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.
摘要:目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy, LC)后发生严重并发症的原因、治疗措施和经验教训。方法:分析 2007 年 8 月至2009 年 4月期间华西医院胆道外科收治的LC术后发生严重并发症的7例患者的临床资料。结果:2例继发性胆总管结石合并化脓性胆管炎患者,采用内镜下十二指肠乳头切开(endoscopic sphincterotomy, EST)取出结石;3例胆道损伤患者,均进行肝门胆管成形和肝总管空肠吻合术;1例绞窄性肠梗阻患者,切除坏死空肠管后,行空肠对端吻合术;以上6例患者均顺利出院,随访8～20个月,均生活良好。1例患者LC术后发生肺动脉栓塞,积极抢救后因呼吸衰竭而死亡。结论:术中仔细轻柔的操作以及辩清肝总管、胆总管与胆囊管的三者关系是预防LC术后发生严重并发症的关键。合理可行的治疗措施是提高发生并发症的患者生活质量的保障。LC术时,胆道外科医生思想上要高度重视,不可盲目追求速度,必要时及时中转开腹。Abstract: Objective: To investigate the causes and therapeutic measures and the experience and lesson of sever complications after laparoscopic cholecystectomy (LC). Methods:Clinical data of 7 patients with severe complications after LC from August 2007 to April 2009 were analyzed retrospectively. The clinical data was got from biliary department of West China Hospital. Results: Two cases of secondary common bile duct stone with acute suppurative cholangitis got cured by endoscopic sphincterotomy. Three cases of severe bile duct injury after LC had stricture of the hilar bile duct, and all of the cases were performed RouxenY hepaticojejunostomy with the diameter of stoma 2.03.0 centimeters. One case of strangulating intestinal obstruction was cured through jejunum endtoend anastomosis after cutting off the necrotic jejunum. All of the above 6 patients recovered well. Following up for 820 months, all lived well. One patient got pulmonary embolism after LC and dead of respiratory failure after active rescue. Conclusion: Carefully making operation and distinguishing the relationship of hepatic bile duct and common bile duct and the duct of gallbladder are the key points to prevent sever complications during LC. Reasonable and feasible treatment is the ensurement of increasing the living quality of the patients with sever complications after LC. And the surgeons of biliary department must have a correct attitude toward LC and should concern think highly during LC and should not pursue speed blindly. In necessary, the operation of LC should be turned into open cholecystectomy.
ObjectiveTo explore the cause, clinical diagnosis and treatment, and prevention strategies of iatrogenic bile duct injury (IBDI). MethodsBy means of literature retrieval, the clinical diagnosis and treatment measures of patients with IBDI were summarized. ResultsThe related risk factors of IBDI include man-made factors, the local anatomy variation factors, and pathological factors. According to the damage diagnosis time and local pathological state, the repair operations such as bile duct suture repair, biliary tract end to end anastomosis, bile duct jejunum Roux-en-Y anastomosis, bile duct jejunum Roux-en-Y anastomosis, and jejunal artificial valve forming, or liver resection, and liver transplantation were performed. Moreover, it was also available that biliary stent or papillary balloon dilation through ERCP for the bile duct distal stricture. ConclusionsIt is important that prevention of IBDI. Operation should pay attention to upper abdominal operation prior to the implementation of the correct understanding of IBDI. In case of IBDI, the reasonable repair operation mode should be choose according to the damage types and time, and it can significantly improve the treatment effect and quality of life of patients.
