腹腔镜胆囊切除术14例中转开腹原因的分析

目的探讨如何提高腹腔镜胆囊切除术的成功率,减少并发症的发生率。方法对2002年7月~2004年8月间共439例腹腔镜胆囊切除术的临床资料进行回顾性分析,研究中转开腹的原因和并发症的处理方式。结果本组LC439例中转开腹14例,中转率3.19%。其中主动中转开腹12例,肝总管横断1例,合并结肠肝曲肿瘤1例。术后4例发生胆漏。结论LC是胆囊良性疾病的首先术式。严格掌握LC的手术适应证,提高镜下操作技术,及时中转开腹,可减少术后并发症。     

腹腔镜肝门肠吻合术治疗胆道闭锁的探讨(12例报告)

目的:探讨经腹腔镜辅助行肝门解剖和肝门肠吻合术治疗先天性胆道闭锁的临床效果。方法:先天性胆道闭锁患儿12例,29~87d11例,5.5个月1例。2例为肝总管闭锁(Ⅱ型),肝门部有直径1.2~2.5cm囊肿与肝内胆管相通;10例为肝门部胆管闭锁(Ⅲ型)。于脐部纵切口置入10mmTrocar,然后分别于右上腹、右中腹和左上腹置入3个5mmTrocar。术中胆道造影,确诊为胆道闭锁,暴露肝门;切除胆囊,游离切除肝门纤维块,空肠行Roux-en-Y吻合术保留肝支30~35cm,然后将肠管送回腹腔,将空肠肝支经结肠后拉至肝门下;用5-0可吸收缝线将空肠与肝门端侧连续吻合。结果:本组12例患儿中1例因肝门渗血中转开腹手术;另11例均在腹腔镜辅助下完成手术,手术时间平均为3.5h(3.1~4.6h),出血量约10ml,没有需在术中和术后输血者,全组患儿无手术后肠粘连梗阻和腹腔感染。结论:经腹腔镜行肝门肠吻合术治疗先天性胆道闭锁安全可靠,具有暴露肝门清晰、肝门纤维块分离和切除准确、对患儿打击小等优点。     

胆道良性病变内引流术式与胆管癌变

目的探讨胆肠引流术后发生的胆管癌的原因。方法回顾分析我院1982年～2000年因胆道良性疾病作胆肠引流术后75例病人的病历和随访记录,按照胆肠吻合术将病人分为胆管空肠．Roux—y吻合术48例。胆管间置空肠吻合术4例,胆总管十二指肠吻合术16例,经十二指肠乳头切开术7例,随访期最长10年。结果胆管空肠Roux—y吻合术后发生吻合口癌2例,胆总管十二指肠吻合术后发生原发性胆管癌1例。发生癌变的病人中为肝内胆管结石及术后反复发生胆管炎者。结论长期胆肠引流和胆管恶性肿瘤存在相关性,可能与术后胆道结石、排石、反复胆管炎有关。     

Impaired expression of hepatic multidrug resistance protein 2 is associated with posthepatectomy hyperbilirubinemia in patients with biliary cancer

Background and aims Hyperbilirubinemia is a critical complication following hepatectomy for biliary cancer. Hepatic multidrug resistance protein 2 (MRP2), a bilirubin transporter, is shown to be down-regulated by acute biliary obstruction in rats. However, little is known about the effect of chronic obstruction by malignancy on the MRP2 expression in patients or the association of MRP2 expression with posthepatectomy hyperbilirubinemia.Materials and Methods The MRP2 expression before hepatectomy was determined by immunostaining and Western blotting in patients with biliary cancer. To directly determine the effect of chronic bile duct obstruction on the MRP2 expression, the expression levels were compared between the cholestatic and noncholestatic lobes in each of seven patients. In another 39 patients, the correlation of the MRP2 expression of the anticipated remnant liver with the posthepatectomy severe hyperbilirubinemia, defined as a serum total bilirubin concentration200 mol/l, was evaluated.Results The MRP2 staining in the cholestatic lobes was weak and not restricted to the canalicular membrane, unlike the noncholestatic lobes. The expression levels in the cholestatic lobes were 45% of those in the noncholestatic lobes. Postoperative maximum bilirubin levels were significantly correlated with MRP2 expression of the anticipated remnant liver. The MRP2 expression had been already impaired before hepatectomy in all patients who eventually developed severe hyperbilirubinemia.Conclusions Decreased MRP2 expression, caused by biliary obstruction due to cancer, is a possible risk factor for posthepatectomy severe hyperbilirubinemia.     

