Extreme' vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders
Extreme' vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders
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DOI：
10.1111/j.1477-2574.2011.00393.x
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发表时间：
2012-01-01
期刊：
影响因子：
2.9
通讯作者：
Gouma, Dirk J.
中科院分区：
文献类型：
--
作者：
Strasberg, Steven M.;Gouma, Dirk J.
目的：严重的血管胆道损伤通常累及主要肝动脉和门静脉。它们是罕见的，但有严重的后果，包括肝脏的快速梗死。这些损伤的发病机制还不清楚。本研究的目的是阐明损伤的机制，通过分析的临床记录，特别是手术笔记的索引procedure.Methods：胆道损伤数据库中的两个机构进行了搜索极端vasculobiliary损伤的数据。要求初级机构提供首次手术（胆囊切除术）的手术记录。这些笔记和病人被转介到的第三级中心的治疗记录都得到了检查。从初级机构的X光片，当可用的时候，以及那些从第三centers，进行了study.Results：8例患者极端vasculobiliary损伤被发现。手术开始于腹腔镜，由于严重的慢性或急性炎症转为开放手术。曾尝试过胃底胆囊切除术。由于门静脉和肝动脉损伤，患者出现严重出血。四名患者需要右肝切除术，一名患者需要原位肝移植。八名患者中有四人死亡，一人仍在治疗中。结论：当胃底胆囊切除术在严重炎症的存在下进行时，往往会发生极端的血管纤毛损伤。收缩性炎症使胆囊板变厚变短，使胆囊与肝脏分离危险。
Objectives: Extreme vasculobiliary injuries usually involve major hepatic arteries and portal veins. They are rare, but have severe consequences, including rapid infarction of the liver. The pathogenesis of these injuries is not well understood. The purpose of this study was to elucidate the mechanism of injury through an analysis of clinical records, particularly the operative notes of the index procedure.Methods: Biliary injury databases in two institutions were searched for data on extreme vasculobiliary injuries. Operative notes for the index procedure (cholecystectomy) were requested from the primary institutions. These notes and the treatment records of the tertiary centres to which the patients had been referred were examined. Radiographs from the primary institutions, when available, as well as those from the tertiary centres, were studied.Results: Eight patients with extreme vasculobiliary injuries were found. Most had the following features in common. The operation had been started laparoscopically and converted to an open procedure because of severe chronic or acute inflammation. Fundus-down cholecystectomy had been attempted. Severe bleeding had been encountered as a result of injury to a major portal vein and hepatic artery. Four patients have required right hepatectomy and one had required an orthotopic liver transplant. Four of the eight patients have died and one remains under treatment.Conclusions: Extreme vasculobiliary injuries tend to occur when fundus-down cholecystectomy is performed in the presence of severe inflammation. Contractive inflammation thickens and shortens the cystic plate, making separation of the gallbladder from the liver hazardous.