医源性胆管狭窄的手术治疗

目的 探讨医源性胆管狭窄的手术治疗方法.方法 回顾性总结1989年1月至2006年12月收治的235例医源性胆管损伤及胆管狭窄患者的临床资料.对损伤或狭窄患者采用胆肠通路重建术、保留和利用乳头括约肌的修复术、肝移植术等进行修复.结果 本组182例患者行胆肠Roux-en-Y吻合术,12例行胆总管对端吻合术,34例行自体带蒂组织瓣吻合术,6例行胆总管切开成形T管引流术,1例行肝移植术.随访时间1～10年,189例获随访.手术优良率为94.7%(179/189).狭窄复发率为5.3%(10/189),复发原因主要为合并结石、硬化性胆管炎、胆汁性肝硬化等.1例因严重胆汁性肝硬化、门静脉高压症,术后死于肝功能衰竭.结论 胆肠Roux-en-Y吻合术是可靠的治疗方法.利用自体带蒂组织瓣修复胆管能保留胆管下端Oddi括约肌的功能,效果良好,但远期疗效有待进一步评估.胆管内不需要常规放置支撑管.肝移植是治疗胆管狭窄引起的终末期胆病的有效方法.     

医源性胆管损伤的外科处理

探讨医源性胆管损伤的外科处理。方法回顾性分析近9年的30例医源性胆管损伤病人的外科处理。结果30例医源性胆管损伤的病人,2例死亡。1例保守治愈。随访24例(3月至5年)。结论大多数医源性胆管损伤需再手术并且疗效不太理想,早期(48小时以内)或4周以后修复损伤的胆管可能会减少胆管狭窄．提高疗效。梗阻性医源性胆管损伤再手术时机值得进一步探讨。     

医源性胆管损伤远期并发症及处理

医源性胆管损伤远期并发症是指：在上腹部手术中已经发生胆管损伤并作相应修复手术后再出现以胆管炎为主要特征的一组临床症候群；或术中未发现而术后近期发现，但限于病人全身及局部条件而未能作胆道重建手术以漏胆、腹腔内严重感染、全身营养欠佳、水电解质失衡为主要特...     

医源性胆管损伤手术修复的要点

医源性胆管损伤系指因医源性因素如外科手术或其他有创性诊疗操作造成的胆管损伤。处理不恰当、未修复或修复失败，可导致胆管梗阻或胆管炎反复发作，病程迁延，痛苦伴随病人余生，甚至危及生命。修复失败导致胆管再狭窄，而再修复、再狭窄的病例在临床也屡见不鲜，修复术一次更比一次困难。迄今，如何避免胆管损伤或对损伤后进行成功修复，仍是肝胆外科领域的热点，修复后再狭窄的正确、有效处理更是外科难题。     

胆囊切除术相关胆管损伤手术修复的临床分析

目的探讨胆囊切除相关医源性胆管损伤的原因、临床分型、手术修复的预后,为临床治疗提供参考。方法回顾性分析安徽医科大学第一医附属医院2004年1月～2015年12月收治的31例胆囊切除术导致医源性胆管损伤行手术修复治疗的患者临床资料,电话随访预后。结果 31例患者年龄M (P25, P75)为44 (37, 57)岁,男性11人,女性20人。行开放胆囊切除术11人,行腹腔镜下胆囊切除术20人(laparoscopic cholecystectomy,LC)。4例在行胆囊切除术中发现胆管损伤;非术中发现胆管损伤的27例患者中21例首发症状表现为黄疸,19例在行内引流手术前明确受伤部位。中华医学会胆道损伤临床分型:Ⅱ1、Ⅱ2、Ⅱ3的比例分别是74.2%、22.6%、3.2%;临床分类:a、b、c、d的比例分别是35.5、9.7、35.5、19.3;2例合并血管损伤。即时处理、早期处理(≤2周)、延迟处理(2周)的比例分别是12.9%、19.4%、67.7%。干预方式上胆总管端端吻合、桥式内引流+Y管外引流、胆管-空肠Roux-en-Y吻合、胆管-空肠Roux-en-Y吻合+外引流管置入的比例分别是3.2%、3.2%、25.8%、67.7%。修复术后30天内并发症(Clavien-Dindo Classification≥3)发生率是35.5%,长期并发症发生率是41.9%。延期修复术后胆肠吻合口漏的发生率显著低于即时修复(P=0.043),延期手术的围手术期并发症(Clavien-Dindo Classification≥3)的发生率明显低于即时手术和早期手术组(P值分别为0.017、0.044),但三者间的胆肠吻合口狭窄的发生率无明显差异。单因素分析显示存在胆管组织缺损的胆管损伤是远期胆管炎反复发作的预测因素。结论胆肠吻合是一种相对安全的治疗胆道损伤的手术方式,延期手术可能有利于患者的预后,胆囊切除相关医源性胆道损伤中存在胆管组织缺损的损伤类型与修复手术后远期发生胆管炎反复发作明显相关,行确定性修复手术应注意胆管的整形。     

