经腹腔镜治疗非扩张性胰胆合流异常

目的探讨经腹腔镜治疗非扩张性胰胆合流异常的效果。方法 2003年2月～2009年1月,13例不合并胆总管囊肿的胰胆合流异常患儿,年龄4～12岁,中位年龄5岁,男5例,女8例。均有腹痛病史,反复胆管炎发作3例,反复梗阻性黄疸病史8例,胰腺炎病史3例。术前超声检查肝内外胆管无扩张,总胆红素(TBIL)34～120μmol/L,直接胆红素(DBIL)18.4～70.8μmol/L。6例转氨酶升高,天冬氨酸转氨酶(AST)38.7～89IU/L,丙氨酸转氨酶(ALT)45～81IU/L。4例血淀粉酶升高,147～198U/L。4例术前ERCP检查发现胰胆合流异常。13例均经术中胆道造影证实存在胰胆合流异常,然后实施胆总管切除、肝管空肠Roux-en-Y吻合术。2例合并肝外胆管结石,首先以3mm镜头用作胆道镜探查,然后用8号尿管以生理盐水冲洗,或用小儿尿道镜将结石勾出或冲出。4例合并蛋白栓处理方法与并发结石者基本相同,但相对容易。结果全部手术均获成功。术中胆道造影显示Komi分型Ⅰ型10例、Ⅱ型3例;共同管长度5～12mm,中位数7.0mm,无中转开腹。手术时间152～216min,中位数170min。术中出血5～10ml,无需输血病例,无脏器损伤,无胆漏、肠漏。术后住院4～7天。TBIL、DBIL术后3周均恢复至正常范围。6例AST、ALT升高者在术后4个月内恢复正常,4例淀粉酶升高者术后3周内恢复正常。术后随访6～50个月,中位数28个月。患儿生长发育良好,无腹痛、黄疸、发热等。肝胆系统超声无胆管扩张、肝硬化表现。结论经腹腔镜治疗伴有反复腹痛、黄疸、胰腺炎等并发症的非扩张性胰胆合流异常效果良好。

Laparoscopic Excision of the Extrahepatic Bile Duct and Roux-en-Y Hepatoenterostomy for Pancreaticobiliary Maljunction without Choledochal Cyst

Objective To assess the efficacy of laparoscopic extrahepatic bile duct excision and Roux-en-Y hepatoenterostomy for Pancreaticobiliary maljunction（PBM）without choledochal cyst.Methods From February 2003 to January 2009,thirteen symptomatic patients with PBM（5 boys and 8 girls,aged from 4 to 12 with a median of 5 years）were enrolled in our hospital.Before hospitalization,all of the patients presented with stomachache;repeated jaundice occurred in eight of them,and cholelithiasis in three;Elevated TBIL（34-120 μmol/L）and DBIL（18.4-70.8 μmol/L）were detected in 13 patients,increased amylase（147-198 U/L）in four,and high levels of AST（38.7-89 IU/L）and ALT（45-81 IU/L）in six.On admission,ERC detected PBM in 4 patients.All the patients underwent cholangiography,which confirmed the diagnosis of PBM;and then laparoscopic total bile duct excision and Roux-en-Y hepatoenterostomy were performed.In two of the cases,who were complicated with extrahepatic bile ducts,3-mm fiberscope was employed to explore the bile duct,and then the stones were removed by using urethrascope or washing by PBS through a 8 Fr Urethral catheter.Same procedure was also used in the 4 patients who were complicated with protein plug.ResultsThe operations were completed successfully in all of the patients.During the operation,cholangiography showed Komi Ⅰ in 10 cases,and Komi Ⅱ in the other 3.The length of common tube was 5 to 12 mm with a medium of 7.0 mm.No patients were converted to open surgery.The operation time ranged from 152 to 216 minutes with a medium of 170 minutes.Intraoperative blood loss was 5 to 10 ml.No patients needed blood transfusion;none of them developed injuries to internal organs or biliary or intestinal leakage.The patients were discharged form hospital in 4 to 7 days after the operations,and were followed up for 6 to 50 months（medium,28 months）.The levels of TBIL and DBIL recovered in all the patients in 3 weeks;the six patients who had elevated levels of AST and ALT recovered in 4 months.And the 4 patients with increased amylase recovered in 3 weeks.The patients grew up well during the follow-up without showing jaundice,abdominal pain,or fever;no signs of dilated bile ducts or liver cirrhosis were detected by ultrasonography during the period.Conclusion Laparoscopic extrahepatic bile duct excision and Roux-en-Y hepatoenterostomy is effective for patients with symptomatic PBM without choledochal cyst.