腹腔镜肝叶切除治疗复杂肝内胆管结石术后肝断面感染原因分析及处理

Analysis and treatment of liver resection surface infection following laparoscopic hepatolithiectomy for complicated intrahepatic bile duct stones

目的分析复杂肝内胆管结石患者行腹腔镜肝叶切除治疗后肝断面感染的危险因素及其处理策略。方法回顾性分析2014年1月至2017年4月期间川北医学院附属医院对复杂肝内胆管结石行腹腔镜肝叶切除治疗的45例患者的临床资料,统计肝断面感染、感染病原菌分布情况、患者一般情况、手术情况、抗生素使用时间、引流管放置时间及引流量情况,并分析引起肝断面感染的危险因素。结果 45例行腹腔镜肝叶切除治疗复杂肝内胆管结石患者术后发生肝断面感染13例,感染率为28.89%;13例感染患者分离出24株病原菌,其中革兰阳性菌9株,革兰阴性菌15株;术后肝断面发生胆汁漏16例,断面积液、积脓5例;平均引流量约200 mL;术中放置双套管10例;术后B超或CT介入下重置引流管23例,引流管放置时间平均为8 d,引起全身感染2例。单因素分析结果显示,既往多次胆道手术史、合并肝硬变、术中放置双套管、手术时间及术后胆汁漏与复杂肝内胆管结石行腹腔镜肝叶切除术后肝断面感染有关(P<0.050);多因素分析结果显示,既往多次胆道手术史及术后胆汁漏是腹腔镜肝叶切除治疗复杂肝内胆管结石术后发生肝断面感染的危险因素(P<0.050),而术中放置双套管是其保护因素(P<0.050)。结论对于复杂肝内胆管结石行腹腔镜肝叶切除治疗患者,可针对其术后肝断面感染的相关危险因素加强术前管理和术中精细操作进行预防,若术后发生了肝断面感染应采取积极有效的治疗策略。

Objective To explore risk factors and treatment strategies of liver resection surface infection following laparoscopic hepatolithiectomy for patient with complicated intrahepatic bile duct stones. Methods The clinical data of 45 patients with complicated intrahepatic bile duct stone underwent laparoscopic hepatectomy from January 2014 to April 2017 in this hospital were analyzed. The liver resection surface infection rate, pathogenic bacteria distribution, factors of operation, antibiotic use time, volume of drainage, and drainage tube placement time were analyzed. Results A total of 13 cases of liver resection surface infection occurred following the laparoscopic hepato- lithiectomy in the 45 cases, the infection rate was 28.89%. Totally 24 strains of pathogens were isolated from the infected patients, including 9 strains of gram-positive bacteria and 15 strains of gram-negative bacteria. The mainly postoperative complications included 16 cases of the biliary leakage, 5 cases of the effusion and empyema, the average drainage volume was about 200 mL after the surgery. The double pipes were placed in the 10 patients in the operation. The drainage tubes were placed in the 23 patients under the ultrasound or CT intervention after the surgery, the average time of drainage tube placement was 8 d. The results of univariate analysis showed that the past biliary surgery history, combined with liver cirrhosis, double pipe drainage, operation time, and postoperative biliary leakage were associated with the liver section surface infection following the laparoscopic hepatolithiectomy （P〈0.050）. The results of multivariate analysis identified that the past biliary surgery history and postoperative biliary leakage were the risk factors （P〈0.050）, while the double pipe drainage was the protectNe factor （P〈0.050） for liver resection surface infection following the laparoscopic hepatolithiectomy. Conclusions Prophylactic treatment such as perfect preoperative management and careful intraoperation should be taken for risk factors of liver section surface infection following laparoscopic hepatolithiectomy. Actively effective treatment strategies should be given if postoperative liver section surface infection existence.