医源性胆管损伤伴狭窄的手术治疗

目的:探讨肝管空肠吻合术治疗医源性胆管损伤伴狭窄的效果及注意事项。方法:回顾分析17例医源性胆管损伤患者的临床资料,着重分析了手术前准备、手术操作方法及影响手术效果的各项因素。结果:17例患者均为胆囊切除术时损伤胆管,其中5例为开腹胆囊切除,12例为腹腔镜胆囊切除。损伤分型:Ⅱ型5例,Ⅲ型8例,Ⅳ型3例,Ⅴ型1例。修复手术(肝管空肠吻合术)时间离前次胆囊手术最短者为4个月,最长者为6年。术后经2个月至5年随访,患者情况良好。结论:在行决定性手术前,患者全身及局部条件必须得到满意改善,清晰全面的胆管造影片必不可少,术中正确操作,肝管空肠吻合术治疗医源性胆管狭窄可获得满意疗效。     

29例医源性胆管损伤手术疗效的临床分析

目的:探讨医源性胆管损伤的手术时机与修复方式,以期提高术后的远期疗效。方法:回顾性分析1999年1月至2010年12月我院收治的29例医源性胆管损伤病人的临床资料,并对所有病人手术修复后进行随访。结果:根据2008年中华医学会外科学分会胆道外科学组制定的《胆管损伤的预防与治疗指南》中胆管损伤的分型,29例胆管损伤中Ⅰ型损伤3例,Ⅱ1型22例,Ⅱ2型3例,Ⅱ3型1例。即时修复12例,早期修复(两周以内)6例,延期修复(6-8周)11例。修复手术方式有迷走胆管结扎术1例,胆总管修补术1例,胆管修补加T管引流术9例,胆管端端吻合加T管引流术2例,胆管空肠Roux-en-Y吻合术16例。29例病人中失访6例,死亡1例,平均随访时间为4.7年。在随访的22例病人中有20例一次修复成功,所有随访病人末次手术至今均无明显胆道感染及黄疸。结论:腹腔镜胆囊切除术是高位胆管损伤最主要的原因。只要正确选择手术时机、手术方式,掌握修复技巧,胆管损伤可以获得较好的远期效果。在胆管修补术中,适时留置T管有助于减少术后胆漏和狭窄,一般留置3个月左右。     

医源性高位胆管损伤狭窄的处理

目的探讨医源性高位胆管损伤后狭窄的处理方法，以期提高疗效、减少并发症。方法对23年中183例医源性胆管损伤病例资料进行回顾性分析，以修复后再手术作为判断疗效标准。结果183例中有173例行不同方式修复术，有144例因高位胆管狭窄再行1～5次手术，再手术率83．24％(144／173)。结论采用狭窄以上正常胆管进行胆肠Roux-Y吻合术，注意吻合方法和质量，可减少术后胆管再狭窄复发的发生率，提高疗效。     

一种治疗良性高位胆管狭窄的新手术方式

良性高位胆管狭窄临床上屡见不鲜 ,常由于肝胆管结石、胆管炎或医源性胆管损伤后所致。本病的治疗颇为棘手 ,特别是后者 ,病人常有多次胆道手术史 ,肝门粘连严重 ,病变位置高而深 ,术时找寻狭窄的肝门胆管颇感费力 ,且易损伤十二指肠球部 ,增加术后的危险。为此 ,我们设计了一种新的手术方式 :肝门胆管十二指肠端端大口吻合、十二指肠球部与十二指肠三段端侧同步吻合术。曾施行多例 ,其中随访超过 1 5年以上者 3例 ,情况良好 ,无再发生胆道狭窄、重症胆管炎、胆石等症状 ,疗效满意 ,现介绍该手术方法。所有选用本手术治疗的病人 ,术前均经 …     