原位肝移植术后胆道内窥镜的观察

目的探讨纤维胆道镜在肝移植术后的胆结石诊治中的作用。方法对5例肝移植术后出现反复胆系感染、梗阻性黄疸的病人进行纤维胆道镜观察,同时采取等离子碎石技术、网篮取石、异物钳取石。结果在纤维胆道镜直视下,可以清楚地观察到胆管的愈合及胆管血运情况,同时可以成功取石。结论肝移植术后T管的留置和纤胆镜的应用具有重要的价值。     

Screening for VACTERL Anomalies in Children with Anorectal Malformations: Outcomes of a Standardized Approach

PurposeThe majority of patients with an anorectal malformation (ARM) have associated congenital anomalies. It is well established that all patients diagnosed with an ARM should undergo systematic screening, including renal, spinal, and cardiac imaging. This study aimed to evaluate the findings and completeness of screening, following local implementation of standardized protocols.MethodsA retrospective cohort study was performed assessing all patients with an ARM managed at our tertiary pediatric surgical center, following a standardized protocol implementation for VACTERL screening (January 2016–December 2021). Cohort demographics, medical characteristics, and screening investigations were analyzed. Findings were compared with our previously published data (2000–2015), conducted prior to protocol implementation.ResultsOne hundred twenty-seven (64 male, 50.4%) children were eligible for inclusion. Complete screening was performed in 107/127 (84.3%) children. Of these, one or more associated anomalies were diagnosed in 85/107 (79.4%), whilst the VACTERL association was demonstrated in 57/107 (53.3%). The proportion of children that underwent complete screening increased significantly in comparison with those assessed prior to protocol implementation (RR 0.43 [CI 0.27–0.66]; p < 0.001). Children with less complex ARM types were significantly less likely to receive complete screening (p = 0.028). Neither presence of an associated anomaly, nor prevalence of the VACTERL association, differed significantly by ARM type complexity.ConclusionScreening for associated VACTERL anomalies in children with ARM was significantly improved following standardized protocol implementation. The prevalence of associated anomalies in our cohort supports the value of routine VACTERL screening in all children with ARM, regardless of malformation type.Level of EvidenceII.     

Esophageal Surveillance Practices in Esophageal Atresia Patients: A Survey by the Eastern Pediatric Surgery Network

IntroductionEndoscopic surveillance guidelines for patients with repaired esophageal atresia (EA) rely primarily on expert opinion. Prior to embarking on a prospective EA surveillance registry, we sought to understand EA surveillance practices within the Eastern Pediatric Surgery Network (EPSN).MethodsAn anonymous, 23-question Qualtrics survey was emailed to 181 physicians (surgeons and gastroenterologists) at 19 member institutions. Likert scale questions gauged agreement with international EA surveillance guideline-derived statements. Multiple-choice questions assessed individual and institutional practices.ResultsThe response rate was 77%. Most respondents (80%) strongly agree or agree that EA surveillance endoscopy should follow a set schedule, while only 36% claimed to perform routine upper GI endoscopy regardless of symptoms. Many institutions (77%) have an aerodigestive clinic, even if some lack a multi-disciplinary EA team. Most physicians (72%) expressed strong interest in helping develop evidence-based guidelines.ConclusionsOur survey reveals physician agreement with current guidelines but weak adherence. Surveillance methods vary greatly, underscoring the lack of evidence-based data to guide EA care. Aerodigestive clinics may help implement surveillance schedules. Respondents support evidence-based protocols, which bodes well for care standardization. Results will inform the first multi-institutional EA databases in the United States (US), which will be essential for evidence-based care.Level of EvidenceThis is a prognosis study with level 4 evidence.     

Evolution of left-sided thoracoscopic approach for long gap esophageal atresia repair

BackgroundLeft-sided repair for long gap esophageal atresia (LGEA) has been described for patients with a large leftward upper pouch, no thoracic tracheoesophageal fistula (TEF) nor tracheobronchomalacia (TBM), or as salvage plan after prior failed right-sided repair. We describe our experience with left-sided MIS traction induced growth process.MethodsWe retrospectively reviewed patients who underwent Foker process for LGEA at two institutions between December 2016 and November 2021. Patient characteristics, surgical techniques, and outcomes were reviewed.Results71 patients underwent Foker process. Of 34 MIS cases, 28 patients (82%) underwent left-sided repair (median gap length 5 cm) at median age 4 months with median 3 (range 2–8) operations and median 13.5 (IQR 11–21) days on traction until esophageal anastomosis. 9 patients (32%) underwent completely MIS approach, whereas 5 patients (18%) converted to open at first operation and 14 patients (50%) converted to open later in the traction process. Traction was internal in 68%, external in 11%, and combination in 21%. Median follow-up was 15.4 (IQR 7.5–31.7) months after anastomosis. 14% had anastomotic leak managed with antibiotics and/or esophageal vacuum therapy. Median number of esophageal dilations was 3.5 (range 0–13). 18% required stricture resection. 39% underwent Nissen fundoplication. None have needed esophageal replacement.ConclusionsFor multiple reasons including the tendency of both esophageal pouches to have a leftward bias, less tracheal compression by upper pouch, and clean field of surgery for reoperative cases, we now more commonly use left-sided approach for MIS LGEA repair compared to right side, regardless of left aortic arch.Level of evidenceLevel IV Treatment Study.     

胆道疾患对肝脏的影响及手术选择

通过对胆道疾患病人的肝脏活检与非胆道疾患病人肝活检对比分析，探讨对肝脏的影响，从而确定哪些胆道疾患必须手术，哪些胆道疾患可以不须手术。并对手术方法选择提出一些看法。     

胆道良性疾病术中肝外胆管癌漏诊的防治

目的 分析近年来胆道良性疾患术中漏诊肝外胆管的原因及临床特点，并进行防治的探讨，方法 收集９２年至９７年间９例临床资料。结果 全部经手术探查，８便在胆道良性疾患术中漏诊，结论 应联合应用多种以获得早期诊断，确诊后力争根治性切除。