endoscopic management of postcholecystectomy biliary leakage
TRANSCRIPT
14 ®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬, ¡°√“§¡-‡¡…“¬π 2555
Endoscopic Management ofPostcholecystectomy Biliary Leakage
∏π— π’ ÿπ∑√¡‚π°ÿ≈, ª√–‡¥‘¡™—¬ §ß§”Àπ૬‚√§∑“߇¥‘πÕ“À“√·≈–μ—∫ ‚√ß欓∫“≈®ÿÓ≈ß°√≥å
Review Article
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
°“√ºà“μ—¥∂ÿßπÈ”¥’ (cholecystectomy) ‡ªìπ°“√√—°…“¡“μ√∞“π„πºŸâªÉ«¬
π‘Ë«„π∂ÿßπÈ”¥’∑’Ë¡’Õ“°“√ (symptomatic gallstones) ‚¥¬„πªí®®ÿ∫—π°“√ºà“μ—¥‚¥¬
°“√ àÕß°≈âÕß (laparoscopic cholecystectomy - LC) ‡ªìπ«‘∏’∑’ˉ¥â√—∫§«“¡π‘¬¡
¡“°°«à“°“√ºà“μ—¥·∫∫‡ªî¥Àπâ“∑âÕß ‡π◊ËÕß®“°¡’√–¬–æ—°„π‚√ß欓∫“≈ —Èπ°«à“ (6.4±4.2
«—π ‡∑’¬∫°—∫ 2.4±1.7 «—π)1 ·≈–‡®Á∫·º≈πâÕ¬°«à“ Õ’°∑—ÈߺŸâªÉ«¬ “¡“√∂°≈—∫¡“∑”ß“π
‰¥â‡√Á« (5.8±2.8 —ª¥“Àå ‡∑’¬∫°—∫ 1.8±1.8 —ª¥“Àå)2 Õ¬à“߉√°Áμ“¡Õ“®‡°‘¥°“√∫“¥
‡®Á∫μàÕ∑àÕπÈ”¥’ (bile duct injuries) ‰¥â∫àÕ¬°«à“ §◊Õª√–¡“≥√âÕ¬≈– 0.5-2.7
‡ª√’¬∫‡∑’¬∫°—∫√âÕ¬≈– 0.2-0.5 ‡¡◊ËÕºà“μ—¥·∫∫‡ªî¥Àπâ“∑âÕß (open cholecy-
stectomy)3,4 °“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’·∫à߉¥â‡ªìπ 2 ª√–‡¿∑„À≠àÊ §◊Õ∑àÕπÈ”¥’μ’∫
(biliary stricture) ·≈–∑àÕπÈ”¥’√—Ë« (biliary leakage) ´÷Ëß∫“ߧ√—ÈßÕ“®π”‰ª Ÿà¿“«–
·∑√°´âÕπ∑’Ë√ÿπ·√ß®π∂÷ß™’«‘μ ¥—ßπ—Èπ·æ∑¬å§«√μ√–Àπ—°·≈–∑”°“√ ◊∫§âπ‡¡◊ËÕ ß —¬
¿“«–π’È „π∫∑§«“¡π’È®–°≈à“«∂÷ß°“√«‘π‘®©—¬·≈–·π«∑“ß°“√¥Ÿ·≈√—°…“¿“«–∑àÕπÈ”¥’
√—Ë«‡ªìπÀ≈—°
Õÿ∫—μ‘°“√≥å·≈–ªí®®—¬‡ ’ˬߢÕß°“√∫“¥‡®Á∫∑àÕπÈ”¥’∑’ˇ°‘¥À≈—ߺà“μ—¥ LC
æ∫Õÿ∫—μ‘°“√≥å°“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’‰¥â√âÕ¬≈– 0.5-2.7 ‚¥¬‡ªìπ∑àÕπÈ”¥’√—Ë«
√âÕ¬≈– 0.2-25 ‚¥¬μ”·Àπàß∑’Ë√—Ë«¡“°∑’Ë ÿ¥§◊Õ cystic duct (√âÕ¬≈– 70) √Õß≈ß¡“
§◊Õ hepatic duct of Luschka (√âÕ¬≈– 14)6 ‚¥¬æ∫«à“¡’ªí®®—¬∑’ˇæ‘Ë¡§«“¡‡ ’ˬß
15Endoscopic Management of Postcholecystectomy Biliary Leakage
μàÕ°“√∫“¥‡®Á∫¢Õß∑àÕπÈ”¥’ (μ“√“ß∑’Ë 1) ´÷Ëß·∫à߉¥â‡ªìπ 3 ¥â“π
1. ªí®®—¬®“°ºŸâªÉ«¬7 ‡™àπ ‡æ»™“¬ Õ“¬ÿ¡“° Õâ«π ™“«‡Õ‡™’¬ ·≈– æ—ߺ◊¥∑’Ë
‡°“–∫√‘‡«≥∑’˺à“μ—¥
2. ªí®®—¬®“°μ”·Àπàß∑’˺à“μ—¥ ‰¥â·°à °“√Õ—°‡ ∫∑’Ë√ÿπ·√ß °“¬«‘¿“§∑’Ë
º‘¥ª°μ‘8 °“√«“ßμ—«¢Õß cystic duct ∑’ËμË”°«à“ª°μ‘ (low lying cystic duct)9
‡ªìπμâπ
3. ªí®®—¬∑’ˇ°‘¥®“°¿“¬πÕ° ‰¥â·°à§«“¡™”π“≠¢Õß»—≈¬·æ∑¬å Õÿª°√≥å∑’Ë
„™â„π°“√ºà“μ—¥ °“√ºà“μ—¥¢≥–∑’Ë∂ÿßπÈ”¥’Õ—°‡ ∫‡©’¬∫æ≈—π
