腹腔镜胆囊切除术后迟发性迷走胆管漏的预防及处理
张成 王羊 安东均
摘 要
目的：探讨腹腔镜胆囊切除术后迟发性迷走胆管漏的诊断、治疗及经验教训。
方法：对1997年2月～2009年8月13例LC后迟发性迷走胆管漏，分别采用开腹胆总管切开、T管引流（1例），超声定位下腹腔置管引流术（2例）及超声定位下腹腔置管联合ERCP、ENBD（10例）3种方法进行治疗。
结果：13例经腹部B超及腹腔穿刺后确诊为迟发性迷走胆管漏，1例因休克急诊行开腹胆总管切开、T管引流术，2例行腹部B超定位下腹腔置管引流术，10例行腹部B超定位下腹腔置管引流、ENBD。2例选择胆囊窝积液区穿刺腹腔置管及ENBD后腹部症状及体征未完全消失，复查腹部B超仍提示腹腔积液，在超声定位下取右下腹麦氏点穿刺置管引流后胆漏停止、腹部症状及体征完全消失。1例迷走胆管漏并发休克，纠正休克后急诊行腹腔探查、胆管切开引流术，术中出现呼吸、心搏骤停，心肺复苏成功，术中经胆总管注水发现胆囊床有直径约0.2mm胆管漏胆，放置T管缝合管壁后，T管缝线针眼渗胆，术后再次出现胆漏，经充分引流等治疗32 d后痊愈。腹B超定位下腹腔置管引流术，治愈时间12～15 d，平均13.5 d。腹部B超定位下腹腔置管引流、ENBD，治愈时间2～5 d，平均2.8 d。12例随访12～24个月，平均15个月，无胆道狭窄、肠梗阻、胆管结石及其他并发症出现。
结论：采用腹部B超定位下腹穿刺置管引流联合ENBD胆管减压治疗LC后迷走胆管漏，能达到开腹手术引流胆汁、胆道减压的效果，且具有创伤小，痛苦少，恢复快及住院时间短等优点，值得推广应用。
关键词
腹腔镜胆囊切除术；迷走胆管漏
Prevention and Management of Delayed Luschka Duct Leakage after Laparoscopic Cholecystectomy
Zhang Cheng，Wang Yang，An Dongjun.Department of General Surgery，Xianyang Central Hospital，Xianyang 712000，China
ABSTRACT
Objective:To investigate the diagnosis，treatment of delayed Luschka duct leakage after laparoscopic cholecystectomy（LC），as well as the lessons we learnt from our experience.
Methods:The clinical data of 13 cases of delayed Luschka duct leakage after LC in our hospital from February 1997 to August 2009 were collected in this study.The patients received T-tube drainage（1 case），B-ultrasonography guided drainage（2 cases）or B-ultrasonography guided drainage combined with endoscopic nasobiliary drainage（ENBD，10 cases），respectively.
Results:Results The delayed Luschka duct leakage was confirmed with B-ultrasonography and abdominal paracentesis in all the 13 cases.Among them，open choledocholithotomy and T-tube drainage were performed in emergency in one patient because of shock；B-ultrasonography guided drainage via a lower abdominal tube was carried out in two cases；the other 10 patients received B-ultrasonography guided drainage combined with ENBD.After the ENBD and B-ultrasonography guided drainage，two patients still suffered from retroperitoneal symptoms，and their reexamination by B-ultrasonography showed abdominal fluid；they were then cured by B-ultrasonography guided drainage at the Mc Burney point.One patient developed shock during the operation，and thus underwent abdominal exploration choledocholithotomy and drainage in emergency after the shock was corrected；by using T-tube and suturing，however，biliary leakage occurred once again at the suture points on the T-tube after the operation.This patient was finally cured by complete drainage and conservative treatments after 32 days.The two patients who received B-ultrasonography guided drainage were cured in 12 and 15 days respectively（mean，13 days），and the10 who underwent B-ultrasonography guided drainage combined with ENBD were cured in a mean of 2.8 days（2-5 days）.Follow-up was achieved in 12 cases for 12-24 months（mean，15 months ）during which no bile duct stenosis or calculi，nor intestinal obstruction occurred.
Conclusion:B-ultrasonography guided percutaneous drainage combined with ENBD is effective，less traumatic for patients with post-LC Luschka duct leakage with less pain and quick recovery.
KEY WORDS
Laparoscopic cholecystectomy；Luschka duct leakage
在广泛开展LC的同时，随着临床经验的不断积累，术中、术后即发胆漏发生率逐渐下降，而迟发性迷走胆管漏相比之下逐渐升高，值得关注。我院1997年2月～2009年8月共行26000例LC，发生胆漏72例，其中即发性胆漏59例，迟发性迷走胆管漏13例。本文对迟发性迷走胆管漏的预防、诊断、治疗及经验教训进行探讨，现报道如下。