敞开囊腔紧贴囊壁切除囊肿治疗先天性胆总管囊肿

先天性胆总管囊肿为最常见的一种先天性胆道扩张症。切除囊肿胆道重建术已被公认为先天性胆总管囊肿的首选治疗方法,但任何保留囊壁的手术都被认为是姑息性的。随着病例的增多、经验的积累、技巧的提高、手术各环节日益完善,有关手术并发症逐渐减少。囊肿切除方法已从完整剥离囊肿法向囊腔敞开横断剥离切除囊肿法转变。我院自2003年2月至10月间收治先天性胆总管囊肿7例,     

急危重胆总管囊肿的治疗(附41例报道)

目的探讨急危重胆总管囊肿的治疗。方法对我院1984-2001年收治的41例急危重胆总管囊肿患者的临床资料进行回顾性分析。结果41例患者均行囊肿切除、胆道重建术，其中3例患者分两期完成，全部病例均获治愈，随访9例近、远期效果均较好。结论囊肿切除、胆道重建术已成为根治胆总管囊肿的首选术式．但必须做好高危因素的处理．以提高手术安全性及疗效．只要度过围手术期．其预后较好。     

囊肿切除胆道重建治疗胆总管囊肿20年经验

目的 探讨改进胆总管囊肿切除的疗效及预防胆道重建术后并发症。方法 总结1981-2000年49例胆总管囊肿施行切除及胆道重建术的疗效。其中地994年前的22例保留囊肿后壁一期囊肿次全切除,胆总管近端或肝总管远端保留少许囊壁与肠管吻合;近年27例行囊肿全部切除（4例外引流后二期切除）,扩大正常肝管与肠管吻合,吻合口≥3.0cm。结果 囊肿次全切除组手术死亡2例,胆瘘2例,切口感染2例,随访17例,4例常有腹痛、发热,的年囊肿全切组术后平稳,仅切口感染2例,21例随诊3个月-5年,仅1例偶有腹痛、发热。结论 胆总管囊肿全切除,扩大正常肝管吻合口可预防吻合口狭窄及复发性胆管炎等并发症。对全身情况差者先行胆囊或囊肿外引流,情况改善后二期囊肿切除可提高疗效。     

腹腔镜下胆总管囊肿根治切除及胆道重建术

目的探讨腹腔镜下行胆总管囊肿根治切除及胆道重建术的可行性。方法全身麻醉后腹腔镜辅助下按悬吊肝圆韧带、游离胆囊、术中胆道造影、游离切除囊肿、空肠Roux-Y吻合、肝管空肠吻合、缝合系膜裂孔、放置腹腔引流的步骤完成手术。结果 18例患者腹腔镜下顺利根治切除胆总管囊肿,15例经结肠后、3例经结肠前吻合胆道重建术,手术时间3.5～6.5h,2例术后出现并发症。结论经腹腔镜胆总管囊肿根治切除及胆道重建手术安全可靠,值得临床进一步推广应用。     

先天性胆总管囊肿的手术治疗经验

自１９７４年至１９９５年共手术治疗先天性胆总管囊肿１２３例，其中１０６例地囊肿切除、胆道重建术，讨论了囊肿发除的理论根据、手术步骤及要点、安放左右肝管支架管引流等问题，强调切除胆总管囊肿是治疗先天性胆总管囊肿最佳选择，肝、总管空肠Ｒｏｕｘ－ｅｎ－Ｙ型手术是胆道重建术的一种理想术式。     

成人胆总管囊肿的外科治疗

我院自１９７８年至１９９３年共收治成人胆总管囊肿４４例，其中３３例行囊肿切除，间置空肠、间置胆囊或空肠Ｒｏｕｘ一Ｙ型胆道重建术。文章讨论了成人胆总管囊肿的特点、囊肿切除的理论根据、手术要点、囊肿切除的优点。详细阐述了囊肿切除的具体操作方法。本组手术死亡２例（６％）。２５例（７５．８％）经１～１２年随访疗效满意。     

成人型胆总管囊肿诊治体会

目的 探讨成人型胆总管囊肿的诊断和手术治疗. 方法 回顾总结27例成人型胆总管囊肿的临床资料,术后随访3月~16年. 结果 B超,CT,ERCP,MRCP对胆总管囊肿的诊断率都比较高,尤其是ERCP和MRCP.除1例因囊肿恶变不能切除,3例因急性胆系感染并腹膜炎者单纯行内引流术外,其余23例均行囊肿切除、肝管空肠Roux-Y型胆道重建术. 结论 在胆总管囊肿诊断中应推广MRCP.手术方式首选囊肿切除、肝管空肠Roux-Y型胆道重建术.     