“‡Àμÿ·≈–°≈‰°¢Õß°“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’¿“¬À≈—ߺà“μ—¥ LC12
·∫à߉¥â 2 “‡ÀμÿÀ≈—° ‰¥â·°à
1. ≈—°…≥–∑“ß°“¬«‘¿“§¢Õß common bile duct ∑”„À⇢Ⓞ®º‘¥«à“‡ªìπ
cystic duct ‡ªì𠓇Àμÿ∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥ (√âÕ¬≈– 61)8 ‚¥¬Õ“®‡¢â“„®«à“ common
bile duct À√◊Õ aberrant sectoral hepatic duct ¥â“π¢«“ ‡ªìπ cystic duct
‡π◊ËÕß®“°¿“æ∑’ˇÀÁπ¢≥–ºà“μ—¥‡ªìπ¿“æ 2 ¡‘μ‘
2. ‡∑§π‘§¢≥–ºà“μ—¥ ‡™àπ ‰¡à “¡“√∂Õÿ¥√Õ¬√—Ë«¢Õß cystic duct ‰¥âÀ¡¥
¡’°“√∫“¥‡®Á∫μàÕ‡π◊ÈÕμ—∫¢≥–‡≈“–∂ÿßπÈ”¥’ °“√∑” cephalad retraction ¢Õß gall-
bladder fundus ∑’Ë¡“°‡°‘π‰ª À√◊Õ¡’°“√Õ—°‡ ∫√ÿπ·√ß„π∫√‘‡«≥ Calotûs triangle
®–∑”„Àâ cystic duct ·≈– common bile duct ¡“Õ¬Ÿà„°≈â°—π®π·¬°®“°°—π‰¥â
μ“√“ß∑’Ë 1 ªí®®—¬‡ ’ˬߢÕß°“√∫“¥‡®Á∫∑àÕπÈ”¥’∑’ˇ°‘¥À≈—ߺà“μ—¥ LC
ªí®®—¬‡ ’Ë¬ß Odd ratio 95%CI
‡™◊ÈÕ “¬‡Õ‡™’¬7 2.62 1.28-5.39
‡æ»™“¬10 1.26 1.04-1.53
Õ“¬ÿ > 70 ªï10 2.46 1.65-3.66
°“√Õ—°‡ ∫∑’Ë√ÿπ·√ß11 3.61 1.27-10.21
16 ®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬, ¡°√“§¡-‡¡…“¬π 2555
¬“° ‡ªìπμâπ
°“√®”·π°ª√–‡¿∑¢Õß°“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’
¥—ß∑’Ë°≈à“«·≈â««à“‡√“ “¡“√∂·∫àß°“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’∑’ˇ°‘¥À≈—ß°“√ºà“μ—¥
LC ÕÕ°‡ªìπ 2 ª√–‡¿∑„À≠àÊ §◊Õ ∑àÕπÈ”¥’μ’∫·≈–∑àÕπÈ”¥’√—Ë« ‚¥¬∑àÕπÈ”¥’√—Ë«®–·∫àß
‰¥â‡ªìπ simple bile leakage §◊Õ√—Ë«®“° cystic duct stump À√◊Õ duct of Luschka
·≈– complex bile leakage §◊Õ√—Ë«®“° common bile duct À√◊Õ common he-
patic duct13 ´÷Ëß®–¡’°“√√—°…“·≈–欓°√≥å‚√§∑’Ë·μ°μà“ß°—π¥—ß®–°≈à“«μàÕ‰ª
ªí®®ÿ∫—π¡’√–∫∫∑’Ë·∫àß°“√∫“¥‡®Á∫¢Õß∑àÕπÈ”¥’ÕÕ°‡ªìπª√–‡¿∑μà“ßÊ À≈“¬
√–∫∫ ‡æ◊ËÕ„™â«“ß·ºπ°“√√—°…“·≈–欓°√≥å‚√§ ·μà‰¡àæ∫«à“¡’√–∫∫„¥√–∫∫Àπ÷Ëß∑’Ë
‡ªìπ¡“μ√∞“π‡æ’¬ß√–∫∫‡¥’¬« Bismuth classification ‡ªìπ√–∫∫·√°∑’Ë∂Ÿ° √â“ß
¢÷Èπ‚¥¬·∫àß°“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’μ“¡μ”·Àπàß∑’ˇ°‘¥‡ªìπ 5 ª√–‡¿∑ (¿“æ∑’Ë 1)14
μàÕ¡“ Mc Mahon ·≈–§≥–15 ‡ πÕ«à“§«√®–·∫àß√“¬≈–‡Õ’¬¥‡æ‘Ë¡μ“¡
≈—°…≥–°“√∫“¥‡®Á∫¢Õß∑àÕπÈ”¥’¥—ßπ’È
1. ∑àÕπÈ”¥’∫“¥‡®Á∫·∫∫ major (major bile duct injury) μâÕ߇¢â“‡°≥±å
«‘π‘®©—¬Õ¬à“ßπâÕ¬ 1 ¢âÕ¥—ßμàÕ‰ªπ’È
¿“æ∑’Ë 1 °“√·∫àߪ√–‡¿∑°“√∫“¥‡®Á∫¢Õß∑àÕπÈ”¥’μ“¡μ”·Àπàß∑’ˇ°‘¥ ‚¥¬ Bismuth classification
™π‘¥∑’Ë 1 ∑àÕπÈ”¥’μ’∫∑’Ë common hepatic duct ‚¥¬¡’ hepatic duct stump ¬“«¡“°°«à“ 2 ´¡.
