周程 嚴(yán)白莉 龔昭 曾志武 楊光耀 夏輝 朱鵬 蘇瑛

·論 著·(臨床實(shí)踐)

膽管損傷十二例分析

周程 嚴(yán)白莉 龔昭 曾志武 楊光耀 夏輝 朱鵬 蘇瑛

目的 膽管損傷是腹腔鏡膽囊切除術(shù)最為嚴(yán)重的并發(fā)癥。最佳的膽道修復(fù)措施仍存在爭議。本研究旨在評估在武漢市第一醫(yī)院肝膽專科其術(shù)中膽管損傷的發(fā)生、修復(fù)處理及預(yù)后情況。方法 單中心回顧性分析2012年1月至2015年12月膽道手術(shù)病例3 126例，對12例膽管損傷病例的人群分布、疾病原因、損傷類型、修復(fù)方式、中轉(zhuǎn)率、術(shù)后并發(fā)癥、預(yù)后結(jié)果、醫(yī)療糾紛等因素進(jìn)行分析。結(jié)果 在3 126例膽道手術(shù)中，膽管損傷的總體發(fā)生率為0.38%，而腹腔鏡膽囊切除術(shù)中Strasberg A型以上的損傷率僅為0.17%；依照Strasberg分類，其中A型5例(41.7%)，D型3例(25.0%)，E1型1例(8.3%)，E2型3例(25.0%)，均未合并血管損傷。12例膽管損傷主要的疾病性原因為Mirizzi綜合征(25.0%)、炎癥水腫(25.0%)、迷走膽管(25.0%)和膽囊萎縮(16.7%)。腔鏡下簡單處理(凝閉、套扎、夾閉或縫閉)6例，中轉(zhuǎn)開腹處理6例(50.0%)，其中一期縫合1例、臍靜脈修補(bǔ)1例、膽管端端吻合2例、Roux-en-Y肝管空腸吻合2例。術(shù)后并發(fā)癥3例(25.0%)，其中Dindo-Clavien分級，2級1例(膽漏)、3a級1例(膽漏并后期狹窄)，5級1例(死亡)。膽管損傷處理總體成功率為83.3%，醫(yī)療投訴糾紛率為16.7%。結(jié)論 憑借專科經(jīng)驗的累積，膽管損傷的發(fā)生率是可以控制在較低水平的。正確地辨識高危因素、膽道修復(fù)醫(yī)師的專業(yè)經(jīng)驗、合理的外科決策對于提高膽道修復(fù)的成功率、回避醫(yī)療糾紛至關(guān)重要。

膽管損傷； 腹腔鏡膽囊切除術(shù)； 膽道重建

隨著腔鏡技術(shù)的普及，腹腔鏡膽囊切除術(shù)(laparoscopic cholecystectomy,LC)已成為我國各級別醫(yī)療機(jī)構(gòu)肝膽外科的常規(guī)術(shù)式[1]。然而，LC技術(shù)的大規(guī)模應(yīng)用卻伴隨著膽管損傷(bile duct injuries,BDI)并發(fā)癥的升高[2]，其發(fā)生率已由開腹膽囊切除(open cholecystectomy,OC)時期的0.1%～0.2%，上升至0.4%～0.6%[3]。正確地認(rèn)識和處理術(shù)中BDI，是一種外科挑戰(zhàn)，通常需要經(jīng)驗豐富的肝膽外科醫(yī)生參與其中[4-5]，因此專科醫(yī)生的例數(shù)積累及處理經(jīng)驗顯得尤為重要。本研究旨在通過回顧性研究，分析武漢市第一醫(yī)院肝膽外科BDI的發(fā)生、處理及預(yù)后的相關(guān)情況。

資料與方法

本研究為單中心的回顧性資料分析，檢索并整理武漢市第一醫(yī)院肝膽外科2012年1月至2015年12月期間，包括平診及非平診手術(shù)在內(nèi)的，所有LC、開腹膽總管探查(open common bile duct exploration,OCBDE)以及腔鏡膽總管探查(laparoscopic common bile duct exploration,LCBDE)手術(shù)病例。平診手術(shù)定義為病人入院完善相關(guān)檢查后直接接受手術(shù)病例，非平診手術(shù)為入院后因存在膽道癥狀、膽道炎癥等原因需行相應(yīng)保守治療，并在該次住院期間完成手術(shù)者。

