肝移植后胆道并发症的诊断和处理

目的 研究肝移植后胆道并发症的诊断和处理及分析相关因素。方法 回顾性研究Pittsburgh移植中心96例肝移植病人。结果 94例（97次移植）存活2d以上的病人，92例为端端＋T管的胆道吻合，随访时间为5.8个月（0.3-10.2个月）。分析发现92例病人中8例有胆道并发症（8.51%）；T管拔除时胆漏2例，术后早期胆漏2例，狭窄2例。75％胆道并发症有诱因，诱因：肝动脉狭窄2例，其中1例合并严重排斥反应；肝动脉血栓3例；供一受体胆管直径不匹配1例。冷缺血时间无显著性差异。5例有肝动脉血栓和（或）狭窄＞50％行再移植，另3例无肝动脉血栓和（或）狭窄＜50％经皮穿刺和内窥镜＋支架或行气囊扩张，所有病人均获得良好疗效。结论 肝移植术后胆道并发症发生率为8.51％（胆－胆端端吻合＋T管），胆道狭窄晚于胆漏，肝动脉检塞和（或狭窄是最重要的相关因素；无肝动脉栓塞和（或）狭窄，则无需手术治疗，若有肝动脉栓塞和（或）狭窄＞50％，应尽早做再次肝移植。     

胆道探查术中及术后纤维胆道镜应用价值探讨(附216例报告)

目的：探讨纤维胆道镜在胆道探查术中及术后的应用价值。方法：216例胆道探查手术病人术中常规使用胆道镜，102例同时使用术中和术后胆道镜，结果：90例肝胆管结石病人术中联合应用胆道镜技术，术后残石率由46．7％（42／90）降为23．3％（21／90），应用胆道镜经T管窦道结石取净率为95．2％（20／21），结论：强调胆道探查术中常规应用胆道镜有助于降低胆管残石率，肝胆管结石术后经T管窦道应用胆道镜技术可有效清除胆管残石。     

Laparoscopically assisted esophagectomy and colon interposition for esophageal replacement in children: preliminary results of a novel technique

Background

Colonic interposition is one of the surgical options in children when esophageal replacement is necessary, especially when the stomach is not suitable as a conduit. Conventional open surgery and blind mediastinal dissections present reasonable morbidity, which can be reduced by videosurgery. The authors present novel techniques and the preliminary results of the first series of laparoscopically assisted esophagectomies and colonic interpositions (LECIN) in children.

Methods

Five children aged 19 months to 4 years underwent LECIN. Indications were complicated esophageal atresia and severe caustic esophagitis. The patients were operated on laparoscopically using 3 ports, including the gastrostomy site. Transhiatal esophagectomy was carried out, followed by pyloroplasty and mobilization of the transverse colon maintaining a double blood supply from the left pedicle. The stomach at the gastrostomy site was freed and closed in 3 cases. The colon was exteriorized through this 2- to 3-cm site or through the umbilicus, and the conduit was fashioned extracorporeally, including the colocolic and gastrocolic anastomosis. The colon was pulled up along the retromediastinal tunnel for the coloesophageal anastomosis through a cervical incision.

Results

Operative times ranged from 3 to 4.3 hours; there were no conversions and no complications related to laparoscopy. There were no cardiorespiratory problems, and 4 were extubated immediately after operation. Feedings could be started by day 3 to 4. Postoperative complications included atelectasis (1), pneumonia (1), and cervical stenosis because of persistent fibrotic esophagus, requiring cervical revision (1). One needed dilatations for mild dysphagia. After a follow-up period of 10 to 29 months, all patients are asymptomatic, gaining weight, and feeding well.

Conclusions

These preliminary data suggest that LECIN is feasible and can be safely performed with very low morbidity in children. Further studies with larger series and follow-up are expected.     

Type A esophageal atresia: a critical review of management strategies at a single center

Purpose

The purpose of was to study the short- and long-term outcomes in the management of isolated esophageal atresia with different operative strategies.

Methods

All patients undergoing type A atresia repair over a 15-year period were included. Demographic data, birth weight, gestational age, incidence of associated anomalies, management, and long-term outcomes were studied.

Results

Fifteen patients with type A atresia (9 male) were treated in the study period. The mean gestational age was 35.5 weeks (range, 27-39 weeks), and the mean birth weight was 2179 g (range, 670-3520 g). Eight babies had associated anomalies. Thirteen patients underwent gastrostomy as the initial procedure, and 2 underwent the Foker procedure. In the delayed management group, 9 patients underwent primary anastomosis, with 2 patients needing proximal pouch myotomy. Two patients underwent a Collis gastroplasty. Two patients underwent a cervical esophagostomy and a gastric tube replacement at 4 months and 1 year, respectively. Eight patients (60%) in this group had anastomotic leaks. All patients are currently on prokinetics and proton pump inhibitors. Seven required antireflux surgery. The median length of hospital admission was 4 months (range, 3-19 months). The native esophagus was preserved in 13 (85%) of 15 babies. All patients are alive, and 14 of 15 are capable of feeding orally.

