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RouxenY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。
Objective To investigate the choleenterostomy type and the longterm results in treatment of benign diseases of biliary tract. MethodsA total of 614 cases of choleenterostomy from January 1981 to December 2000 were followed up and analysed. The original diseases: 321 were original hepatolithiasis and/or bileduct stricture (52.3%)， 106 congenital cyst of common bile duct (17.3%), 151 iatrogenic bile duct injury (24.6%) and others 36 cases (5.9%). Choledochoduodenostomy was performed in 89 cases and choledochojejunostomy in 525 cases. Five hundred and twentyfour cases have been followed up for 1 to 20 years. The rate of followup was 87.9%. ResultsIn 84.5% of the cases, excellent or good longterm results were achieved. Reoperation rate were 49.4% in cases of choledochoduodenostomy or cystoduodenostomy, 14.2% in sideside (cyst) cholangiojejunostomy and 4.4% in endside cholangiojejunostomy, respectively. Conclusion The choledochoduodenostomy should be abolished. The endside cholangiojejunostomy shoud be the best choice when it is needed to perform choledochojejunostomy in benign bile duct diseases and can promise a satisfactory longterm result.
Objective To evaluate the linkage between the proxmal as well as long term outcome and choice of therapeutical modality for benign hilar stricture of bile duct prospectively. Methods 25 patients have been catergorized into 4 groups according to different pathogen and the proxmal as well as long term outcome after pathogen based management have been studied prospectively. Results The hepatic portal cholangio-jejunostomy applied for iatrogenic hilar stricture of bile duct has been proved to be effective and the incidence of refulux cholangitis is only 10%(1/10). Hepatic hilar plasty procedures keep the physiological entitity of bile duct and the vital, sufficient autologous repair materials as well as reliable operation design are needed. Resection of atrophic right liver lobe bearing hepatolithiasis combined hepatic hilar plasty has reached both elimination of liver focus and maintaining the physiological entitity of bile duct. The ballon dilation for mild ring-like hilar stricture of bile duct is valide but not for hilar tubular stricture of secondary sclerosing cholangitis.Conclusion The strategy of individualized management (pathogen based management) for benign hilar stricture of bile duct has proved to be reliable and effective.
Objective To observe the effects of basic fibroblast growth factor (bFGF) on wound healing of bilioenteric anastomosis as to prevent postoperative biliary strictures. Methods A model of choledochodundenostomy in 31 dogs were constructed at first, then bFGF was administered on the local anastomosis(bFGF group) for 1 week after the operation as compared with sodium chloride solution(control group). Both groups were observed with light microscope(HE,Masson staining) and electron microscope 3 days, 1 and 3 weeks and 3 and 6 months after the operation（n＝3）. Hydroxyproline was measured at the same time. Results bFGF group healed more quickly compared with control group. Good function of cells were detected by electron microscope. Better mucosa epithelia, fibroblast,and capillary vessel proliferation were detected by histological observation in bFGF group. In bFGF group, collagen fibers were arranged orderly. Three weeks after operation, collagen fibers in control group were orderless and in whirlpool. Hydroxyproline of bFGF group was lower than that of control group(P＜0.05）.Conclusion bFGF administered in local anastomosis is an effective method to prevent postoperative anastomotic stenosis.
The secondary anastomotic stenosis is often occured from the repair and reconstructive operation of the injured bile duct. It is difficult to treat and the outcome is serious. In order to prevent this complication, the fibrin glue instead of traditional suturing technique combined with inner support was used. Fifty-four hybrid dogs were divided into 3 groups. Group A received Roux-en-y choledochojejunostomy with fibrin glue; group B received Roux-en-y choledochojejunostomy, with a fibrin glue combined support left permanently in the bile duct and group C received Roux-en-y choledocholejejunostomy with fibrin glue combined a support left temporarily in the bile duct. The amount of collagen in the scar was measured at 3/4, 3, 6, 9, 12 months respectively after operation. The results showed: 1. the mature period of scar was shortened from 12 months to 9 months when fibrin glue instead of suture was used in choledochojejunostomy; 2. the mature period of scar was further shortened from 9 months to 6 months when fibrin glue combined with inner support instead of fibrin glue was used in choledochojejunostomy. The conclusions were as follows: 1. fibrin glue could facilitate the healing of wound by inhibiting the formation of scar and accelerrate the maturation of scar; 2. when the inner support was used with fibrin glue in the operation, the mature period of scar could be further shortened; 3. the mechanism of action of the fibrin glue included minimizing the injury, avoiding foreign-body reaction, modifying organization of hematoma, preventing formation of biliary fistular and enhancing intergration and cross-linkage of collagen.
