儿童先天性胆管扩张症的诊断与治疗

目的:探讨儿童先天性胆管扩张症(CBD)的临床、病理、影像特点及治疗.方法:回顾性分析58例经影像学检查、手术和病理证实CBD患儿的临床资料.结果:58例均出现临床症状,主要表现为腹痛、黄疸、腹部肿块,部分患者合并发热、呕吐症状.CT(45例)、超声(40例)、MRCP(17例)检查均显示胆管扩张;11例MRCP诊断为胰胆管合流异常(PBM).57例成功进行术中胆道造影,影像和手术分型:Ⅰ型43例,其中囊状35例,8例表现为梭型或柱形;Ⅱ型2例;Ⅳ型13例;未发现Ⅲ型患者.58例患儿术后病理显示CBD囊壁纤维组织增生,囊肿壁内衬上皮部分或全部脱落,40例囊壁伴有炎症,39例慢性胆囊炎.53例行一次性囊肿切除肝管空肠Roux-en-Y吻合术,5例先行胆道外引流后二次肝管空肠Roux-en-Y吻合术,术后短期均无严重并发症发生.随访1～9年,患儿无胆道梗阻、胆管炎、肠梗阻和胆道肿瘤发生.结论:超声检查、术中造影、CT和MRCP均对儿童CBD诊断有一定价值;MRCP为CBD合并PBM首选诊断方法;儿童CBD的治疗应早期采用肝管空肠Roux-en-Y吻合术.     

成人Ⅰ型胆总管囊肿的诊治体会

目的探讨成人Ⅰ型胆总管囊肿的诊断和治疗。方法回顾性分析1997年1月至2004年7月期间收治的8例成人Ⅰ型胆总管囊肿的临床资料。结果5例行胆总管囊肿全切除、Roux-en-Y肝管空肠吻合术；2例行囊肿部分切除、Roux-en-Y囊肿空肠吻合术；1例行囊肿部分切除、Roux-en-Y肝管空肠吻合术，术中常规行胆道镜检查，无一例手术死亡。8例患者术后平均随访2．8年（1～7年），未发现胆道恶性肿瘤。1例行囊肿部分切除的患者，在术后出现3次右上腹绞痛，1次急性胆管炎表现，均经支持、对症、抗感染等治疗后好转。结论成人Ⅰ型胆总管囊肿的诊断主要依靠B超、逆行胰胆管造影（ERCP）或磁共振胆胰管造影（MRCP）检查，囊肿全切除、Roux-en-Y肝管空肠吻合是安全、有效的手术方式，其疗效比较满意；囊肿部分切除、Roux-en-Y囊肿空肠吻合术虽疗效不及完整囊肿切除令人满意，但对于在技术上难以作到囊肿完全切除者，部分囊肿切除是明智的选择，建议术中常规胆道镜检查。     

成人先天性胆总管囊肿的诊断和治疗

目的 探讨成人先天性胆总管囊肿的诊断及手术疗效.方法 回顾性分析1997年1月至2010年12月南京医科大学第一附属医院手术治疗的58例成人先天性胆管囊肿患者的临床资料.术前采用B超、CT、MRCP和ERCP检查,确诊后根据Todani分型决定手术方式.计量资料采用t检验;计数或等级资料采用x2检验.结果 58例患者中,术前腹部B超、CT、MRCP和ERCP检查确诊率分别为78％ (45/58)、92％(23/25)、9/9和5/5.手术治疗方式为开腹胆总管囊肿切除+肝管空肠Roux-en-Y吻合术41例(其中2例为腹腔镜中转开腹手术);腹腔镜胆总管囊肿切除+肝管空肠Roux-en-Y吻合术8例;胰十二指肠切除术3例(其中1例联合肝部分切除术);胆总管囊肿并部分肝叶切除+肝管空肠Roux-en-Y吻合术2例;胆囊切除+胆总管探查术2例;左半肝切除术1例;因肿瘤晚期行囊肿外引流术1例.胆总管囊肿切除+肝管空肠Roux-en-Y术中,开腹手术与腹腔镜手术平均手术时间分别为(235±70) min和(320±50) min,两者比较,差异有统计学意义(=3.157,P＜0.05);术后并发症发生率分别为18％(7/39)和3/8,两者比较,差异无统计学意义(x2 =1.515,P＞0.05);术后平均住院时间分别为(10.0±2.3)d和(12.6±6.6)d,两者比较,差异有统计学意义(t=2.162,P＜0.05).术后病理检查发现患者癌变率为10％(6/58).全组患者无围手术期死亡,手术并发症发生率为24％(t4/58).随访1～15年,良性病变患者无严重远期并发症;6例癌变患者中4例于术后1年内死亡,另2例已分别生存3年和5年.结论 成人先天性胆总管囊肿影像学诊断首选腹部B超检查,MRCP检查是诊断金标准.患者确诊后应尽早手术治疗,首选术式为完整胆总管囊肿切除+肝管空肠Roux-en-Y吻合术.     

