伴有并发症的儿童胆总管囊肿的临床处理

目的 讨论合伴有各类并发症的儿童胆总管囊肿的临床处理及手术时机和方法.方法 回顾性分析2013年1月至2015年12月上海新华医院小儿外科收治的45例合伴有各类并发症的儿童胆总管囊肿患儿的临床资料.其中,胆道穿孔7例,胆源性胰腺炎9例,胆管炎、阻塞性黄疸、肝功能受损29例,保守治疗效果不佳.7例胆道穿孔中,5例胆汁性腹膜炎行囊肿外引流和二期根治术;2例隐匿性胆道穿孔一期行根治术.9例胆源性胰腺炎给予内镜下鼻胆管引流,待淀粉酶正常后一期行根治术.29例阻塞性黄疸伴肝功能受损的患儿中,17例发病年龄小于3个月行一期根治手术;12例发病年龄大于6个月患儿先行ERCP置鼻胆管引流,待黄疸消退、转氨酶正常后一期行根治性手术.结果 伴胆道穿孔的7例胆总管囊肿患儿中,2例在外引流期间出现水电解质紊乱,1例T管脱落,1例隐匿性穿孔在根治术后出血再次手术,余者术后均痊愈出院.9例胆源性胰腺炎患儿置鼻胆管引流后淀粉酶均恢复正常,根治术后均痊愈出院.并发急性胆管炎、伴有梗阻性黄疸、肝功能受损29例中,12例发病年龄大于6个月,其中11例行内镜下置鼻胆管引流后并发症改善行根治手术,1例ERCP失败后改行外引流和二期根治术;小于3月龄婴儿直接行一期根治性手术,术后均痊愈出院.所有患儿保持随访,术后随访时间1～3年.1例术后慢性胰腺炎史,1例胆管炎史,均通过药物治疗缓解症状.结论 对合伴有各类并发症的儿童胆总管囊肿选择合理的处理手段和合适的手术方式将有效减少并发症所造成的危害.

Clinical management of complicated choledochal cysts in children

Objective To explore the clinical management,surgical timing and approaches of complicated choledochal cysts in children.Methods From January 2013 to December 2015,retrospective reviews were conducted for the clinical data of pediatric choledochal cysts with complications.There were biliary perforation (n =7),biliary pancreatitis (n =9) and cholangitis,obstructive jaundice & liver dysfunction (n =29).There was no improvement after conservative measures.And 5/7 biliary perforation patients underwent cyst external drainage and definitive surgery after 3 months.Another 2 patients of sealed perforation underwent one-stage definitive surgery.Nine cases of biliary pancreatitis underwent endoscopic nasobiliary drainage and one-stage definitive surgery after serum amylase returned to normal.Among 29 cases of obstructive jaundice and liver dysfunction,17 patients with an onset age under 3 months had one-stage definitive surgery while 11 patients aged over 6 months nasobiliary drainage and one-stage definitive surgery after relieved complications.Results For patients of choledochal cysts complicated with biliary perforation,there were dehydration and electrolyte disturbance (n =2),T-tube dislodging (n =1) and sealed perforation reoperated because of postoperative bleeding (n =1).The remainder was discharged uneventfully.When serum amylase recovered after endoscopic nasobiliary drainage,patients complicated with biliary pancreatitis underwent definitive surgery and were discharged uneventfully.Among patients complicated with acute cholangitis,obstructive jaundice and liver dysfunction,12 were aged over 6 months.And 11 complicated cases were relieved after nasobiliary drainage.One case of papilla cannulation failure underwent emergent cyst external drainage and definitive surgery 1 month later.Seventeen cases with an onset age of under 3 months had one-stage definitive surgery.They were all discharged uneventfully.During follow-ups,chronic pancreatitis (n =1) and cholangitis (n =1) became relieved after conservative medications.Conclusions Appropriate management and surgical approaches can effectively improve the outcomes of pediatric complicated choledochal cysts.