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Experience of Diagnosis and Treatment for Iatrogenic Bile Duct Injury During Cholecystectomy in 17 Cases

目的总结胆囊切除术致医源性胆管损伤的原因、诊断、治疗及预防的经验。方法回顾性分析昆明市第一人民医院2006年5月至2011年5月期间经治的17例胆囊切除术致医源性胆管损伤患者的临床资料。结果损伤部位包括隆突2例，肝总管3例，胆囊管汇入胆总管部7例，胆总管4例，副肝管1例。1例一期术中端端吻合，2例一期吻合并留置T管支撑，1例行胆囊管结扎，2例内镜下留置鼻胆管引流，4例术后内镜下留置胆管支架，6例术后行胆肠Roux-en-Y吻合，1例行脱细胞基质材料修补。随访0.3～5年，平均2.3年，效果良好16例，1例反复发生胆管炎。结论医源性胆管损伤重在预防，精细解剖胆囊三角、严格遵循“确认-剪断-确认”三步骤是防止医源性胆管损伤的关键; 及时发现和正确的处理方法是降低其死亡率及改善预后的关键。

Early Diagnosis and Treatment of Iatrogenic Injury in Distal Part of Common Bile Duct

Objective To explore the measures for early diagnosis and treatment of iatrogenic injury in the distal part of common bile duct. Methods The clinical data of 20 patients with iatrogenic injury in the distal part of common bile duct treated in our hospital from 1990 to 2008 were analyzed retrospectively. Results The injuries of 15 cases were found during the operation: 11 cases were treated with 3-stoma (bile duct, pancreas, duodenum)+Oddi sphinctreoplasty (OSP), 1 case with OSP+choledochojejunostomy, 2 cases with the perforated common bile duct suture repair+T tube drainage, 1 case with T tube drainage; All of them were cured after surgery. The other 5 cases were not found during the primary operation, 2 cases in which were cured with several operations, the other 3 were dead from infectious shock. Conclusions Early diagnosis and treatment of iatrogenic injury in the distal part of common bite duct can obtain perfect effects. Different procedures should be performed according to different degrees of the injury. The perfect preoperative imaging examination and intraoperative choledochoscopy before bile duct exploration may reduce the occurrence of the injury.

Analysis of Iatrogenic Injury to Bile Duct （ Report of 25 Cases)

目的 探讨医源性胆管损伤的原因、诊治及预防。方法 回顾性分析25例医源性胆管损伤。结果 医源性胆管损伤多发生于胆囊切除术，主要原因有人为因素、胆管解剖变异、局部病理因素等。胆管一旦损伤，如果首次处理不当，则可引发一系列严重并发症。各种类型的胆管损伤应采取不同方法及早处理，对胆漏、腹腔感染较重者先行胆道及腹腔引流术，3个月后再作胆道重建或修复术，手术方法以胆管空肠RouxenY吻合术最为理想。结论 提高医生对胆管损伤的警觉性，术中细致地解剖和规范的操作，是预防医源性胆管损伤的关键。

医源性十二指肠损伤11例诊治体会

REPORT OF 31 CASES WITH IIATROGENIC CHOLANGIC INJURY

31 cases of iatrogenic cholangic injury reported. 28 cases followed from 9 months to 6 years. iatrogenic cholangic injury is not an uncommon occurence main cases are inregular procedures, and carelessness in this group, only 9 cases were found intraoperatively. The main manifestations after injury were aggravating jaundice and/or bilious peritonitis. Symptoms, signs, B-type ultrsound and sometimes ERCP were used for diagnosis. Once the injury ascertained ends are the best treatment, an alternative Roux-Y Cholangiojejunostomy was also commonly used. In this group, 4 cases received the first methos and all with good results; 23 patients treated by the second methos, 17 were uneventful, 4 experienced more or less abdomenal pain, 2 suffered difinite repeated cholangitis and another 1 died.

Surgical Intervention of Iatrogenic Tracheobronchoesophageal Fistula

Abstract： Objective To investigate the cause and treatment of iatrogenic tracheobronchoesophageal fistula and provide experiences for clinic treatment. Methods Between January 1995 to December 2008, 21 patients with tracheobronchoesophageal fistula were treated in Shanghai Chest Hospital and Shanghai 6th Hospital. Among them, iatrogenic fistula happened in 12 patients including 8 males and 4 females whose age ranged from 35 to 74 years old with an average age of 47. Fistula developed 21 d to 5 years after the treatment of the primary diseases which were mainly tumors. Two of them developed tracheoesophageal fistula, 10 bronchoesophageal fistula; 6 right bronchoesophageal fistula, and 4 left bronchoesophageal fistula. Fistula excision and surgical repair of the tracheobronchoesophageal fistula were performed on 2 patients; Lung lobectomy and repair of the esophageal fistula were performed on 5 patients; Tracheal fistula repair and pneumonectomy with reconstruction of the digestive tract were done on the rest 5 patients. Results No operative death occurred. Postoperative complications in 2 cases were cured without recurrence. In the 1year followup to all the 12 patients, no recurrence of fistula occurred. Conclusion Iatrogenic tracheobronchoesophageal fistula is a complex and severe disease for which surgery is the only best treatment.

