Lillemoe K D
Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Am Surg. 2000 Feb;66(2):138-44.
Despite major advances in surgical and nonsurgical therapy, biliary tract infections remain a significant cause of morbidity and mortality. The two classic biliary tract infections most commonly encountered are acute cholecystitis (either calculous or acalculous) and acute cholangitis. In addition, bile leakage associated with bile duct injuries during laparoscopic cholecystectomy has become a problem not infrequently encountered by surgeons. Acute calculous cholecystitis results from a combination of mechanical, biochemical, and infectious mechanisms, initiated by stone impaction in the cystic duct. After instituting empiric antibiotics, early laparoscopic cholecystectomy should be performed. Although conversion to open cholecystectomy is more common than in chronic cholecystitis, there appears to be no increased morbidity or mortality in that setting. Acute acalculous cholecystitis usually occurs in critically ill patients and may present both a diagnostic and therapeutic dilemma. Aggressive management, however, is warranted, both because of the critical nature of illness in these patients and the high incidence of perforation. Percutaneous cholecystostomy is indicated, particularly in high-risk patients both for diagnosis and treatment. Acute cholangitis results from a combination of bactibilia and biliary obstruction. The majority of patients can be successfully managed with intravenous antibiotics and fluid resuscitation. In those patients in whom initial management is not successful, biliary drainage, which is best accomplished nonoperatively, should be instituted. There is a very limited role for early surgical intervention in acute suppurative cholangitis. Biliary leaks resulting in bile "peritonitis" or bilomas are common sequelae of laparoscopic bile duct injury. Although surgeons may feel it is necessary to operate urgently, delineation of the proximal biliary anatomy via percutaneous transhepatic cholangiography and biliary stent placement is the appropriate first step in management. This procedure will usually control the bile leak and allow delineation of the anatomy and opportune timing of definitive reconstruction.
尽管在手术和非手术治疗方面取得了重大进展，但胆道感染仍然是发病和死亡的重要原因。最常见的两种经典胆道感染是急性胆囊炎（结石性或非结石性）和急性胆管炎。此外，腹腔镜胆囊切除术中与胆管损伤相关的胆漏已成为外科医生经常遇到的问题。急性结石性胆囊炎是由机械、生化和感染机制共同作用引起的，起因于胆囊管结石嵌顿。在使用经验性抗生素后，应尽早进行腹腔镜胆囊切除术。虽然转为开腹胆囊切除术比慢性胆囊炎更常见，但在这种情况下发病率和死亡率似乎并未增加。急性非结石性胆囊炎通常发生在危重病患者中，可能带来诊断和治疗上的两难困境。然而，鉴于这些患者病情危急且穿孔发生率高，积极的治疗是必要的。经皮胆囊造瘘术是合适的选择，特别是对于高危患者的诊断和治疗。急性胆管炎是由胆汁细菌感染和胆道梗阻共同引起的。大多数患者通过静脉使用抗生素和液体复苏可以成功治疗。对于初始治疗不成功的患者，应进行胆道引流，最好通过非手术方式完成。急性化脓性胆管炎早期手术干预的作用非常有限。导致胆汁“腹膜炎”或胆汁瘤的胆漏是腹腔镜胆管损伤的常见后遗症。尽管外科医生可能认为有必要紧急手术，但通过经皮肝穿刺胆管造影和胆道支架置入来明确近端胆道解剖结构是治疗的合适第一步。该操作通常可以控制胆漏，并有助于明确解剖结构以及确定最终重建的合适时机。
