囊肿切除胆道重建术治疗成人胆总管囊肿

本文报道成人胆总管囊肿３５例，２４例行囊肿切除。胆道重建的方法：间置空肠府管十二指肠吻合术〔人工乳头）４例，肝管十二指肠吻合术１例，肝管空肠Ｒｏｕｘ－ｙ型吻合术１９例。２２例痊愈，２例分别因腹腔严重感染、肝功能衰竭死亡。文中讨论了囊肿切除的理论根据、手术要点、囊肿切除的优点及并发症。     

先天性胆总管囊肿切除后不同胆道重建术的疗效

目的 评价先天性胆总管囊肿切除后不同胆道重建术的疗效。方法 对行囊肿切除，肝总管空肠Roux-en-Y吻合重建胆道的106例先天性胆道囊肿病例进行回顾性分析和随访复查。结果 在106例重建的胆道中，胆支空肠袢套叠瓣成形37例，矩形瓣成形21例，未做抗反流瓣48例。获随访61例，平均4．82年。无1例发生吻合口狭窄，逆行性胆感染4例（矩形瓣组1例，未做抗反流瓣组3例），2例再手术并于胆支空肠袢套叠瓣成形术后症状消失；偶有腹痛症状8例，其中未做抗反流瓣组5例，矩形瓣成形组2例，套叠瓣成形组1例。结论 在先天性胆总管囊肿切除后胆道重建中，肝总管空肠Roux-en-Y吻合加胆支空肠袢套叠成形术胆道生理，能有效预防术后胆道反流和吻合口狭窄。     

胆总管囊肿切除回盲部间置胆道重建术病人的护理

因胆总管囊肿有潜在的恶变性［１］,故囊肿切除胆道重建已为学者们所共识。预防胆肠返流是决定远期疗效的关键,应用回盲部间置重建胆道,虽国内外曾有报道［２,３］,但所用回盲部的下端系与空肠吻合,我院外科１９９０年６月至１９９５年７月对８例病人行胆总管囊肿切...     

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。     

两种胆道重建术治疗胆总管囊肿的远期疗效对比观察

胆总管囊肿切除之后 ,重建胆道的方式有多种 ,但何种为优尚无统一意见。我们于 1988年 10月至 1998年 2月 ,共收治胆总管囊肿 16例 ,以回盲部间置肝管十二指肠吻合及Ｒｏｕｘ ｅｎ Ｙ式吻合胆道重建各 8例 ,经过 8个月至 10年的随访观察 ,均取得良好效果 ,现报告如下。一、临床资料本组共 16例 ,男 2例 ,女 14例 ,年龄 5～ 6 0岁 ,平均 2 4岁 ;本组小儿 3例 ,成人 13例。第 1次手术 12例 ,再手术 4例。再手术的 4例中 ,囊肿未切除 3例 ,已切除 1例。本组16例均以上腹部胀痛为主要症状 ,伴发热畏寒 12例 ,黄疸 6例 ,腹部肿物 6例。按Ｔｏｄａ…     

先天性胆总管囊肿切除及胆道重建

目的 评价先天性胆总管囊肿切除胆道重建的术式。方法 对1984年7月－1999年12月行囊肿切除胆道重建的106例先天性胆总管囊肿进行随访复晒,胆道重建包括单纯Roux-Y吻合48例、Roux-Y吻合套瓣成形37例和Roux-Y吻合矩形瓣成形21例。结果 获随访59例,随访时间平均4.68年,术中加作抗返流措施者无一例发生返流性胆管炎,未作抗返流瓣者术后发生逆行性胆道感染3例,2例再次行套叠瓣成形后症状消失。结论 规范性的彻底切除病变囊壁组织、有效的空肠袢肝总管Roux-Y吻合加套叠瓣成形,可有效的防止术后逆行感染,在患儿能耐受的情况下应尽早选择该术式。     

腹腔镜在胆总管囊肿切除、胆道重建术中的应用

先天性胆管囊肿（congenital bile duct cysts，CBD）是小儿常见的胆道发育畸形，临床多表现为胆总管的囊状扩张或梭形扩张，其病因尚存诸多争议。近年来随着对本病形态学、胆汁酶学及动物实验等研究的进展，认为CBD是由于多种因素造成的先天性发育畸形，即胚胎时期因胰、胆管分化异常所引起的胰胆管合流异常（anomalous junction of pancreaticobiliary duct，APBD）、胆总管远端狭窄及Oddi’s括约肌异常等综合因素所致，其中APBD是其主要致病因素。治疗本病的最佳术式是囊肿的根治切除、肝管空肠Roux-Y吻合胆道重建手术，这是小儿腹部外科最复杂的手术之一，     