医源性胆管损伤21例治疗体会

目的总结医源性胆管损伤的原因、预防及处理经验。方法对21例医源性胆管损伤的临床资料进行回顾性分析。结果本组21例病例中,痊愈出院17例（81%）,死亡1例（4.8%）,死亡原因为胆汁性腹膜炎导致的感染中毒性休克。3例术后晚期胆管狭窄患者,经单纯的ERCP扩张并置支架内引流,效果不佳,自动放弃手术治疗。术后存活的17例患者中,术后1年有3例出现胆管炎反复发作,影像学证实为胆管再狭窄,经再次手术后痊愈。结论提高对医源性胆管损伤的认识和术中细致的解剖是预防的关键。胆管空肠吻合术是医源性胆管损伤或损伤性胆管狭窄的修复重建的主要手段。     

Long-term follow-up and risk factors for strictures after hepaticojejunostomy for bile duct injury: An analysis of surgical and percutaneous treatment in a tertiary center

Background

Hepaticojejunostomy is commonly indicated for major bile duct injury after cholecystectomy. The debate about the timing of hepaticojejunostomy for bile duct injury persists since data on postoperative outcomes, including postoperative strictures, are lacking. The aim of this study was to analyze short- and long-term outcomes of hepaticojejunostomy for bile duct injury, including risk factors for strictures.

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??Evaluation of endoscope treatment in iatrogenic bile duct injury FENG Qiu-shi. Department of Hepatobiliary Surgery, Peking University First Hospital, Beijing 100034, China
Abstract Improper treatment of iatrogenic bile duct injury can cause serious consequences. After various initial repair surgery, some patients may still have biliary tract, biliary stricture, repeated biliary tract infection, biliary calculi, and eventually biliary cirrhosis. Endoscopic treatment of iatrogenic bile duct injury mainly includes choledochoscopy and duodenoscopy, which is minimally invasive, safe and effective, and is an important means to treat iatrogenic bile duct injury. Only by properly selecting the appropriate endoscopic treatment and mastering the indications and contraindications can give full play to the advantages of endoscopic treatment.     

腹腔镜胆囊切除术胆管损伤修复术后的远期效果观察

目的探讨LC胆道损伤修复术后的远期效果。方法回顾我院1993至2002年收治的27例LC胆管损伤病人的临床资料，结合部分病人随访结果进行分析总结。结果27例病人中，6例经介入方法治愈；21例行手术治疗，其中16例同时进行肝穿刺组织活检；术后1例在20个月时出现轻度吻合口狭窄并发胆管炎，1例在T管拔除之前吻合口近端节段性狭窄，均经气囊扩张治愈；16例行肝穿刺活检的病人中，5例肝组织显著纤维化，其中4例已发展为肝硬化。结论本组平均46个月的随访的病例中，胆肠吻合术的近期有效率为90．5％，远期有效率达100％。反复的盲目修复手术使延误收治的时间平均在16个月后，将导致肝组织损害。     

医源性胆管损伤的内镜诊疗及其评价

医源性胆管损伤处理不当,会造成严重后果,且经各种初期修复手术治疗后,部分病人后期仍可出现胆漏、胆道狭窄、反复胆道感染、形成胆道结石,最终导致胆汁性肝硬化。医源性胆管损伤的内镜治疗主要包括胆道镜和十二指肠镜治疗,具有微创、安全、有效的特点,是处理医源性胆管损伤的重要手段。正确选择相应的内镜治疗,掌握适应证、禁忌证,才能充分发挥内镜治疗的优势。     

Management of Bile Duct Injury at Various Stages of Presentation: Experience from a Tertiary Care Centre

