Kupferschmidt H, Havelka J, Schwery S, Bernardi M, Bühler H
Medizinische Klinik, Stadtspital Waid, Zürich.
Schweiz Med Wochenschr Suppl. 1996;79:89S-93S.
Biliary leakages are more frequent in laparoscopic than in open cholecystectomy. The aim of our study was to evaluate the diagnostic and therapeutic value of endoscopic retrograde cholangiography (ERC) in the management of bile leakages after laparoscopic cholecystectomy. The primary management was endoscopic sphincterotomy and extraction of remaining gallstones in the common bile duct to provide a decrease of biliary pressure, allowing closure of the fistulas. We report on 20 patients with bile leakage at ERCP, presenting between January 1991 and October 1995 with persistent bile discharge out of drainages, increasing fluid collections subhepatic (termed bilomas) or in the free peritoneal cavity (cholascos), abdominal pain, fever, cholestasis, intraoperatively diagnosed choledocholithiasis, and subhepatic abscess in one case. In 19 cases, after fluoroscopic visualization of the biliary tree and the leak, endoscopic sphincterotomy was performed. The biliary leaks were located at the cystic duct remnant (n = 12), at the gallbladder fossa (n = 5), or at lesions at the hepatic or common bile duct (n = 2). In 7 patients residual common bile duct stones were endoscopically removed. Most patients had localized small subhepatic fluid collections (n = 13) and the others had cholascos (n = 6). The leaks closed with endoscopic sphincterotomy alone in 11 patients, 4 patients had endoscopic sphincterotomy plus percutaneous or laparoscopic drainage of the bile collections, and 4 patients underwent laparotomy. All 6 cases with cholascos but only 2 of the 13 patients with localized collections underwent a second therapeutic procedure (drainage, laparotomy). Five of these procedures were performed within 7 days of ERCP, in most cases due to persistent bile leak. We conclude that biliary leakages after laparoscopic cholecystectomy require laparotomy only exceptionally. Endoscopic sphincterotomy, combined with percutaneous drainage in the case of large collections, represents a safe and successful strategy ensuring closure of the leaks in most cases.
与开腹胆囊切除术相比，腹腔镜胆囊切除术后胆漏更为常见。本研究的目的是评估内镜逆行胆管造影术（ERC）在腹腔镜胆囊切除术后胆漏处理中的诊断和治疗价值。主要治疗方法是内镜下括约肌切开术及取出胆总管内残留结石，以降低胆管压力，促使瘘口闭合。我们报告了1991年1月至1995年10月期间接受ERCP检查的20例胆漏患者，这些患者持续经引流管引流出胆汁，肝下（称为胆汁瘤）或游离腹腔内（胆汁性腹水）积液增多，伴有腹痛、发热、胆汁淤积，术中诊断为胆总管结石，其中1例合并肝下脓肿。19例患者在X线透视下观察胆管树及漏口后，进行了内镜下括约肌切开术。胆漏部位位于胆囊管残端（12例）、胆囊窝（5例）或肝或胆总管病变处（2例）。7例患者通过内镜取出了胆总管残留结石。大多数患者有局限性小的肝下积液（13例），其他患者有胆汁性腹水（6例）。11例患者仅通过内镜括约肌切开术漏口即闭合，4例患者行内镜括约肌切开术加经皮或腹腔镜引流胆汁积液，4例患者接受了剖腹手术。所有6例胆汁性腹水患者中，但13例局限性积液患者中只有2例接受了第二次治疗性操作（引流、剖腹手术）。其中5例操作在ERCP后7天内进行，大多数情况是由于持续胆漏。我们得出结论，腹腔镜胆囊切除术后胆漏仅在极少数情况下需要剖腹手术。内镜括约肌切开术，在积液量大时联合经皮引流，是一种安全且成功的策略，在大多数情况下可确保漏口闭合。