急诊胆总管囊肿切除术12例报告

作者1991年～1998年行急诊胆总管囊肿切除术12例,获良好治疗效果。作者认为:①胆总管囊肿并感染保守治疗无效在72小时内,患者生命体征稳定情况下,行急诊胆总管囊肿切除术是可行的,避免了再手术及粘膜癌变、上行性感染等。②术中沿内膜下剥离囊壁可减少术中出血、避免损伤肝动脉、门静脉。③胆肠吻合口内放置支撑外引流管对预防术后胆瘘是必要的。     

完全腹腔镜成人胆总管囊肿切除术10例分析

目的探讨完全腹腔镜胆总管囊肿切除术的技术方法与优点。方法回顾性分析2008年1月至2011年1月10例完全腹腔镜胆总管囊肿切除术患者的临床资料,所有患者均未行辅助体外肝肠吻合术。结果 10例患者均成功完成完全腹腔镜胆总管囊肿切除术。手术时间为210～300min,术后住院天数为3～7d,术后随访1～36个月,其中1例患者于术后发生吻合口狭窄,经开腹行胆肠吻合口拆除重建后,治愈出院,无死亡病例。结论完全腹腔镜胆总管囊肿切除是安全可行的,值得进一步推广。     

婴儿胆道扩张症伴胆道发育不良的手术治疗

目的 探讨巨大胆总管囊肿伴胆道发育不良症患儿的诊断和手术难点.方法 回顾性分析胆道扩张症患儿278例,其中3例伴有肝外巨大囊肿的胆道发育不良症患儿.本组患儿术中都进行胆道造影检查,了解肝内、外胆管通畅情况以及肝内胆管扩张情况;术中行肝脏活检,行囊肿切除术,术中放置肝总管支架管,并行肝总管-空肠Roux-en-Y吻合手术. 结果 3例患儿手术年龄在1～2个月之间,术中造影显示囊肿较巨大,左、右肝管发育较细且与肝内相通,有黄色胆汁流出.切开囊肿时有1例损伤肝总管,行肝总管修补手术,并行肝总管部位囊肿成型术,再行肝门-空肠吻合术.3例患儿术后无吻合口狭窄和结石形成;肝活检病理证实有通畅胆管,但胆管数量减少,未见类似胆道闭锁的胆管增生以及胆栓形成.术后随访1～5年,未见黄疸发生,超声显示无肝内胆管扩张.结论 术中胆道造影检查非常必要,如遇囊肿巨大,左、右肝管较细,切开囊肿时应小心,切口位置选择在胆囊管水平以下,勿损伤肝管,造成吻合困难,吻合时放置支架管对于早期胆汁引流意义重大.     

经腹腔镜行先天性胆总管囊肿根治术并发症的探讨

目的 探讨腹腔镜胆总管囊肿切除肝管空肠Roux-en-Y吻合术后并发症和预防。方法 2001年7月～2006年6月,经腹腔镜行先天性胆总管囊肿根治术66例（65例为2个月～14岁,中位数3岁9个月,另1例28岁）。囊肿型61例,直径2.5～18cm;梭形5例,直径1.2～2.2cm。其中9例合并肝门部肝管狭窄,行肝管扩大成形术。结果 66例均在腹腔镜下成功完成手术,平均手术时间3.8h（2.6～9.5h）,术后平均住院时间4.5d（3～8d）。早期并发症：胆漏2例,1例腹腔引流后自愈,另1例因腹腔引流不畅行开腹手术,术中见吻合口漏,重新吻合后愈合;1例术后7h高血钾（10.8mmol/L）心跳停止,复苏成功后于术后第3天死于肾功能衰竭;应激性溃疡2例,自行缓解。无腹腔和伤口感染。远期并发症：术后6个月突发肠梗阻1例,开腹探查见空肠肝支肠管粘连梗阻坏死,行肠切除吻合手术。无吻合口狭窄和胆管炎,65例存活者随访6～56个月,中位数21个月,行B超检查未见胆石发生,肝功能正常。结论 经腹腔镜行先天性胆总管囊肿切除肝管空肠Roux-en-Y吻合术是复杂的高风险手术,有与开腹手术类似的胆漏、应激性溃疡和肠梗阻并发症。高钾血症是该手术特殊的严重并发症,可能与长时间的CO2气腹有关,术后必须常规监测血钾变化。     

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.     

