美蓝试验预防肝囊型包虫病内囊摘除联合外囊次全切除术后胆汁漏的临床价值

Clinical value of methylene blue test in the prevention of the bile leakage after excision of internal capsule combined with external capsular subtotal resection of hepatic cystic echinococcosis

目的：探讨肝囊型包虫病内囊摘除联合外囊次全切除术中采用美蓝试验检测手术创面以预防胆汁漏的临床价值。 方法：采用回顾性队列研究方法。收集2008年12月至2016年6月内蒙古自治区锡林郭勒盟医院收治的128例行肝囊型包虫病内囊摘除联合外囊次全切除术患者的临床资料。后期（2011年5月至2016年6月）收治的68例患者术中采用美蓝试验检测手术创面以预防胆汁漏，设为试验组；前期（2008年12月至2011年4月）收治的60例患者术中未采用美蓝试验检测手术创面，设为对照组。试验组患者行胆囊切除术后，经胆囊管残端插导管至胆总管内，阻断胆总管下端。向细导管内注射美蓝稀释液至胆总管，观察残腔是否蓝染，判断是否存在胆汁漏。对照组患者采用干纱布沾擦残留外囊壁，判断是否存在胆汁漏。观察指标：（1）手术及术后恢复情况。（2）随访情况。采用门诊和电话方式进行随访，了解患者术后生存及肝包虫病复发情况。随访时间截至2017年6月。正态分布的计量资料以±s表示，组间比较采用t检验；计数资料比较采用x2检验。 结果：（1）手术及术后恢复情况：两组患者均成功完成手术，无围术期死亡患者。试验组患者术中发现显性胆汁漏30例、隐性胆汁漏34例；对照组患者术中各发现15例和0。试验组患者手术时间、术中出血量、术后胃肠功能恢复时间、术后引流管拔除时间、术后胆汁漏、术后住院时间分别为（191±37）min、（156±20）mL、（2.8±1.5）d、（6.4±2.5）d、8例、（10.3±2.5）d，对照组患者上述指标分别为（137±22）min、（115±11）mL、（2.2±1.2）d、（9.5±3.9）d、22例、（13.5±3.8）d，两组上述指标比较，差异均有统计学意义（t=9.944，14.540，2.477，-5.415， x2=11.015，t=-5.689，P〈0.05）。试验组患者术后切口液化、切口感染、残腔脓肿、黄疸例数分别为5例、2例、0、0，对照组分别为6、3、1、1例，两组上述指标比较，差异均无统计学意义（x2=0.284，0.360，1.142，1.142，P〉0.05）。术后胆汁漏患者予充分引流，切口液化和切口感染患者予引流、换药，残腔脓肿患者行再次手术置管、充分引流，黄疸患者予保肝、利胆处理。所有并发症患者好转。（2）随访情况：128例患者中，120例获得术后随访，其中试验组66例，对照组54例。随访时间为6～36个月，中位随访时间为24个月。随访期间，120例患者生存；3例患者肝囊型包虫病复发，其中2例行再次手术，1例予阿苯达唑药物治疗。 结论：行肝囊型包虫病内囊摘除联合外囊次全切除术中采用美蓝试验检测手术创面以预防胆汁漏具有较好的临床应用价值。

Objective：To investigate the clinical value of methylene blue test detecting intraoperative surgical wounds in prevention of the bile leakage after excision of internal capsule combined with external capsular subtotal resection of hepatic cystic echinococcosis. Methods：The retrospective cohort study was conducted. The clinical data of 128 patients who underwent excision of internal capsule combined with external capsular subtotal resection of hepatic cystic echinococcosis in the Xilin Gol League Hospital of Inner Mongolia Autonomous Region between December 2008 and June 2016 were collected. Sixty-eight patients in the later stage （between May 2011 and June 2016） whose surgical wounds were detected using methylene blue test for preventing postoperative bile leakage were allocated into the study group, and 68 in the early stage （between December 2008 and April 2011） whose surgical wounds were not detected using methylene blue test were allocated into the control group. After cholecystectomy, catheters of patients in the study group were inserted into common bile duct for blocking the distal common bile duct via stump of cystic duct, and mehylene blue dilutions were injected into common bile duct via catheters, observing and judging whether or not there were blue dyes of residual cavity and bile leakage. Patients in the control group used dry gauze to wipe residual external capsular wall, and judging whether or not there was bile leakage. Observation indicators： （1） surgical and postoperative recovery situations; （2） follow-up. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative patients′ survival and recurrence of hepatic cystic echinococcosis up to June 2017. Measurement data with normal distribution were represented as ±s. The comparisons between groups were evaluated with the t test, and the count data were analyzed using the chi-square test. Results：（1） Surgical and postoperative recovery situations： all patients between groups underwent successful surgery, without perioperative death. Dominant and recessive bile leakages were detected in 30, 34 patients in the study group and 15, 10 patients in the control group, respectively. Operation time, volume of intraoperative blood loss, time of postoperative gastrointestinal function recovery, time of postoperative drainage-tube removal, cases with postoperative bile leakage and duration of postoperative hospital stay were respectively （191±37）minutes, （156±20）mL, （2.8±1.5）days, （6.4±2.5）days, 8, （10.3±2.5）days in the study group and （137±22）minutes, （115±11）mL, （2.2±1.2）days, （9.5±3.9）days, 22, （13.5±3.8）days in the control group, with statistically significant differences between groups （t=9.944, 14.540, 2.477,-5.415, x2=11.015, t=-5.689, P〈0.05）. Number of patients with postoperative incision liquefaction and infection, residual cavity abscess and jaundice were respectively 5, 2, 0, 0 in the study group and 6, 3, 1, 1 in the control group, with no statistically significant difference between groups （x2=0.284, 0.360, 1.142, 1.142, P〉0.05）. Patients with postoperative bile leakage received sufficient drainage, patients with postoperative incision liquefaction and infection received drainage and changing dressing, patients with residual cavity abscess received tube placement by reoperation and sufficient drainage and patients with jaundice received liver- and cholagogic-protective treatments. All the patients with complications were improved. （2） Follow-up： 120 of 128 patients were followed up for 6-36 months, including 66 in the study gorup and 54 in the control group, with a median time of 24 months. During the follow-up, all patients were survived; 3 patients had recurrence of hepatic cystic echinococcosis, including 2 undergoing reoperation and 1 undergoing albendazole treatment. Conclusions： Methylene blue test detecting intraoperative surgical wounds has better clinical value in prevention of the bile leakage after excision of internal capsule combined with external capsular subtotal resection of hepatic cystic echinococcosis.