腹腔镜胆总管探查术后胆漏的处理
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摘要
目的探讨腹腔镜胆管探查术后胆漏处理策略。方法收集并分析荆州市中心医院近5年腹腔镜胆管探查治疗的536例胆石症病人临床资料,其中腹腔镜下胆管探查胆总管一期缝合术264例,腹腔镜下胆管探查T管引流术259例,经胆囊管胆管探查13例。将80例胆总管一期缝合术后胆漏病人依引流方式的不同分成A、B两组,A组19例,分别于温氏孔、胆囊窝处放置14F脑室引流管,B组61例,只于温氏孔常规放置一根橡皮引流管,对比两组置管时间、引流效果、术后并发症发生情况。结果腹腔镜胆管探查T管引流术后出现胆漏与T管护理、宣教有关,一期缝合术后胆漏较T管引流术后胆漏发生率高,但呈逐年下降趋势。A、B两组病例置管时间分别为(7.1±1.4)d、(6.9±1.5)d,两组差异无统计学意义;但在术后引流效果上,A组19例全部引流通畅,B组出现5例引流不畅,差异有统计学意义;A组无术后胆漏相关并发症。结论腹腔镜胆管探查术后胆漏是无法避免的,充分、有效的引流预防措施能保证腹腔镜胆管探查的安全、有效,发挥其微创优势。
Objective To explore the management of bile leak after laparoscopic common bile duct exploration.Methods The clinical data of 536 patients undergoing laparoscopic common bile duct exploration because of cholelithiasis in recent five years were collected and analyzed.264 cases underwent primary closure,259 cases underwent T tube drainage,and 13 cases underwent transcystic choledochotomy respectively.Eighty cases of bile leak after primary closure were divided into two groups according to different ways of drainage.The indwelling time,the effects of drainage,and postoperative complications were compared between the two groups.Results Bile leak in patients undergoing T tube drainage after common bile duct exploration was associated with T tube nursing and education.The incidence of bile leak was higher in primary closure group than in T tube drainage group,but it descended year by year.The indwelling time in group A and group B was(7.1±1.4)and(6.9±1.5)days respectively,with no significant difference.There was significant difference in terms of drainage effect after surgery between the two groups.There was no postoperative complication related to bile leak in group A.Conclusions Postoperative bile leak was inevitable in patients undergoing laparoscopic common bile duct exploration.Adequate and effective drainage can be precaution measure to guarantee the safety and effectiveness of laparoscopic common bile duct exploration and exert its minimally invasive advantages.
Objective To explore the management of bile leak after laparoscopic common bile duct exploration.Methods The clinical data of 536 patients undergoing laparoscopic common bile duct exploration because of cholelithiasis in recent five years were collected and analyzed.264 cases underwent primary closure,259 cases underwent T tube drainage,and 13 cases underwent transcystic choledochotomy respectively.Eighty cases of bile leak after primary closure were divided into two groups according to different ways of drainage.The indwelling time,the effects of drainage,and postoperative complications were compared between the two groups.Results Bile leak in patients undergoing T tube drainage after common bile duct exploration was associated with T tube nursing and education.The incidence of bile leak was higher in primary closure group than in T tube drainage group,but it descended year by year.The indwelling time in group A and group B was(7.1±1.4)and(6.9±1.5)days respectively,with no significant difference.There was significant difference in terms of drainage effect after surgery between the two groups.There was no postoperative complication related to bile leak in group A.Conclusions Postoperative bile leak was inevitable in patients undergoing laparoscopic common bile duct exploration.Adequate and effective drainage can be precaution measure to guarantee the safety and effectiveness of laparoscopic common bile duct exploration and exert its minimally invasive advantages.
引文
1王行雁,徐智,王立新,等.胆囊结石合并胆总管结石的外科微创治疗.中国微创外科杂志,2012,12:515-517.
2朱振新,杨志奇,胡涛,等.腹腔镜胆管探查术在老年胆石症中的应用.腹部外科,2010,23:24-25.
3 Zhang K,Zhan F,Zhang Y,et al.Primary closure following laparoscopic common bile duct re-exploration for the patients who underwent prior biliary operation.Indian J Surg,2016,78:364-370.DOI:10.1007/s12262-016-1482-1.
4 Cai JS,Qiang S,Bao-Bing Y.Advances of recurrent risk factors and management of choledocholithiasis.Scand J Gastroenterol,2017,52:34-43.DOI:10.1080/00365521.2016.1224382.
5 Lee HM,Min SK,Lee HK.Long-term results of laparoscopic common bile duct exploration by choledochotomy for choledocholithiasis:15-year experience from a single center.Ann Surg Treat Res,2014,86:1-6.DOI:10.4174/astr.2014.86.1.1.
6 Pu Q,Zhang C,Ren R,et al.Choledochoscopic lithotripsy is a useful adjunct to laparoscopic common bile duct exploration for hepatolithiasis:a cohort study.Am J Surg,2016,211:1058-1063.DOI:10.1016/j.amjsurg.2014.01.012.