Ⅰ型先天性胆总管囊肿的手术治疗

目的探讨Ⅰ型先天性胆总管囊肿的手术治疗。方法回顾性分析笔者所在医院1987年3月至2011年6月期间收治的42例Ⅰ型先天性胆总管囊肿患者手术治疗后的效果。结果本组中2例因并发腹膜炎先行囊肿外引流术后4周再行囊肿空肠吻合术;3例直接行囊肿空肠吻合术;35例行囊肿切除肝总管空肠Roux-en-Y吻合术;2例行囊肿切除间置空肠肝总管十二指肠吻合术。手术成功率为100%。5例内引流术(囊肿空肠吻合术)后均有不同程度的胆道感染症状。37例行囊肿根治术(即囊肿切除肝总管空肠Roux-en-Y吻合或间置空肠肝总管十二指肠吻合术)中有2例囊肿切除肝总管空肠Roux-en-Y吻合术后患者偶有右上腹隐痛不适,经X线钡餐检查,诊断为胆管逆行性感染,抗炎治疗有效;其余病例无腹痛、黄疸、发热、再生结石、吻合口狭窄、癌变及其他手术并发症。结论囊肿外引流术仅作为急诊手术,待患者一般情况改善后再行第二次手术;囊肿根治术是治疗Ⅰ型先天性胆总管囊肿理想的手术方式。     

成人胆总管囊肿的诊断和治疗(附72例分析)

目的:探讨成人胆总管囊肿的诊断和治疗。方法:收集2004年5月—2009年5月收治的72例成人胆总管囊肿患者临床资料,其中男20例,女52例,年龄18~67岁(平均31岁)。Ⅰ型41例,Ⅳa型28例,Ⅳb型3例,无其他类型患者。4例囊肿癌变患者因多发脏器受累未能行手术治疗,余68例均行手术治疗。1例行胰十二指肠切除术,1例行胆总管囊肿切除+左半肝切除术,余66例行胆总管囊肿切除+肝管空肠Roux-en-Y吻合术,其中17例联合肝部分切除术。结果:术后出现近期并发症者6例(8.8%)。随访1~8年,4例癌变未手术患者均于确诊后2年内死亡,8例(11.7%)出现远期并发症。结论:成人胆总管囊肿患者明确诊断后,应尽早手术,将囊肿完整切除术,达到改善患者生活质量、延长患者生存时间的目的,手术方式以胆总管囊肿切除+肝管空肠Roux-en-Y吻合为首选术式。     

完全腹腔镜手术治疗成人先天性胆总管囊肿的临床分析

目的:探讨完全腹腔镜胆总管囊肿切除并肝管空肠Roux-en-Y吻合术治疗成人先天性胆总管囊肿的可行性、安全性及疗效。方法:回顾性分析昆明医科大学第一附属医院2014年5月—2016年5月12例行腹腔镜下胆总管囊肿手术治疗患者的临床资料。结果:11例患者完全腹腔镜下完成胆总管囊肿切除+肝管空肠吻合术,1例为减少手术费用在腹腔外行手工肠肠吻合。手术时间240~310 min,平均280 min;术中出血20~150 m L,平均60 m L;术后住院时间5~7 d,平均6.5 d。术后随访2~12个月,未出现手术并发症,无死亡病例。结论:完全腹腔镜下胆总管囊肿切除+肝管空肠Roux-en-Y吻合术治疗成人先天性胆总管囊肿是安全可行的,且具有明显微创优势,可进一步推广。     

先天性胆管囊状扩张症的手术治疗体会

目的探讨先天性胆管囊状扩张症的手术方法。方法回顾性分析我院2005年1月至2008年8月15例先天性胆总管囊状扩张症的临床资料。11例（9例Ⅰ型、2例Ⅳ型）行胆总管囊肿切除＋肝总管空肠Roux-en-Y吻合术,1例Ⅰ型癌变行胰头十二指肠切除术,Ⅱ型1例行单纯囊肿切除＋T管引流术,Ⅲ型1例行Oddi括约肌成形术,Ⅴ型1例行肝门部胆管空肠Roux-en-Y吻合术。结果全组15例均恢复顺利,无一例发生胆瘘、胰瘘,1例Ⅳ型病人术后出现肝内胆管结石并反复发作胆管炎。结论手术是先天性胆管囊状扩张症惟一有效的治疗方法,胆总管囊肿切除、肝管空肠Roux-en-Y吻合术是Ⅰ型先天性胆管囊状扩张症的一种较为合理的手术方式。     

