Qu Xin-cai, Zheng Qi-chang, Wang Guo-bin, Wang Ji-liang, Cheng Bo, Liu Shao-bin
Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
Zhonghua Wai Ke Za Zhi. 2006 May 1;44(9):591-3.
To investigate the early diagnosis on iatrogenic injuries in distal part of common bile duct and the prevention of severe retroperitoneal infection.
From 1990 to 2004, 17 patients with bile duct injures in the distal part of common biliary tract were admitted. And the clinical data of the 17 cases were retrospectively analyzed.
Of the 17 cases, the injuries of 15 cases were caused by the operation, and the injuries of the other 2 cases were caused in the process of removing the stone by endoscopic retrograde cholangiopancreatography (ERCP). The injuries of 14 cases were found during the operation, but the other one was not found in time. Before the operation, 16 cases were examined by B-type ultrasonography, 2 by MRCP and 6 by intraoperative choledocho-endoscope after the biliary tract exploration. Ten cases underwent perforating suture repair and T-tube drainage; 2 with Odd's sphincter incision and shaping; 2 with choledochojejunostomy; 1 with duodenum wall and bile duct repair and drainage. When the bile duct injured, the major findings during operation were bile duct explorer located out of the duodenum wall and bile duct, two or more than cleft in the distal part of common biliary tract found by choledocho-endoscopic examination, retroperitoneal edema and liquid accumulation found by irrigating water through T-tube, and/or retroperitoneal tissues stained blue by irrigating methylthioninium chloride through T-tube. The clinical manifestations after injuries were abdominal distention, abdominal pain, pain in the waist and back, fever and shock, et al. Thirteen cases were cured. And the syndromes included 1 case with intestinal fistula, 1 with incisional infection, 4 dead (3 died from infectious shock; 1 from bleeding in gastrectomy).
The postoperative clinical manifestations for iatrogenic injuries in the distal part of common biliary tract lack specificity, CT examinations are necessary to doubtful patients. Early diagnosis and timely management can obtain better results, and can effectively lower severe retroperitoneal infection. The perfect preoperative imaging examinations and intraoperative choledocho-endoscopic examinations before the biliary tract exploration maybe reduce iatrogenic injuries in the distal part of common biliary tract.
探讨胆总管下段医源性损伤的早期诊断及严重腹膜后感染的预防。
回顾性分析1990年至2004年收治的17例胆总管下段胆管损伤患者的临床资料。
17例中，15例损伤由手术所致，另2例损伤由内镜逆行胰胆管造影（ERCP）取石过程中造成。14例损伤于手术中发现，但另1例未及时发现。术前16例行B型超声检查，2例行磁共振胰胆管造影（MRCP）检查，6例行术中胆道探查后经胆道镜检查。10例行穿孔缝合修补及T管引流；2例行Oddi括约肌切开成形术；2例行胆总管空肠吻合术；1例行十二指肠壁与胆管修补引流术。胆管损伤时，手术中的主要表现为胆管探子穿出十二指肠壁及胆管外、经胆道镜检查发现胆总管下段有两处或多处裂口、经T管注水发现腹膜后水肿及积液、和/或经T管注入亚甲蓝后腹膜后组织染成蓝色。损伤后的临床表现为腹胀、腹痛、腰背部疼痛、发热及休克等。13例治愈。并发症包括肠瘘1例、切口感染1例、死亡4例（3例死于感染性休克；1例死于胃切除术后出血）。
胆总管下段医源性损伤术后临床表现缺乏特异性，对可疑患者需行CT检查。早期诊断并及时处理可取得较好效果，并能有效降低严重腹膜后感染。完善的术前影像学检查及术中胆道探查前的胆道镜检查可能减少胆总管下段医源性损伤。
