肝切除术治疗医源性胆管损伤

Hepatectomy for iatrogenic bile duct injury

目的探讨医源性胆管损伤(IBDI)诊治经验。方法回顾性分析2016年1月至2017年4月在新疆维吾尔自治区人民医院行肝切除术的2例IBDI患者临床资料。例1女,62岁,因LC术后3 d出现发热、黄疸。例2女,44岁,因LC术后即出现皮肤、黏膜黄染。2例均诊断为"梗阻性黄疸,IBDI"。2例患者均签署知情同意书,符合医学伦理学规定。结果例1患者于超声引导下行胆管穿刺引流术,1个月后出现腹痛、腹胀、食欲减退等不适。CT示肝内多发低密度灶,考虑肝脓肿。行"右半肝切除+肝胆管-空肠吻合术"。例2患者完善术前准备后行"剖腹探查+胆管-空肠吻合术",2个月后患者出现发热,CT示肝脓肿,CT血管造影(CTA)示肝右动脉假性动脉瘤。经多学科讨论后行"右半肝切除术+左肝管-空肠吻合术"。2例患者术后恢复顺利,出院后随访6个月无明显并发症发生。结论对于IDBI患者,应行CTA检查有否合并肝右动脉损伤,如有损伤应及时重建,无法重建应考虑胆管修复的同时行右半肝切除;肝右动脉损伤未能重建血运者,术后应严密观察病情变化,及时发现肝右叶坏死及肝脓肿,行右半肝切除术。

Objective To investigate the experience of diagnosis and treatment of iatrogenicbile duct injury(IBDI).Methods Clinical data of2patients with IBDI who underwent hepatectomy inthe People's Hospital of Xinjiang Uygur Autonomous Region between January2016and April2017wereretrospectively analyzed.Case1was a62-year-old female,presented with fever and jaundice3d afterlaparoscopic cholecystectomy(LC).Case2was a44-year-old female,presented with yellow skin and mucosa3d after LC.Both patients were diagnosed with obstructive jaundice and IBDI.The informed consentsof two patients were obtained and the local ethical committee approval was received.Results Case1underwent ultrasound-guided transhepatic biliary drainage,and suffered from abdominal pain,abdominaldistension and anorexia1month later.Computed tomography(CT)scan revealed multiple intrahepatichypodense lesions,which were considered as liver abscess.Right hemihepatectomy combined withintrahepatic cholangiojejunostomy was performed in Case1.Case2underwent exploratory laparotomy andcholangiojejunostomy after well preoperative preparations.The patient suffered from fever after2month.CT scan revealed liver abscess,CT angiography(CTA)revealed a pseudoaneurysm in the right hepaticartery.After multi-disciplinary consultation,right hemihepatectomy combined with left hepaticojejunostomywas performed.Two patients recovered well.No significant complication was observed in the patients during the6-month follow-up after discharged from hospital.Conclusions For IDBI patients,CTAshould be performed to check if complication of right hepatic artery injury exists.Revascularization shouldbe performed timely.If it cannot be revascularized,bile duct repairing and right hemihepatectomy can beperformed simultaneously.For patients with right hepatic artery injury which cannot be revascularized,postoperative conditions should be closely observed.Right hemihepatectomy should be performed timelywhen necrosis and liver abscess are detected in the right lobe.