Objective To summarize the classification, diagnosis, and treatment of iatrogenic bile duct injury. Method The clinical data of 27 cases of iatrogenic bile duct injuries who treated in Central Hospital of Huzhou City from 2008–2013 were retrospectively analyzed. Results The classification of 27 cases: 5 cases of type Ⅰ, 18 cases of type Ⅱ, 2 cases of type Ⅲ, 2 cases of type Ⅳ. Diagnosis: 11 cases were immediately discovered at the time of the initial operation, include 1 case of type Ⅰ, 8 cases of type Ⅱ, 1 case of type Ⅲ, 1 case of type Ⅳ; 10 cases were detected in early stage after the initial operation, include 2 cases of type Ⅰ, 7 cases of type Ⅱ, 1 case of type Ⅲ; 6 cases were detected in delayed stage after the initial operation, include 2 cases of type Ⅰ, 3 cases of type Ⅱ, 1 case of type Ⅳ. Treatment effect: 17 cases for excellent, 5 cases for good, 4 cases for bad, the well recover rate was 84.6% (22/26). One case died after operation. A total of 26 cases were followed up, 1 case was lost to follow up. During the follow-up period, bile leakage occurred in 3 cases, infection of incision occurred in 2 cases, cholangitis occurred in 3 cases, and bile duct stricture occurred in 2 cases. Conclusions The best time of repairing for the iatrogenic bile duct injuries is at the time of the initial operation or early stage. According to the type of injury and the time of the injury was diagnosed, timely and effective treatment by intervention and (or) surgery is the key.
ObjectiveTo explore technical essentials and safety of laparoscopic cholecystectomy (LC) guided by gallbladder ampulla localization on an imaginary clock for cholecystitis.MethodsA retrospective study of 8 707 continuous patients with mild cholecystitis who underwent LC from July 1998 to February 2018 at a single institution was conducted. Among them, 3 168 patients were treated by the traditional LC from July 1998 to February 2007 (a traditional LC group), 5 539 patients were treated by the LC with the guidance of the gallbladder ampulla localization on an imaginary clock from March 2007 to February 2018 (a gallbladder ampulla localization group). The conversion to open surgery, bile duct injury, return to the operating room due to postoperative massive abdominal bleeding, bile leakage without bile duct injury, operative time, intraoperative blood loss, and postoperative hospital stays were compared between the traditional LC group and the gallbladder ampulla localization group.ResultsThere were no significant differences in the gender, age, course of disease, and type of cholecystitis between these two groups (P>0.050). The rates of conversion to open surgery, bile duct injury, return to the operating room due to postoperative massive abdominal bleeding, bile leakage without bile duct injury and the operative time, intraoperative blood loss and postoperative hospital stays in the traditional LC group were 3.00% (95/3 168), 0.13% (4/3 168), 0.09% (3/3 168), 0.03% (1/3 168), (43.6±12.6) min, (18.7±3.3) mL, (3.6±2.7) d, respectively, which in the gallbladder ampulla localization group were 0 (0/5 539), 0 (0/5 539), 0 (0/5 539), 0 (0/5 539), (32.2±10.5) min, (12.4±3.5) mL, (3.5±2.8) d, respectively. The differences of conversion to open surgery, bile duct injury, return to the operating room due to postoperative massive abdominal bleeding rates, and the operative time and intraoperative blood loss were statistically significant between these two groups (P<0.050). The differences of the bile leakage without bile duct injury rate and postoperative hospital stays were not statistically significant between the two groups (P>0.050).ConclusionThis study shows that gallbladder ampulla localization on an imaginary clock is useful for ductal identification so as to reduce bile duct injury and improve safety of LC in case of no conversion to open surgery.