回顧3年資料，共計3 126例膽道手術(shù)病人納入分析，其中LC 2 968例(94.9%)，OC+OCBDE 95例(3.0%)，LC+LCBDE 63例(2.0%)。平診入院手術(shù)者2 253例(72.1%)，非平診手術(shù)即急診入院經(jīng)保守治療后于同次住院期間實(shí)施手術(shù)者873例(27.9%)。女性2 464例(78.8%)，男性662例(21.2%)；高年資醫(yī)師主刀1 211例(38.7%)，低年資醫(yī)師主刀1 915(61.3%)。12例病人均于術(shù)中診斷發(fā)現(xiàn)膽管損傷。采用Strasberg分型法及Stewart-Way分型法[6]，評估膽管損傷的類型。該分型法與國內(nèi)常用的Bismuth分型法不同，其中Strasberg A～D型未被納入Bismuth評價體系中，而Strasberg E1～E5型則分別對應(yīng)Bismuth 1～5型。以改良Dindo-Clavien分類法[7]評估術(shù)中膽管修復(fù)后并發(fā)癥的嚴(yán)重程度。

腔鏡手術(shù)操作均為常規(guī)LC技巧，病人平臥左傾、頭高足低位，術(shù)者立于病人左側(cè)。LCBDE為4孔法、LC則根據(jù)困難程度采用3孔或4孔。術(shù)中膽管損傷的診斷均基于視檢判斷，而未采用選擇或常規(guī)性術(shù)中造影。針對Strasburg A型損傷，我們僅在腔鏡下進(jìn)行簡單修復(fù)，如肝床毛細(xì)膽管漏，通常予以凝閉、縫閉或吸收夾夾閉，對于膽囊管漏則以圈套扎向膽囊管近端游離后結(jié)扎緊固，有時也予以鏡下縫閉。一旦術(shù)中發(fā)現(xiàn)除Strasburg A型以外的BDI，則無論原主刀醫(yī)師年資高低，均由我科肝膽胰組醫(yī)師實(shí)施手術(shù)修復(fù)。處理原則依照我科膽管損傷修復(fù)方法(圖1)實(shí)施，其中主要涉及因素包括受損類型、熱損傷病灶、膽管缺如長度。單純的鏡下或開腹縫合修復(fù)僅用于無熱損傷的膽管側(cè)壁損傷，而存在熱損傷者或膽管缺損者則行開腹膽管修整，如修整后側(cè)壁缺損面積<50%周徑者可考慮臍靜脈修補(bǔ)(圖2)，如修整后膽管缺損的長度<2.5 cm者予以端端吻合+T管引流(圖3)，如>2.5 cm者行Roux-en-Y膽管吻合+T管引流(圖4)。

圖1 我院肝膽外科術(shù)中主膽管損傷的修復(fù)方法

一般情況下，常規(guī)膽囊切除、膽總管探查及Strasberg A型損傷病例于術(shù)后3～6個月常規(guī)復(fù)診B超檢查膽道情況。其他類型BDI病例(包括：Strasberg D型、E1型、E2型)，則于術(shù)后1、3、6、9、12個月，門診或住院復(fù)查了解膽道情況。

對膽管損傷者的人群分布、疾病原因、手術(shù)時機(jī)、手術(shù)類型、損傷類別、致傷機(jī)制、原主刀醫(yī)師、修復(fù)方式、中轉(zhuǎn)率、手術(shù)時間、術(shù)后并發(fā)癥、住院時間、預(yù)后結(jié)果、醫(yī)療投訴等均予以記錄分析。采用SPSS(20.0版)統(tǒng)計軟件進(jìn)行分析，對計數(shù)資料以交叉表行卡方檢驗，P<0.05為差異有統(tǒng)計學(xué)意義。