EFFECT OF IATROGENIC STAPHYLOCOCCUS EPIDERMIDIS INTERCELLAR ADHESION OPERON ON FORMATION OF BACTERIAL BIOFILM ON SURFACE OF POLYVINYL CHLORIDE

Objective The intercellular adhesion (ica) gene of Staphylococcus epidermidis (SE) is a key factor to bacterial aggregation, to analysis the genotype of iatrogenic SE and to explore the effect of iatrogenic SE ica operon on theformation of bacterial biofilm on the surface of polyvinyl chloride (PVC). Methods Fifty-six cl inical isolates of iatrogenic SEwere selected, and PCR and gene sequencing were used to detect the genes related with bacterial biofilm formation. The genes contained 16S rRNA, autolysin (atlE), fibrinogen binding protein (fbe), and icaADB. The bacteria suspension of 1 × 105 cfu/mL iatrogenic SE was prepared; according to the test results of target genes, the PVC material and the genotype of icaADB+, atlE+, fbe+ strains were co-cultivated as the ica positive group; the PVC material and the genotype of icaADB-, atlE+, fbe+ strains were co-cultivated as the ica negative group. The thickness of biofilm and bacterial community quantity unit area on PVC materials were measured by confocal laser scanning microscope, and the surface structure of biofilm formation was observed by scanning electron microscope (SEM) at 6, 12, 18, 24, and 30 hours. Results The positive rate of 16S rRNA of iatrogenic SE strains was 100% (56/56). The genotype of icaADB+, atlE+, and fbe+ strains accounted for 57.1% (32/56). The genotype of icaADB-, atlE+, and fbe+ strains accounted for 37.5% (21/56). The sequencing results showed that the product sequences of 16S rRNA, atlE, fbe, and icaADB were consistent with those in GenBank. With time, no significant bacterial biofilm formed on the surface of PVC in ica operon negative group. But in ica operon positive group, the number of bacterial community was gradually increased, and the volume of bacterial biofilms was gradually increased on the surface of PVC. At 24 hours, mature bacterial biofilm structure formed, and at 30 hours, the volume of bacterial biofilms was tending towards stabil ity. The thickness of biofilm (F=6 714.395, P=0.000) and the bacterial community quantity unit area on PVC materials (F=435.985, P=0.000) in ica operon positive groupwere significantly higher than those in ica operon negative group. Conclusion Iatrogenic SE can be divided into 2 types ofica operon negative and ica operon positive bacteria. The iatrogenic SE ica operon can strengthen bacterium biofilm formation capabil ity on PVC materials, bacterium community quantity, and thickness of biofilm, it plays an important role in bacterium biofilm formation on PVC materials.

从医源性角度探讨股骨锁定钢板断裂的原因及防治措施

目的 探讨股骨锁定钢板断裂的医源性因素及防治措施。 方法 回顾分析2007 年5 月－ 2009 年8 月收治的11 例股骨骨折内固定术后锁定钢板断裂患者临床资料。其中男7 例，女4 例；年龄22 ～ 65 岁，平均38 岁。原骨折位于股骨干5 例，股骨远端6 例。切开复位锁定钢板内固定术后2 ～ 6 个月钢板断裂；断裂原因：适应证选择不当，违反锁定钢板操作原则，术后功能锻炼及康复训练不到位，医患交流缺失。11 例均再次手术，其中股骨干骨折5 例、股骨远端骨折1 例行髓内钉固定，余5 例股骨远端骨折再次行锁定钢板固定。 结果 二次术后11 例均获随访，随访时间8 ～ 20 个月，平均12 个月。术后4 ～ 8 个月，平均6 个月，所有患者骨折均达骨性愈合。无钢板再断裂及其他相关并发症发生。术后8 个月根据美国特种外科医院（HSS）评分系统对膝关节功能评定：优7 例，良3 例，可1 例；优良率90.9%。 结论 合理选择适应证、规范手术操作、正规康复训练、加强医患交流是防治股骨骨折内固定术后锁定钢板断裂的有效措施。

医源性淋巴管漏的治疗

IATROGENIC PERIPHERAL NERVE INJURIES AND ITS REPAIR

In order to investigate the causes, diagnosis, treatment, outcome and prevention of iatrogenic nerve injury in the neck, 8 cases with iatrogenic nerve injuries were analyzed. Among them, 5 cases were accessory nerve injury, 3 cases were brachial plexus injury. All of the cases were treated by surgical methods, including neurolysis, repair by direct suture, nerve graft and transposition. After 1-3 years follow up the effect was excellent in 2 cases who were accessory nerve injury, good in 5 cases, and poor in 1 case who was brachial plexus injury. It was concluded that high responsibility of surgeons and careful manipulation during operation were the key to prevention of nerve injuries.