Sulpice L, Garnier S, Rayar M, Meunier B, Boudjema K
Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Centre Hospitalier Universitaire, Université de Rennes 1, Rennes, France,
Langenbecks Arch Surg. 2014 Jun;399(5):601-8. doi: 10.1007/s00423-014-1205-7. Epub 2014 May 6.
Major bile duct injury (MBDI) remains frequent after laparoscopic cholecystectomy (LC) reaching 0.3 to 0.6 % and is associated with a significant mortality rate. The aim of this study was to retrospectively analyze the factors likely to influence the long-term results of surgical repair for MBDI occurring after LC.
Medical records of patients referred to our referral center from January 1992 to January 2010 for management of bile duct injury following LC were retrospectively analyzed, and patients with MBDI were identified. Clinicopathological factors likely to influence long-term results after surgical repair were assessed by univariate and multivariable analysis.
During the study period, 38 patients were treated for MBDI. These 38 patients underwent Roux-en-Y hepaticojejunostomy (HJ) or HJ revision in 25 (66 %) and 13 (34 %) cases, respectively. The median follow-up period was 93 (26-204) months. A Clavien-Dindo post-operative morbidity class >3 occurred in 10 (26 %) cases and was independently associated with a surgical repair performed during a sepsis period (OR = 102.5; IC 95 % [7.12; 11,352], p < 0.007). Long-term results showed that biliary strictures occurred in 5 (13 %) cases and were associated with sepsis (p < 0.006), liver cirrhosis (p < 0.002) and post-operative complications (p < 0.012). Multivariate analysis revealed that only liver cirrhosis remained predictive of stricture (OR = 26.4, 95 % CI [2; 1,018], p < 0.026).
When MBDI occurs following LC, HJ seems to be the optimal treatment but should not be performed during a sepsis period. Long-term results are significantly altered by the presence of a biliary cirrhosis at time of repair.
腹腔镜胆囊切除术（LC）后，主要胆管损伤（MBDI）仍然频发，发生率达0.3%至0.6%，且与显著的死亡率相关。本研究的目的是回顾性分析可能影响LC术后发生的MBDI手术修复长期结果的因素。
回顾性分析1992年1月至2010年1月转诊至我们转诊中心接受LC术后胆管损伤治疗的患者的病历，并确定MBDI患者。通过单因素和多因素分析评估可能影响手术修复后长期结果的临床病理因素。
在研究期间，38例患者接受了MBDI治疗。这38例患者分别有25例（66%）和13例（34%）接受了Roux-en-Y肝空肠吻合术（HJ）或HJ翻修术。中位随访期为93（26 - 204）个月。10例（26%）患者出现Clavien-Dindo术后并发症分级>3级，且与脓毒症期进行的手术修复独立相关（OR = 102.5；95%置信区间[7.12；11,352]，p < 0.007）。长期结果显示，5例（13%）患者出现胆管狭窄，且与脓毒症（p < 0.006）、肝硬化（p < 0.002）和术后并发症（p < 0.012）相关。多因素分析显示，只有肝硬化仍然是狭窄的预测因素（OR = 26.4，95%置信区间[2；1,018]，p < 0.026）。
当LC术后发生MBDI时，HJ似乎是最佳治疗方法，但不应在脓毒症期进行。修复时存在胆汁性肝硬化会显著改变长期结果。
