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。

On complications after laparoscopic total cyst excision with Roux-en-Y hepatoenterostomy for congenital choledochal cyst

Objective To explore the categories and precautions of complications after laparoscopic total cyst excision with Roux-en-Y hepatoenterostomy for congenital choledochal cyst in children. Methods Laparoscopic cyst excision with Roux-en-Y hepatoenterostomy was performed in 66 cases of congenital choledochal cyst from July 2001 to June 2006. Their median age was 3.8 years (range, 2 months ~ 28 years). The choledochal cyst was classified as cystic type in 61 cases, with a diameter ranged 2.5~18 cm, and fusiform type in 5 cases, with a diameter ranged 1.2~2.2 cm. Nine cases were associated with hepatic ductal stenosis; they underwent a laparoscopic excision of the cyst with a ductoplasty. Results The laparoscopic operation was successfully completed in all the 66 patients, with a mean operation time of 3.8 h (2.6~9.5 h) and a mean hospital stay of 4.5 d (3~8 d). Early complications included 2 cases of bile leakage (spontaneous recovery in 1 case, and an open surgery required in 1 case because of obstructed drainage, with anastomotic leakage identified and re-anastomosis performed during the operation), 1 case of hyperkalemia (10.8 mmol/L at 7 h after operation, resulting in heart failure and cardiopulmonary resuscitation, and died of renal failure on the 3rd postoperative day), and 2 cases of stress ulcer (spontaneously relieved). There were no infections of the abdominal cavity or the wound. Long-term complications included 1 case of intestinal obstruction (open exploration showed intestinal adhesion and necrosis, and an enterectomy with enteroanastomosis was given). No anastomotic stenosis and postoperative cholangitis were encountered.Follow-up observations for 6~56 months (median, 21 months) were conducted in 65 survived cases, B-ultrasonography found no bilestone, and liver functions were in normal limits. Conclusions Laparoscopic total cyst excision with Roux-en-Y hepatoenterostomy is a complicated operation with high risks. Some complications are similar to those after conventional operations, such as bile leakage, stress ulcer, and intestinal obstruction. Hyperkalemia is perhaps the most serious one, which maybe related to carbon dioxide pneumoperitoneum. It is essential to monitoring hyperkalemia in postoperative period.