The clinical presentation, management and outcome of all patients with bile duct injury who presented to our tertiary care centre at various stages after cholecystectomy were analyzed. The patients were categorized into three groups: group A–patients in whom the injury was detected during cholecystectomy, group B–patients who presented within 2 weeks of cholecystectomy and group C–patients who presented after 2 weeks of cholecystectomy. Our team acted as rescue surgeons and performed ‘on-table’ repair for injuries occurring in another unit or in another hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transections were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intra-abdominal collection when present. For those with complete transection, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded into three categories: grade A–no clinical symptoms, normal LFT; grade B–no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C–pain, cholangitis and abnormal LFT; grade D–surgical revision or dilatation required. Fifty nine patients were included in the study and the distribution was group A–six patients, group B–33 patients and group C–20 patients. In group A, one patient with complete transection of the right hepatic duct (type C) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one of the 18 patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of 8 days in all, except one patient who died of fulminant sepsis. Of the 15 patients with type E injury, five underwent hepaticojejunostomy after a minimum gap of 3 months. Early repair was considered in 10 patients. Twenty patients in group C underwent hepaticojejunostomy. In a mean follow-up of 40 months, the outcome was grade A in 54 patients, grade B in three patients (one from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.     

Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases

BACKGROUND: Bile duct injuries in combination with major vascular injuries may cause serious morbidity and may even require liver resection in some cases. We present two case studies of patients requiring right hepatic lobectomy after bile duct and right hepatic artery injury during laparoscopic cholecystectomy. PATIENTS: Two patients sustained combined major bile duct and hepatic artery injury during laparoscopic cholecystectomy. Surgical management consisted of immediate hepaticojejunostomy with reconstruction of the artery in one patient and hepaticojejunostomy alone in the other patient. In both cases the initial postoperative course was uncomplicated. RESULTS: After 4 and 6 months both patients suffered recurrent cholangitis due to anastomotic stricture. Both developed secondary biliary cirrhosis and required right hepatic lobectomy with left hepaticojejunostomy. The patients remain well 31 months and 4.5 years after surgery. CONCLUSIONS: The outcome of bile duct reconstruction may be worse in the presence of combined biliary and vascular injuries than in patients with an intact blood supply of the bile ducts. We recommend arterial reconstruction when possible in early recognized injuries to prevent late strictures. Short-term follow-up is most important for early recognition of postoperative strictures and to avoid further complications such as secondary biliary cirrhosis.     

Use of an opened umbilical vein patch for the reconstruction of the injured biliary tract

Background/Purpose When iatrogenic biliary tract injury occurs, there is the risk of complications such as bile leak and biliary stricture, and hepaticojejunostomy is the conventional procedure used for injury repair. However, this procedure can be complicated by retrograde biliary tract infection and the procedure can destroy the normal anatomical structure. Methods We report here a method of end-to-end biliary tract reconstruction that uses an opened umbilical vein (OUV) patch and two stents to reduce bile leakage and biliary stricture formation following injury to the common bile duct or right main bile duct. The postoperative courses of four patients are reviewed. Results In two of the patients, there was a small amount of postoperative bile drainage (for 3 days in the first patient and 2 days in the second patient). Of the two stents, the first stent was removed 1 month postoperatively, and the second stent at 2 to 3 months postoperatively. Three patients have returned to normal activity without symptoms after 44, 62, and 93 months, respectively. One patient died of a liver tumor recurrence in the fifth postoperative month, without a biliary problem. Conclusions An OUV patch for end-to-end biliary reconstruction reduced the volume and duration of bile leakage. Further research is needed to accurately evaluate the stenting period so as to reduce its duration.     

Biliary reconstruction without transanastomotic stent

Twenty three operations for common bile duct (CBD) stricture were performed on 22 consecutive patients by a single surgeon without the use of transanastomotic stents. All strictures resulted from operative injury; four were acute (less than 1 month postinjury), and 18 were treated a mean of 44 months (2-124 months) after injury. All but two of these patients had had previous repair attempts. Mean follow-up after reconstruction was 72 months (17-128 months). Reconstructive procedures included hepaticojejunostomy seven, choledochojejunostomy ten, and choledochoduodenostomy six. Twenty one of the 22 patients (95%) have had excellent results, with stable liver function an no evidence of cholangitis or jaundice. Early postoperative complications (one abscess, one fistula) resolved. In two of the 22, stricture recurred at one and five months, requiring balloon dilatation in one and reoperation in the other. Both are now asymptomatic at 37 and 64 months. Reoperation was also required to remove an infected distal CBD stump in one patient 29 months after reconstruction, and another had mild intermittent cholangitis, now resolved. The only death occurred 70 months after reconstruction in a patient who developed biliary cirrhosis. These results suggest that biliary enteric anastomosis for acute and chronic bile duct strictures associated with benign disease can be performed without stenting, yielding low postoperative morbidity and excellent long-term patency.     

