Chinnery Galya Eileen, Krige Jake E J, Bornman Phillipus C, Bernon Marc M, Al-Harethi Salem, Hofmeyr Stefan, Banderker Mohamed Asif, Burmeister Sean, Thomson Sandie Rutherford
Surgical and Medical Gastroenterology Units, Groote Schuur Hospital and Departments of Surgery and Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
S Afr J Surg. 2013 Oct 25;51(4):116-21. doi: 10.7196/sajs.1829.
A bile leak is an infrequent but potentially serious complication after biliary tract surgery. Endoscopic intervention is widely accepted as the treatment of choice. This study assessed the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and biliary stenting in the management of postoperative bile leaks.
An ERCP database in a tertiary referral centre was reviewed retrospectively to identify all patients with bile leaks after laparoscopic cholecystectomy. Patient records and endoscopy reports were reviewed.
One hundred and thirteen patients (92 women, 21 men; median age 47 years, range 22 - 82 years) with a bile leak were referred for initial endoscopic management at a median of 12 days (range 2 - 104 days) after surgery. Presenting features included intra-abdominal collections with pain in 58 cases (51.3%), abnormal liver function tests (LFTs) in 22 (19.5%), bile leak in 25 (22.1%), and sepsis in 8 (7.1%). Twenty-nine patients (25.7%) were found to have either major bile duct injuries without duct continuity, vascular injuries or other endoscopic findings requiring surgical or radiological intervention. Of 84 patients managed endoscopically, 44 had a cystic duct (CD) leak, 26 a CD leak and common bile duct (CBD) stones, and 14 a CBD injury amenable to endoscopic stenting. Of the 70 patients with CD leaks (group A), 24 underwent sphincterotomy only (including 8 stone extractions), 43 had a sphincterotomy with stent placement (including 18 stone extractions) and 1 had only a stent placed, while 2 patients with previous sphincterotomies required no further intervention. The average number of ERCPs in group A was 2.3 (range 1 - 7). Of the 14 patients with bile duct injuries treated endoscopically (group B), 7 had a class D, 5 an E5 and 2 a class B injury; 13 patients underwent sphincterotomy and stenting, and 1 had a sphincterotomy only. Group B required an average of 3.6 ERCPs (range 2 - 5). The 113 patients underwent a total of 269 ERCPs (mean 2.4, range 1 - 7). Seven patients had one or more complications related to the ERCP: 3 acute pancreatitis, 2 cholangitis, 2 sphincterotomy bleeds, 1 duodenal perforation and 1 impacted Dormia basket, the latter 2 requiring operative intervention.
Three-quarters of bile leaks after laparoscopic cholecystectomy were due to CD leaks (with or without retained stones) or lesser bile duct injuries and were amenable to definitive endoscopic therapy. Nineteen patients (16.8%) had major injuries that required operative intervention.
胆漏是胆道手术后一种少见但可能严重的并发症。内镜干预被广泛认为是首选治疗方法。本研究评估了内镜逆行胰胆管造影（ERCP）、括约肌切开术和胆道支架置入术在处理术后胆漏中的有效性。
回顾性分析一家三级转诊中心的ERCP数据库，以确定所有腹腔镜胆囊切除术后发生胆漏的患者。查阅患者记录和内镜检查报告。
113例胆漏患者（92例女性，21例男性；中位年龄47岁，范围22 - 82岁）在术后中位12天（范围2 - 104天）被转诊接受初始内镜治疗。临床表现包括58例（51.3%）有腹痛的腹腔内积液、22例（19.5%）肝功能检查异常、25例（22.1%）胆漏和8例（7.1%）脓毒症。29例患者（25.7%）被发现有主胆管损伤且胆管连续性中断、血管损伤或其他需要手术或放射介入的内镜检查结果。在84例接受内镜治疗的患者中，44例为胆囊管（CD）漏，26例为CD漏合并胆总管（CBD）结石，14例为适合内镜支架置入的CBD损伤。在70例CD漏患者（A组）中，24例仅接受了括约肌切开术（包括8例取石），43例进行了括约肌切开术并置入支架（包括18例取石），1例仅置入了支架，而2例既往已行括约肌切开术的患者无需进一步干预。A组平均ERCP次数为2.3次（范围1 - 7次）。在14例接受内镜治疗的胆管损伤患者（B组）中，7例为D级损伤，5例为E5级损伤，2例为B级损伤；13例患者接受了括约肌切开术和支架置入术，1例仅接受了括约肌切开术。B组平均需要3.6次ERCP（范围2 - 5次）。113例患者共接受了269次ERCP（平均2.
