医源性胆管损伤远期并发症五例诊治体会  

Clinical experience on 5 patients with delayed complications after iatrogenic bile duct injuries

作　　者：陈曙光[1] 李炎[1] 张振寰[1] 何小东[1] 

机构地区：[1]中国医学科学院北京协和医院基本外科,100730

出　　处：《中华肝胆外科杂志》2013年第8期586-588,共3页Chinese Journal of Hepatobiliary Surgery

摘　　要：目的探讨医源性胆管损伤导致远期胆管狭窄及闭锁并发症的治疗方法及要点。方法回顾性分析2002年6月至2006年7月收治的5例因胆囊切除手术时胆管损伤导致胆管狭窄及闭锁远期并发症患者的临床资料。结果5例医源性胆管损伤远期并发症包括：肝总管完全闭锁2例，肝门部胆管狭窄2例，胆肠吻合口狭窄1例。其中，2例为腹腔镜胆囊切除手术，3例为小切口胆囊切除术。损伤部位按Strasberg分型包括：E1型、E2型、E3型各1例、E5型2例。5例胆管损伤远期并发症患者，均于经皮肝胆管穿刺造影及引流减黄治疗后进行手术探查及胆道重建。手术方法包括肝门部肝管成型、肝管空肠Roux-en-Y吻合术3例，肝总管空肠Roux-en—Y吻合术2例，术后均恢复良好出院。5例患者均随访7年以上，未再发生梗阻性黄疸及胆道感染，目前仍在随访中。结论对医源性胆管损伤导致胆管狭窄及胆管闭锁远期并发症患者，应先施行经皮肝胆管穿刺造影及引流治疗，待黄疸及炎症控制后二期手术行胆管空肠Roux-en—Y吻合。耐心细致解剖肝门、将损伤近端正常胆管组织与空肠吻合及保证吻合口足够大是手术治疗成功的要点。Objective To evaluate the therapeutic methods and the key points in the manage ment of delayed complications of bile duct stenosis after iatrogenic bile duct injuries. Methods Five patients with bile duct injuries developed delayed complications of bile duct stenosis after cholecystec tomy were retrospectively studied. All clinical information were derived from the medical data of these 5 patients treated in our department from June 2002 to July 2006. Results Of the 5 patients with delayed complications of iatrogenic bile duct injuries, 2 patients developed common bile duct occlusion, 2 patients developed hilar bile duct stenosis, and 1 patient developed anastomotie stenosis after cholan- giojejunostomy. Bile duct injuries occurred in 3 patients after laparoscopic cholecystectomy, and in another 2 patients after mini-laparotomy-cholecystectomy. The locations of the bile duct injuries, accord ing to Strasberg classification, were type E1 （n=1）, type E2 （n=1）, type E3, （n=1）, and type E5 （n= 2）. All 5 patients received PTCD initially to relieve obstructive jaundice and then they received surgical exploration and biliary reconstruction. These patients received cholangioplasty at the porta hepatis, and hepaticojejunostomy using a Roux-en-Y anastomosis. Two patients received Roux en-Y anastomosis of the common hepatic duct to the jejunum. All these patients had good recovery and were discharged well postoperatively. All patients had been followed-up for 7 years or more, with no evi dence of obstructive jaundice or biliary tract infection. Conclusions For patients who present with de layed complications of bile duct stenosis after iatrogenic bile duct injuries, primary PTCD is carried out to relieve jaundice and to control infection. Meticulous dissection of the porta hepatis, reliable anasto mosis of the proximal healthy bile duct tissues to a jejunal loop, and adequate size of anastomosis guarantee success of surgery.

关 键 词：胆道损伤 手术后并发症 

分 类 号：R657.4[医药卫生—外科学]