腹腔镜先天性胆总管囊肿切除术

目的 比较开腹和腹腔镜手术治疗先天性胆总管囊肿的效果.方法 回顾性分析1999年5月至2007年3月140例先天性胆总管囊肿患儿的临床资料.按不同手术方法分为开腹组和腹腔镜组,均采用胆总管囊肿切除+肝管空肠Roux-en-Y吻合术,比较两组疗效.结果 1999年5月至2001年2月开腹组收治患儿38例,2001年4月至2007年3月腹腔镜组收治患儿102例.平均手术时间:开腹组190 min,腹腔镜组224 min.开腹组术中、术后输血3例.腹腔镜组无术中、术后输血.开腹组术后并发症发生率为16%(6/38),明显高于腹腔镜组的5%(5/102),两组比较差异有统计学意义(χ2=4.33,P<0.05).结论 对于先天性胆总管囊肿患儿采用腹腔镜行胆总管囊肿切除+肝管空肠Roux-en-Y吻合术治疗,手术打击小,术后恢复快.     

成人先天性胆管囊状扩张症的临床分析

目的:探讨成人先天性胆管囊状扩张症的诊断及治疗。方法:回顾性分析1996年1月—2012年5月收治的53例成人先天性胆管囊状扩张症患者的临床资料。结果:53例患者均行手术治疗,Ia,Ib,Ic型39例和II型4例行囊肿完整切除、肝总管空肠Roux-en-Y吻合术,另3例Ia型行囊肿大部分切除、肝总管空肠Roux-en-Y吻合术;IVa型1例行肝左外叶切除、囊肿完整切除、胆管成形、肝总管空肠Roux-en-Y吻合术,另1例行囊肿完整切除、肝总管空肠Roux-en-Y吻合术;V型1例行左肝内胆管囊肿切除术;2例癌变患者,其中1例行癌变囊肿切除、局部转移淋巴结清扫术,1例行囊肿切除、左肝内胆管肿瘤切除术。53例手术患者中获随访42例,随访时间为6个月至3年,良性患者情况良好;2例癌变患者,1例术后生存26个月,死于肿瘤复发,多系统器官功能衰竭,1例术后26个月肿瘤复发,肝转移,再次手术行左半肝切除、S5(第V段肝脏)切除、肝肠吻合术,术后2个月出现肿瘤进展,死于多系统器官功能衰竭。结论:成人先天性胆管囊状扩张症的手术方式选择与治疗效果密切相关,不同的临床分型应选择不同的手术方式。     

先天性胆总管囊肿外科治疗

目的 探讨先天性胆总管囊肿最佳术式及术后并发症的预防。方法 分析50例先天性胆总管囊肿手术时机、手术方法、治疗效果。结果 15例行胆总管囊肿切除、肝总管空肠Roux-en-Y吻合,术后症状复发1例;35例行胆总管囊肿十二指肠或空肠吻合术,术后症状复发20例。结论 先天性胆总管囊肿的手术治疗以囊肿切除、胆管空肠吻合最佳;术中应尽可能作大口吻合;避免行单纯囊肿内引流,急症情况下可先行囊肿外引流。     

