腹腔镜胆总管囊肿切除肝管空肠Roux-en-Y吻合手术总结

目的 本研究对腹腔镜胆总管囊肿切除肝管空肠Roux-en-Y吻合手术6年经验进行总结,探讨该技术的近期和远期疗效.方法 从2001年4月至2007年3月,本课题组采用腹腔镜技术治疗先天性胆总管囊肿患儿102例,平均年龄3.2岁.其中13～28d9例,29d～6个月23例,7个月～3岁28例,4～18岁42例.采用四trocars技术完成胆道造影、胆囊和胆总管囊肿壁全层切除;同时利用腹腔镜头对扩张的肝内胆管进行探查;从脐部切口提出空肠,直视下行Roux-en-Y空肠吻合,然后还纳肠管;经结肠后上提空肠的肝支,镜下将肝管与空肠连续吻合.结果 102例全部在腹腔镜下完成手术,无中转开放手术者,平均手术时间224min(155～456min),手术中出血5～10ml,无手术中需要输血者.21例患儿合并肝门部肝管狭窄,行肝管扩大成形术;其中1例患儿手术后并发胆漏,持续腹腔引流26d,自然愈合.2例患儿分别于手术后第二天至第五天和第七天并发消化道出血.1例5岁女孩手术后7.5h突发心跳骤停,高血钾(K+10.85mmol/L),死亡.其他98例患儿手术后恢复顺利,手术后3～6d出院.1例患儿于手术后6个月发生空肠肝支梗阻坏死,行坏死肠管切除,二次肝管空肠Roux-Y吻合手术.患儿手术后经3～72个月的随访肝功能正常,无结石和胰腺炎发生.结论 腹腔镜胆总管囊肿切除肝管空肠Roux-en-Y吻合手术是治疗先天性胆总管囊肿可靠的手段,镜下放大的手术视野有利于精确的手术操作,近期和远期疗效良好.手术后早期有必要密切观察血钾的变化.     

Laparoscopic surgery for biliary atresia and choledochal cyst

Minimally invasive surgery in children has evolved to the extent that complex procedures can be performed with safety and outcome comparable with open surgery, with the advantage of minimal scarring. Here we describe the latest laparoscopic techniques used by us at the Juntendo University Hospital, Japan, for treating biliary atresia and choledochal malformation, with presentation of our postoperative management and discussion of preliminary outcomes.     

达芬奇机器人辅助腹腔镜胆总管囊肿根治术治疗儿童胆总管囊肿

目的总结达芬奇机器人辅助腹腔镜胆总管囊肿根治术治疗胆总管囊肿患儿的临床经验。方法回顾性分析中山大学附属第一医院小儿外科自2015年12月至2020年1月运用达芬奇机器人辅助腹腔镜胆总管囊肿根治术治疗的15例胆总管囊肿患儿。其中,男3例,女12例;患儿年龄为(62.40±34.64)个月,体重为(19.67±11.84)kg;Ⅰ型10例,Ⅳa型5例。患儿就诊的主要症状是腹痛和呕吐,术前行B型超声、CT或者磁共振胰胆管成像(magnetic resonance cholangiopancreatography,MRCP)检查,发现胰胆管合流异常7例,诊断明确后采用达芬奇机器人辅助手术治疗。结果1例因肝右动脉解剖变异中转开放手术,其余14例均顺利完成达芬奇机器人辅助腹腔镜胆总管囊肿根治术,手术时间为(341.40±65.54)min,范围为240~460 min;机器人操作时间为(170.71±41.97)min,范围为95~243 min;胆肠吻合时间为(40.18±15.39)min,范围为25~67 min;胆肠吻合口直径为(14.57±9.94)mm,范围为4~35 mm。2例患儿术中输血;2例术中发现右副肝管,予行达芬奇机器人辅助下肝总管副肝管侧侧吻合术后再行肝管空肠吻合术。所有患儿随访至今,无近期或远期并发症出现。结论达芬奇机器人辅助腹腔镜胆总管囊肿根治术可顺利完成对直径较细肝总管和合并副肝管患儿的胆肠吻合,是一种安全有效的方法。     

