CAJ | 학술논문

目的胆道损伤经修复手术后发生再次胆道狭窄是外科处理的难点,该文探讨此类病例的手术时机和手术方法 .方法回顾性分析了自2005年11月至2007年10月间,上海交通大学医学院附属瑞金医院收治的胆道损伤经一次或二次修复手术后发生再次胆道狭窄的病例16例,对这些病例的临床资料进行分析.结果胆道损伤绝大多数是由胆囊切除所造成,其中14例为腹腔镜胆囊切除术.1例为小切口胆囊切除术,另1例为腹部外伤.初次胆道损伤按Strasberg分型,E1 1例、E2 7例、E3 5例和E43例,其中2例E4类型的病人合并动脉损伤.末次修复手术方式分别为11例胆肠Roux-en-Y吻合,3例胆总管端端吻合并放置T管,1例左肝管T管引流,另1例胆道外引流术.该次入院12例病人接受了胆肠Roux-en-Y吻合,其中1例接受了二期右半肝切除术(E4类型合并右肝动脉损伤);1例病人接受了胆总管端端吻合;1例病人(E4类型合并肝固有动脉损伤)接受了尸肝移植;1例病人(腹部外伤所致)接受了活体右半肝移植;另1例病人接受了胆道外引流术.经初步随访,病人恢复基本良好.结论尽管再次手术时因炎症瘢痕等因素使得胆道狭窄平面高于初次损伤平面,但胆肠Roux-en-Y吻合依然是修复胆道损伤的主要治疗方法 .术前评估应尤其重视是否合并血管损伤,并根据情况考虑是否需要行半肝切除或肝移植术;而对于全身条件较差者,可先行胆道外引流治疗.
목적 담도손상경수복수술후발생재차담도협착시외과처리적난점,해문탐토차류병례적수술시궤화수술방법 .방법 회고성분석료자2005년11월지2007년10월간,상해교통대학의학원부속서금의원수치적담도손상경일차혹이차수복수술후발생재차담도협착적병례16례,대저사병례적림상자료진행분석.결과 담도손상절대다수시유담낭절제소조성,기중14례위복강경담낭절제술.1례위소절구담낭절제술,령1례위복부외상.초차담도손상안Strasberg분형,E1 1례、E2 7례、E3 5례화E43례,기중2례E4류형적병인합병동맥손상.말차수복수술방식분별위11례담장Roux-en-Y문합,3례담총관단단문합병방치T관,1례좌간관T관인류,령1례담도외인류술.해차입원12례병인접수료담장Roux-en-Y문합,기중1례접수료이기우반간절제술(E4류형합병우간동맥손상);1례병인접수료담총관단단문합;1례병인(E4류형합병간고유동맥손상)접수료시간이식;1례병인(복부외상소치)접수료활체우반간이식;령1례병인접수료담도외인류술.경초보수방,병인회복기본량호.결론 진관재차수술시인염증반흔등인소사득담도협착평면고우초차손상평면,단담장Roux-en-Y문합의연시수복담도손상적주요치료방법 .술전평고응우기중시시부합병혈관손상,병근거정황고필시부수요행반간절제혹간이식술;이대우전신조건교차자,가선행담도외인류치료.
Objective It is a considerable surgical challenge to handle biliary re-stricture after reparation for bile duct injury. This paper is aimed to discuss the operation timing and method for such cases. Methods From November 2005 to October 2007, 16 cases of biliary re-stricture after repara-tions for bile duct injury were admitted into our hospital. Their clinical data were analyzed retrospec-tively. Results The bile duct injury was caused by cbolecystectomy and laparoscopic cholecystectomy in 14 cases, mini-incision choleystectomy in 1 and abdominal injury in the remaining 1. According to the classification of Strasberg, type E1 injury was found in 1 patient, type E2 injury in 7, type E3 inju-ry in 5 and type E4 injury in 3. Two of the patients with type E4 injury had also a vascular injury of the hepatic artery. For the last reparation operation, eleven patients received Roux-en-Y hepaticojejunos-tomy, 3 patients duct to duct reconstruction with T tube stent, 1 patient T tube drainage in the left hepatic duct and 1 patient external biliary drainage. For this time in our hospital, 12 patients under-went Roux-en-Y hepaticojejunostomy, and one of them received right hepatectomy afterward. One pa-tient received duct to duct re-anastomosis, one of the type E4 injury received corpse liver transplanta-tion, one patient caused by abdominal injury received living related liver transplantation and the remai-ning one patient received external biliary drainage. All these patients recovered fairly well. Conclusion Although the level of scarred biliary stricture could be much higher than that of the primary bile duct injury, Roux-en-Y hepaticojejunostomy is still the main approach for bile duct injury reparation. We should pay special attention to concomitant vascular injury in preoperative assessment. It may be ap-propriate to consider a hemihepatectomy or liver transplantation based on different circumstances. In case of poor general condition, external biliary drainage might be the unique choice upon emergency.