™π‘¥∑’Ë 2 ∑àÕπÈ”¥’μ’∫∑’Ë common hepatic duct ‚¥¬¡’ hepatic duct stump ¬“«πâÕ¬°«à“ 2 ´¡.
™π‘¥∑’Ë 3 ∑àÕπÈ”¥’μ’∫∑’Ë¢—È«μ—∫ (hepatic hilum) ‚¥¬∑’Ë hepatic duct ´â“¬·≈– ¢«“¬—ß¡’∫“ß à«π∑’ˇ™◊ËÕ¡°—π
™π‘¥∑’Ë 4 ∑àÕπÈ”¥’μ’∫∑’Ë¢—È«μ—∫ (hepatic hilum) ‚¥¬∑’Ë hepatic duct ´â“¬·≈– ¢«“‰¡à¡’ à«π∑’ˇ™◊ËÕ¡°—π
™π‘¥∑’Ë 5 ∑àÕπÈ”¥’μ’∫∑’Ë aberrant sectoral hepatic duct ¢â“ߢ«“‚¥¬Õ“®æ∫«à“¡’√Õ¬μ’∫¢Õß common he-
patic duct √à«¡¥â«¬À√◊Õ‰¡à°Á‰¥â
17Endoscopic Management of Postcholecystectomy Biliary Leakage
1.1 °“√©’°¢“¥∫“ß à«π¢Õß∑àÕπÈ”¥’ (bile duct laceration) Õ¬à“ßπâÕ¬
√âÕ¬≈– 25 ¢Õ߇ âπºà“π»Ÿπ¬å°≈“ß∑àÕπÈ”¥’
1.2 °“√μ—¥¢“¥¢Õß∑àÕπÈ”¥’ (transection of common hepatic duct
or common bile duct)
1.3 ∑àÕπÈ”¥’μ’∫À≈—ߺà“μ—¥
2. ∑àÕπÈ”¥’∫“¥‡®Á∫·∫∫ minor (minor bile duct injury) ¡’ 2 ≈—°…≥–
䴉ᡈ
2.1 °“√©’°¢“¥∫“ß à«π¢Õß∑àÕπÈ”¥’ (bile duct laceration) ‰¡à‡°‘π
√âÕ¬≈– 25 ¢Õ߇ âπºà“π»Ÿπ¬å°≈“ß∑àÕπÈ”¥’
2.2 °“√©’°¢“¥∫“ß à«π∑’Ë√Õ¬μàÕ¢Õß common bile duct ·≈– cys-
tic duct (cystic-CBD junction)
Bergman ·≈–§≥– ∑’Ë Amsterdam Academic Medical Center16 ‰¥â
·∫àß°“√∫“¥‡®Á∫¢Õß∑àÕπÈ”¥’À≈—ß LC ‡ªìπ 4 ·∫∫‡æ◊ËÕ·¬°μ“¡«‘∏’°“√√—°…“
Type A minor bile ducts leaks ‡°‘¥®“°°“√√—Ë« cystic duct
À√◊Õ peripheral hepatic duct
Type B major bile duct leaks ‡°‘¥®“°°“√√—Ë«®“° major he-
patic duct À√◊Õ aberrant segmental extrahepatic branch of the hepatic
duct ¥â“π¢«“
Type C ∑àÕπÈ”¥’μ’∫ (bile duct stricture)
Type D ∑àÕπÈ”¥’©’°¢“¥·∫∫ ¡∫Ÿ√≥å (complete transection of
bile duct)
¿“¬À≈—ß Strasberg14 ‰¥â∑”°“√¥—¥·ª≈ß Bisthmuth classification ‡æ‘Ë¡
‡μ‘¡‚¥¬‡ªìπ√–∫∫∑’ˉ¥â√—∫§«“¡π‘¬¡¡“°∑’Ë ÿ¥ ·∫à߇ªìπ 5 ª√–‡¿∑ (¿“æ∑’Ë 2) §◊Õ
Type A ∑àÕπÈ”¥’√—Ë«®“°∑àÕπÈ”¥’¢π“¥‡≈Á°∑’Ëμ‘¥μàÕ°—∫ common bile
duct (bile leak from minor duct still in continuity with the common bile
duct)
Type B ∑àÕπÈ”¥’Õÿ¥μ—π (occlusion of part of biliary tree)
18 ®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬, ¡°√“§¡-‡¡…“¬π 2555
Type C ∑àÕπÈ”¥’¢π“¥‡≈Á°∂Ÿ°μ—¥¢“¥ (minor duct transected with-
out ligation)
Type D °“√∫“¥‡®Á∫¥â“π¢â“ߢÕß∑àÕπÈ”¥’ à«π∑’ËÕ¬ŸàπÕ°μ—∫ (lateral
injury to extrahepatic bile duct)
Type E ·∫à߬àÕ¬‡ªìπ E1-5 μ“¡ Bismuth classification ¥—ßπ’È
E1 ∑àÕπÈ”¥’μ’∫∑’Ë common hepatic duct ‚¥¬¡’ hepatic duct stump
¬“«¡“°°«à“ 2 ´¡.
E2 ∑àÕπÈ”¥’μ’∫∑’Ë common hepatic duct ‚¥¬¡’ hepatic duct stump
¬“«πâÕ¬°«à“ 2 ´¡.