結(jié) 果

一、12例膽管損傷基本情況

1.一般資料 術(shù)中診斷膽管損傷12例，男性4例，女性8例；年齡28～81歲，平均為52.6歲；體質(zhì)量指數(shù)為21.4～33.6 kg/m2，平均為28.2 kg/m2。人口資料分布顯示，男性發(fā)生率為0.6%(4/662)，女性發(fā)生率為0.3%(8/2 464)兩者間差異無統(tǒng)計學(xué)意義(χ2=1.064，P=0.302)。手術(shù)時間68～447 min，平均188.2 min。

2.膽管損傷疾病性原因 Mirizzi綜合征占25.0%(3/12)，其中1型Mirizzi綜合征1例(8.3%)，2型Mirizzi綜合征2例(16.7%)；膽囊炎性水腫占25.0%(3/12)；迷走膽管亦占25.0%(3/12)，但其僅導(dǎo)致Strasberg A型損傷；膽囊萎縮占16.7%(2/12)；意外膽囊癌占8.3%(1/12)。

3.平診手術(shù)與否 膽管損傷平診手術(shù)占0.35%(8/2 253)，非平診手術(shù)占0.46%(4/873)，兩者差異無統(tǒng)計學(xué)意義(χ2=0.174，P=0.677)。

4.原術(shù)式 10例膽管損傷繼發(fā)于LC(0.34%，10/2 968)，2例繼發(fā)于LC+LCBDE(3.17%，2/63)，而OCBDE病例中無膽管損傷發(fā)生(0/95)，LCBDE的膽管損傷率明顯高于LC(χ2=12.118，P<0.01)。

5.主刀醫(yī)生 高年資醫(yī)師主刀膽管損傷發(fā)生率為0.05%(6/1 211)，低年資醫(yī)師主刀膽管損傷發(fā)生率為0.03%(6/1 915)，兩者相比差異無統(tǒng)計學(xué)意義(χ2=0.644，P=0.422)。

6.Stewart-Way分型 5例因膽囊管漏或肝床小膽漏不能歸入Stewart-Way分型；Stewart-Way 3型損傷的發(fā)生率略高于2型，分別為33.3%(4/12)和25.0%(3/12)，均未合并右肝動脈損傷。

7.醫(yī)療投訴 膽道術(shù)后導(dǎo)致相關(guān)醫(yī)療投訴2例(16.7%，2/12)，而非膽管損傷醫(yī)療投訴事件發(fā)生率僅為0.5%(16/3 114)，兩者相比差異有統(tǒng)計學(xué)意義(χ2=54.48，P<0.01)。

二、12例膽管損傷具體情況

Strasberg A型損傷5例(41.7%)，其中肝床小膽漏3例(25.0%)、膽囊管漏2例(16.7%)；D型3例(25.0%)，包括膽總管面狀缺損1例(8.3%)，膽總管側(cè)壁損傷2例(16.7%)；E1型1例(8.3%)為膽總管橫斷損傷；E2型3例(25.0%)，其中肝總管橫斷1例(8.3%)、膽總管缺損2例(16.7%)。針對膽管損傷的修復(fù)，腔鏡下處理6例(50.0%)，其中5例為A型損傷、1例為D型損傷，而中轉(zhuǎn)開腹6例(50.0%)均為非A型損傷，因此，除A型以外的膽管損傷中轉(zhuǎn)處理率為85.7%(6/7)；術(shù)中證實(shí)膽管熱灼傷4例(33.3%)，經(jīng)開腹膽管修整后缺損>2.5 cm者2例(16.7%)?？傮w術(shù)后并發(fā)癥率為25.0%(3/12)，按Dindo-Clavien外科并發(fā)癥分級標(biāo)準(zhǔn)，2級膽漏1例，予以胃腸減壓、抑酶、腸外營養(yǎng)支持治療；3a級膽漏并后期狹窄1例(圖5)，予以內(nèi)鏡下擴(kuò)張及膽道支架處理；5級1例，因腹腔內(nèi)感染、高齡、多器官功能衰竭死亡。平均住院天數(shù)為17.5 d。膽管損傷處理成功率為83.3%(10/12)(表1)。

