Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and Paris Descartes University-Paris, France.
Ann Surg. 2011 Jan;253(1):88-93. doi: 10.1097/SLA.0b013e3181f9b9f0.
The aim of this study was to evaluate the safety and efficacy of endoscopic treatment for biliary fistulas after complex liver resection.
The role of endoscopy in the treatment of fistulas of the common bile duct is well documented. On the contrary, results of endoscopic procedures for fistulas arising from peripheral bile ducts after liver resections are poorly studied, although more complex hepatectomies are increasingly performed. We analyzed retrospectively the results of these procedures in our experience.
Twenty-six patients aged 10 to 74 years were included. Fistulas arose after extended right hepatectomy, n = 14; extended left hepatectomy, n = 2; segmentectomy, n = 7; and split-liver transplantation, n = 3. All patients underwent radiologic or surgical external drainage before endoscopic retrograde cholangiopancreatography (ERCP). Mean bile outflow before endoscopy was 493.1 ± 386.1 mL/24 h (median, 400; range, 100-2000 mL). The mean time from surgery to diagnosis was 29.4 ± 45.5 days.
The ERCP was performed after a median of 13 days after the diagnosis of biliary fistula. A sphincterotomy was required in 96.1% of patients. A 5F to 10F polyethylene stent bypassing the leaking bile duct was implanted in 21 (80.7%) of 26 patients. Fistulas were dried up completely in 25 (96.1%) of 26 patients. The mean time from initial ERCP to running dry of the leaks was 17.5 ± 12.4 days. Procedure-related morbidity was 0%. There was no mortality.
Biliary fistulas arising from intrahepatic ducts after complex liver resections are more difficult to treat than distal fistulas arising from the common bile duct. However, despite a longer time for cure and the need for repeated ERCP, endoscopic therapy appears efficient and does not induce additional morbidity.
本研究旨在评估内镜治疗复杂肝切除术后胆瘘的安全性和疗效。
内镜治疗胆总管瘘的作用已有充分的文献记载。相反，对于肝切除术后源于肝外胆管的瘘，内镜治疗的结果研究得较少，尽管更复杂的肝切除术越来越多地开展。我们回顾性分析了我们的经验中这些手术的结果。
26 例年龄 10 至 74 岁的患者被纳入研究。胆瘘发生于扩大右半肝切除术 14 例，扩大左半肝切除术 2 例，肝段切除术 7 例，劈裂式肝移植 3 例。所有患者在进行内镜逆行胰胆管造影（ERCP）之前均接受了放射学或外科外引流。内镜前平均胆汁流出量为 493.1 ± 386.1ml/24h（中位数 400；范围 100-2000ml）。从手术到诊断的平均时间为 29.4 ± 45.5 天。
在诊断胆瘘后中位 13 天进行 ERCP。96.1%的患者需要行括约肌切开术。26 例患者中的 21 例（80.7%）植入了 5F 至 10F 聚乙烯支架以绕过漏胆管。26 例患者中有 25 例（96.1%）完全停止漏胆。初次 ERCP 至漏胆停止的平均时间为 17.5 ± 12.4 天。与操作相关的发病率为 0%。无死亡病例。
与源于胆总管的远端瘘相比，源于复杂肝切除术后肝内胆管的胆瘘更难治疗。然而，尽管治愈时间更长且需要重复 ERCP，但内镜治疗似乎有效且不会增加额外的发病率。