E3 ∑àÕπÈ”¥’μ’∫∑’Ë ¢—È«μ—∫ (hepatic hilum) ‚¥¬∑’Ë hepatic duct ´â“¬
·≈–¢«“¬—ß¡’∫“ß à«π∑’ˇ™◊ËÕ¡°—π
E4 ∑àÕπÈ”¥’μ’∫∑’Ë¢—È«μ—∫ (hepatic hilum) ‚¥¬∑’Ë hepatic duct ´â“¬
·≈– ¢«“‰¡à¡’ à«π∑’ˇ™◊ËÕ¡°—π
¿“æ∑’Ë 2 °“√·∫àߪ√–‡¿∑°“√∫“¥‡®Á∫¢Õß∑àÕ
πÈ”¥’ ‚¥¬ Strasberg classification
19Endoscopic Management of Postcholecystectomy Biliary Leakage
E5 ∑àÕπÈ”¥’μ’∫∑’Ë aberrant sectoral hepatic duct ¢â“ߢ«“‚¥¬Õ“®
æ∫«à“¡’√Õ¬μ’∫¢Õß common hepatic duct √à«¡¥â«¬À√◊Õ‰¡à°Á‰¥â
„π∫“ß°√≥’ ¡’°“√·∫àß∑àÕπÈ”¥’√—Ë«μ“¡®ÿ¥¡ÿàßÀ¡“¬„π°“√√—°…“‡ªìπ 2 ™π‘¥§◊Õ
∑àÕπÈ”¥’√—Ë«πâÕ¬ (low-grade leaks) À¡“¬∂÷ß ‡¡◊ËÕ©’¥ “√∑÷∫· ß·≈â« “√π—Èπ‡¢â“‰ª
„π∑àÕπÈ”¥’„πμ—∫°àÕπ∑’Ë®–‡ÀÁπ√Õ¬√—Ë« ·≈–∑àÕπÈ”¥’√—Ë«¡“° (high-grade leaks)
À¡“¬∂÷ß«à“ ‡¡◊ËÕ©’¥ “√∑÷∫· ß·≈â« “√π—Èπ√—Ë«ÕÕ°°àÕπ®–‡¢â“‰ª∑’Ë∑àÕπÈ”¥’„πμ—∫6 Õ’°
¥â«¬
Õ¬à“߉√°Áμ“¡¥—ß∑’Ë°≈à“«‰«â·≈â««à“‰¡à¡’√–∫∫„¥∑’Ë ¡∫Ÿ√≥å∑’Ë ÿ¥ ¢âÕ¡Ÿ≈ ”§—≠∑’Ë
§«√ª√–‡¡‘π°àÕπ∑’Ë®–∑”°“√ºà“μ—¥·°â‰¢∑àÕπÈ”¥’∑’Ë∫“¥‡®Á∫ (biliary reconstruction)
‰¥â·°à μ”·Àπàß∑àÕπÈ”¥’∑’ˉ¥â√—∫∫“¥‡®Á∫ ·≈–°“√ª√–‡¡‘π«à“¡’°“√∫“¥‡®Á∫¢ÕßÀ≈Õ¥
‡≈◊Õ¥„°≈⇧’¬ß (patency of hepatic arterial and portal venous blood sup-
ply) √à«¡¥â«¬À√◊Õ‰¡à
Õ“°“√·≈–Õ“°“√· ¥ß
à«π„À≠à·æ∑¬å®– “¡“√∂«‘π‘®©—¬°“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’‰¥âÀ≈—ß®“°∑’Ë°“√
ºà“μ—¥‡ √Á® ‘Èπ·≈â« ‚¥¬∑’ËÕ“°“√·≈–Õ“°“√· ¥ß¢÷ÈπÕ¬Ÿà°—∫™π‘¥·≈–§«“¡√ÿπ·√ߢÕß
°“√∫“¥‡®Á∫«à“‡ªìπ∑àÕπÈ”¥’μ’∫À√◊Õ√—Ë« ‚¥¬√“¬∑’Ë∑àÕπÈ”¥’μ’∫ ºŸâªÉ«¬Õ“®®–¡“¥â«¬
Õ“°“√ª«¥∑âÕß ‡∫◊ËÕÕ“À“√ ¥’´à“π À√◊Õμ√«®æ∫°“√∑”ß“π¢Õßμ—∫º‘¥ª°μ‘ (abnor-
mal liver function tests) Õ¬à“߉√°Áμ“¡ Õ“®æ∫°“√∑”ß“π¢Õßμ—∫º‘¥ª°μ‘‰¥â®“°
¿“«–Õ◊Ë𠇙àπ ≈¡√—Ë«„π™àÕß∑âÕß (pneumoperitoneum) À≈—ß®“°∑” LC ·μà¿“«–
¥—ß°≈à“«®–¥’¢÷Èπ‡Õß„π 1-2 —ª¥“Àå
Õ“°“√‡À≈à“π’ÈÕ“®‡°‘¥‰¥âμ—Èß·μà —ª¥“Àå·√°À≈—ߺà“μ—¥ ‚¥¬‡©æ“–™π‘¥∑’ˇªìπ
Strasberg classification ·∫∫ A, C ·≈– D À√◊Õ‡°‘¥À≈—ߺà“μ—¥π“π°«à“π—Èπ ‚¥¬
ºŸâªÉ«¬Õ“®®–¡“¥â«¬Õ“°“√∑’ˇ°‘¥®“°°“√°≈—∫‡ªìπ´È”¢Õß°“√μ‘¥‡™◊ÈÕ∑“߇¥‘ππÈ”¥’ (re-
current acute cholangitis) À√◊Õ μ—∫·¢Áß®“°∑àÕπÈ”¥’Õÿ¥μ—π‡√◊ÈÕ√—ß (secondary
biliary cirrhosis)
„π√“¬∑’ˇ°‘¥¿“«–∑àÕπÈ”¥’√—Ë«Õ“®æ∫„π¢≥–ºà“μ—¥‰¥â∂Ⓡªìπ Strasberg clas-
