腹腔镜胆囊切除术致胆道损伤的危险因素及处理

doi:10.3877/cma.j.issn.2095-3232.2021.05.008

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）
组别	例数	年龄（岁，±s）	男	女	≤2分	>2分	BMI（kg/m²，±s）	WBC（×10⁹/L，±s）	ALT（U/L，±s）	TB（μmol/L，±s）	GGT（U/L，±s）
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）
组别	例数	年龄（岁，±s）	男	女	≤2分	>2分	BMI（kg/m²，±s）	WBC（×10⁹/L，±s）	ALT（U/L，±s）	TB（μmol/L，±s）	GGT（U/L，±s）
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）
组别	例数	NLR	CRP（mg/L）	<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

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）
组别	例数	NLR	CRP（mg/L）	<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

[1]	Lau KN, Sindram D, Agee N, et al. Bile duct injury after single incision laparoscopic cholecystectomy[J]. JSLS, 2010, 14(4):587-591.
[2]	Booij KA, de Reuver PR, Yap K, et al. Morbidity and mortality after minor bile duct injury following laparoscopic cholecystectomy[J]. Endoscopy, 2015, 47(1):40-46.
[3]	伍万权. 腹腔镜胆囊切除术胆道损伤相关因素分析及预防[J/OL]. 中华肝脏外科手术学电子杂志, 2019, 8(6):538-541.
[4]	Parikh SP, Szczech EC, Castillo RC, et al. Prospective analysis of laparoscopic cholecystectomies based on postgraduate resident level[J]. Surg Laparosc Endosc Percutan Tech, 2015, 25(6):487-491.
[5]	Phatak UR, Chan WM, Lew DF, et al. Is nighttime the right time? risk of complications after laparoscopic cholecystectomy at night[J]. J Am Coll Surg, 2014, 219(4):718-724.
[6]	Giger U, Ouaissi M, Schmitz SF, et al. Bile duct injury and use of cholangiography during laparoscopic cholecystectomy[J]. Br J Surg, 2011, 98(3):391-396.
[7]	Aziz H, Pandit V, Joseph B, et al. Age and obesity are independent predictors of bile duct injuries in patients undergoing laparoscopic cholecystectomy[J]. World J Surg, 2015, 39(7):1804-1808.
[8]	Greyasov VI, Chuguevsky VM, Sivokon NI, et al. Non-functioning gallbladder as a risk factor for bile ducts injury during laparoscopic cholecystectomy[J]. Khirurgiia, 2018(2):52-56.
[9]	Downing SR, Datoo G, Oyetunji TA, et al. Asian race/ethnicity asa risk factor for bile duct injury during cholecystectomy[J]. Arch Surg, 2010, 145(8):785-787.
[10]	Georgiades CP, Mavromatis TN, Kourlaba GC, et al. Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy?[J]. Surg Endosc, 2008, 22(9):1959-1964.
[11]	Morgenstern L, Wong L, Berci G. Twelve hundred open cholecystectomies before the laparoscopic era. a standard for comparison[J]. Arch Surg, 1992, 127(4):400-403.
[12]	Flum DR, Dellinger EP, Cheadle A, et al. Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy[J]. JAMA, 2003, 289(13):1639-1644.
[13]	Törnqvist B, Waage A, Zheng Z, et al. Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy,a population-based case-control study[J]. World J Surg, 2016, 40(5): 1060-1067.
[14]	Low JK, Barrow P, Owera A, et al. Timing of laparoscopic cholecystectomy for acute cholecystitis: evidence to supporta proposal for an early interval surgery[J]. Am Surg, 2007, 73(11): 1188-1192.
[15]	Zhu B, Zhang Z, Wang Y, et al. Comparison of laparoscopic cholecystectomy for acute cholecystitis within and beyond 72 h of symptom onset during emergency admissions[J]. World J Surg, 2012, 36(11):2654-2658.
[16]	Elshaer M, Gravante G, Thomas K, et al. Subtotal cholecystectomy for "difficult gallbladders": systematic review and meta-analysis[J]. JAMA Surg, 2015, 150(2):159-168.
[17]	Henneman D, da Costa DW, Vrouenraets BC, et al. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review[J]. Surg Endosc, 2013, 27(2):351-358.
[18]	De Filippo M, Calabrese M, Quinto S, et al. Congenital anomalies and variations of the bile and pancreatic ducts: magnetic resonance cholangiopancreatography findings, epidemiology and clinical significance[J]. La Radiol Med, 2008, 113(6):841-859.
[19]	Chehade M, Kakala B, Sinclair JL, et al. Intraoperative detection of aberrant biliary anatomy via intraoperative cholangiography during laparoscopic cholecystectomy[J]. ANZ J Surg, 2019, 89(7/8):889-894.
[20]	Wakabayashi G, Iwashita Y, Hibi T, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)[J]. J Hepatobiliary Pancreatic Sci, 2018, 25(1):73-86.

