The Discussion Of The Risk Factors Of Iatrogenic Bile Duct Injury About The Surgical Operation Of Extrahepatic Biliary System

Objective:To investigate the risk factors of iatrogenic bile duct injury about the operations of extrahepatic biliary system,summarize the diagnosis and treatment of bile duct injury and summarize the experience of prevention and treatment.Methods:Collect cases from the Department of general surgery Provincial Hospital Affiliated to Medical College of Shandong University in 2010-2016,about th surgery of extrahepatic biliary system,2092 cases including 51 caes of iatrogenic bile duct injury.Collect the relevant statistical informations(gender,age,body mass index BMI,primary disease,degree of biliary infection,operation which led to the injuries,classifications of operation,repair plan and total hospitalization time,the follow-up).Baesd on the Chinese Medical Association bile duct injury classification method,[1]to determine the type of bile duct injury.Observe the damage distribution,and to investigate the patient size(overweight and normal body weight),surgery classification(laparotomy and laparoscopic),duration of biliary infection(acute biliary infection and chronic biliary infection),operation time(emergency operation and selective operation),Stone distribution(gallstones,common bile duct stones or merger multiple calculi),common bile duct exploration without T tube drainage or with the T tube drainage,level of hospital diagnosed,surgical experience and other risk factors on the impact of biliary injury,compare different groups of bile duct injury under the total group.Use chi square test or Fisher exact test,P<0.05 believes that the difference has got the statistical significance.Summarize the bile duct injury classification,diagnosis,treatment,provide experience for the prevention and treatment of biliary injury.Results:There are 2092cases of biliary surgery patients totally,by preoperative examination combined with clinical manifestations,surgical records,confirm a total of 51 cases of bile duct injury,51 cases of patients by clinical manifestations,surgical records and the relevant auxiliary examination(MRCP,abdominal ultrasound and CT)confirmed the injury,the ratio of male to female was 21:28,the average age was 51.59 years,18 cases occurred in our hospital,the incidence rate was 0.85%,33 cases occurred in the other hospital,The overall incidence of 2.41%.According to the Chinese Medical Association classification type,type I(the pancreaticoduodenal region)6 cases,type Ⅱ1(confluence to supraduodenal margin)in 30 cases,type Ⅱ2(left and right hepatic duct)in 9 cases,type Ⅱ3(left and right hepatic duct injury)in 6 cases.According to the main clinical performance,type of bile leakage accounted for 25.5%(13),type of obstruction 68.6%(35),type of bile leakage and obstruction 5.9%(3).The bile duct injury group and non injury group factor analysis results are as follows:cases were divided into two groups by the BMI(BMI>=23,overweight),overweight group of 21 cases(1287),normal body group of 30 cases(805),X2=0.21076851<3.84,the P>0.05,the difference was not statistically significant.According to the type of operation,cases are divided into:17 cases of open surgery(907)(2 cases of cholecystectomy,4 cases of cholecystectomy and choledocholithotomy(with T tube drainage in 15cases),11 cases of cholecystectomy and choledochotomy lithotomy(without T tube drainage in 15 cases),27 cases of laparoscopic surgery(1185)(30 cases of laparoscopic cholecystectomy,4 cases of laparoscopic cholecystectomy plus choledocholithotomy),x2=7.9945>3.84,P<0.05.The incidence of bile duct injury laparoscopic surgery(2.86%)is much higher than the incidence of open surgery(1.87%).46 cases of patients with biliary infection,divided by the inflammation duration,acute infection group was 19 cases(502),chronic infection group 27cases(1050),X2=0.7631<3.84,so P>0.05,no statistical significance,so it can not be considered that there was significant difference between the incidence of bile duct injury of acute the infection group and chronic infection group.46 cases of biliary calculi,according to the distribution of stone,only gallbladder stones in 22 cases(1231),gallbladder stones with common bile duct stones 24 cases(321),x2=12.9680>3.84,P<0.05.therefore,the distribution of biliary calculi of biliary injury affects the incidence of bile duct injury,the occurrence rate of bile duct injury in gallbladder stones with common bile duct stones is higher.A total of 417 cases of emergency operation,a total of 1675 cases of elective surgery,then IBDI grouped according to the operation timing,18 cases of undergoing emergency operation,33 cases of undergoing elective surgery.x2=5.5068>3.84,so P<0.05,that duct injury incidence of the emergency operation and selective operation of bile was not same,incidence rate of emergency operation for bile duct injury(4.32%)was significantly higher than that of elective surgery(1.97%).In common bile duct surgery,a total of 978 cases,482 cases of intraoperative placement with T tube drainage,496 cases of intraoperative placement without T tube drainage,4 cases were placed T tube drainage of bile duct injury,11 cases were placed without T tube drainage,so x2=3.98>3.84,P<0.05,which can not consider the incidence of bile duct injury of group with T tube and group without T tube equally.bile duct injury incidence of T tube placement group(0.83%)was lower than that of the non placement group(2.21%).From the hospital which the bile duct injury admitted to,bile duct injury rate of Grade three hospital was lower,and it is not clear between the surgical experience and the relationship and the incidence of bile duct injury,this research can’t make it sure.Conclusions:Causes of iatrogenic bile duct injury is complex,cases collected by this study,I find that cholecystectomy(with or without common bile duct surgery)is still the main injury operation of biliary injury,which laparoscopic cholecystectomy is the most common type.In bile duct injury,type Ⅱ,is the most common which may be associated with ischemia,over clamp and so on,in the operation of extrahepatic biliary system we should pay more attention to bile duct from the confluence of bile duct to margin of duodenum.laparoscopic surgery,wide biliary stones distribution、emergency operation,common bile duct incision without T tube placement are the risk factors for the occurrence of bile duct injury,Overweight(BMI>23)、infection duration(acute biliary infection and chronic biliary infection)are not biliary injury risk factors.on the basis of profound understanding to biliary damage,surgeons should strengthen prevention.Before biliary surgery,biliary reconstruction should be built by abdominal MRCP examination,during the abdominal surgery,we should carefully identify the anatomy of Calot’s triangle,distinguish the cystic duct,intrahepatic bile duct,the relationship between the hepatic duct and bile duct.Standardized operation is the key to prevent injury,at the end of the operation,we should carefully check the wound and surgical field,timely detection of problems in operation,postoperative close observation to the patient’s condition changes,or the routine MRCP examination of the abdomen to confirm the structure of biliary tract without defect will do a lot to prevent the IBDI.