CAJ | 학술논문

目的探讨医源性胆管损伤的治疗方法并评价远期疗效.方法回顾性分析1982年1月至2012年4月北京协和医院收治的62例医源性胆管损伤患者的临床资料.LC致胆管损伤24例,开腹胆囊切除术致胆管损伤38例.10例患者接受非手术治疗,其中8例行PTCD治疗、2例行ERCP+支架治疗.52例患者接受手术治疗,其中47例行胆管空肠Roux-en-Y吻合、2例行肝胆管十二指肠吻合或重建、3例行胆管缝合或端端吻合.术前36例患者行PTCD治疗.术中42例患者放置胆管支架.为了预防术后腹腔积液或包裹性胆汁积液,50例患者术中行腹腔引流.结果接受手术治疗的52例患者中,13例出现1种以上并发症,其中伤口感染1例、胆管炎4例、吻合口漏2例、吻合口出血2例、吻合口不畅1例、胆管支架脱落1例、胃肠道相关疾病3例.18例患者术后早期进行胆道造影检查,其中2例提示胆汁漏.15例患者术后行PTCD+胆道支架植入,其中1例患者行经皮腹腔穿刺引流.2例患者因吻合口出血分别于术后1d和术后2周行再次手术治疗.50例行术中腹腔引流术患者引流管平均放置时间为(7.7±2.6)d.全组患者无围手术期死亡,术后平均住院时间为(18 ±12)d.本组62例患者中55例获得随访(非手术治疗10例、手术治疗45例),中位随访时间为93个月.接受非手术治疗的10例患者中,1例行PTCD后因胆汁漏于外院接受再次手术治疗,3例行PTCD后因胆管炎反复发作伴结石形成多次行PTCD.接受手术治疗的45例患者中,6例出现远期并发症,其中发热6例、黄疸4例、胆管结石3例、胆管癌变1例；4例于术后2年行再次手术.结论尽早发现胆管损伤并由经验丰富的专科医师治疗是保证患者近期和远期疗效的最佳方案.外科修复仍为治疗胆管损伤的首选.
목적 탐토의원성담관손상적치료방법병평개원기료효.방법 회고성분석1982년1월지2012년4월북경협화의원수치적62례의원성담관손상환자적림상자료.LC치담관손상24례,개복담낭절제술치담관손상38례.10례환자접수비수술치료,기중8례행PTCD치료、2례행ERCP+지가치료.52례환자접수수술치료,기중47례행담관공장Roux-en-Y문합、2례행간담관십이지장문합혹중건、3례행담관봉합혹단단문합.술전36례환자행PTCD치료.술중42례환자방치담관지가.위료예방술후복강적액혹포과성담즙적액,50례환자술중행복강인류.결과 접수수술치료적52례환자중,13례출현1충이상병발증,기중상구감염1례、담관염4례、문합구루2례、문합구출혈2례、문합구불창1례、담관지가탈락1례、위장도상관질병3례.18례환자술후조기진행담도조영검사,기중2례제시담즙루.15례환자술후행PTCD+담도지가식입,기중1례환자행경피복강천자인류.2례환자인문합구출혈분별우술후1d화술후2주행재차수술치료.50례행술중복강인류술환자인류관평균방치시간위(7.7±2.6)d.전조환자무위수술기사망,술후평균주원시간위(18 ±12)d.본조62례환자중55례획득수방(비수술치료10례、수술치료45례),중위수방시간위93개월.접수비수술치료적10례환자중,1례행PTCD후인담즙루우외원접수재차수술치료,3례행PTCD후인담관염반복발작반결석형성다차행PTCD.접수수술치료적45례환자중,6례출현원기병발증,기중발열6례、황달4례、담관결석3례、담관암변1례；4례우술후2년행재차수술.결론 진조발현담관손상병유경험봉부적전과의사치료시보증환자근기화원기료효적최가방안.외과수복잉위치료담관손상적수선.
Objective To investigate the management of iatrogenic bile duct injury and evaluate the longterm efficacy.Methods The clinical data of 62 patients with iatrogenic bile duct injury who were admitted to the Peking Union Hospital from January 1982 to April 2012 were retrospectively analyzed.Of the 62 cases of iatrogenic bile duct injuries,24 were caused by laparoscopic cholecystectomy (LC) and 38 were caused by open cholecystectomy. Ten patients received non-surgical treatment, including 8 patients received percutaneous transhepatic cholangiography and drainage (PTCD) and 2 received endoscopic retrograde cholangiopancreatography (ERCP) + stent implantation. Fifty-two patients received surgical treatment,including 47 received cholecystojejunostomy,2 received cholecystoduodenostomy,3 received biliary end-to-end anastomosis. Thirty-six patients received PTCD preoperatively,and 42 received biliary stent implantation intraoperatively.Fifty patients received intraoperative peritoneal drainage to prevent postoperative peritoneal effusion or encapsulated bile collection.Results Of the 52 patients who received surgery,13 patients were complicated by more than 1 complication,including 1 case of wound infection,4 cases of cholangitis,2 cases of anastomotic leakage,2 cases of anastomotic bleeding,1 case of anastomotic occlusion, 1 case of biliary stent falling out and 3 cases of gastrointestinal diseases.Eighteen patients received cholangiography postoperatively,and 2 patients were diagnosed as with bile leakage.Fifteen patients received PTCD + biliary stent implantation,and 1 patient of them received percutaneous puncture drainage.Two patients received reoperation due to anastomotic bleeding.The mean time of peritoneal drainage for the 50 patients was (7.7 ± 2.6) days.No perioperative death was observed,and the mean operation time was (18 ± 12) days.Fifty-five patients were followed up (10 patients received non-surgical treatment,and 45 patients received surgical treatment),with a median time of 93 months.Of the 10 patients who received nonsurgical treatment,1 received reoperation due to bile leakage,3 received PTCD for the second time due to repeated cholangitis after PTCD. Of the 45 patients who received surgical treatment,6 patients had long-term complications,including 6 cases of fever,4 cases of jaundice,3 cases of choledocho-lithiasis and 1 case of bile duct canceration; 4 received reoperation at the second year after operation.Conclusions Early diagnosis of bile duct injury and operation carried out by experienced surgeons are important for a better short- and long-term prognosis.Surgical repair is the first line therapy for bile duct injury.