婴幼儿先天性胆总管囊肿自发穿孔的诊治

目的探讨先天性胆总管囊肿自发性穿孔的诊断和治疗。方法回顾性分析11例婴幼儿先天性胆总管囊肿自发性穿孔患儿的临床资料。结果本组8例经术前腹腔穿刺确诊胆道自发性穿孔,其中5例经B超或CT诊断胆总管囊肿。3例行一期胆总管囊肿切除加胆道重建术(胆总管空肠Roux-Y吻合术);6例行胆道外引流加腹腔引流术,2例行胆囊置管引流加腹腔引流术,3~6个月后行胆总管囊肿切除加胆道重建术。11例患儿治疗后均恢复良好。结论婴幼儿胆总管囊肿自发穿孔容易误诊,掌握其临床特点、提高诊断意识以及根据患儿具体情况选择合理的手术方式是提高术前诊断率和减少术后并发症的关键。     

先天性胆总管囊肿手术治疗经验

目的：总结先天性胆总管囊肿的手术治疗经验。方法：对194例先天性胆总管囊肿的手术治疗经验进行回顾性分析。结果：194例均行囊肿切除,胆道重建术：（1）肝管十二指肠吻合术4例;（2）间置空肠肝管十二指肠吻合术（人工乳头）15例;（3）间置胆囊肝管十二指肠吻合术4例;（4）肝管空肠Roux-en-Y型吻合术171例。本组190例术后恢复顺利,手术死亡4例（2．06％）。结论：囊肿可使胆汁流入胰管内并发胰腺炎,囊肿易癌变,囊肿可形成盲袋和死腔易形成结石,故囊肿切除胆道重建术是治疗先天性胆总管囊肿的最佳选择。尽管胆道建术式较多,但以肝总管空肠Roux-en-Y型吻合术是胆道重建术的一种理想手术。     

先天性胆总管囊肿再次手术的原因分析及治疗

目的 探讨先天性胆总管囊肿再次手术的原因及治疗方法.方法 对41例先天性胆总管囊肿再次手术患者的临床资料进行总结分析.结果 按先天性胆总管囊肿Todani分型,41例中Ⅰ型32例,Ⅱ型1例,Ⅳ型3例,Ⅴ型5例(其中1例呈弥漫性左右肝分布).既往有1次胆道手术史者30例,2次者8例,3次者3例.41例中合并有胆管结石40例,胆道感染33例,肝门部胆管狭窄7例,原胆肠吻合口狭窄6例,囊肿癌变5例.本次行切除肝外胆管囊肿、肝管空肠Boux-en-Y吻合术者32例,其中2例囊肿癌变者同时行肝十二指肠韧带骨骼化和区域淋巴结清扫术;行肝叶切除联合胆总管囊肿切除、肝管空肠Roux-en-Y吻合术者8例;行胆肠吻合口狭窄切开成形、胆肠内引流重建术1例.41例术后均获随访,随访时间3个月至10年,平均53.7±32.1个月,随访期内发生胆道感染4例,无吻合口狭窄或结石复发等并发症发生.结论 胆总管囊肿术式选择不当及诊断失误导致的多种并发症是导致再手术的主要原因,肝内外胆管囊肿切除、肝管空肠Roux-en-Y吻合术可取得较为满意的疗效.     

外科治疗小儿先天性胆总管囊肿20例体会

目的 总结外科治疗小儿先天性胆总管囊肿的疗效。方法 20例先天性胆总管囊肿患儿，6例先行外引流术，待3～5周病情平稳后，2例行Ⅱ期囊肿切除、胆总管空肠Roux-en-Y吻合术；9例行胆总管囊肿后壁囊内粘膜剥离及囊肿空肠Roux-en-Y吻合术；5例小囊肿行囊肿全切除及肝总管空肠Roux-en-Y吻合术。结果 1例行外引流的患者术后2d死于感染性休克、DIC，余19例中术后发牛腹水3例，胆肠吻合口瘘2例，切口裂开2例，肺部感染1例，经对症治疗后治愈。16例获8个月～8年获访，无明显胆道感染的临床表现。13例胃肠道钡餐检查，仅2例有反流但不超过空肠胆支的1／3；无一例发生癌变。结论 小儿先天性胆总管囊肿一经确诊应早期手术，手术时应尽量切除病变，并行适宜的胆道重建术。     