20 ®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬, ¡°√“§¡-‡¡…“¬π 2555
sification Type E À√◊Õ¡“æ∫·æ∑¬å¿“¬À≈—ߥ⫬Փ°“√∑’ˉ¡à®”‡æ“–‡®“–®ß ‡™àπ
∑âÕßÕ◊¥ Õ‘Ë¡ßà“¬ §≈◊Ëπ‰ â Õ“‡®’¬π ª«¥∑âÕß À√◊Õ‰¢âμË”Ê ‡π◊ËÕß®“°πÈ”¥’∑’ËÀ≈—Ëß‚¥¬μ√ß
®“°μ—∫¡’§«“¡‡¢â¡¢âππâÕ¬°«à“πÈ”¥’∑’ËÀ≈—Ëß®“°∂ÿßπÈ”¥’®÷߉¡à∑”„À⇰‘¥¿“«–‡¬◊ËÕ∫ÿ™àÕß
∑âÕßÕ—°‡ ∫√ÿπ·√ß
°“√«‘π‘®©—¬
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®“°ºà“μ—¥‡ √Á®·≈â« ¡’‡æ’¬ß√âÕ¬≈– 10-30 ¢ÕߺŸâªÉ«¬‡∑à“π—Èπ∑’ˉ¥â√—∫°“√«‘π‘®©—¬μ—Èß
·μà„π¢≥–ºà“μ—¥ ‚¥¬Õ“®®–‡ÀÁπ√–À«à“ß∑’Ë∑” intra-operative cholangiography
À√◊Õæ∫°“√√—Ë«¢ÕßπÈ”¥’¢≥–ºà“μ—¥‚¥¬μ√ß ´÷Ëß„π°√≥’∑’Ë«‘π‘®©—¬À≈—ß®“°°“√ºà“μ—¥ ºŸâ
ªÉ«¬Õ“®¡“¥â«¬Õ“°“√∑’ˉ¡à®”‡æ“–‡®“–®ß ‡™à𠪫¥∑âÕß ∑âÕßÕ◊¥ ∑”„Àâ«‘π‘®©—¬‰¥â¬“°
¥—ßπ—Èπ·æ∑¬åºŸâ¥Ÿ·≈§«√μâÕßπ÷°∂÷ß¿“«–π’È·≈–∑”°“√ ◊∫§âπÕ¬à“ß≈–‡Õ’¬¥ ‡æ√“–¬‘Ëß
«‘π‘®©—¬‰¥â‡√Á«°Á®–≈¥¿“«–·∑√°´âÕπ∑’Ë√ÿπ·√ß·≈–‡æ‘Ë¡§«“¡ ”‡√Á®„π°“√√—°…“18
„πªï 2010 International Study Group of Liver Surgery19 ‰¥â®—¥
ª√–™ÿ¡‡æ◊ËÕ„À⧔®”°—¥§«“¡·≈–·∫àߧ«“¡√ÿπ·√ߢÕß¿“«–πÈ”¥’√—Ë«À≈—ߺà“μ—¥ (post-
operative bile leakage) «à“‡ªìπ¿“«–∑’Ë¡’°“√§—ËߢÕߢÕ߇À≈«„π™àÕß∑âÕß∑’Ë¡’
§«“¡‡¢â¡¢âπ¢Õß bilirubin „π¢Õ߇À≈«π—Èπ¡“°°«à“ bilirubin „π‡≈◊Õ¥ 3 ‡∑à“‚¥¬
æ∫À≈—ß®“°ºà“μ—¥·≈⫇°‘π 3 «—π¢÷Èπ‰ª À√◊Õ¡’¿“«–‡¬◊ËÕ∫ÿ™àÕß∑âÕßÕ—°‡ ∫®“°πÈ”¥’
À√◊Õ¡’πÈ”¥’∑’˧—Ëß (biliary collections) ∑’ËμâÕß°“√°“√√–∫“¬‚¥¬°“√ºà“μ—¥À√◊Õ«‘∏’∑“ß
√—ß ’«‘∑¬“19 Õ¬à“߉√°Áμ“¡°“√μ√«®¬◊π¬—π§ßμâÕßÕ“»—¬°“√μ√«®∑“ß√—ß ’«‘∑¬“‡æ◊ËÕ
¬◊π¬—π«à“¡’∑àÕπÈ”¥’∫“¥‡®Á∫®√‘ß
°“√μ√«®«‘π‘®©—¬∑“ß√—ß ’«‘∑¬“®—¥‡ªìπ°“√μ√«®∑’Ë¡’ª√–‚¬™πåÕ¬à“߬‘Ëß„π
¿“«–∑’Ë ß —¬∑àÕπÈ”¥’∫“¥‡®Á∫À≈—ߺà“μ—¥ ‚¥¬¡’√“¬≈–‡Õ’¬¥¥—ßπ’È
1. °“√μ√«®™àÕß∑âÕߥ⫬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß (ultrasonography) À√◊Õ
‡Õ°´‡√¬å§Õ¡æ‘«‡μÕ√å (computed tomography - CT) ¢Õß™àÕß∑âÕß à«π∫π ¡—°
‡ªìπ°“√μ√«®≈”¥—∫·√°∑’Ë∂Ÿ°‡≈◊Õ°„™â ‚¥¬®–æ∫«à“ ¡’¢Õ߇À≈«§—Ëß„π™àÕß∑âÕߺ‘¥ª°μ‘
(intra-abdominal fluid collections) ·μà‰¡à “¡“√∂·¬°™π‘¥‰¥â«à“‡ªìπ‡≈◊Õ¥ (he-
21Endoscopic Management of Postcholecystectomy Biliary Leakage
matoma) À√◊ÕπÈ”¥’ (biloma) Õ¬à“߉√°Áμ“¡√âÕ¬≈– 10-1420 ¢ÕߺŸâªÉ«¬À≈—ߺà“μ—¥
