应建立以ALP、γ-GT及生活质量评分为核心的长期随访体系。

Objective To evaluate remedy therapy for biliary restenosis after repair of bile duct injury. Methods Clinical data of 60 patients with bile duct injury including 16 patients with restenosis after repair admitted to Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine from January 2000 to December 2012 was retrospectively analyzed. Results 16 patients suffering from biliary duct restenosis included 3 cases of type Ⅱ1 d, 10 cases of type Ⅱ2 d , 2 cases of type Ⅱ3 d and 1 case of type Ⅱ 4 d. The reoperative procedures included hepatic hilar biliary plasty with bilioenteric anastomosis in 15 cases, right hemihepatectomy with left hepatic bilioenteric anastomosis in 1 case. Postoperative bile leakage in 3 cases and pleural effusion in 10 cases were cured by watchful therapy. All of the 16 cases were followed up with an average time of 5.2 years. No occurrence of cholangitis and elevated liver enzymes were observed up to now in 8 patients, increased γ-GT and ALP, no cholangitis but anastomotic stenosis as showed by MRCP in 6 patients with 2 patients neccesitating reoperation to address repeated cholaugitis. Conclusions Restenosis after bile duct repair was closely associated with injury type, repair opportunity, repair methods and the surgeon＇s expertise. Precise preoperative evaluation, the choice of rational surgical approach, the clinging to mucosa-to-mucosa bilioenteric anastmosis principle and the establishment of postoperative long-term followup system centered on ALP, γ-GT and life quality score are required in the reoperation of stenosis after bile duct repair.