Mercado Miguel Angel, Chan Carlos, Jacinto Juan Carlos, Sanchez Norberto, Barajas Alexandra
Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico, Mexico DF, Mexico.
J Gastrointest Surg. 2008 Jun;12(6):1029-32. doi: 10.1007/s11605-007-0434-2. Epub 2007 Dec 1.
Bile duct injuries related to laparoscopic and/or open cholecystectomy are a frequent finding and require surgical treatment. Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to "facilitate identification of the duct by bile duct dilation." Considering that we are a national referral center for such injuries, we decided to analyze our cases of voluntary and involuntary duct ligation after iatrogenic bile duct injury.
We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts, operative treatment, and postoperative results were analyzed.
A total of 413 patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. Bile duct dilation (>10 mm) was demonstrated in one case of voluntary (6%) and three cases of involuntary ligations (10%). The remaining cases in both groups had no duct dilation and developed necrosis at the blinded duct and leakage proximal to the ligature, with different degrees of bilioperitoneum and/or biloma. In all cases, a Roux-en-Y hepatojejunostomy was performed.
Bile duct ligature produces dilation in a very small number of patients (less than 10%) and usually produces necrosis of the blinded stump with subsequent bile leakage. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.
与腹腔镜和/或开腹胆囊切除术相关的胆管损伤很常见，需要手术治疗。完全梗阻是由于有意或无意放置的结扎线或夹子所致。有意应用通常是为了“通过胆管扩张便于识别胆管”。鉴于我们是此类损伤的全国转诊中心，我们决定分析医源性胆管损伤后自愿和非自愿胆管结扎的病例。
我们回顾了自愿或非自愿胆管结扎患者的病历。分析了术前胆管评估结果、手术治疗及术后结果。
共纳入413例患者。45例出现完全梗阻。其中15例结扎是有意的，30例梗阻是非自愿的。1例自愿结扎（6%）和3例非自愿结扎（10%）出现胆管扩张（>10mm）。两组其余病例均无胆管扩张，在盲端胆管处发生坏死，结扎近端出现渗漏，伴有不同程度的胆汁性腹膜炎和/或胆汁瘤。所有病例均行Roux-en-Y肝空肠吻合术。
胆管结扎在极少数患者中（不到10%）会导致扩张，通常会使盲端残端坏死并随后出现胆汁渗漏。如果主刀医生无法进行修复，放置肝下引流并将患者转至有资质的中心进行重建是最佳方法。
