腹腔镜胆总管探查取石和胆管一期缝合术后胆瘘的防治策略

The strategy of the prevention and treatment post-operative bile leakage following laparoscopic common bile duct exploration with primary duct closure for common bile duct stone

目的探讨腹腔镜胆总管探查取石(laparoscopic common bile duct exploration,LCBDE)和胆管一期缝合(primary duct closure,PDC)术后胆瘘的防治策略。方法回顾性总结2016年3月至2020年6月多中心应用LCBDE+PDC治疗的217例胆总管结石患者的病例资料,其中男93例,女124例,年龄34~89岁,中位年龄44岁;胆管切开部位最大直径7~19mm,平均(11.8±2.1)mm;胆管前壁纵行切开183例,经胆囊管微切开34例。分析其胆瘘的发生原因及防治措施。结果217例患者手术成功率为100%,结石完全取出率为99.5%(216/217)。术后胆瘘发生率为10.1%(22/217)。胆瘘发生时间:术后3~5d 14例,6~7d 5例,8~10d 2例,术后40d 1例。每天最大瘘量:<50ml 12例,50~99ml 4例,100~199ml 2例,200~500ml 2例,700ml 1例,不详1例。胆瘘的分级和治疗:20例为A级,经保守治疗后痊愈;1例胆管下段残留结石于术后42d再次手术;1例抗心磷脂抗体综合征患者术后40d发生自发性胆瘘和弥漫性腹膜炎,经腹腔穿刺引流后痊愈。术后随访3~65个月,结石再发5例(2.3%),4例经逆行胰胆管造影术取出,1例行腹腔镜下Roux-en-Y胆肠吻合术治疗;无胆管狭窄、胆道疾病相关性死亡等远期并发症发生。结论通过系统的防治策略,可将胆总管结石LCBDE+PDC术后胆瘘发生率控制在较低水平,且多数胆瘘可通过保守治疗在短期内痊愈。

Objective To investigate the prevention and treatment strategy of biliary leakage after laparoscopic common bile duct exploration(LCBDE)with primary duct closure(PDC)for common bile duct stones.Method The clinical data of 217 patients with LCBDE+PDC in multi-center from March 2016 to June 2020 were retrospectively summarized.Among the patients,93 were male and 124 were female;the age ranged from 34 to 89 years,with a median age of 44 years;the maximum diameter of bile duct incision was 7-19 mm,with an average of(11.8±2.1)mm;the CBDE was done through longitudinal anterior wall of bile duct in 183 cases and through cystic duct with micro incision in 34 cases.The causes and prevention measures of post-operative biliary leakage were retrospectively summarized.Result The success rate of operation was 100%;the complete removal rate of stone was 99.5%(216/217).The incidence of postoperative biliary fistula was 10.1%(22/217).The occurrence time of postoperative bile leakage:14 cases within 3-5 days after operation,5 cases within 6-7 days after operation,and 8-10 days after operation in 2 cases,40 days after operation in 1 case.The maximum amount of postoperative bile fistula per day:12 cases less than 50ml/d,4 cases 50-99ml/d,2 cases 100-199ml/d,2 cases 200-500ml/d,1 case 700ml/d,1 case unknown.Severity grading of bile leakage and the treatment modalities:20 cases were grade A;1 case with residual stone in the lower part of the bile duct was reoperated 42 days after operation,and 1 case with anticardiolipin antibody syndrome developed spontaneous bile leakage and diffuse peritonitis 40 days after operation was cured after abdominal puncture and drainage.During the follow-up period of 3-65 months,5 cases(2.3%)had recurrent stones,4 cases were removed by ERCP,and 1 case underwent laparoscopic Roux-en-Y choledochojejunostomy.There were no long-term complications such as biliary stricture and biliary disease-related death.Conclusion LCBDE+PDC for choledocholithiasis is safe and effective;through systematic prevention and treatment strategy,the incidence of postoperative biliary fistula can be controlled at a low level,and mostly can be cured in a short time by conservative treatment.