45例腹腔镜辅助胆总管囊肿根治术

目的本研究对腹腔镜先天性胆总管囊肿切除，肝管空肠Roux-Y吻合术进行探讨。方法从2001年6月至2003年9月，共收治先天性胆总管囊肿患儿45例，年龄2个月到12岩。其中42例为囊肿型，平均囊肿直径3.8cm（2-18cm）；其余3例为梭形，直径分别为1．5、2．0和2．2cm。本组45例患儿均经腹腔镜行先天性胆总管囊肿切除，肝管空肠Roux-Y吻合术。结果本组45例患儿手术全部成功，手术时间平均为4.3h（3．5～7．6h），术中出血量约5～10ml。本组8例患儿合并肝管狭窄，术中同时行腹腔镜胆总管囊肿切除及肝管成形；6例患儿合并共同管内蛋白栓，术中通过腹腔镜导入肠道或插管冲洗清除。其中1例患儿于术后第1d发生胆漏，术后第26d时自愈；其余44例患儿术后恢复顺利，住院时间3～6d。术后随访3～30个月，无肠粘连梗阻和吻合口狭窄等术后并发症发生。结论经腹腔镜先天性胆总管囊肿切除，肝管空肠吻合术是一种安全可靠的方法，术中胆道造影全面了解胆道的结构，清晰的肝门暴露，准确的囊肿分离和熟练的缝合技术是手术成功的关键。     

Laparoscopic treatment of biliary atresia and choledochal cyst

Minimally invasive surgery (MIS) has overcome many technical limitations and has evolved into a safe alternative for the treatment of many complex pediatric surgical procedures. The introduction of this approach for the correction of congenital biliary tract anomalies had to wait until instrumentation and surgeons' skills improved enough. This happened not so long ago: less than 10 years have elapsed since the first reported case of a minimally invasive operation for choledochal cyst and less than 3 years since the first reported case of a laparoscopic Kasai. This article summarizes the experience gained by the authors in laparoscopic treatment of 41 patients with biliary atresia and 15 patients with choledochal cyst with similar surgical techniques, which are described in detail. Based on the encouraging results, the authors believe that MIS will soon become the gold standard for the correction of congenital biliary tract anomalies.     

小儿腹腔镜胆总管囊肿切除术45例

目的总结腹腔镜下小儿胆总管囊肿切除、肝总管空肠Roux-en-Y吻合术的经验。方法回顾性分析2010年1月至2012年12月我们收治的45例小儿先天性胆总管囊肿患儿临床资料,其中囊肿型32例,梭形扩张型13例,囊肿直径约1．2-5．5em,均在腹腔镜下行胆总管囊肿根治术,空肠Roux-en-Y吻合在腹壁外经脐部小切口进行,肝肠吻合在腹腔镜下完成。结果本组45例中,1例因炎症较重,游离囊肿前壁时渗血较多,解剖困难而中转开腹手术;1例术后6d进食后出现乳糜腹（经肠内、肠外营养14d后治愈）。其余43例均未出现并发症,痊愈出院。术后平均住院时间11d。结论初期开展腹腔镜下胆总管囊肿切除手术时要严格挑选病人,先从囊肿小、炎症轻、发病时间短的病例开始,逐渐积累经验后再扩大腔镜手术指征。腹腔镜手术具有创伤小、视野清晰、恢复快,并发症少等优点。腹腔镜下胆总管囊肿切除术是先天性胆总管囊肿的理想手术方法。     

先天性胆总管囊肿手术治疗

目的　探讨先天性胆总管囊肿的治疗方法。方法　回顾 1992年 1月～ 2 0 0 2年 12月手术治疗的 4 7例先天性胆总管囊肿患儿所用手术方式及治疗效果。结果　采用囊肿切除、肝总管空肠Roux Y吻合术治疗 ,均痊愈出院 ,1例术后 4年行 2次手术。结论　囊肿切除、肝总管空肠Roux Y吻合术是治疗先天性胆总管囊肿的有效方法 ,保留合适的肠襻 ,可不必使用防返流装置     

Preoperative imaging of a choledochal cyst in children: non-breath-holding magnetic resonance cholangiopancreatography

Magnetic resonance cholangiopancreaticography (MRCP) was used to visualize the biliary tract in two children, aged 7 weeks and 10 years, with a choledochal cyst. MRCP was successful in both cases and the findings were confirmed by intraoperative cholangiography. Accepted: 26 April 1999     

Endoscopic treatment of intrahepatic gallstones after surgery for choledochal cyst

Three patients with intrahepatic gallstones after surgery for a choledochal cyst were successfully treated with lithotomy under percutaneous transhepatic cholangioscopy. We conclude that this technique should be considered as one of the potential treatment modalities for intrahepatic gallstones in such a situation.     

