肝囊型包虫病术后顽固性残腔胆瘘术式探讨

摘要

目的 探讨肝囊型包虫病内囊摘除术后顽固性残腔胆瘘的治疗方法.方法 回顾性分析于2002年6月至2012年6月因肝囊型包虫术后胆瘘长期不愈就诊于新疆医科大学第一附属医院行手术治疗的31例患者.其中15例行T管引流+瘘口缝合+腹腔引流术,8例行经胆漏口置入T管+腹腔引流术,4例行半肝切除术,2例行肝叶切除+胆肠吻合术,1例行外囊剥离术,1例因腹腔感染严重行残腔脓肿清除术,半年后行半肝切除术.结果 随访1～8年,1例患者T管引流术2年后出现胆管狭窄,行胆肠吻合术治愈;1例患者T管引流术后再次出现残腔胆漏,给予充分引流后1个月后自闭;1例患者残腔脓肿清除术后再次出现残腔胆漏,经充分引流半年后行半肝切除术,术后恢复顺利;1例半肝切除术后出现创面胆漏,经充分引流后治愈;其余患者术后恢复良好.结论 (1)肝切除术及肝包虫外囊完整剥离术因完整去除残腔可彻底解决残腔顽固性胆瘘,但此类患者多为多次手术后且残腔反复继发感染而致手术难度及风险较大;(2)经胆管注射美蓝行胆管造影及减压术,探查包虫残腔壁与胆道的漏口,并进行准确的缝闭,可彻底解决术后残腔胆漏的问题,而留置减压管则对漏口的愈合、防止漏口再次裂开形成胆漏具有一定作用;(3)针对包虫残腔与主肝管相通,且瘘口周残腔壁钙化严重,于残腔胆瘘口内置入合适T管,可有效解决残腔胆瘘.%Objective To explore the efficacy of various managements of indurative biliary fistula after HCE operation.Methods 31 patients who underwent surgery for indurative biliary fistula after HCE operation in Xinjiang Medical University were studied retrospectively.Cholangiography and common bile duct exploration through a T tube were done in 15 patients,cholangiography and decompression through a T tube which led to the orifice of the fistula of the cavity in 8 patients,hepatectomy in 4 patients,lobe resection + choledochojejunostomy in 2 patients,total pericystectomy in 1 patient,and cavity abscess debridement in 1 patient for severe infection of the abdominal cavity,followed by hemihepatectomy after half a year.Result On follow-up of 1-8 years,choledochojejunostomy had to be done in 1 patient for stricture of the bile duct after T tube drainage,hepatectomy in 1 patient for bile leakage after the cavity abscess debridement operation,and bile leakage in 1 patient after hepatectomy although with drainage the patient was cured.Conclusion The results suggested that hepatectomy and total pericystectomy completely solved the problems arising from indurative biliary fistula.However,these procedures are complicated,and have higher operative risks.Cholangiography and common bile duct exploration solved the cavity-related problems.For patients with severe calcified cavities which communicated with large hepatic ducts,cholangiography and decompression through a T tube put into the orifice of the fistula of the cavity solved the indurative biliary fistula efficaciously and safely.