腹腔镜治疗小儿胆道穿孔12例临床体会

目的:总结腹腔镜手术治疗小儿胆道穿孔的临床体会。方法:2008年12月至2015年12月收治12例胆道穿孔患儿,均经腹腔镜探查证实为胆道穿孔,根据病情分别行胆总管囊肿T管引流+腹腔引流、胆囊造瘘术+腹腔引流、单纯腹腔引流。结果:12例患儿均成功完成手术,术后未出现胆道出血、胆漏等并发症。胆汁引流及腹腔引流24~72 h后,临床症状缓解,腹痛显著减轻,体温降至正常,黄疸逐步消退。8例胆总管囊肿穿孔患者术后6个月行二期胆总管囊肿切除、肝总管空肠Roux-Y吻合术,其中5例在腹腔镜下完成二期手术,3例因胆总管周围粘连重、分离困难中转开腹。结论:腹腔镜用于小儿自发性胆道穿孔的诊断与治疗避免了盲目开腹探查的缺点,创伤小,手术视野广,对腹腔及肠管干扰小,手术时间短,胆总管囊肿穿孔不影响二次腹腔镜手术。     

Caroli病11例报告

目的 探讨Caroli病的临床特点和诊治方法。方法 11例Caroli病人，对其临床资料进行回顾性总结。结果 曾有胆道手术史3例，合并胆道结石6例，癌变4例，合并肝外胆管囊肿5例，左肝局限囊状扩张5例，中肝5例，弥漫性胆管囊状扩张1例。手术治疗9例，采用胆总管囊肿切除＋中肝部分切除或左肝外侧叶切除＋胆肠内引流4例，单纯肝外囊肿切除＋内引流1例，另4例合并癌变病人，胆总管切开清除癌组织＋T管引流2例，探查活检2例。结论 提高对Caroli病的认识，减少误诊误治，降低癌变率，手术切除囊状扩张病灶，重建胆肠通道是有效治疗手段。     

Hepatic portocholecystostomy for biliary atresia.

Four infants with biliary atresia had gross obliteration of the common hepatic duct but residual patency of the gallbladder, cystic duct and common bile duct. The patients were treated by hepatic portocholecystostomy utilizing the extant bile ducts for biliary reconstruction. Bile drainage was achieved in all four infants. There was a conspicuous absence of postoperative cholangitis. Subsequent obstruction of the distal ducts in two patients necessitated reoperation and construction of a standard biliointestinal conduit. The other two children are surviving, jaundice-free, 5 1/2 and 5 years after operation with minimal sequelae of biliary atresia. Hepatic portocholecystostomy is a feasible surgical alternative to intestinal reconstruction in patients with biliary atresia in whom the disease is limited to the proximal extrahepatic bile ducts.     

�����Ե��ܹ�������������ֵ��ע��ļ�������

先天性胆管扩张症是指肝内、外胆管单独或联合的先天性发育异常,多发生于女性,常在婴幼儿期发现。随着医学影像检查在临床应用,少数于成年期发现确诊。先天胆管扩张症多发生于胆总管,并呈梭形扩张,最多见者为I型(先天性胆总管囊肿)。扩张的胆管内胆汁淤滞潴留,可并发胆管炎、结石、穿孔,少数囊壁发生恶变。先天性胆总管囊肿于成年期一经确诊,无论症状轻重,如无手术禁忌证均应手术治疗。目前主张,除非有特殊的适应证,不宜采取内引流或外引流术。彻底切除囊肿,重建肝外胆道是根治先天性胆总管囊肿的标准术式。     

Spontaneous perforation of right hepatic duct in a child with choledochal cyst

A 5-year-old girl with choledochal cyst (Alonso Lej, type I) and spontaneous perforation of the right hepatic duct during an attack of acute pancreatitis was treated by two-stage surgery. Biliary panperitonitis was diagnosed by abdominal paracentesis, bilirubin and amylase levels in the collected fluid being 41.3 mg/dl and 1812 Somogyi U, respectively. The initial surgery involved simple peritoneal drainage and decompression of the bile duct, followed by removal of a choledochal cyst and the common hepatic bile duct, including the biliary stricture of the left hepatic duct, and biliary reconstruction 5 months later. Cholangiogram after the initial surgery demonstrated pancreaticobiliary maljunction and stricture in the left hepatic duct and the common hepatic duct. Regurgitation of pancreatic juice into the bile duct was shown by the extremely high amylase level (90100 Somogyi U) in the bile drained through a T-tube. The patient is currently well, with normal liver and pancreatic function tests. The experience in this patient is significant in that it should be known that spontaneous perforation of the bile duct may occur at the right hepatic duct in choledochal cyst, causing biliary peritonitis.     

