Di Lascia Alessandra, Tartaglia Nicola, Fersini Alberto, Petruzzelli Fabio, Ambrosi Antonio
Ann Ital Chir. 2018;89:270-277.
Laparoscopic cholecystectomy for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography. The aim of this study was to assess the effectiveness of endoscopic strategy in the management of minor biliary injuries.
Twenty-two patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 2007 and 2017 and they were all treated with endoscopic approach, with ERCP in order to confirm the nature of the injury and decompress the bile duct with sphincterotomy, stent insertion, or the placement of nasobiliary drains. In 15 patients, the leak was diagnosed by persistent bile drainage, in the other 7 patients without a drain the biliary leak was suspected because of symptoms in the immediate postoperative period.
Controlled biliary fistulae were established in all 22 patients (100%), without further intervention. A complete cholangiogram was obtained in all patients (100%). The most common sites of minor leak were the cystic duct stump and the Luschka duct, but in one patients the site of the leak was unclear.
Early in the series, sphincterotomy alone or nasobiliary tube placement was performed. Subsequently patients underwent sphincterotomy with stent insertion, in order to promote preferential drainage of bile into the duodenum. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. The median hospital stay was 15 days (range, 10-31 days) post-laparoscopic cholecystectomy. ERCP was performed 4-6 weeks later to document healing of the leaking point and to remove the stent. Routine follow was at median 50 days.
This review confirms that postoperative minor biliary injuries can be successful managed by endoscopic ERCP biliary decompression.
Bile leak, Bile duct injury, Biliary fistula, Endoscopy, ERCP, Laparoscopic cholecystectomy.
在西方国家，腹腔镜胆囊切除术治疗胆结石疾病是最常见的外科手术，胆漏仍是发病的重要原因。公认的轻微胆管损伤治疗方法是通过内镜逆行胰胆管造影术进行胆管内减压。本研究的目的是评估内镜治疗策略在处理轻微胆管损伤中的有效性。
2007年至2017年连续记录了22例腹腔镜胆囊切除术后发生胆漏的患者，他们均接受了内镜治疗方法，采用内镜逆行胰胆管造影术（ERCP）来确认损伤的性质，并通过括约肌切开术、支架置入或放置鼻胆管引流来减压胆管。15例患者通过持续胆汁引流诊断出胆漏，另外7例未放置引流管的患者因术后即刻出现症状而怀疑有胆漏。
所有22例患者（100%）均成功建立了可控性胆瘘，无需进一步干预。所有患者（100%）均获得了完整的胆管造影。轻微胆漏最常见的部位是胆囊管残端和卢氏管，但有1例患者胆漏部位不明。
在该系列研究早期，仅进行了括约肌切开术或放置鼻胆管。随后患者接受了括约肌切开术并置入支架，以促进胆汁优先排入十二指肠。成功进行ERCP后胆漏缓解的中位时间为4天。2例患者进行ERCP后并发轻度胰腺炎。腹腔镜胆囊切除术后的中位住院时间为15天（范围为10 - 31天）。4 - 6周后进行ERCP以记录漏点愈合情况并取出支架。常规随访时间中位数为50天。
本综述证实，术后轻微胆管损伤可通过内镜ERCP胆管减压成功处理。
胆漏；胆管损伤；胆瘘；内镜检查；ERCP；腹腔镜胆囊切除术