討 論

Pekolj等[8]回顧分析了10 123例膽囊切除術(shù)病例，其中BDI的發(fā)生率為0.18%。同樣Hamad等[9]的數(shù)據(jù)也為0.18%。而本組BDI的發(fā)生率為0.38%，略高于上述報道。嚴(yán)格意義上說，如膽囊管漏、肝床小膽漏等Strasberg A型損傷亦屬于膽管損傷，只是對病人生理功能影響較輕，未被列入Bismuth分型，往往未被其他筆者統(tǒng)計為BDI，而我們將Strasberg A型的膽管損傷也納入其中，這可能是本組病例BDI數(shù)據(jù)偏高的原因。除去Strasberg A型損傷，本組BDI發(fā)生率為0.22%，與上述報道接近。我們在回顧資料時，還集合了腔鏡膽總管探查63例，如除去因LCBDE導(dǎo)致的BDI病人2例，我科實(shí)際LC術(shù)后的BDI率僅為0.17%。這一數(shù)據(jù)結(jié)果提示，在肝膽外科的專科中心，憑借專科化膽道外科技術(shù)的精細(xì)操作，可以將膽管損傷的發(fā)生概率控制在極低水平。

圖2 臍靜脈帶蒂修補(bǔ)膽管面狀缺損 圖3 膽管端端吻合,內(nèi)襯支架 圖4 Roun-en-Y肝管空腸吻合 圖5 術(shù)后3個月隨訪復(fù)查MRCP提示膽管狹窄,黃色箭頭所示部位為膽總管狹窄處

表1 12例膽管損傷病人手術(shù)資料與整體預(yù)后情況分析

自1956年始，Hepp等[18]的肝管空腸吻合一直是膽道重建的金標(biāo)準(zhǔn)。原因在于，大部分BDI涉及到橫斷和切除部分膽管，導(dǎo)致端端吻合無法實(shí)施[19]。然而Iannelli等[20]的數(shù)據(jù)顯示：術(shù)中一期行Roux-en-Y肝管空腸吻合修復(fù)重建，將導(dǎo)致術(shù)后高達(dá)62.9%的再修正手術(shù)率。同樣有觀點(diǎn)認(rèn)為[21]，一期膽腸吻合的成功率實(shí)際上低于二期膽管端端重建。在Pekolj等[8]的膽管修復(fù)處理算法中，將膽道熱損傷作為膽腸吻合與膽管端端重建的分水嶺。不可否認(rèn)，熱損傷的膽管經(jīng)切除修整后往往形成長段的缺如，過長的膽管缺損會導(dǎo)致膽管吻合口的高張力，是導(dǎo)致重建失敗、術(shù)后膽漏的直接原因。我們的經(jīng)驗是，通過游離鐮狀韌帶、并以Kocher切口松解十二指腸可以很好地提高殘余膽管間的對合性，以達(dá)到無張力(tension-free)的吻合要求。因此我們將膽管缺如<2.5 cm者，列入一期膽管端端吻合算法之中。膽管端端吻合的優(yōu)勢在于保留了膽管的生理結(jié)構(gòu)，但隨訪發(fā)現(xiàn)50.0%的病例可能因狹窄而需要后期干預(yù)[22]，因此術(shù)中保留T管支撐及術(shù)后內(nèi)鏡介入成為了不可或缺的組成部分。本研究中膽管端端吻合1例，術(shù)后半年出現(xiàn)膽管狹窄表現(xiàn)，予以內(nèi)鏡支架處理后緩解，現(xiàn)仍在隨訪中，擬適時撤除支架并決定是否進(jìn)一步手術(shù)修復(fù)。

