阶梯式经皮胆道镜激光技术在胰十二指肠切除术后胆肠吻合口狭窄的应用

doi:10.3877/cma.j.issn.1674-6899.2026.02.005

目的

探讨阶梯式经皮胆道镜激光技术在胰十二指肠切除(pancreaticoduodenectomy, PD)术后胆肠吻合口狭窄的临床应用效果和安全性。

方法

回顾性分析2020年7月至2025年6月期间，西湖大学医学院附属杭州市第一人民医院肝胆胰外科收治的11例患者接受阶梯式经皮胆道镜激光技术治疗PD术后胆肠吻合口狭窄的临床资料。记录分析穿刺部位、间隔时间、手术次数、手术时间、手术出血量、术后胆漏、术后出血等术中资料及并发症发生情况，以及远期疗效。

结果

11例患者均顺利完成手术，无中转开腹，其中穿刺右肝入路4例，左肝入路7例，中位穿刺至手术间隔时间7 d，中位手术时间153 min，中位手术出血量10 ml，其中3例患者分两次手术进行。术后患者出现3例患者发热，无术后出血，胆漏等并发症发生，术后复查中位胆红素21.3 μmol/L，术后中位拔管时间7 d。随访期间(中位随访24个月)，患者无明显腹痛、黄疸等情况发生，无再次入院手术。

结论

在严密规划及精细手术操作下，阶梯式经皮胆道镜激光技术治疗PD术后胆肠吻合口狭窄安全有效，远期胆肠吻合口未再次狭窄。

关键词: 经皮胆道镜激光技术, 胰十二指肠切除术, 胆肠吻合口狭窄

Objective

To investigate the clinical efficacy and safety of stepwise percutaneous cholangioscopy-guided laser technique for treating biliary-enteric anastomotic stricture after pancreaticoduodenectomy (PD).

Methods

Clinical data of 11 patients with biliary-enteric anastomotic stricture after PD who underwent treatment with stepwise percutaneous cholangioscopy-guided laser technique in the Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People′s Hospital Affiliated to Medical School of Westlake University from Jul. 2020 to Jun. 2025 were retrospectively analyzed. The puncture approach, interval time, number of procedures, operative time, intraoperative blood loss, and perioperative complications (including postoperative bile leakage and bleeding) were recorded and analyzed, along with long-term outcomes.

Results

All 11 patients successfully completed the procedures without conversion to laparotomy. A right hepatic approach was used in 4 cases and a left hepatic approach in 7 cases. The median interval from puncture to operation was 7 days. The median operative time was 153 min, and the median intraoperative blood loss was 10 ml. Three patients underwent two-stage procedures. Postoperatively, fever occurred in 3 patients, no postoperative bleeding, bile leakage, or other complications were observed. The median postoperative bilirubin level was 21.3 μmol/L, and the median time to catheter removal was 7 days. During follow-up (median 24 months), no obvious abdominal pain or jaundice occurred, and no patient required readmission for reoperation.

Conclusion

With meticulous preoperative planning and refined operative technique, the stepwise percutaneous cholangioscopy-guided laser technique is safe and effective for treating biliary-enteric anastomotic stricture after PD, with no restenosis of the biliary-enteric anastomosis observed in long-term follow-up.

Key words: Percutaneous cholangioscopy-guided laser technique, Pancreaticoduodenectomy, Biliary-enteric anastomotic stricture

图1 胰十二指肠术后胆肠吻合口狭窄患者影像学及术中图片展示注：病例1：A.CT提示肝管内结石形成(箭头所示)；B.PTCD穿刺至左肝内胆管内(箭头所示)；C.CT显示经皮胆道镜激光术后肝内引流管(箭头所示)；D.经皮胆道镜图像显示激光碎石(箭头所示)；E.肝管空肠吻合口狭窄伴吻合口缝线(箭头所示)；F.经皮胆道镜激光烧灼缝线及狭窄环(箭头所示)。病例2：G.二次手术胆肠吻合口重建后再次狭窄(箭头所示)；H.经皮胆道镜激光烧灼狭窄环后胆道镜顺利通过吻合口，可见肠黏膜(箭头所示)；I.术后患者腹部切口展示，前两次手术瘢痕及本次手术仅胆道引流管切口(箭头所示)

