Ponsky J L
Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
Surg Clin North Am. 1996 Jun;76(3):505-13. doi: 10.1016/s0039-6109(05)70457-6.
Operative injury of the biliary tree is not a new complication of cholecystectomy but has become increasingly more visible during the emergence of the laparoscopic approach. Optimal treatment of such problems depends upon early recognition and strategic planning of a therapeutic approach. ERCP has become increasingly important in identifying bile leaks and their source after cholecystectomy. A high index of suspicion is mandatory in patients complaining of discomfort several days after surgery, and liberal use of CT or ultrasound imaging helps identify bile leaks before peritonitis is severe. Once bile leaks or ductal injury are suspected, ERCP should be performed to confirm the leak, identify its site and cause, and help define a therapeutic plan. In minor leaks, endoscopic diversion by sphincterotomy or stenting provides a rapid solution. In more significant injuries where ductal integrity is intact, endoscopic dilatation and stenting may play a role in closing leaks and resolving strictures while averting surgery. Where injury is severe, ERCP, often combined with transhepatic cholangiography, helps to rapidly assess the extent of injury and plan a strategy for operative repair.
胆道手术损伤并非胆囊切除术的新并发症，但在腹腔镜手术出现后，其愈发常见。此类问题的最佳治疗取决于早期识别及治疗方案的战略规划。内镜逆行胰胆管造影术（ERCP）在胆囊切除术后胆汁漏及其来源的识别中变得愈发重要。对于术后数天主诉不适的患者，高度怀疑指数必不可少，且广泛使用CT或超声成像有助于在腹膜炎严重之前识别胆汁漏。一旦怀疑有胆汁漏或胆管损伤，应进行ERCP以确认漏口、确定其部位和原因，并帮助制定治疗方案。对于轻微漏口，通过括约肌切开术或支架置入进行内镜引流可迅速解决问题。在导管完整性完好的更严重损伤中，内镜扩张和支架置入可能在闭合漏口和解决狭窄方面发挥作用，同时避免手术。在损伤严重的情况下，ERCP通常联合经皮肝穿刺胆管造影术，有助于快速评估损伤程度并制定手术修复策略。
