Gal'perin E I, Kuzovlev N F, Chevokin A Iu
Khirurgiia (Mosk). 1998(9):26-30.
Retrospective evaluation of experience in treatment of 378 patients (1972-1997 years) with cicatricial stricture of hepatic ducts is presented. For the period for 1972 to 1986 years the basic principle consisted in obligatory use of a drainage--frame for prolonged (not less than 2 years) drainage of the biliary anastomosis aimed at a decrease of the recurrence risk. Changeable transhepatic drainage (CTD) was used. 199 patients were operated on, 18 died. In postoperative period a number of specific complications caused by CTD were observed: leak into infradiaphragmatic space (hemobilia, bile biliduodenal fistula, etc.). At follow-up period after restorative operations (34) relapse of cicatricial stricture was observed in 8 patients, which was a consequence of complications due to CTD. After reconstructive operations CTD was removed in 109 patients, relapse being detected in 5 (4.5%). Atraumatic needles with inert monifilament sutures as well as resolving suture threads enabled creation of high bilio-intestinal anastomoses without drainage-frame. Since 1987 to 1997 years 130 patients were operated on. Dissection of the hepatic ducts was made proximally to the cicatricial tissues, longitudinal cut of the left hepatic duct was performed. Atraumatic needles with threads of small size were used, the bilio-intestinal anastomosis was established by one layer nodular suture with nodules exteriorly faced and without seizure of intestinal mucous membrane. Complications in postoperative period were observed in 24 patients, no lethal outcomes occurred. In late postoperative period unsatisfactory results were documented in 7 patients. At present time we give preference to operations without drainage-frame. CTD is indicated in the presence of severe pyogenic and inflammatory infiltration at hepatic porta with involvement of the bile ducts' walls, cyrrhosis of the liver and portal hypertension hindering hepatic ducts' dissection; cicatricial stricture of the right hepatic duct followed by sclerosing process in sectoral ducts.
本文对1972年至1997年间378例肝管瘢痕性狭窄患者的治疗经验进行了回顾性评估。1972年至1986年期间，基本原则是必须使用引流支架对胆管吻合口进行长期（不少于2年）引流，以降低复发风险。采用了可变经肝引流（CTD）。199例患者接受了手术，18例死亡。术后观察到一些由CTD引起的特定并发症：漏入膈下间隙（血胆、胆十二指肠瘘等）。在修复手术后的随访期（34例），8例患者出现瘢痕性狭窄复发，这是CTD并发症的结果。重建手术后，109例患者拔除了CTD，5例（4.5%）检测到复发。使用带惰性单丝缝线的无创伤针以及可溶解缝线能够创建无引流支架的高位胆肠吻合术。1987年至1997年期间，130例患者接受了手术。在瘢痕组织近端进行肝管解剖，对左肝管进行纵向切开。使用带细缝线的无创伤针，通过一层结节状缝合建立胆肠吻合术，结节朝外，不抓取肠黏膜。24例患者术后出现并发症，无死亡病例。在术后晚期，7例患者记录到不满意的结果。目前，我们更倾向于不使用引流支架的手术。当肝门处存在严重化脓性和炎性浸润、胆管壁受累、肝硬化和门静脉高压阻碍肝管解剖时；右肝管瘢痕性狭窄伴节段性胆管硬化过程时，建议使用CTD。
