医源性胆管损伤外科治疗策略及疗效

Strategy and efficacy of surgical treatments for iatrogenic bile duct injury

目的探讨医源性胆管损伤(IBDI)外科治疗策略及疗效。方法回顾性分析2010年1月至2019年12月首都医科大学附属北京朝阳医院收治的34例IBDI患者临床资料。其中男20例,女14例;平均年龄(53±15)岁。患者均签署知情同意书,符合医学伦理学规定。本院首诊的6例患者均为腹腔镜胆囊切除术中损伤。外院转入28例,其中腹腔镜胆囊切除术中损伤18例,开腹胆囊切除术中损伤5例,腹腔镜胆总管切开取石术中损伤4例,开腹胆总管切开取石术中损伤1例。分析患者外科治疗策略及疗效。结果本组患者胆管损伤主要发生在肝外胆总管区域,尤其是肝门区和胆总管上段。即时修复18例,早期修复6例,延迟修复10例。6例本院IBDI患者均及时一期行胆总管端端吻合术,其中2例患者留置T管。外院转入的28例患者再次手术方式包括:胆总管-空肠吻合术13例,组织瓣胆总管修复术9例(胃瓣4例,胆囊瓣3例,空肠瓣2例),胆总管端端吻合+ T管引流术5例,右半肝切除术1例。围手术期并发症发生率为18%(6/34),无发生围手术期死亡。随访时间2~114个月,中位随访时间46个月。随访期间,评级优23例,良8例,优良率达91%(31/34)。结论术中早期诊断和合理的外科处理是治疗IBDI的关键,保留Oddi括约肌功能的各种胆道修复术是最佳治疗方式,远期效果确切。

Objective To explore the strategy and efficacy of surgical treatments for iatrogenic bile duct injury(IBDI).Methods Clinical data of 34 IBDI patients admitted to Beijing Chaoyang Hospital of Capital Medical University from January 2010 to December 2019 were retrospectively analyzed.Among them,20 patients were male and 14 female,aged(53±15)years on average.The informed consents of all patients were obtained and the local ethical committee approval was received.6 patients,initially admitted to our hospital,were diagnosed with laparoscopic cholecystectomy-induced injuries.28 cases were transferred to our hospital from other hospitals including 18 cases of laparoscopic cholecystectomy-induced injuries,5 cases of open cholecystectomy-induced injuries,4 cases of laparoscopic choledocholithotomy-induced injuries and 1 case of open choledocholithotomy-induced injury.The strategy and efficacy of surgical treatments were evaluated.Results The bile duct injuries mainly occurred in the extrahepatic common bile duct area,especially in the hilar area and the upper segment of common bile duct.Immediate repair was delivered in 18 cases,early repair in 6 cases and delayed repair in 10 cases.6 IBDI patients in our hospital immediately underwent end-to-end anastomosis of common bile duct,including 2 cases with T-tube retention.28 patients transferred from other hospitals underwent repeated operations as follows:choledochojejunostomy in 13 cases,common bile duct repair with tissue flaps in 9 cases(4 cases with stomach flaps,3 cases with gallbladder flaps,2 cases with jejunal flaps),end-to-end anastomosis of common bile duct and T-tube drainage in 5 cases,and right hemihepatectomy in 1 case,respectively.The incidence of perioperative complications was 18%(6/34).No perioperative death occurred.The follow-up time was 2 to 114 months with a median of 46 months.During the follow-up,excellent efficacy was observed in 23 cases and good in 8 cases,with an excellent and good rate of 91%(31/34).Conclusions Early diagnosis and reasonable surgical treatments during operation play a key role in the treatment of IBDI.Biliary tract repair with Oddi sphincter function-preserved is the optimal treatment which yields definite long-term efficacy.