7 Hu MG,Zhao GD,Ouyang CG,et al.Lithotomy using cholangioscopy via the left hepatic duct orifice versus the common bile duct in laparoscopic treatment of left-sided hepatolithiasis:a comparative study.J Laparoendosc Adv Surg Tech A,2013,23:332-338.DOI:10.1089/lap.2012.0397.
8 Wang Y,Bo X,Wang Y,et al.Laparoscopic surgery for choledocholithiasis concomitant with calculus of the left intrahepatic duct or abdominal adhesions.Surg Endosc,2017,31:4780-4789.DOI:10.1007/s00464-017-5555-4.
9杨志奇,朱振新,胡涛,等.经腹腔镜胆道镜胆总管探查及取石术的临床应用.腹部外科,2006,19:18-19.
10秦鸣放,赵宏志.肝内外胆管结石的微创治疗.腹腔镜外科杂志,2012,17:166-168.
11陈斌,秦仁义,胡明彦,等.腹腔镜胆总管探查胆管一期缝合术(附35例报告).中国普通外科杂志,2002,10:581-583.
12 Decker G,Borie F,Millat B,et al.One hundred laparoscopic choledochotomies with primary closure of the common bile duct.Surg Endosc,2003,17:12-18.
13 Yi HJ,Hong G,Min SK,et al.Long-term outcome of primary closure after laparoscopic common bile duct explorationcombined with choledochoscopy.Surg Laparosc Endosc Percutan Tech,2015,25:250-253.DOI:10.1097/SLE.0000000000000151.
14 Hua J,Lin S,Qian D,et al.Primary closure and rate of bile leak following laparoscopic common bile duct exploration via choledochotomy.Dig Surg,2015,32:1-8.DOI:10.1159/000368326.
15 Fernandez LC,Toriz A,Hernandez J,et al.Knotless choledochorraphy with barbed suture,safe and feasible.Surg Endosc,2016,30:3630-3635.DOI:10.1007/s00464-015-4620-0.
2朱振新,杨志奇,胡涛,等.腹腔镜胆管探查术在老年胆石症中的应用.腹部外科,2010,23:24-25.
3 Zhang K,Zhan F,Zhang Y,et al.Primary closure following laparoscopic common bile duct re-exploration for the patients who underwent prior biliary operation.Indian J Surg,2016,78:364-370.DOI:10.1007/s12262-016-1482-1.
4 Cai JS,Qiang S,Bao-Bing Y.Advances of recurrent risk factors and management of choledocholithiasis.Scand J Gastroenterol,2017,52:34-43.DOI:10.1080/00365521.2016.1224382.
5 Lee HM,Min SK,Lee HK.Long-term results of laparoscopic common bile duct exploration by choledochotomy for choledocholithiasis:15-year experience from a single center.Ann Surg Treat Res,2014,86:1-6.DOI:10.4174/astr.2014.86.1.1.
6 Pu Q,Zhang C,Ren R,et al.Choledochoscopic lithotripsy is a useful adjunct to laparoscopic common bile duct exploration for hepatolithiasis:a cohort study.Am J Surg,2016,211:1058-1063.DOI:10.1016/j.amjsurg.2014.01.012.
7 Hu MG,Zhao GD,Ouyang CG,et al.Lithotomy using cholangioscopy via the left hepatic duct orifice versus the common bile duct in laparoscopic treatment of left-sided hepatolithiasis:a comparative study.J Laparoendosc Adv Surg Tech A,2013,23:332-338.DOI:10.1089/lap.2012.0397.
8 Wang Y,Bo X,Wang Y,et al.Laparoscopic surgery for choledocholithiasis concomitant with calculus of the left intrahepatic duct or abdominal adhesions.Surg Endosc,2017,31:4780-4789.DOI:10.1007/s00464-017-5555-4.
9杨志奇,朱振新,胡涛,等.经腹腔镜胆道镜胆总管探查及取石术的临床应用.腹部外科,2006,19:18-19.
10秦鸣放,赵宏志.肝内外胆管结石的微创治疗.腹腔镜外科杂志,2012,17:166-168.
11陈斌,秦仁义,胡明彦,等.腹腔镜胆总管探查胆管一期缝合术(附35例报告).中国普通外科杂志,2002,10:581-583.
12 Decker G,Borie F,Millat B,et al.One hundred laparoscopic choledochotomies with primary closure of the common bile duct.Surg Endosc,2003,17:12-18.
13 Yi HJ,Hong G,Min SK,et al.Long-term outcome of primary closure after laparoscopic common bile duct explorationcombined with choledochoscopy.Surg Laparosc Endosc Percutan Tech,2015,25:250-253.DOI:10.1097/SLE.0000000000000151.
14 Hua J,Lin S,Qian D,et al.Primary closure and rate of bile leak following laparoscopic common bile duct exploration via choledochotomy.Dig Surg,2015,32:1-8.DOI:10.1159/000368326.
15 Fernandez LC,Toriz A,Hernandez J,et al.Knotless choledochorraphy with barbed suture,safe and feasible.Surg Endosc,2016,30:3630-3635.DOI:10.1007/s00464-015-4620-0.