Three types of intestinal loops were used to reestablish the internal drainage of bile in 17 cases. The leeway derived from the peristaltic cycle of the intestinal loop for gastrointestinal reflux pressure, the cholangeitis after operation from reflux following choladocho-intestinal anastomosis could be avoided, and, naturally it had changed the traditional method of purèly blockade of the reflux, thus the result from treatment was far more satisfactory.
The antireflux spur-valvewas originally designed for the Roux-Y cholenterostomy. It is made by plication of the two upper limbs of the "Y" after the removal of the seromusculature from the biliary limb, so that the conjoined wall-in-between will he compassed deviating to the biliary, side to form a spur value. It could successfully stop the reflux due to normal peristalsis or intestinal distension. This value was primarily used in choledochal cyst and biliary atresia for more than 100 cases, and also applielied to many other operations for perventing reflux, including: gastroesophageal refluk-Nissen fundoplication, colon replacement of esophagus, side to side shert-circuit of intestinal obstruction, and Kock scontinent ileoslomny. The detailed procedures were described.
目的 探讨Oddi括约肌松弛症（SOR）的原因，总结其临床特点及处理经验，观察横断胆管＋胆肠Roux-en-Y吻合术治疗SOR的效果。方法 回顾性分析我院2001年1月至2011年1月期间收治的76例SOR患者的临床资料，将患者分为3组，分别采用横断胆管＋胆肠Roux-en-Y吻合术（39例）、胆道探查T管引流术（28例）及不横断胆管仅行胆肠Roux-en-Y吻合术（9例）治疗。结果 76例病例均经手术治疗，无手术死亡。手术并发症为：横断胆管＋胆肠Roux-en-Y吻合术组胆瘘1例，胸腔积液1例，切口脂肪液化2例；胆肠Roux-en-Y吻合术组胆瘘1例，胸腔积液1例，切口脂肪液化2例；胆道探查T管引流术组胸腔积液2例，切口脂肪液化1例。均经保守治疗好转。76例均获随访，随访时间3～83个月，平均45个月。因本研究是回顾性研究，考虑到胆肠Roux-en-Y吻合术组例数较少（仅9例），因此在分析其疗效时合并到胆道探查T管引流术组与横断胆管＋胆肠Roux-en-Y吻合术组进行比较。横断胆管＋胆肠Roux-en-Y吻合术组术后治愈34例，好转3例，无效2例，有效率为94.9% （37/39）；胆道探查T管引流术组和胆肠Roux-en-Y吻合术组术后治愈5例（2组分别为4例和1例），好转11例（2组分别为4例和7例），无效21例（2组分别为1例和20例），有效率为43.2% （17/37）。横断胆管＋胆肠Roux-en-Y吻合术组术后有效率明显高于胆道探查T管引流术组和胆肠Roux-en-Y吻合术组（P＜0.05）。结论 横断胆管＋胆肠Roux-en-Y吻合术是治疗SOR较有效的手术方式。
目的探讨胆管残余和复发结石的原因、特点和处理经验。方法回顾性分析128例胆管残余和复发结石再手术临床资料。 结果残余或复发结石位于肝外胆管68例，肝内胆管48例，肝内、外胆管12例。再手术行残株胆囊切除术2例（1.5%）， 胆总管探查、T管引流术64例（50.0%），肝左外叶切除或肝左叶切除术+胆总管切开取石29例（22.7%），肝右叶、段切除加胆总管切开取石6例（4.7%），同时行狭窄胆管切开整形胆管空肠吻合术13例（10.2%），单独或联合行胆管空肠Roux-en-Y吻合术14例（10.9%）。术后痊愈出院124例，自动出院2例，死亡2例。 术后出现并发症18例（14.1%），其中切口感染 10例，胸腔积液3例，胆肠瘘3例，上消化道出血2例，均经保守治疗治愈。出院的124例中117例获随访1～2年，89例（76.1%）恢复满意，18例（15.4%）恢复较好， 10例（8.5%）经B超、CT、MRCP等检查证实再次复发胆管结石，其中6例经再次手术治愈，4例经中西医结合药物治疗好转。 结论术前全面了解病情，选择合适的手术时机，术中认真仔细的探查确认，并结合术中造影、胆道镜以及术者的经验技术，术后有效的治疗，是降低残石、结石复发及再手术的关键因素。