Chapman W C, Halevy A, Blumgart L H, Benjamin I S
Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn., USA.
Arch Surg. 1995 Jun;130(6):597-602; discussion 602-4. doi: 10.1001/archsurg.1995.01430060035007.
To evaluate management strategies for the treatment of patients with postcholecystectomy bile duct strictures.
Retrospective study.
The Hepatobiliary Unit of Hammersmith Hospital, London, England.
One hundred thirty consecutive patients referred for treatment of postcholecystectomy bile duct strictures. The majority (80 patients [61.5%]) had undergone multiple operative procedures before referral, and 81 (62.3%) had undergone at least one previous stricture repair. At referral, more than half of the patients had a stricture involving the confluence of the bile ducts (n = 78 [60%]), and 23 (17.7%) had evidence of portal hypertension.
Perioperative mortality, stricture recurrence, and long-term outcome.
One hundred twenty-two patients (94%) underwent operative treatment: 110, stricture repair alone; four, portosystemic shunt and stricture repair; and eight, miscellaneous operative procedures. Among the 110 patients treated by stricture repair alone, there was an operative mortality rate of 1.8% (n = 2), and 79 patients (76%) had a good result, with no biliary symptoms and no need for intervention during mean follow-up of 7.2 years (range, 1 to 13 years). Twenty-two patients (21%) required either radiological intervention or operative revision of the biliary-enteric anastomosis, but 11 (50%) of these patients subsequently did well and had no biliary symptoms. Thus, 90 patients (87%) had a good or excellent long-term result after initial or follow-up treatment. There were no deaths among the 108 patients who underwent stricture repair alone by direct suture techniques. Factors influencing mortality included hypoalbuminemia, an elevated serum bilirubin level, and the presence of liver disease and portal hypertension. Preoperative factors influencing failure of the stricture repair in long-term follow-up included discontinuity of the right and left ducts at the time of stricture repair (Bismuth grade 4) and three or more previous attempts at operative repair before referral to our center.
Operative repair of bile duct strictures using direct sutured techniques remains the procedure with which alternative methods will need to be compared, with close attention to long-term outcome.
评估胆囊切除术后胆管狭窄患者的治疗管理策略。
回顾性研究。
英国伦敦哈默史密斯医院肝胆科。
连续130例因胆囊切除术后胆管狭窄前来治疗的患者。大多数患者（80例[61.5%]）在转诊前接受过多次手术，81例（62.3%）至少接受过一次先前的狭窄修复。转诊时，超过一半的患者胆管汇合处存在狭窄（n = 78[60%]），23例（17.7%）有门静脉高压的证据。
围手术期死亡率、狭窄复发率和长期预后。
122例患者（94%）接受了手术治疗：110例仅行狭窄修复；4例行门体分流术和狭窄修复；8例行其他手术。在仅接受狭窄修复的110例患者中，手术死亡率为1.8%（n = 2），79例患者（76%）效果良好，在平均7.2年（范围1至13年）的随访期间无胆道症状且无需干预。22例患者（21%）需要进行放射学干预或对胆肠吻合口进行手术修正，但其中11例患者（50%）随后情况良好且无胆道症状。因此，90例患者（87%）在初始治疗或后续治疗后获得了良好或优异的长期预后。采用直接缝合技术单独进行狭窄修复的108例患者中无死亡病例。影响死亡率的因素包括低白蛋白血症、血清胆红素水平升高以及肝病和门静脉高压的存在。影响长期随访中狭窄修复失败的术前因素包括狭窄修复时左右肝管不连续（Bismuth 4级）以及在转诊至本中心之前曾进行过三次或更多次手术修复尝试。
使用直接缝合技术进行胆管狭窄的手术修复仍是需要与其他方法进行比较的手术方式，同时要密切关注长期预后。