儿童胆道扩张症与胰胆管合流异常的相关性

目的 通过回顾性分析先天性胆道扩张症（CBD）临床病例资料,比较合并胰胆管合流异常（PBM）与无合流异常病例的临床特征之间的差异,探讨PBM以及共同管长度与CBD的发病、临床症状、相关实验室检查结果的相关性,为CBD的发病机理和诊断治疗提供新的理论依据。方法 回顾性总结2017年1月至2019年12月首都医科大学附属北京儿童医院普外科收治的胆道扩张症病例临床资料,83例胆道扩张症患儿纳入研究,以MRCP中胰胆管共同管长度为分组标准,分为合流异常组（共同管长度≥5 mm,n=47）与非合流异常组（共同管长度＜5 mm,n=36）,研究指标包括发病年龄、性别、临床症状、相关实验室检查、共同管长度、胆道结石以及胆总管囊肿大小,研究结果采用非参数检验和χ2 检验。结果 在临床症状中,发热、黄疸、白色大便及胆道结石两组间无统计学差异（P＞0.05）,腹痛症状合流异常组多于无合流组（P＜0.05）;实验室检查结果AST、ALT、TBIL、DBIL及IBIL两组间无统计学差异（P＞0.05）,血清淀粉酶检测合流异常组高于无合流异常组（P＜0.05）;合流异常组胆总管呈囊肿型32例（38.6%）,梭型15例（18.1%）,无合流异常组胆总管呈囊肿型26例（31.3%）,梭型10例（12.0%）,两组间无统计学差异（P＞0.05）,但胆总管囊肿体积合流异常组小于无合流异常组（P=0.02）。结论 先天性胆道扩张症合并胰胆管合流异常的患儿出现腹痛症状较早、较严重,同时血清淀粉酶较高,合并胰腺炎较常见,故易于做出早期诊断,可能也是本组胆总管囊肿体积较小的原因。本研究胰胆管共同管长短与先天性胆道扩张症的临床症状、肝功能、胆红素及血清淀粉酶等水平无明确相关性,故不能单纯以胰胆管共同管长度判断病情轻重。     

胆总管囊肿切除术治疗先天性胆总管囊肿的术式比较

目的 评价腹腔镜胆总管囊肿切除术治疗先天性胆总管囊肿患者的疗效.方法 40例先天性胆总管囊肿患者随机分为开腹手术组和腹腔镜手术组,开腹组行开腹胆总管囊肿切除术,腹腔镜组在腹腔镜下采用胆总管囊肿切除术.结果 两组40例手术均顺利完成.腹腔镜组手术时间较开腹组长(P＜0.01);但腹腔镜组术中出血量、肛门排气时间、术后进食时间、术后住院时间以及切口大小等均明显优于开腹组(均P＜0.001);治疗和随访(随访1年)过程中两组未见与手术直接相关的严重并发症.结论 腹腔镜胆总管囊肿切除术治疗先天性胆总管囊肿患者虽然手术时间较开腹组长、费用可能要比开腹组高,但疗效佳、安全.     

胰胆管合流异常与先天性胆总管囊肿

目的:探讨胰胆管合流异常(PBM)致先天性胆总管囊肿(CCC)的可能机制。方法:将21例经B超诊断为胆总管囊肿患者行ERCP检查，检查时经选择性胆管插管抽取胆汁检测其中淀粉酶(AMS)及C反应蛋白(CRP)浓度。结果: 21例PBM均合并CCC，其中13例为胆管合流型(C-P型)，8例为胰管合流型(P-C型) PBM。21例胆汁中AMS及CRP浓度均较对照组显著升高(P<0.01)，C-P型较P-C型升高更明显(P<0.05)。 结论:PBM可能是CCC形成的解剖学基础，胰液返流至胆管，被激活的高浓度胰酶破坏胆管壁，则可能是CCC形成的促发因素。     

Laparoscopic resection of congenital choledochal cyst, hepaticojejunostomy, and externally made Roux-en-Y anastomosis

The authors present a 3-month-old patient with a congenital choledochal cyst, which was asymptomatic until treatment. On laparoscopy, a type I choledochal cyst was confirmed and excised laparoscopically. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. A laparoscopic end-to-side hepaticojejunostomy was carried out. The operation lasted 4½ hours, without intraoperative problems. Oral food intake was started on day 2 and well tolerated with bile stained stools. Symptoms of bowel obstruction occurred on day 8. On minilaparotomy, the Roux-en-Y anastomosis was found to be adherent to the mesenterium of the colon, leading to obstruction. After mobilizing the loop, the postoperative course was uneventful. We conclude that laparoscopic resection of congenital choledochal cyst and choledochojejunostomy was feasible in the youngest patient operated on so far. However, adhesive small bowel obstruction can also occur, as after conventional operation, when the bowel is exteriorized for Roux-en-Y hepaticojejunostomy.     

Laparoscopic-assisted total cyst excision of choledochal cyst and Roux-en-Y hepatoenterostomy

Purpose

The aim of this study was to describe the technical experience and outcome in laparoscopic-assisted total cyst excision of choledochal cyst with Roux-en-Y hepatoenterostomy.

Methods

Thirty-five patients with choledochal cyst were studied. Their age ranged from 3 months to 9 years (average age, 3.6 years). The choledochal cysts were cyst type in 33 cases and fusiform type in the other 2 cases. Four trocars were utilized with 3- to 5-mm instrumentation. Under laparoscopic guidance, the gallbladder and the dilated bile duct were excised completely. The Roux-en-Y jejunojejunostomy was performed extracorporeally by exteriorizing the jejunum through the extending umbilical incision (1.5 to 2 cm), and an end-to-side hepaticojejunostomy was carried out intracorporeally by the hand suture methods.