表1 PD术后胆肠吻合口狭窄患者基线资料

特征	分类	数值
病例数		11
性别[例(%)]	男	5 (45.5)
	女	6 (54.5)
年龄(岁，±s)		64.91±6.20
BMI (kg/m²，±s)		20.85±1.08
总胆红素[μmol/L，M (P₂₅，P₇₅)]		75.40(68.10, 87.90)
原肿瘤位置[例(%)]	胰头	7 (63.6)
	壶腹部	4 (36.4)
狭窄时长(月，±s)		15.82±3.57
肝内胆管直径[mm，M [P₂₅，P₇₅)]		4.80(4.40, 5.55)
肝内胆管结石[例(%)]	有	10 (90.9)
	无	1 ( 9.1)

表1 PD术后胆肠吻合口狭窄患者基线资料

特征	分类	数值
病例数		11
性别[例(%)]	男	5 (45.5)
	女	6 (54.5)
年龄(岁，±s)		64.91±6.20
BMI (kg/m²，±s)		20.85±1.08
总胆红素[μmol/L，M (P₂₅，P₇₅)]		75.40(68.10, 87.90)
原肿瘤位置[例(%)]	胰头	7 (63.6)
	壶腹部	4 (36.4)
狭窄时长(月，±s)		15.82±3.57
肝内胆管直径[mm，M [P₂₅，P₇₅)]		4.80(4.40, 5.55)
肝内胆管结石[例(%)]	有	10 (90.9)
	无	1 ( 9.1)

表2 PD术后胆肠吻合狭窄患者手术及术后资料

特征	分类	数值
病例数		11
穿刺部位[例(%)]	右肝	4 ( 36.4)
	左肝	7 ( 63.6)
穿刺手术间隔时间[d，中位数(P₂₅，P₇₅)]		7.00 (6.00, 8.00)
手术时间[min，中位数(P₂₅，P₇₅)]		153.00 (130.00, 211.00)
手术出血量[ml，中位数(P₂₅，P₇₅)]		10.00 (7.50, 22.50)
手术次数[例(%)]	1	7 ( 63.6)
	2	4 ( 36.4)
术后发热[例(%)]	无	8 ( 72.7)
	有	3 ( 27.3)
术后胆红素[μmol/L，中位数(P₂₅，P₇₅)]		21.30 (19.20, 23.75)
术后胆漏[例(%)]	无	11 (100.0)
术后出血[例(%)]	无	11 (100.0)
术后拔管时间[d，中位数(P₂₅，P₇₅)]		7.00 (7.00, 8.00)

表2 PD术后胆肠吻合狭窄患者手术及术后资料

特征	分类	数值
病例数		11
穿刺部位[例(%)]	右肝	4 ( 36.4)
	左肝	7 ( 63.6)
穿刺手术间隔时间[d，中位数(P₂₅，P₇₅)]		7.00 (6.00, 8.00)
手术时间[min，中位数(P₂₅，P₇₅)]		153.00 (130.00, 211.00)
手术出血量[ml，中位数(P₂₅，P₇₅)]		10.00 (7.50, 22.50)
手术次数[例(%)]	1	7 ( 63.6)
	2	4 ( 36.4)
术后发热[例(%)]	无	8 ( 72.7)
	有	3 ( 27.3)
术后胆红素[μmol/L，中位数(P₂₅，P₇₅)]		21.30 (19.20, 23.75)
术后胆漏[例(%)]	无	11 (100.0)
术后出血[例(%)]	无	11 (100.0)
术后拔管时间[d，中位数(P₂₅，P₇₅)]		7.00 (7.00, 8.00)

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Application of stepwise percutaneous cholangioscopy-guided laser technique in biliary-enteric anastomotic stricture after pancreaticoduodenectomy

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Application of stepwise percutaneous cholangioscopy-guided laser technique in biliary-enteric anastomotic stricture after pancreaticoduodenectomy