肝切除术后损伤性胆管狭窄的临床特征与手术修复

Clinical features and surgical repair of posthepatectomy bile duct strictures

目的分析肝切除术后损伤性胆管狭窄患者的临床特征与确定性修复策略。方法采用回顾性横断面研究，收集解放军总医院2000-2013年和北京清华长庚医院2014—2017年因肝切除术后胆管狭窄再手术患者的临床资料。结果21例肝切除术后胆管狭窄患者接受了再次手术修复治疗，其中13例合并手术后持续胆漏。致伤手术类型为左肝／扩大左肝切除10例、右肝／扩大右肝切除7例、肝中叶肿瘤切除2例，肝尾叶肿瘤切除2例。依据中华医学会胆道外科学组分型，本组胆管狭窄分别为Ⅱ2型4例，113型12例，114型5例。21例患者中，19例采用肝管空肠吻合术行确定性修复治疗，长期随访成功率89．0％。结论损伤累及2级或2级以下主要胆管的肝切除术后胆管损伤，继发持续胆漏或损伤性胆管狭窄时，需手术修复。肝管空肠吻合术是有效的确定性修复方法。左肝切除术后胆管狭窄，可经肝门板入路联合右前／右后肝管切开后整形吻合。右肝切除术后胆管狭窄，需经肝门板或经矢状部入路解剖左侧肝内胆管后空肠吻合。

Objective To analyze the clinical features and definitive repair strategies of bile duct strictures after hepatectomy. Methods The clinical data of patients undergoing definite repair for bile duct strictures after hepatectomy in the PLA General Hospital from 2000 to 2014 and Beijing Tsinghua Changgung Hospital from 2014 to 2017 were retrospectively collected. Results Twenty-one patients with bile duct stric- ture after hepatectomy were treated with reoperation. Among them, 13 cases showed continuous bile leakage after operation. The types of hepatectomy include 10 cases of left or extended left hemihepatectomy, 7 cases of right or extended right hemihepatectomy, 2 cases of mesohepatectomy, and 2 cases of hepatic caudate labectomy. According to classification formulated by the Biliary Surgery Group of Chinese Medical Association, the types of injuries of the patients included four of II 2, twelve of 113, and five of 114 respectively. 19 of 21 patients underwent definitive repair with hepaticojejunostomy. The long-term follow-up success rate was 89.0%. Conclusions Biliary injury after hepatectomy in which the injury affects the secondary or below he- patic ducts requires surgical repair. Hepaticjejunostomy is an effective definitive repair method. Hepaticjeju- nostomy for bile duct stenosis after fight hemihepatectomy always need to dissect the left intrahepatic bile duct by a hilar plate approach or UPV approach, due to the effect of hepatic portal transposition. Surgical re- pair for bile duct stenosis after the left hepatectomy, always need the incision of the fight anterior and fight posterior hepatic duct, due to extensive injuries of hepatic duct.