Laparoscopic excision of choledochal cysts in children: an intermediate-term report

Purpose  To assess the intermediate-term result of the use of the minimally invasive technique in the treatment of choledochal cysts in children. Methods  This is a retrospective review of all cases of choledochal cyst treated in the tertiary referral centre. The surgical technique is described and all the medical records were reviewed to assess the intraoperative and postoperative complications and follow-up problems. Results  From October 2000 to April 2008, laparoscopic excision and reconstruction were attempted in 37 patients. Laparoscopic surgery was successfully performed in 34. Conversion was required in three patients due to oozing on cyst dissection (two) and bleeding from small bowel mesentry (one) during the early part of the series. Postoperative complications were observed in 15 patients including subhepatic collection (6), bile leakage (3), minor wound infection (4) and prolonged ileus (2). At a mean follow-up of 4.2 years, four patients developed surgical complications including intrahepatic ductal strictures in a type IV cyst (one), stump pancreatitis (one), terminal ileal obstruction from internal herniation (one) and cholangitis (one). The cosmetic result was good in all patients. Conclusion  We conclude that laparoscopic excision and reconstruction can be safely performed in children with a choledochal cyst with satisfactory intermediate-term results.     

小儿胆总管囊肿的手术治疗及并发症处理

胆总管囊肿(choledochal cyst,CC),亦被称作胆管扩张症,可以在患儿母亲产检时发现.据相关报道,在日本每1000人就有1人患病,远远高于西方人群[1].病患中女性占多数,男女比例为1:3～1:4.30％～60％的患者在10岁之前就出现临床症状[2].CC的长时间存在会引起胆道一系列的炎症反应,由于囊肿壁...     

Abnormal pancreatic isoamylases in the serum of children with choledochal cyst.

PURPOSE: To investigate the changes of pancreatic isoamylases in the serum of children with choledochal cyst. METHODS: Serum and bile from 20 children with choledochal cyst were studied for total amylase activity and isoamylases. Using electrophoresis, the assay of pancreatic isoamylases was expressed by peak appearance rate (PAR) and ratio of isoenzyme activity (RIA). Serum from 20 healthy children and 12 adults with acute pancreatitis served as a comparison. RESULTS: The total amylase activity in the serum of children with choledochal cyst was slightly higher than that of healthy controls, but dramatically lower than that of acute pancreatitis. The serum of children with choledochal cyst showed 5 pancreatic peaks (PAR: P1, 100 %; P2, 100 %; P3, 100 %; P4, 75 %; P5, 45 %) without any major peak. In healthy controls, only P1 and P2 were present (PAR: P1, 40 %; P2, 100 %) with the latter being a major peak (RIA: 81.8 +/- 25.3 %). These results in children with choledochal cyst differed from those of patients with acute pancreatitis who presented with the less common P4 and no P5 (PAR: P1, 100 %; P2, 100 %; P3, 91.6 %; P4, 8.3 %). The pattern of pancreatic isoenzymes in bile was similar to that in the serum from patients with choledochal cyst. These abnormal pancreatic isoamylases gradually disappeared after operation. CONCLUSIONS: Abnormal pancreatic isoamylases, especially P4 and P5, are found in the serum of patients with choledochal cyst, which would point to a reflux of pancreatic juice into the biliary tract.     

腹腔镜与开放性肝管空肠吻合术治疗先天性胆总管囊肿的疗效比较

目的比较腹腔镜与开放性肝管空肠吻合术治疗先天性胆总管囊肿的中期疗效,探讨腹腔镜下肝管空肠吻合术治疗先天性胆总管囊肿的可行性及安全性。方法回顾性分析2001年10月至2009年10月作者采取腹腔镜下肝管空肠吻合术治疗的218例先天性胆总管囊肿患儿临床资料,并将1993年9月至2001年9月行开放性肝管空肠吻合术的200例患儿作为对照,对其诊疗情况及术后恢复、随访情况进行比较。结果腹腔镜手术组与开放手术组手术时中位年龄分别为4．16岁（7d至18岁）、4．59岁（13d至17岁）,中位随访时问分别为38个月、146个月,差异均无统计学意义;病例数超过35例时,腹腔镜组平均手术时间较前明显缩短（P〈0．01）,至2009年,与开放手术组相比,平均手术时间无显著差异[（3．04±0．98）hVS（2．95±0．91）h,P=0．557）]。腹腔镜手术组术中平均失血量约（9．08±6．13）mL,而开放手术组约（35．33±33．29）mL,差异有统计学意义（P〈0．001）。腹腔镜手术组术后住院时间、恢复饮食时间及引流时间均较开放手术组明显缩短（P〈0．001）,腹腔镜手术组术后并发症较开放手术组明显减少（P〈0．01）。结论腹腔镜下肝管空肠吻合术治疗先天性胆总管囊肿安全可行,其中期疗效与开放手术相似,甚至优于开放手术。     

