de Santibañes E, Palavecino M, Ardiles V, Pekolj J
General Surgery and Liver Transplantation Unit, Hospital Italiano de Buenos Aires, Esmeralda 1319 4to piso 4to cuerpo CP 1007, Buenos Aires, Argentina.
Surg Endosc. 2006 Nov;20(11):1648-53. doi: 10.1007/s00464-006-0491-8. Epub 2006 Oct 23.
Laparoscopic cholecystectomy is the treatment of choice for gallbladder stones. In the current study, this approach was associated with a higher incidence of biliary injuries. The authors evaluate their experience treating complex biliary injuries and analyze the literature.
In a 15-year period, 169 patients with bile duct injuries (BDIs) resulting from open and laparoscopic cholecystectomies were treated. The patients were retrospectively evaluated through their records. Biliary injury and associated lesions were evaluated with imaging studies. Surgical management included therapeutic endoscopy, percutaneous interventions, hepaticojejunostomy, liver resection, and liver transplantation. Postoperative outcome was recorded. Survival analysis was performed with G-Stat and NCSS programs using the Kaplan-Meier method.
Of the 169 patients treated for BDIs, 148 were referred from other centers. The injuries included 115 lesions resulting from open cholecystectomy and 54 lesions resulting from laparoscopic cholecystectomy. A total of 110 patients (65%) fulfilled the criteria for complex injuries, 11 of whom met more than one criteria. Injuries resulting from laparoscopic and open cholecystectomies were complex in 87.5% and 72% of the patients, respectively. The procedures used were percutaneous transhepatic biliary drainage for 30 patients, hepaticojejunostomy for 96 patients, rehepaticojejunostomy for 16 patients, hepatic resection for 9 patients, and liver transplantation projected for 18 patients. Hepaticojejunostomy was effective for 85% of the patients. The mean follow-up period was 77.8 months (range, 4-168 months). The mortality rate for noncomplex BDI was 0%, as compared with the mortality rate of 7.2% (8/110) for complex BDI. Mortality after hepatic resection was nil, and morbidity was 33.3%. The actuarial survival rate for liver transplantation at 1 year was 91.7%.
Complex BDIs after laparoscopic cholecystectomy are potentially life-threatening complications. In this study, late complications of complex BDIs appeared when there was a delay in referral or the patient received multiple procedures. On occasion, hepatic resections and liver transplantation proved to be the only definitive treatments with good long-term outcomes and quality of life.
腹腔镜胆囊切除术是胆囊结石的首选治疗方法。在本研究中，这种方法与较高的胆管损伤发生率相关。作者评估了他们治疗复杂胆管损伤的经验并分析了相关文献。
在15年期间，对169例因开腹和腹腔镜胆囊切除术导致胆管损伤（BDI）的患者进行了治疗。通过患者记录对其进行回顾性评估。利用影像学检查评估胆管损伤及相关病变。手术治疗包括治疗性内镜检查、经皮介入治疗、肝空肠吻合术、肝切除术和肝移植。记录术后结果。使用G-Stat和NCSS程序，采用Kaplan-Meier方法进行生存分析。
在169例接受BDI治疗的患者中，148例是从其他中心转诊而来。损伤包括115例开腹胆囊切除术导致的病变和54例腹腔镜胆囊切除术导致的病变。共有110例患者（65%）符合复杂损伤标准，其中11例符合多项标准。腹腔镜和开腹胆囊切除术导致的损伤分别在87.5%和72%的患者中为复杂损伤。所采用的治疗方法为30例患者行经皮经肝胆管引流术，96例患者行肝空肠吻合术，16例患者行再次肝空肠吻合术，9例患者行肝切除术，预计18例患者行肝移植。肝空肠吻合术对85%的患者有效。平均随访期为77.8个月（范围4 - 168个月）。非复杂性BDI的死亡率为0%，而复杂性BDI的死亡率为7.2%（8/110）。肝切除术后死亡率为零，发病率为33.3%。肝移植1年的精算生存率为91.7%。
腹腔镜胆囊切除术后的复杂性BDI是潜在的危及生命并发症。在本研究中，当转诊延迟或患者接受多次手术时，复杂性BDI的晚期并发症出现。有时，肝切除术和肝移植被证明是唯一具有良好长期预后和生活质量的确定性治疗方法。