[1]	施娜, 邱文倩, 何丹青, 张超学, 毛萍, 杨艳婷. 瞬时弹性成像评价慢性乙型肝炎患者抗病毒治疗的效果[J]. 中华医学超声杂志（电子版）, 2022, 19(05): 428-433.
[2]	万莉, 唐芮, 操雨婷, 程晨, 林晓红, 蒋琴琴, 胡中倩, 李攀. pH响应型纳米探针用于超声/光声成像引导下的乳腺癌光热治疗[J]. 中华医学超声杂志（电子版）, 2022, 19(05): 459-466.
[3]	韦静涛, 季鑫, 季加孚. 不断提高中国胃癌外科手术治疗规范化[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 237-241.
[4]	陈凛, 鲁意迅, 张珂诚. 中国腹腔镜胃癌根治术式选择与规范化[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 242-245.
[5]	李乐平, 杨建桥, 商亮. 中国腹腔镜近远端胃癌切除精准淋巴结清扫与原则[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 246-250.
[6]	陈纲, 吕远, 李世拥. 腹腔镜胃癌根治术需关注的几个问题[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 251-254.
[7]	刘刚, 黄云, 张朝军, 张炎, 袁新普. 双通道吻合与食管-管状胃吻合在近端胃癌腹腔镜切除术消化道重建中的应用比较[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 258-262.
[8]	张吴楼, 郑立锋, 刘宏达. 腹腔镜辅助双通道消化道重建技术在近端胃切除术的临床疗效研究[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 263-266.
[9]	郑尧帆, 林方德, 史方义, 林师佈. 改良腹腔镜-内镜双镜联合手术与腹腔镜辅助内镜下切除术治疗早期胃癌的临床效果分析[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 267-270.
[10]	黄洋, 周连帮. 不同食管空肠吻合术的全腹腔镜根治性全胃切除术临床效果对比研究[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 271-274.
[11]	刘烺飚, 牛磊, 赵晓牧, 蔡军, 张忠涛. 体内W型悬吊肝左叶在腹腔镜胃手术中的应用价值[J]. 中华普外科手术学杂志(电子版), 2022, 16(03): 275-278.
[12]	谢玉莹, 德丽娜尔·乌尔肯别克, 毛新敏, 张莉. 强化心理干预护理模式对子宫内膜异位症手术患者负性情绪的改善效果研究[J]. 中华临床医师杂志(电子版), 2022, 16(05): 457-462.
[13]	李辉, 刘登湘, 李华. 腹腔镜下根治术对结直肠癌患者胃肠功能、氧化应激及免疫功能的影响[J]. 中华临床医师杂志(电子版), 2022, 16(04): 332-336.
[14]	郑朝军, 王洪年, 贾玉虎, 胡其生. 单独使用NSAIDs与联合防风汤治疗老年膝关节炎的临床疗效比较[J]. 中华临床医师杂志(电子版), 2022, 16(04): 343-348.
[15]	陈小玲, 孙乐妹, 吴纪萍, 桂翠, 莫御姬. 居家康复锻炼对乳腺癌患者术后淋巴水肿治疗的作用[J]. 中华临床医师杂志(电子版), 2022, 16(04): 362-367.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

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

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

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