医源性胆管损伤:胆囊切除术的阿喀琉斯之踵  

Iatrogenic bile duct injuries: the Achilles' Heel of cholecystectomy

作　　者：梁廷波[1] 粟伟[1] 马涛[1] 白雪莉[1] 

机构地区：[1]浙江大学医学院附属第二医院肝胆胰外科浙江省胰腺病研究重点实验室,杭州310009

出　　处：《腹部外科》2017年第5期329-333,共5页Journal of Abdominal Surgery

基　　金：国家重点基础研究发展计划项目(973计划;2014CB542101);国家自然科学基金面上项目(81472212);国家卫生和计划生育委员会公益性行业科研专项子项目(201502014)

摘　　要：医源性胆管损伤(iatrogenic bile duct injuries,IBDI)是胆囊切除术的一种严重并发症,其不仅损害病人的身心健康,同时也对外科医生及医保系统造成严重负面影响。IBDI核心在于预防,关键在于及时诊断。把握手术时机,选择合理手术方式,IBDI亦可取得良好的远期治疗效果。本文将从预防、诊断及治疗三方面对IBDI的诊治现状与趋势进行阐述。Iatrogenic bile duct injuries （IBDI） continue to be a major concern in open and lapa- roscopic cholecystectomy. They have profound implications for patients, medical personnel and health- care providers due to significant morbidity and mortality, high rates of litigation and raised healthcare expenditure. Misidentification of the biliary system is the major cause of IBDI. Precision assessment preoperatively and secure identification intraoperatively can lessen and even avoid these injuries. Critical view of safety, intraoperative cholangiography, anatomic landmark-based intraoperative navigation and near-infrared fluorescence cholangiography are useful methods of targets identification. Once IBDI occur,early diagnosis produces far-reaching effects on prognosis. Imaging examinations are invaluable in postoperative diagnosis, which makes up over half of the cases. Various classifications have been estab- lished to guide the mode of intervention. If biliary injury is recognized intraoperatively, reconstruction should be undertaken immediately. Otherwise, surgical repair should be performed before sepsis or af- ter sepsis is controlled adequately. A specialist surgeon, instead of the IBDI surgeon,is recommended to perform the primary definitive repair. The Roux-en-Y hepaticojejunostomy is the most widely used procedure for major injuries and has been shown to provide favorable long-term outcomes. Percutaneous and endoscopic interventions are useful in draining bile collections and used in some minor injuries with uncertain efficacy. Recently, minimally invasive techniques, including laparoscopic and robotic surgery have been applied to IBDI reconstruction. And preserving innate physiological structure obtains increasing attention.

关 键 词：医源性胆管损伤 胆囊切除术 手术中并发症 预防 诊断 治疗 

分 类 号：R657.4[医药卫生—外科学] R619.5[医药卫生—临床医学]