LC Õ“®æ∫«à“¡’¢Õ߇À≈«ª√‘¡“≥‡≈Á°πâÕ¬∑’Ë∫√‘‡«≥ gallbladder fossa ‰¥â πÕ°®“°π’È
„π°√≥’∑’Ë¡’∑àÕπÈ”¥’μ’∫ ®–æ∫∑àÕπÈ”¥’ à«π∑’ˇÀπ◊Õ¢÷Èπ‰ª¢¬“¬¡“°°«à“ª°μ‘ (ductal di-
latations)
2. °“√μ√«®¿“æ√—ß ’¢Õß∑“߇¥‘ππÈ”¥’ (cholangiography)21,22 ‡ªìπ°“√
μ√«®¡“μ√∞“π (gold standard) „π°“√ª√–‡¡‘π°“√∫“¥‡®Á∫μàÕ∑àÕπÈ”¥’ ∑”„Àâ‡ÀÁπ
μ”·Àπàß∑’Ë¡’°“√∫“¥‡®Á∫¢Õß∑àÕπÈ”¥’ ·≈–∑àÕπÈ”¥’¢¬“¬¡“°°«à“ª°μ‘„π°√≥’∑’Ë∑àÕ
πÈ”¥’μ’∫´÷Ëß∑”‰¥âÀ≈“¬«‘∏’¥—ßπ’È
2.1 °“√μ√«®¿“æ√—ß ’¢Õß∑“߇¥‘ππÈ”¥’‚¥¬©’¥ “√∑÷∫√—ß ’‡¢â“∑“ß√Ÿ‡ªî¥∑’Ë
º‘«Àπ—ß (percutaneous transhepatic cholangiography - PTC)
2.2 °“√ àÕß°≈âÕßμ—∫ÕàÕπ·≈–∑“߇¥‘ππÈ”¥’ (endoscopic retrograde
cholangiopancreatography - ERCP) ¡’¢âÕ¥’∑’Ë “¡“√∂„Àâ°“√√—°…“ºŸâªÉ«¬‰¥â∑—π∑’
·μàÀ“°¡’°“√Õÿ¥μ—π¢Õß common bile duct Õ¬à“ß ¡∫Ÿ√≥å °Á®–∑”„Àâ‰¡à “¡“√∂
μ√«®§«“¡º‘¥ª°μ‘ à«π∑’ËÕ¬Ÿà∫π°«à“π—Èπ‰¥â ·≈–‰¡à “¡“√∂„Àâ√“¬≈–‡Õ’¬¥‡°’ˬ«°—∫
À≈Õ¥‡≈◊Õ¥«à“¡’°“√∫“¥‡®Á∫√à«¡¥â«¬À√◊Õ‰¡à
2.3 °“√μ√«®¿“æ∑“߇¥‘ππÈ”¥’¥â«¬§≈◊Ëπ·¡à‡À≈Á°‰øøÑ“ (magnetic
resonance cholangiopancreatography - MRCP) “¡“√∂„Àâ√“¬≈–‡Õ’¬¥
‡°’ˬ«°—∫À≈Õ¥‡≈◊Õ¥«à“¡’°“√∫“¥‡®Á∫√à«¡¥â«¬À√◊Õ‰¡à ·≈–„Àâ√“¬≈–‡Õ’¬¥¢Õß
‡π◊ÈÕ‡¬◊ËÕμà“ßÊ (soft tissue) ‰¥â¥’°«à“
°“√√—°…“
°“√√—°…“∑’ˇÀ¡“– ¡¢Õß°“√∫“¥‡®Á∫¢Õß∑àÕπÈ”¥’À≈—ߺà“μ—¥ LC ¢÷Èπ°—∫ ‡«≈“
™π‘¥ μ”·ÀπàߢÕß°“√∫“¥‡®Á∫·≈– ¿“æ¢ÕߺŸâªÉ«¬ ‡√‘Ë¡μ—Èß·μà°“√„Àâ°“√¥Ÿ·≈√—°…“
¿“«–μ‘¥‡™◊ÈÕ „Àâ “√πȔլà“߇撬ßæÕ ¬“ªØ‘™’«π–∑’ˇÀ¡“– ¡ ·≈–∑”°“√√–∫“¬πÈ”¥’
∑’˧—Ëß„π™àÕß∑âÕß ´÷Ëß®”‡ªìπμâÕß∑”°“√√–∫“¬ÕÕ°„Àâ¡“°æÕ23 ‡æ◊ËÕªÑÕß°—π‰¡à„À⇰‘¥
¿“«–‡¬◊ËÕ∫ÿ™àÕß∑âÕßÕ—°‡ ∫®“°πÈ”¥’ (bile peritonitis) À√◊Õ‡ªìπÀπÕß„π™àÕß∑âÕß
‚¥¬¬‘Ëß∑”°“√√–∫“¬‰¥â‡√Á«¡“°‡∑à“‰√°Á®–≈¥‚Õ°“ μ‘¥‡™◊ÈÕ‰¥â¡“°¢÷Èπ24
22 ®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬, ¡°√“§¡-‡¡…“¬π 2555
‡ªÑ“À¡“¬¢Õß°“√√—°…“∑àÕπÈ”¥’∫“¥‡®Á∫ §◊Õ ∑”„ÀâπÈ”¥’‰À≈‰¥âμ“¡ √’√«‘∑¬“ª°μ‘
(reconstitution of bile flow) ‚¥¬‰¡à¡’¿“«–·∑√°´âÕπ∑—Èß√–¬– —Èπ·≈–√–¬–¬“«
„πÕ¥’μμâÕßÕ“»—¬°“√ºà“μ—¥·°â‰¢ (surgical reconstruction with biliary enteric
anastomosis) ·μàªí®®ÿ∫—π°“√ àÕß°≈âÕß∑àÕπÈ”¥’¡’∫∑∫“∑„π°“√√—°…“‡æ‘Ë¡¢÷Èπ25
‚¥¬‡©æ“–Õ¬à“߬‘Ëß„π°√≥’∑’Ë∑àÕπÈ”¥’´â“¬·≈–¢«“¬—߇™◊ËÕ¡μàÕ°—π ·μà∂â“∑àÕπÈ”¥’´â“¬
