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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2021, Vol. 10 ›› Issue (05) : 470 -473. doi: 10.3877/cma.j.issn.2095-3232.2021.05.008

临床研究

腹腔镜胆囊切除术致胆道损伤的危险因素及处理
张硕1, 杨军1, 顾元龙1,†()   
  1. 1. 214041　江苏省无锡市，江南大学附属医院肝胆外科　无锡市肝胆外科研究所
  • 收稿日期:2021-06-22 出版日期:2021-08-17
  • 通信作者: 顾元龙
  • 基金资助:
    无锡市科教强卫医学工程医学重点学科(ZDXK007); 无锡市科教强卫医学工程青年人才计划(QNRC001); 无锡市卫计委转化医学项目(ZM007); 无锡市首届"双百"中青年医疗卫生拔尖人才(BJ2020045); 无锡市社会发展科技示范工程项目(N20201003); 江南大学公共卫生研究中心青年项目(JUPH201825)

Risk factors and treatments of biliary tract injury caused by laparoscopic cholecystectomy

Shuo Zhang1, Jun Yang1, Yuanlong Gu1,†()   

  1. 1. Department of Hepatobiliary Surgery of Affiliated Hospital of Jiangnan University, Wuxi Institute of Hepatobiliary Surgery, Wuxi 214041, China
  • Received:2021-06-22 Published:2021-08-17
  • Corresponding author: Yuanlong Gu
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张硕, 杨军, 顾元龙. 腹腔镜胆囊切除术致胆道损伤的危险因素及处理[J/OL]. 中华肝脏外科手术学电子杂志, 2021, 10(05): 470-473.

Shuo Zhang, Jun Yang, Yuanlong Gu. Risk factors and treatments of biliary tract injury caused by laparoscopic cholecystectomy[J/OL]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2021, 10(05): 470-473.

目的

探讨腹腔镜胆囊切除术（LC）致胆道损伤的危险因素、治疗及预后。

方法

回顾性分析2008年1月至2020年1月江南大学附属医院收治的6 830例LC患者临床资料。其中男3 063例，女3 767例；平均年龄（51±6）岁。根据患者有无胆道损伤，将患者分为胆道损伤组（17例）和对照组（6 813例）。患者均签署知情同意书，符合医学伦理学规定。分析胆道损伤的可能危险因素、治疗、预后情况。两组术前中性粒细胞/淋巴细胞比值（NLR）、C-反应蛋白（CRP）比较采用t检验；率的比较采用χ2检验。

结果

LC致胆道损伤发生率为2.49%（17/6 830）。胆道损伤组术前NLR、CRP分别为1.4±0.4、（1.8±0.6）mg/L，明显高于对照组的1.2±0.3、（1.5±0.4）mg/L（t=2.742，3.084；P<0.05）。胆囊壁明显增厚、胆道解剖变异、胆囊颈部结石嵌顿与胆道损伤有关（χ2=4.418，4.046，4.361；P<0.05）。17例胆道损伤患者中，10例为术中发现，术中及时修复处理；7例为术后发现，处理方式包括迷走胆管结扎、胆道修补、胆道端端吻合、胆肠吻合、腹腔引流，大部分患者术后恢复良好，仅1例术后急性胆管炎反复发作。

结论

术前炎症反应重、胆囊壁明显增厚、胆道解剖变异、胆囊颈部结石嵌顿是LC致胆道损伤的影响因素。临床实践中应根据危险因素进行合理预防，降低LC致胆道损伤发生率。

关键词: 胆囊切除术, 腹腔镜, 胆道损伤, 危险因素, 治疗
Objective

To investigate the risk factors, treatments and clinical prognosis of patients with biliary tract injury caused by laparoscopic cholecystectomy (LC).

Methods

Clinical data of 6 830 patients undergoing LC admitted to Affiliated Hospital of Jiangnan University from January 2008 to January 2020 were retrospectively analyzed. Among them, 3 063 patients were male and 3 767 female, aged (51±6) years on average. All patients were divided into the biliary tract injury group (n=17) and control group (n=6 813) according to whether biliary tract injury occurred. The informed consents of all patients were obtained and the local ethical committee approval was received. The potential risk factors, treatments and clinical prognosis of patients with biliary tract injury were analyzed. Preoperative neutrophil/lymphocyte ratio (NLR) and C-reactive protein (CRP) between two groups were statistically compared by t test. The rate comparison was performed by Chi-square test.

Results

The incidence of bile duct injury caused by LC was 2.49% (17/6 830). In the biliary tract injury group, preoperative NLR and CRP were 1.4±0.4 and (1.8±0.6) mg/L, which were significantly higher than 1.2±0.3 and (1.5±0.4) mg/L in the control group (t=2.742, 3.084; P<0.05). Thickening of gallbladder wall, anatomical variation of biliary tract, incarcerated gallstones at the neck of gallbladder were significantly associated with the biliary tract injury (χ2=4.418, 4.046, 4.361; P<0.05). Among 17 patients, the bile duct injury in 10 cases were found intraoperatively and were immediately repaired during operation, while 7 patients were diagnosed after operation, who were treated with ligation of vagal bile duct, biliary repair, end-to-end anastomosis of biliary tract, biliary-intestinal anastomosis and abdominal drainage. Most patients recovered well after operation, and only 1 case suffered from recurrent acute cholangitis.

Conclusions

Severe preoperative inflammatory reaction, thickening of gallbladder wall, anatomical variation of biliary tract and incarcerated gallstones at the neck of gallbladder are the risk factors for biliary tract injury caused by LC. In clinical practice, corresponding preventive measures should be delivered according to the risk factors, thereby reducing the incidence of LC-induced bile duct injury.

Key words: Cholecystectomy, laparoscopic, Biliary duct injury, Risk factors, Treatment
表1 胆道损伤组和对照组LC患者一般资料比较
组别 例数 年龄（岁，±s） 性别（例） ASA评分（例） BMI（kg/m2，±s） WBC（×109/L，±s） ALT（U/L，±s） TB（μmol/L，±s） GGT（U/L，±s）
男 女 ≤2分 >2分
胆道损伤组 17 52±17 7 10 16 1 25±5 6.9±1.8 32±12 13±5 27±21
对照组 6 813 51±6 3 063 3 767 6 587 226 25±5 6.5±2.0 28±10 12±3 23±13
统计值   t=0.681 χ2=0.092 χ2=0.284 t=0.389 t=0.607 t=1.421 t=0.459 t=0.955
P值   0.248 0.761 0.594 0.349 0.547 0.162 0.649 0.344
表2 LC致胆道损伤影响因素分析
组别 例数 NLR CRP（mg/L） 胆囊壁厚度（例） 胆道解剖变异（例） 胆囊颈部结石嵌顿（例） 术者经验（例）
<4 mm ≥4 mm 无 有 无 有 <10年 ≥10年
胆道损伤组 17 1.4±0.4 1.8±0.6 11 6 13 4 14 3 7 10
对照组 6 813 1.2±0.3 1.5±0.4 5 832 981 6 527 286 6 527 286 2 501 4 312
统计值   t=2.742 t=3.084 χ2=4.418 χ2=4.046 χ2=4.361 χ2=0.146
P值   0.003 0.010 0.036 0.044 0.037 0.703
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