ObjectiveTo summarize the research progress on the pathogenesis of ischemic bile duct injury after transcatheter arterial chemoembolization (TACE).MethodThe recent studies on the incidence, pathological features and related mechanisms of ischemic bile duct injury and ischemic bile duct injury after TACE were reviewed.ResultsThe incidence of ischemic bile duct injury after liver TACE fluctuated greatly and was related to different chemoembolization methods. At present, the causes of ischemic bile duct injury were attributed to the bile duct ischemia caused by embolization and the toxic effects of chemotherapeutic drugs. The destruction of protective mechanism of bile duct epithelium and the expression of transforming growth factor-β might play an important role in ischemic bile duct injury.ConclusionsAfter liver TACE, in addition to the direct injury of bile duct caused by the toxic effects of ischemia and chemotherapy drugs, the damage of bile duct epithelial protection mechanism caused by ischemia and chemotherapy drugs makes the toxic effects of bile acids play a very important role in the ischemic bile duct injury. However, there is still no direct evidence of bile duct epithelial protection mechanism in ischemic bile duct injury after liver TACE. Further clarifying the role of bile duct epithelial protection mechanism in ischemic bile duct injury after liver TACE will be helpful to explore its prevention and treatment measures, and provide new insights for the further studies in future.
ObjectiveTo summarize the research progress of tissue engineered bile duct in recent years.MethodsThis paper summarized recently-published papers related to tissue-engineered bile duct on in vitro test platform, scaffold materials, acquisition methods of seed cells, and in vivo repair effectiveness after the fusion of seed cells and materials, in an attempt to review the basic and clinical application studies of tissue-engineered bile duct.ResultsTissue-engineered bile duct had been developing rapidly. At present, great progress had been made in the fields of in vitro test platform, scaffold materials, seed cells, and repair effectiveness in animal models. However, further study was still needed in terms of its clinical application. The external bile duct platform included 3D printing and biological simulation; in the aspect of scaffold material, apart from the progress of various artificial materials, acellular matrix was introduced; the selection of seed cells included the induction and differentiation of bile duct-derived stem cells, human bone marrow mesenchymal stem cells (hMSCs), hepatic oval cell (HOC), pluripotent stem cells (PSCs), and other stem cells; animal models of tissue-engineered bile ducts had also achieved good results in animals such as pigs and dogs.ConclusionThe development of tissue-engineered bile duct will promote the progress of fundamental in vitro studies on extrahepatic biliary tract diseases, thus introducing new options to the clinical treatment of extrahepatic biliary tract injuries.
ObjectiveTo investigate the clinical value of laparoscopic cholecystectomy following “A-B-D” approach applied in the operation of acute suppurative or gangrenous cholecystitis.MethodsWe sought out 45 patients diagnosed as acute suppurative or gangrenous cholecystitis and treated by laparoscopic cholecystectomy following the “A-B-D” approach in People’s Hospital of Leshan from Sep. 2019 to Dec. 2020 as the observation group (ABD observation group), and sought out 50 patients with the same diseases but treated by conventional laparoscopic cholecystectomy from Jun. 2018 to Aug. 2019 as the matched group (conventional matched group). We analyzed and compared the parameters related to safety and efficacy of the two groups retrospectively.ResultsA total of 95 patients were included, including 45 patients in the ABD observation group (26 cases of acute suppurative cholecystitis, 19 cases of acute gangrenous cholecystitis) and 50 patients in the conventional matched group (24 cases of acute suppurative cholecystitis, 26 cases of acute gangrenous cholecystitis). There were no significant differences in age, gender, body mass index, disease composition, gallbladder condition, and preoperative complications between the two groups (P>0.05). There was no bile duct injury case in the ABD observation group (0), while there were 4 cases (8.0%) in the conventional matched group, but the statistical results showed no statistical significance between the two groups (P=0.054). One case (2.2%) in the ABD observation group converted to laparotomy, which was significantly lower than the 10 cases (20.0%) in the conventional matched group, and the difference was statistically significant (P=0.017). In addition, there were no significant differences for other parameters including operative time, postoperative hospital stay, incidences of intraoperative bleeding and postoperative bleeding between the two groups (P>0.05).ConclusionsThe laparoscopic cholecystectomy following the “A-B-D” approach can help distinguish the anatomical structure of cystic duct and extrahepatic bile duct clearly, and it can help prevent biliary tract injury effectively and reduce the probability of conversion to laparotomy. It is worthy of clinical application and promotion, especially in the majority of county hospitals.