医源性胆管损伤的外科治疗

目的探讨医源性胆管损伤的外科处理方法及其疗效。方法 1992年1月至2011年12月期间共行胆囊切除术3 714例,发生医源性胆管损伤39例,发生率1.05%。其中术中发现胆总管或肝管部分损伤6例,胆总管或肝管被横断1例,左右肝管汇合部以上损伤2例,右侧副肝管损伤1例;术后发现胆囊管漏14例,胆囊床小胆管漏7例,胆总管或肝管部分损伤2例,胆总管或肝管被横断2例,左右肝管汇合部以上损伤1例,胆管严重狭窄2例,右侧副肝管损伤1例。行胆管修补+T管支撑引流术4例,胆管空肠Roux-en-Y吻合术12例,副肝管空肠Roux-en-Y吻合术1例,B超引导下腹腔穿刺置管引流7例,保留腹腔引流管引流14例,右侧副肝管缝扎1例。结果对术中解剖异常或操作困难的病例行术中胆道造影前后,医源性胆管损伤的发生率分别为2.37%(25/1 054)和0.53%(14/2 660),差异显著(P<0.05)。39例患者经外科治疗后均好转。术后出现的主要并发症为吻合口狭窄,共发生6例,其中术中发现损伤组3例,术后发现损伤组3例,两组比较无统计学差异(P>0.05);其他并发症还包括:切口感染4例(术中发现损伤组2例,术后发现损伤组2例),腹腔脓肿3例(术中发现损伤组1例,术后发现损伤组2例)。术后发现组低于术中发现组,为24.1%(7/29)vs.60%(6/10),有统计学差异(P<0.05)。结论医源性胆管损伤可防可治,具体外科治疗方法因病情而异,但总体来讲,胆管空肠Roux-en-Y吻合术的预后较好。     

Postoperative bile duct strictures: management and outcome in the 1990s

OBJECTIVE: To describe the management and outcome after surgical reconstruction of 156 patients with postoperative bile duct strictures managed in the 1990s. SUMMARY BACKGROUND DATA: The management of postoperative bile duct strictures and major bile duct injuries remains a challenge for even the most skilled biliary tract surgeon. The 1990s saw a dramatic increase in the incidence of bile duct strictures and injuries from the introduction and widespread use of laparoscopic cholecystectomy. Although the management of these injuries and short-term outcome have been reported, long-term follow-up is limited. METHODS: Data were collected prospectively on 156 patients treated at the Johns Hopkins Hospital with major bile duct injuries or postoperative bile duct strictures between January 1990 and December 1999. With the exception of bile duct injuries discovered and repaired during surgery, all patients underwent preoperative percutaneous transhepatic cholangiography and placement of transhepatic biliary catheters before surgical repair. Follow-up was conducted by medical record review or telephone interview during January 2000. RESULTS: Of the 156 patients undergoing surgical reconstruction, 142 had completed treatment with a mean follow-up of 57.5 months. Two patients died of reasons unrelated to biliary tract disease before the completion of treatment. Twelve patients (7.9%) had not completed treatment and still had biliary stents in place at the time of this report. Of patients who had completed treatment, 90. 8% were considered to have a successful outcome without the need for follow-up invasive, diagnos tic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture after laparoscopic cholecystectomy had a better overall outcome than patients whose postoperative stricture developed after other types of surgery. Presenting symptoms, number of stents, interval to referral, prior repair, and length of postoperative stenting were not significant predictors of outcome. Overall, a successful outcome, without the need for biliary stents, was obtained in 98% of patients, including those requiring a secondary procedure for recurrent stricture. CONCLUSIONS: Major bile duct injuries and postoperative bile duct strictures remain a considerable surgical challenge. Management with preoperative cholangiography to delineate the anatomy and placement of percutaneous biliary catheters, followed by surgical reconstruction with a Roux-en-Y hepaticojejunostomy, is associated with a successful outcome in up to 98% of patients.