·≈–¢«“‰¡à‡™◊ËÕ¡μàÕ°—π μâÕßÕ“»—¬°“√ºà“μ—¥‡ªìπÀ≈—° ERCP ®–¡’ª√–‚¬™πå„π·ßà
°“√«‘π‘®©—¬‡∑à“π—Èπ
®ÿ¥¡ÿàßÀ¡“¬°“√ àÕß°≈âÕß∑àÕπÈ”¥’ (ERCP) „π°“√√—°…“∑àÕπÈ”¥’√—Ë«
1. ≈¥§«“¡¥—π¿“¬„π∑àÕπÈ”¥’ (transpapillary pressure gradient) ‚¥¬
∑”°“√μ—¥ÀŸ√Ÿ¥∑“߇¥‘ππÈ”¥’‚¥¬«‘∏’ àÕß°≈âÕß (endoscopic sphincterotomy - ES)
‡æ◊ËÕ≈¥·√ßμ÷ß∑’Ë sphincter of Oddi ∑”„ÀâπÈ”¥’‰À≈ºà“π≈ß¡“∑“ß≈”‰ â‡≈Á° à«πμâπ
䴉 дǡ
2. ‡™◊ËÕ¡μàÕ∑àÕπÈ”¥’∫√‘‡«≥∑’Ë√—Ë«‡æ◊ËÕ„ÀâπÈ”¥’‰À≈ºà“π¡“‰¥â ‚¥¬Õ“»—¬°“√„ à
∑àÕ√–∫“¬πÈ”¥’ (biliary stent) ´÷Ëß®–™à«¬∑”„Àâμ”·Àπàß∑’Ë√—Ë«ªî¥‡√Á«¢÷Èπ¥â«¬
°“√√—°…“∑àÕπÈ”¥’√—Ë«À≈—ß®“°ºà“μ—¥ LC ¥â«¬°“√ àÕß°≈âÕß ®–∑”§«∫§Ÿà‰ª
°—∫°“√„ à “¬√–∫“¬πÈ”¥’∑’˧â“ß„π™àÕß∑âÕß (biloma) ¡’ 3 «‘∏’À≈—°Ê ‰¥â·°à
1. °“√ àÕß°≈âÕß∑“߇¥‘ππÈ”¥’√à«¡°—∫°“√„ à∑àÕ√–∫“¬πÈ”¥’∑“ß®¡Ÿ° (ERCP
with nasobiliary tube drainage) Õ“®∑”√à«¡°—∫°“√μ—¥ÀŸ√Ÿ¥∑“߇¥‘ππÈ”¥’ (sphinc-
terotomy) À√◊Õ‰¡à°Á‰¥â ·μà«‘∏’π’È®–∑”„À⺟âªÉ«¬∂Ÿ°√∫°«π®“° “¬∑’Ë®¡Ÿ°®÷ß¡—°‰¡à
‡ªìπ∑’Ëπ‘¬¡‡∑à“∑’˧«√26
2. °“√μ—¥ÀŸ√Ÿ¥∑“߇¥‘ππÈ”¥’‚¥¬«‘∏’ àÕß°≈âÕß (endoscopic sphinctero-
tomy) „™â√—°…“°√≥’∑’Ë∑àÕπÈ”¥’√—Ë«πâÕ¬‚¥¬‰¡àμâÕß„ à∑àÕ√–∫“¬πÈ”¥’√à«¡¥â«¬
3. °“√„ à∑àÕ√–∫“¬πÈ”¥’ (bIliary stent placement) (¿“æ∑’Ë 3) ‚¥¬„π
∫“ߧ√—ÈßÕ“®∑”√à«¡°—∫°“√μ—¥ÀŸ√Ÿ¥∑“߇¥‘ππÈ”¥’ (sphincterotomy)
¡’À≈“¬°“√»÷°…“∑’Ë· ¥ß∂÷ߪ√– ‘∑∏‘¿“æ¢Õß°“√„™â∑àÕ√–∫“¬πÈ”¥’ (biliary
stent) ·≈–°“√μ—¥ÀŸ√Ÿ¥∑“߇¥‘ππÈ”¥’ (sphincterotomy) ‡æ◊ËÕ√—°…“∑àÕπÈ”¥’√—Ë«À≈—ß∑”
23Endoscopic Management of Postcholecystectomy Biliary Leakage
LC ªí®®ÿ∫—π¬—߉¡à¡’°“√∑¥≈Õß·∫∫ ÿà¡∑’Ë¡’°≈ÿࡧ«∫§ÿ¡ (randomized controlled tri-
als) „π§π à«π„À≠à‡ªìπ°“√√“¬ß“π®“°°“√√«∫√«¡√“¬ß“π°≈ÿࡺŸâªÉ«¬∑’Ë¡’®”π«π
‰¡à¡“° (case series) ·≈–‡ªìπ·∫∫»÷°…“¢âÕ¡Ÿ≈¬âÕπÀ≈—ß (retrospective)
„π°√≥’∑’Ë∑àÕπÈ”¥’√—Ë«πâÕ¬ (low-grade leaks) °“√∑” endoscopic sphinc-
terotomy ‡æ’¬ßÕ¬à“߇¥’¬«°ÁÕ“®®–‡æ’¬ßæÕ ‡π◊ËÕß®“° “¡“√∂≈¥§«“¡¥—π¿“¬
„π∑àÕπÈ”¥’‰¥âª√–¡“≥√âÕ¬≈– 9027 ®“°°“√»÷°…“¢Õß Sandha ·≈–§≥–6 æ∫«à“
¡’ºŸâªÉ«¬ 75 ®“° 104 √“¬∑’Ë∑àÕπÈ”¥’√—Ë«πâÕ¬ (low-grade leaks) ∑’ˉ¥â√—∫°“√√—°…“
¥â«¬ endoscopic sphincterotomy ‡æ’¬ßÕ¬à“߇¥’¬« ‡π◊ËÕß®“°Õ’° 29 √“¬¡’§«“¡
®”‡ªìπμâÕß„ à stent ®“°‡ÀμÿÕ◊Ë𠇙àπ ∑àÕπÈ”¥’μ’∫ ¿“«–‡≈◊Õ¥·¢Áßμ—«º‘¥ª°μ‘