膽管損傷所致的醫(yī)療投訴糾紛比率顯著高于非損傷案例(16.7%比0.51%，P<0.01)。來自Perera等[23]和Melton等[24]的數(shù)據(jù)顯示，BDI相關(guān)訴訟率接近1/3，且病人心理創(chuàng)傷比例高達(dá)75%，尤以年輕病人或修復(fù)醫(yī)生經(jīng)驗不足者訴訟率高。近年來，隨著腔鏡膽囊手術(shù)普及、量的遞增，導(dǎo)致病人對其風(fēng)險意識不足，知情不充分[25]，非預(yù)期的長期T管留置、膽腸吻合術(shù)后逆行感染、遠(yuǎn)期膽管狹窄所造成的額外醫(yī)療費(fèi)用及心理負(fù)擔(dān)，均是導(dǎo)致醫(yī)療糾紛的原因。非肝膽?？频囊话阃饪漆t(yī)師在修復(fù)復(fù)雜的膽管損傷時往往專業(yè)技術(shù)和經(jīng)驗略顯不足，而這類損傷以及損傷修復(fù)的失敗，將給病人帶來永久的痛苦。因此，在各級醫(yī)院，均應(yīng)強(qiáng)調(diào)膽囊切除術(shù)的謹(jǐn)慎實(shí)施和精細(xì)操作；一旦發(fā)生該類損傷，應(yīng)將病人送至有條件的?？浦行?，由具有豐富的肝膽外科專業(yè)技術(shù)操作經(jīng)驗的?？漆t(yī)師實(shí)施膽管損傷修復(fù)。

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Retrospective analysis of 12 cases of bile duct injury

ZhouCheng*,YanBaili,GongZhao,ZengZhiwu,YangGuangyao,XiaHui,ZhuPeng,SuYing.

*DepartmentofHepatobiliarySurgeny,WuhanFirstHospital,Wuhan430022,China

Correspondingauthor:GongZhao,Email:gzwolf@sina.com

Objective Bile duct injuries (BDI) remain the most serious complication of laparoscopic cholecystectomy.The best strategy for biliary repair is still controversial.This study aimed to review the status regarding to the incidence,repair approach and outcome of intraoperative BDI at a high volume hepatobiliary surgery institute.Methods 3 126 cases of biliary surgery date in the single-institute were collected and studied retrospectively.In 12 cases of BDI,the parameters such as demography,pathologic reason,types of injury,repair approach,conversion rate,postoperative complication,outcome and medical litigations were analyzed.Results In 3 126 cases of biliary surgery,the total BDI incidence was 0.38%,but concerns about the injuries more than Strasberg A type during laparoscopic cholecystectomy were only 0.17% in our institute.Based on Strasberg Classification System,there were 5 cases for type A (41.7%),3 cases for type B (25.0%),1 case for type E1 (8.3%) and 3 cases of type E2 (25.0%),without concurrent vascular injury.In all of 12 BDI cases,Mirizzi syndrome (25.0%),inflammation edema (25.0%),Luschka duct (25.0%) and scleroatrophic gallbladder (16.7%) were the leading pathologic reasons.Simple laparoscopic management (including cautery,ligation,clip or suture) was performed on 6 cases,and open solution was chosen in the rest 6 cases (50.0%),in which primary suture closure was performed on 1 case,patch with umbilical vein on 1 case,bile duct end to end anastomosis on 2 cases,and Roux-en-Y hepaticojejunostomy on 2 cases respectively.Postoperative complications were observed in 3 patients,according to the Dindo-Clavien classification,including 1 case of class 2 (bile leak),1 case of class 3a (bile leak and late constriction),and 1 case of class 5 (death).Overall success rate of BDI repair was 83.3% with 16.7% of medical litigation incidence.Conclusions With the accumulation of biliary surgical experience,it is possible to maintain the incidence of BDI at plausible low level in a hepatobilliary surgery center of tertiary referral hospital.Correct recognition of risk factors,specialty performance of HPB surgeon involved in repair procedure,and rational surgical strategy are paramount to improve the outcome and avoid medial dispute as well.

Bile duct injury; Laparoscopic cholecystectomy; Biliary reconstruction

湖北省自然科學(xué)基金(2014CFC1039)；2012年武漢市人社局回國留學(xué)人員擇優(yōu)資助項目

430022 武漢，武漢市第一醫(yī)院肝膽外科(周程、龔昭、曾志武、楊光耀、夏輝、朱鵬、蘇瑛)，疼痛科(嚴(yán)白莉)；周程、嚴(yán)白莉共同為第一作者

龔昭，Email：gzwolf@sina.com

R657.4

A

10.3969/j.issn.1003-5591.2017.03.012

.2016-09-05)