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1、 作者：王坚,吴志勇,何敏,王钦尧,施维锦,陈涛 作者单位：上海交通大学医学院附属仁济医院普外科(王坚、吴志勇、何敏、施维锦、陈涛); 200062 上海中医药大学附属普陀医院普外科(王钦尧) 【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+
2、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
3、术; 控制性手术 Diagnosis and treatment of iatrogenic injury in cholodochopancreaticoduodenal junction WANG Jian, WU Zhiyong, HE Min, WANG Qinyao, SHI Weijin, CHEN Tao.Department of General Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China Corresponding auth
4、or WANG Qinyao. Department of General Surgery, Putuo Hospital, Shanghai Traditional Chinese Medicine University, Shanghai 200062, China, Email 【Abstract】 Objective To discuss the diagnosis and appropriate operation method for iatrogenic injury in cholodochopancreaticoduodenal junction. Methods The
5、clinical data of 8 patients with iatrogenic injury in cholodochopancreaticoduodenal 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
6、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 Ttube drainage of the
7、common bile duct. Five patients with cholodochopancreaticoduodenal 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, Ttube drainage of the common bi
8、le duct, abdominal drainage, jejunostomy for nutrition support and gastrostomy, the other 4 died after multiple operations because of intraabdominal infection and repeated bleeding. Conclusions If ventages are discovered during operation, prompt repair combined with Ttube drainage of the common bile
9、 duct and abdominal drainage should be performed; if not, Ttube drainage of the common bile duct and drainage in cholodochopancreaticoduodenal junction should be done. For the injury at the end of common bile duct plus Oddi sphincter stenosis or stone impaction within ampullar Vater, sphincteroplast
10、y and transampullar perforation mending combined with Ttube drainage of the common bile duct and abdominal drainage may be done; if the injury of distal common bile duct is combined with duodenal injury at the same time, the duodenal rupture should be repaired as well. For patients whose injuries in
11、 cholodochopancreaticoduodenal junction are not discovered intraoperatively and have duodenal fistula postoperatively, control operations should be done according to the systemic situation. Complete bile and pancreatic juice separation, duodenal diverticularization, thorough abdominal drainage and t
12、ransjejunal nutrition support are the key points for recovery. 【Key words】 Cholodochopancreaticoduodenal junction; Injury; Oddi sphincteroplasty; Control surgery 胆胰肠结合部解剖位置特殊，损伤后术中不易被发现。漏诊患者常表现为胆、胰、肠漏造成腹膜后及腹腔内感染，病程进展类似急性坏死性胰腺炎，再手术的时机与方法影响预后。本文通过回顾8例胆胰肠结合部损伤患者的临床资料，以提高其诊治水平。 1 资料和方法 1.1 一般资料 收集1997年6
13、月至2007年6月8例医源性胆胰肠结合部损伤患者的临床资料，其中男5例，女3例;中位年龄62岁(3985岁)。1例为院外会诊，2例为外院损伤后转入，5例为院内损伤。胆总管末端损伤5例，均为胆道探条所致;十二指肠前壁损伤3例，其中1例为探条探查所致，2例为十二指肠前壁切开处漏。 1.2 诊断方法 首次手术中发现3例，1例为探条直接从十二指肠降部与胰腺之间穿出而确诊，另2例为术中经胆道注水发现后腹膜渗水及胆道造影发现造影剂外溢入腹膜后而确诊。 术后发现的5例患者确诊时间分别为第1次术后8、15、21、30、45 d。主要表现为反复高热、腹痛、后腰部水肿等症状。CT可见胰头周围、肾周及后腹膜积液、脓
14、肿形成，腹腔引流管可见坏死物质流出，T管造影见造影剂外溢至后腹膜，伴十二指肠损伤的患者口服美蓝后从腹腔引流管中流出。 1.3 治疗方法 首次手术中发现的3例患者均行Oddi括约肌切开成形+经壶腹部直视下破口修补+胆总管T管外引流+腹腔引流术;术后发现的5例患者中，2例行单纯腹腔脓肿引流术，其余3例均经过多次手术。 行多次手术的第1例患者第1次手术因胆总管结石，行Oddi括约肌切开成形+胆总管T管外引流术，术中发现胆总管下端结石嵌顿;第2次因腹膜后脓肿，行腹腔脓肿引流术+调整引流管，术中发现右侧髂窝、肾周及后腹膜有脓液及坏死组织约600 ml;第3次因营养状况差，行胃造瘘、空肠造瘘;第4次因十二
15、指肠瘘、腹腔出血和消化道出血，行胃大部切除毕式吻合+十二指肠前壁瘘口修补+胆总管T管外引流+腹腔引流术，术中发现原十二指肠降部切开缝合处裂开2 cm，十二指肠壁与周围组织活动性出血;第5次因腹腔出血和消化道出血，行十二指肠第2段+部分第3段切除+胰管置管外引流+胆总管T管外引流+胆管远端结扎+腹腔引流术，术中发现原瘘口修补处及周围组织多处出血;第6次因胃肠吻合口漏，行腹腔冲洗引流+伤口网片覆盖术，术中发现腹腔内大量黄色黏稠脓液体，胃肠吻合口裂开。 第2例患者第1次手术因胆总管结石，行Oddi括约肌切开成形+胆总管T管外引流术，术中发现胆总管直径1.5 cm，下端一直径0.6 cm结石嵌顿;第2
16、次因腹腔脓肿，行腹腔脓肿引流+胃造瘘、空肠造瘘术，术中发现约12的胰腺组织坏死，腹腔内大量坏死组织;第3次因十二指肠瘘、胆瘘、胰周坏死，行清创术，术中发现胰周有少量坏死发黑组织，胰头下方见一直径5 cm脓腔，内见黄色脓液，未发现漏口;第4次因十二指肠瘘、出血、结肠肝曲破口，行十二指肠造瘘+末端回肠袢式造瘘+横结肠破口蕈状导尿管引流术，术中发现切口下方广泛出血，十二指肠第2、3段各一破口，结肠肝曲一破口伴出血;第5次因伤口及腹腔出血，行十二指肠造瘘口黏膜缝扎止血术，术中发现十二指肠造瘘口、结肠造瘘口大量渗血及暗红色血块，造口处黏膜外翻;第6、7次因腹腔出血，行止血术，术中发现创面广泛出血。 第3例患者第1次手术因胆总管结石，行胆总管切开取石+胆总管T管外引流术，术中发现胆总管直径1 cm，远端1枚结石嵌顿;第2次因腹膜后脓肿、