Results

Average duration of operation was 4.3 hours (range, 3.5 to 7.6 hours), intraoperative blood loss was 5 to 10 mL, and 8 of the 35 patients had associated hepatic ductal stenosis and underwent laparoscopic excision of the cyst and ductoplasty. In 1 of the 8 cases, bile leak was noticed from day 1 through 26 postoperatively. The postoperative course was uneventful in the other 34 patients with a hospital postoperative stay ranging from 3 to 6 days. There were no postoperative complications in the 3-month to 1-year follow-up.

Conclusions

Laparoscopic-assisted total cyst excision with Roux-en-Y hepatoenterostomy is feasible for the treatment of choledochal cyst in children.     

Laparoscopic Resection Of Congenital Choledochal Cyst, Choledochojejunostomy, and extraabdominal Roux-en-Y anastomosis

Background The feasibility of laparoscopic resection of choledochal cyst and hepaticojejunostomy in children is still unclear. This report presents the author’s experience with a first series of patients. Methods Data from 11 consecutive children (median age 17.5 months, SD 22, range 2 to 70) with choledochal cyst scheduled for laparoscopy were collected prospectively. There were nine type I and 2 type V cysts according to Todani’s classification. All except one patient had intermittent jaundice or recurrent pancreatitis. The laparoscopic technique included excision of the cyst. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. After repositioning of the bowel an end-to-side hepaticojejunostomy was carried out laparoscopically. Results The procedures were carried out in nine children without intraoperative events and a median duration of 289 min (SD 62). In two patients, the operation was converted after 60 and 90 min due to a lack of overview at the dorsal margin with problems in separation of the portal vein. Oral food intake was started within 2 days and tolerated well in all except one patient, in whom biliar fluid from the drain led to laparoscopic reevaluation on day 1. A small leak was resutured and the patient was discharged on day 5. In one patient, recurrent cholangitis and a dilated Roux-en-Y loop led to correction of some kinking of the loop via laparotomy after 3 months. All other patients are well with bile-stained stools after a mean follow-up of 13 months. Conclusions Laparoscopic resection of congenital choledochal cyst and choledochojejunostomy in children is feasible. We feel that there is a considerable learning curve with the technique. Future studies will have to prove the feasibility of laparoscopic Roux-en-Y bowel anastomosis without the need for bowel exteriorization.     

An adult choledochal cyst—the magnetic resonance cholangiopancreatography findings: Report of a case

We herein report an unusual adult patient with a congenital choledochal cyst. A 28-year-old woman presented with recurrent episodes of abdominal pain in the right upper quadrant. Abdominal ultrasonography showed fusiform dilatation of the common bile duct without any obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) were performed to make a precise diagnosis. No abnormal pancreatobiliary junction was detected on ERCP. The MRCP images more clearly defined the type and extent of the choledochal cyst as observed at surgery. The cyst and gallbladder were excised and a Roux-en-Y hepaticojejunostomy was performed. We also reviewed the relevant English literature and concluded that MRCP offers diagnostic information that is equivalent or superior to that of ERCP for the evaluation of type I choledochal cysts in adults and because this modality is noninvasive, it should therefore be the preferred imaging technique for an examination of adult patients with choledochal cysts.     

345例成人先天性胆总管囊肿诊治经验

目的 总结成人先天性胆总管囊肿的诊治经验.方法 回顾性分析1974-2007年收治的345例成人先天性胆总管囊肿患者的临床资料.结果 345例中具有典型临床表现(腹痛、黄疸、腹部肿块三联征)者仅110例.345例检查辅以BUS、CT、ERCP、PTC、MRCP获得确诊,其中BUS检查321例,有311例确诊,确诊率为96.9%.19例囊肿内引流术后发生癌变,癌变率为31%,明显高于未手术者(未住院且拒绝手术的72例中有3例癌变,癌变率为4.2%).345例均行手术治疗,其中284例次行囊肿切除、肝管空肠Roux-en-Y形吻合胆道重建术.337例手术后早期恢复,近期(术后2～3周)死亡8例(2.3%).结论 成人先天性胆总管囊肿仅靠临床表现不易确诊,还应辅以BUS、CT、ERCP、PTC及MRCP等检查,其中BUS是较好的早期诊断方法.手术以采用囊肿切除、肝管空肠Roux-en-Y形吻合胆道重建术为优.