医源性胆胰肠结合部损伤的诊治_临床医学论文.docVIP

医源性胆胰肠结合部损伤的诊治_临床医学论文 医源性胆胰肠结合部损伤的诊治_临床医学论文 作者：王坚 吴志勇 何敏 王钦尧 施维锦 陈涛 【摘要】 目的 总结医源性胆胰肠结合部损伤的经验教训，以提高其诊疗水平。方法 回顾性分析1997年6月至2007年6月收治的8例胆胰肠结合部损伤患者的诊治情况。结果 胆总管末端损伤5例，十二指肠前壁损伤/漏3例。术中发现胆总管末端损伤合并结石嵌顿3例，均行Oddi括约肌切开成形＋经壶腹部直视下穿孔修补＋胆总管T管外引流术治愈；术后发现5例，1例行十二指肠漏口修补+胃窦部可吸收线缝闭+胆总管下段可吸收线结扎+胆总管T管外引流＋腹腔引流＋空肠造瘘＋胃造瘘术治愈；其余4例多次手术，因腹腔感染及反复腹腔出血而死亡。结论 术中发现漏口的患者，可直接修补，并行胆总管T管外引流+腹腔引流术；未发现者则行胆总管T管外引流＋漏口周围引流术；胆总管末端穿通伤，合并Oddi括约肌狭窄或壶腹部结石嵌顿者，行Oddi括约肌切开，经壶腹直视下修补+胆总管T管外引流+腹腔引流术，合并十二指肠损伤，同时行十二指肠修补术；对于首次术中未发现及术后出现十二指肠漏的患者，应根据其情况行合理的控制性手术，其关键是彻底的胆胰分流、十二指肠憩室化、空肠营养性造瘘及有效的腹腔引流。 【关键词】 胆胰肠结合部； 损伤； Oddi括约肌切开成形术； 控制性手术 【Abstract】 Objective To discuss the diagnosis and appropriate operation method for iatrogenic injury in cholodochory in cholodochopancreaticoduodenal junction admitted in our department from June 1997 to June 2007 were retrospectively analyzed. Results Five patients were diagnosed injury at the end of common bile duct and the other 3 with injury or fistula in the anterior wall of duodenum. Three patients were diagnosed injury combined with stone impaction at the end of common bile duct intraoperatively and were cured after Oddi sphincteroplasty, suturing the small hole on distal common bile duct under direct view via ampullar Vater and Ttube drainage of the common bile duct. Five patients with cholodochopancreaticoduodenal junction injury were diagnosed postoperatively, only 1 survived after accepting duodenal ventage repair, pylorus closure with absorbable suture, distal common bile duct ligation with absorbable thread, Ttube drainage of the common bile duct, abdominal drainage, jejunostomy for nutrition support and gastrostomy, the other 4 died after multiple operations because of intraabdominal infection and repeated bleeding. Conclusions If ventages are discovered during operation, prompt repair combined with Ttube drainage of the common bile duct and abdominal drainage should be performed; if not, Ttube drainage of the common bile duct and drainage in cholodochopancreaticoduode