Conclusions

Type A esophageal atresia continues to be associated with significant morbidity despite advances in surgical technique and intensive care.     

Increased susceptibility to liver damage from pneumoperitoneum in a murine model of biliary atresia

Hypothesis

We hypothesized that livers with biliary atresia (BA) are more susceptible to the harmful effects of a high-pressure CO₂ pneumoperitoneum (PP) than healthy livers.

Methods

A murine model of BA was used in this experiment. Mice were divided into 6 groups: (1) control Balb/c; (2) control Balb/c, CO₂-PP; (3) control BA; (4) BA-sham; (5) BA, CO₂-PP; and (6) BA, air-PP. Mice from groups 2, 5, and 6 underwent an 8-mm Hg-PP for 60 minutes. Liver samples were collected for histology, colorimetry, and flow cytometry analysis 18 to 24 hours after the procedure. Markers of apoptosis were investigated as indicators of acute cell damage.

Results

We observed a statistically significant higher rate of apoptosis in livers with BA exposed to a prolonged CO₂-PP or air-PP compared with control groups. There were no significant differences between groups 1 and 2, or between groups 5 and 6.

Conclusions

In this animal model, we have shown that livers with BA are more susceptible than healthy livers to injury by a prolonged PP. This injury was caused by both CO₂ and air-PP, implying that it is the direct result of pressure. These results may have implications for the success of minimally invasive Kasai procedures.     

Experience in treating congenital esophageal atresia in China

Purpose

The aim of the study was to evaluate our recent experience in treating esophageal atresia (EA) and the outcomes observed at a single center for pediatric surgery.

Materials and Methods

The records of infants with EA from 2006 to 2009 were reviewed. Birth weight, associated anomalies, details of management, complications, and outcomes were examined.

Results

Forty-eight consecutive infants with EA were identified from 2006 to 2009, of which 33 (69%) were boys. Mean birth weight was 2668 g (range, 1700-3800 g). Common associated malformations (35%) were cardiac anomalies, imperforate anus, limb anomalies, and chromosomal anomalies. Forty-seven were Gross type C, and one was Gross type A. Forty-five infants underwent ligation of the tracheoesophageal fistula and end-to-side primary anastomosis, and one received a colonic interposition. Six patients died (12.5% mortality). Three died before or during operation because of severe pneumonia and complex cardiac anomalies, and 3 died during recovery (within 1 month after repair) because of aspiration and severe pneumonia (early postoperative mortality was 6.67%). Complications included pneumonia, anastomotic leakage (16%, all recovered after conservative treatment), wound sepsis (11%), recurrent tracheoesophageal fistula (9%) (3/4 recovered after conservative treatment), anastomotic stricture (10%), and gastroesophageal reflux in about 2 of 3 patients. Preoperative computed tomographic imaging and 3-dimensional graphic reconstruction used in 15 patients were useful.

Conclusions

Most patients with EA have excellent short- to midterm surgical outcomes. The main factors for mortality are complex cardiac anomalies, aspiration, and pneumonia. Computed tomographic imaging and 3-dimensional graphic reconstruction can provide surgeons with excellent preoperative reference about the anatomy of the defect. Most anastomotic related complications resolve with conservative treatment. Patients of low-risk prognosis group with type A and long gap EA can be managed with a primary colonic interposition with good results. The main midterm complications are gastroesophageal reflux and stricture.     

联合门静脉切除重建的肝脏左三区切除治疗进展期肝门部胆管癌

The clinical value of applying portal vein resection and reconstruction in left trisectionectomy for treating advanced hilar cholangiocarcinoma is approved, while it is still a big challenge for clinicians. One female patient suffering from abdominal pain and jaundice received treatment in the General Hospital of PLA in July, 2009. She was prelimiarily diagnosed with Bismuth type Ⅲ a hilar cholangiocarcinoma. A tube was inserted in the left lateral inferior bile duct to carry out percutaneous transhepatic biliary drainage (PTBD). After the anatomic variation of the left bile duct was found, the diagnosis was revised as Bismuth type Ⅳ. A left trisectionectomy was proposed, and another PTBD tube was inserted in the right posterior bile duct.Combined portal vein resection and reconstruction and left trisectionectomy was successfully performed. The postoperation course was uneventful, except for the transient liver dysfunction and biliary-enteric anastomotic leakage.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.     

Surgical repair of coronary sinus orifice atresia with persistent left superior vena cava in heterotaxia

A 6-month-old boy was diagnosed with coronary sinus orifice atresia, double-outlet right ventricle, complete atrioventricular septal defect, pulmonary stenosis, and moderate common atrioventricular valve regurgitation associated with heterotaxy syndrome. Cardiac venous flow drained through a persistent left superior vena cava. We decided to perform coronary sinus orifice unroofing through the right atrium under a guide using a bougie. The persistent left superior vena cava was divided. Bidirectional Glenn anastomosis and edge-to-edge common atrioventricular valve repair were concomitantly performed. After a 1-year follow-up period, the patient is alive and well without any ischemic event.