肝切除术后新发胆总管结石致肝切缘胆瘘：病例报告及肝脏手术后胆漏的文献综述

Biliary Fistula at the Margin of Liver Caused by New Common Bile Duct Stones after Hepatectomy: A Case Report and Literature Review of Bile Leakage after Liver Surgery

摘要: 目的：探讨肝部分切除术后短期因新发胆总管结石导致肝切缘胆漏(POBL)的临床特点、诊治过程及预后。方法：报告1例51岁男性患者，因肝血管瘤行肝部分切除术，术后第83天出现右上腹疼痛及黄疸加重入院。影像学提示：肝周积液、肝S8低密度灶及胆总管下段新发结石，实验室检查显示肝功能异常。治疗过程中分阶段实施十二指肠乳头肌切开取石、内镜逆行胰胆管造影(ERCP)、短期经鼻胆管引流(ENBD)、超声引导经皮经肝胆管引流(PTCD)及内镜下胆管支架置入术，最终瘘道愈合良好，肝功能恢复正常。结果：文献复习并纳入18例POBL病例，平均年龄51.89岁，男性占76.47%，主要表现为右上腹痛和黄疸，确诊多依赖CT或MRCP。POBL发生的影响因素包括术中胆管损伤、残端处理不当、术后感染、高胆红素血症、糖尿病等。胆管结石形成具有多因素渐进性特点，时间跨度从数周至数年不等，本例为首次明确报道术后短期结石致POBL。结论：肝部分切除术后发生POBL除常见病因外，应警惕早期胆管结石形成的可能。治疗应采取分阶段、多模式综合策略，先解除梗阻，再行支架植入与引流，以提高瘘道愈合率和改善预后。本病例拓展了POBL病因谱，为类似复杂病例的诊治提供了循证依据。

Abstract: Objective: To investigate the clinical characteristics, management, and prognosis of post-hepatectomy bile leak (POBL) at the liver resection margin caused by newly developed common bile duct (CBD) stones in the early postoperative period. Methods: We report a case of a 51-year-old male who underwent partial hepatectomy for hepatic hemangioma and was readmitted on postoperative day 83 with right upper quadrant pain and worsening jaundice. Imaging revealed perihepatic fluid collection, a low-density lesion in segment 8 of the liver, and a newly formed stone in the distal CBD. Laboratory tests indicated abnormal liver function. A staged therapeutic approach was adopted, including endoscopic sphincterotomy with stone extraction, endoscopic retrograde cholangiopancreatography (ERCP), short-term endoscopic nasobiliary drainage (ENBD), ultrasound-guided percutaneous transhepatic biliary drainage (PTCD), and endoscopic biliary stent placement. The bile leak eventually healed, and liver function returned to normal. Results: Literature review identified 18 reported cases of POBL, with a mean age of 51.89 years and 76.47% being male. The predominant clinical manifestations were right upper quadrant pain and jaundice, with diagnosis mainly relying on CT or MRCP. Risk factors for POBL included intraoperative bile duct injury, inadequate management of the bile duct stump, postoperative infection, hyperbilirubinemia, and diabetes mellitus. CBD stone formation is a multifactorial, progressive process, with a time course ranging from weeks to years. This is the first clearly documented case of early postoperative CBD stone formation leading to POBL. Conclusion: In addition to common etiologies, early CBD stone formation should be considered in the differential diagnosis of POBL after partial hepatectomy. A staged, multimodal treatment strategy—first relieving obstruction, then performing stent placement and drainage—can improve bile leak healing rates and patient outcomes. This case expands the etiological spectrum of POBL and provides evidence-based guidance for the management of similar complex cases.