腹腔镜胆总管囊肿手术操作指南(2017版)

胆总管囊肿(choledochal cysts,CC)又称(先天性)胆道扩张症,是一种胆道系统的发育畸形,其特征是先天性的胆总管扩张(少数患儿胆总管轻度扩张或不扩张),可合并肝内胆管的扩张,绝大多数合并胰胆合流异常[1-4]. 传统上Todani分为五型[2],临床上常见的是囊肿型和梭型(远端狭窄型和非狭窄型)[3],前者多合并胆总管远端狭窄,肝内胆管扩张,胰管和共同管不扩张,发病早,产前可以诊断;后者胆总管远端不狭窄,而合并共同管扩张及蛋白栓梗阻[1,3],合并胰腺炎多,发病稍晚.相当多的患儿合并十二指肠乳头开口向远端异位,提示病因与胚胎早期肝憩室发生远端异位有关[4-7].     

改良肝总管空肠Roux-Y型吻合术治疗小儿先天性胆总管囊肿

目的 探讨小儿先天性胆总管囊肿的治疗方法。方法 本组２８例,男９例,女１９例,年龄１０ｄ￣１４岁,均采用改良的肝总管空肠Ｒｏｕｘ－Ｙ型吻合术治疗先天性胆总管囊肿。结果 ２８例均痊愈出院。随访６个月￣８年,全组患儿未见出现腹痛、黄疸、发热。其中２０例患儿,经Ｂ超检查,未见胆管狭窄及扩张。Ｘ线钡餐检查,未见有钡剂反流入胆道。结论 改良肝总管空肠Ｒｏｕｘ－Ｙ型吻合术是治疗先天性胆总管囊肿的较好方法。     

Spontaneous rupture of extrahepatic choledochal cyst: two pediatric cases and literature review.

Spontaneous rupture of extrahepatic choledochal cysts is very rare. Neonatal cases generally present with biliary ascites, and older children with acute abdomen. Although the cause is unclear, accumulation of protein plugs in an anomalous pancreaticobiliary junction, irritation of the cyst wall due to reflux of pancreatic juice, and weakness due to a developmental error such as common channel syndrome have all been suggested to play contributing roles. The treatment of choice is complete excision of the cyst and hepatico-jejunostomy. In newborns who are in a poor condition, the primary treatment should be simple peritoneal drainage.     

Spontaneous perforation of a choledochal cyst

Two children with spontaneous perforation of a choledochal cyst were treated successfully. In one of the patients an operative cholangiogram demonstrated not only fusiform dilatation of the common bile duct but also an unusual long common channel between the junction of the common bile duct and pancreatic duct, and the papilla. The long common channel, namely an anomalous choledocho-pancreatic ductal junction, under which there were concentrated bile acids and refluxed pancreatic juice, was thought to lead to chronic inflammation of the bile duct, followed by choledochal cyst and/or perforation of the cyst.     

Subdural hemorrhage as a first symptom in an infant with a choledochal cyst: case report

Choledochal cysts are not rare in East Asia. The classic symptoms of these cysts are intermittent abdominal pain, jaundice, and a right upper quadrant abdominal mass. The authors report the case of an infant with a choledochal cyst presenting with intracranial hemorrhage. This 2-month-old girl with a partial coma presented at the authors' hospital. A brain CT scan revealed right-sided subdural hemorrhage. The routine preoperative survey found coagulopathy. After correcting the bleeding disorder, an emergency craniectomy was performed. Further examination found a choledochal cyst during abdominal ultrasonography and CT. Choledochal cysts are a cause of neonatal cholestasis but rarely produce vitamin K deficiency bleeding.