先天性胆总管囊肿术后远期并发症及处理

目的 探讨先天性胆总管囊肿术后远期并发症的治疗。 方法 回顾分析1999年1月至2008年12月中国医科大学附属盛京医院普外科收治的48例先天性胆总管囊肿术后出现远期并发症的临床资料。 结果 先天性胆总管囊肿术后远期并发症主要有胆管结石形成31例,反流性胆管炎25例,吻合口狭窄16例,囊肿癌变3例。手术治疗方式包括囊肿彻底切除、肝总管空肠Roux-en-Y吻合术28例,胆肠吻合口切除、再吻合术7例,胆道探查取石术3例,胆道探查取石术并肝段切除术3例,囊肿切除加胰十二指肠切除术1例。经皮经肝胆道镜治疗吻合口狭窄和（或）胆管结石6例。 结论 先天性胆总管囊肿术后远期并发症的发生常与首次手术方式选择不当有关。治疗上以囊肿切除、去除病灶、解除梗阻、胆胰分流、通畅引流为目标,减少再手术后并发症。     

Early experience with laparoscopic excision of choledochal cyst in 41 children

Objective

This study aims to review our center's early experience in managing children with choledochal cysts using laparoscopic excision.

Methods

A retrospective study was carried out from the time of our first case of laparoscopic excision (2010). A total of 41 patients with choledochal cysts underwent laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy. Patient demographics, operative data, and post-operative outcomes were recorded and analyzed.

Results

Forty patients underwent the operation successfully, and the mean time of operation was 210 min (range 140 min to 380 min). One case was converted to an open operation due to dense adhesions. All patients recovered uneventfully and were discharged between seven and ten days post-operatively. Four patients suffered minor bile leaks after their operations, but they required only percutaneous drainage. The mean time for follow-up was six months (range 1 month to 1 year). No significant complication was noted during that time.

Conclusions

We successfully introduced laparoscopic excision of choledochal cyst in our center and have found this to be a safe and effective method. Long-term follow up is awaited.     

Laparoscopic correction of biliary duct stenosis in choledochal cyst

Background/Purposes

Laparoscopy has been widely accepted as a technique for the excision of choledochal cyst, but there has been little experience using it as a therapeutic modality for hepatic duct stenosis. The aim of this study is to present our experiences in laparoscopic excision of biliary stenosis and Roux-en-Y reconstruction for patients with choledochal cysts.

Methods

Eight patients, 3 boys and 5 girls (ranged from 6 months to 12 years; median age, 3.6 years), with hepatic duct stenosis underwent laparoscopic excision of the cyst and ductoplasty, with a Roux-en-Y hepaticoenterostomy between July 2001 and January 2005. Seven of the 8 patients had common hepatic duct stenosis with intrahepatic duct dilatation, and 1 had right hepatic duct stenosis with proximal dilatation.Four ports were inserted for instruments of 3- and 5-mm sizes. Each patient underwent a laparoscopic cholangiography. The gallbladder and dilated bile ducts were completely excised. The strictures of the hepatic ducts were treated by ductoplasty. The cut end of the duct was widened by incising along the anterior wall of the hepatic duct after excision of the narrow segment. By using intraoperative bile duct endoscopy, the optimal level of resection of the common hepatic duct was determined safely without endangering the orifices of the hepatic ducts or leaving any redundant duct, and the stone debris in the bile duct was identified and washed out. The Roux-en-Y jejunal loop was fashioned extracorporeally by exteriorizing the jejunum through the umbilical incision (1.0-1.5 cm) and passed up retrocolically followed by an end-to-side hepaticojejunostomy.

Results

The median duration of the operation was 4.3 hours (3.8-5.6 hours). Intraoperative bleeding was minimal, with no patients requiring blood transfusion. In 7 of the 8 cases, postoperative hospital stay ranged from 4 to 6 days; the other case had bile leak, which was cured by draining for 26 days without surgical intervention. All the patients had been followed up for 6 to 51 months. They stayed asymptomatic and well with no delayed complication.

Conclusions

Laparoscopically assisted hepatic ductoplasty is effective and safe for children with choledochal cyst. Bile duct endoscopy proved to be a valuable instrument in showing detailed variations of the biliary system and allowed a safe hepatic hilum exploration and accurate placed hepaticojejunal anastomosis.