完全腹腔镜Roux-en-Y吻合术治疗先天性胆总管囊肿

目的探讨完全腹腔镜下Roux-en-Y吻合术治疗先天性胆总管囊肿的可行性。方法 2011年3～9月,对6例先天性胆总管囊肿行完全腹腔镜下Roux-en-Y吻合术。术中常规切除胆囊,游离囊肿壁,于正常肝总管交界处离断。距十二指肠悬韧带15～20 cm处切断空肠,于断端远端下方约50 cm处用腔镜直线切割吻合器行肠肠吻合,镜下用3-0可吸收线行肝总管-空肠端侧吻合。结果手术均获成功。术后随访3～9个月,平均5.5月,无出血、胆漏、吻合口狭窄、肠漏、腹腔脓肿、逆行感染等并发症发生。结论完全腹腔镜Roux-en-Y吻合术治疗先天性胆总管囊肿是可行的,并且具有切口小、术后腹壁瘢痕小、创伤轻、美观等微创特点。     

胆道再手术的原因及对策

目的：探讨胆道再手术的原因和对策。方法：对1994年12月－20000年12月间胆道再手术102例进行回顾性分析。结果：75例行胆管切开取石,其中12例同时行肝叶切除,5例胆总管十二指肠合改行胆总管空肠Roux-en-Y吻合或再做其他术式,12例胆道恶性肿瘤分别行根治术,内外引流和PTCD,4例行胆管整形和胆肠吻合术,4例行囊肿切除胆肠Roux-en-Y吻合,2例行残余胆囊和胆囊残株炎切除,胆道再手术主要原因是结石复发（52．0％）,残石（21．6％）,恶性肿瘤（11．8％）,术式选择或操作不当（8．8％）,及胆管狭窄（3．9％）,续集：为降低胆道再手术率,强调应明确术前诊断,采用正确的术式,术中胆道镜,胆道造和B超检查,审真操作,积极进行根治性手术,尽量避免急诊手术和术后经T管窦道取石。     

胆总管囊肿再次手术11例分析

目的 分析胆总管囊肿再次手术的原因,试图减少再次胆道手术次数.方法 2005年3月～2009年3月,我院收治胆总管囊肿再次手术11例,对其临床资料进行回顾性分析.结果 11例胆总管囊肿再次手术患者,Ⅰ型9例,Ⅳa型1例,Ⅳb型1例;既往一次手术史者9例,两次手术史者2例;就诊时症状,右上腹痛8例,发热4例,黄疸2例;就...     

Congenital biliary tract disease

Jaundice in the pediatric patient requires prompt and directed evaluation. This dictum is highlighted in infants with biliary atresia, in whom the progressive sclerosing process results in complete obliteration of patent but microscopic hilar biliary structures by 4 months of age. Kasai's operation, if done before that time, will re-establish bile drainage in 90% of infants. One fourth to one third of patients achieve long-term jaundice-free survival. Complications of cholangitis, portal hypertension, and fat malabsorption are experienced by many patients. In children with early or late operative failure, liver replacement now offers legitimate hope for extended survival. Choledochal cyst is a conglomerate of pancreaticobiliary anomalies consisting of a choledochal cyst, a common-channel-type pancreaticobiliary junction, intrahepatic cystic disease, and partial obstruction of the distal common bile duct. Many patients have one or more of these malformations. It is now widely accepted that the preferred treatment of choledochal cyst is total excision of the diseased biliary duct with reconstruction by Roux-en-Y choledochojejunostomy. "Internal" excision avoids injury to other structures in the hepatoduodenal ligament, particularly if pericystic inflammation is present. Congenital perforation of the common bile duct responds in most cases to simple peritoneal drainage of the perforation. Retention of the tube cholecystostomy is useful for subsequent cholangiographic follow-up. Tube cholecystostomy may also be useful for irrigation of the biliary tract in infants with inspissated bile syndrome.