(coagulopathy) μ‘¥‡™◊ÈÕ„π°√–· ‡≈◊Õ¥√ÿπ·√ß (severe sepsis) ∑”„Àâ®”‡ªìπμâÕß
ªî¥∑àÕπÈ”¥’∑’Ë√—Ë«∑—π∑’ „π®”π«ππ’È¡’ 68 √“¬ (√âÕ¬≈– 91) ∑’˪√– ∫§«“¡ ”‡√Á®
°√≥’∑’Ë∑àÕπÈ”¥’√—Ë«¡“° (high-grade leaks) §«√‰¥â√—∫°“√√—°…“‚¥¬°“√„ à
∑àÕ√–∫“¬πÈ”¥’ (biliary stent) ™—Ë«§√“«6 ‡π◊ËÕß®“°°“√∑” sphincterotomy ‡æ’¬ß
Õ¬à“߇¥’¬«‰¡à “¡“√∂≈¥§«“¡¥—π∫√‘‡«≥ÀŸ√Ÿ¥∑àÕπÈ”¥’ (transpapillary pressure gra-
dient) ‰¥âæÕ
®“°¢âÕ¡Ÿ≈√«∫√«¡¬âÕπÀ≈—ß∑’Ë MAYO clinic „πºŸâªÉ«¬ 89 √“¬∑’Ë¡’¿“«–
∑àÕπÈ”¥’√—Ë«À≈—ߺà“μ—¥∂ÿßπÈ”¥’ (postcholecystectomy bile leakage) æ∫«à“™à«ß
¿“æ∑’Ë 3 Cholangiogram · ¥ß°“√„ à plas-
tic stent ‡æ◊ËÕ√—°…“∑àÕπÈ”¥’μ’∫ (≈Ÿ°
»√™’È)
24 ®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬, ¡°√“§¡-‡¡…“¬π 2555
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25Endoscopic Management of Postcholecystectomy Biliary Leakage
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wee
ks -
3 ye
ars);
Surg
ery
52 c
ases
und
erwe
nt
ERCP
Koza
rek e
t al38
OC-7
; LC-
26re
trosp
ectiv
eES
±sten
t; St
ent
N/A
25/29
(86%
)3
stent
migr
ation
;1
year
F/U
; 29
case
s
(199
4)(b
ile d
uct
1 ch
olang
itis;
unde
rwen
t ERC
P
leak 2
6)1
death
Foutc
h et
al39OC
-8;
retro
spec
tive
ES±s
tent;
Aver
age
of22
/25 (8
8%)
1 Mi
nor a
mpull
aF/
U 1-
29 m
onths
(199
3)LC
-11;
Sten
t; ES
±NBD
8 we
eks
bleed
ing(m
ean
8 mo
nths)
Othe
rs-4
(1-1
6 we
eks)
Note
: FCS
EMS
= fu
lly c
over
ed s
elf e
xpan
dable
met
allic
stent
; OC
= op
en c
holec
yste
ctom
y; LC
= la
paro
scop
ic ch
olecy
stecto
my;
ES =
end
osco
pic s
phinc
tero
tom
y; NB
D =
naso
biliar
y dr
ainag
e
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10 ¢ÕߺŸâªÉ«¬‰¡àμÕ∫ πÕßμàÕ°“√√—°…“‚¥¬°“√ àÕß°≈âÕß«‘∏’¡“μ√∞“π πÕ°®“°π’È
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√—°…“ºŸâªÉ«¬∑’Ë¡’∑àÕπÈ”¥’√—Ë«À≈—ߺà“μ—¥∂ÿßπÈ”¥’‚¥¬°“√ àÕß°≈âÕß æÕ √ÿª‰¥â¥—ß ¿“æ∑’Ë 4
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27Endoscopic Management of Postcholecystectomy Biliary Leakage
‡Õ° “√Õâ“ßÕ‘ß
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