胆道闭锁术后高胆红素血症并胆管扩张二次手术的探讨

目的 探讨胆道闭锁(BA)术后高胆红素血症者二次手术的条件及必要性、可行性和效果.方法 2001年3月至2007年12月,共对10例BA术后患儿实施了二次手术,男4例,女6例;年龄5个月～6.5岁.距第一次Kasai's手术时间2个月～6年.其中Ⅲ型BA Kasai's手术后9例,Ⅱ型BA囊肿空肠吻合术后1例;所有患儿第一次术后3个月总胆红素(TBIL)直接胆红索(DBIL)曾降至正常,谷草转氨酶(AST)、谷丙转氨酶(ALT)等酶水平下降,后再次出现高胆红素血症、酶水平升高、陶土样便等情况.二次术前经影像学检查证实所有患儿肝门、肝内胆管扩张,1例并发肝门胆管结石;6例伴有肝门部囊肿形成.结果 8例患儿行开腹肝门空肠再吻合术,2例患儿实施囊肿空肠吻合术,手术全部成功,无术中并发症发生.手术时间为2.6～3.2h(平均3.0h),术中出血15～30ml.术后进食中位数时间32h(24～52h);术后2～4d(平均3d)排黄色大便;腹腔引流放置中位时间58 h(38～96 h),黄疸减退至轻度或消退中位时间为术后12 d(7～24 d),6例患儿术后4周 TBIL、DBIL,降至正常水平,4例患儿6周后降至正常水平,转氨酶术后均下降.术后中位住院时间15 d(12～29 d).术后随访4～36个月,3例患儿于术后4周内发牛胆管炎,2例患儿于术后6个月内发作胆管炎2次,均治愈.术后3个月所有患儿 TBIL、DBIL、总蛋白(TP)正常;3例患儿术后3个月AST、ALT、ALP恢复正常,3例术后5～8个月恢复正常.生长发育正常.无吻合口狭窄、粘连肠梗阻等术后并发症.结论 对BA术后高胆红素血症患儿恰当的实施二次肝门肠吻合术能够建立有效的胆汁引流,改善患儿症状,提高生活质量,并长期带自体肝脏生存,避免肝移植或为等待肝源提供时间保障.

Re-do of Kasai operation in post-operative biliary atresia patients with persistent elevation of bilirubin

Objective To assess the feasibility and safety of reoperation for patients with biliary atresia(BA)after Kasai's procedure.Methods Ten children with BA with recurrence of hyperbiliru-binemia and pale stool 2 to 74 months after the first Kasai's operation were enrolled in the study,be-tween April 2001 and November 2007.There were 6 girls and 4 bovs.The age ranged from 5 months to 6.5 years(median,18 months).Before the first operation,Nine patients were of type Ⅲ and one was of type II.Dilated intrahepatic bile ducts were found in all patients.SiX patients presented with cystic dilation at porta hepatis.The median diameter of the dilated intrahepatic ducts was 1.8 cm (range,from 1.5 to 3.0cm).Of the 10 children,eight underwent redo of hepatopo~oenterostomy,and two underwent cyst-jejunum anastomosis.The patients were followed up for a median period of 26 months(range:4 to 36 months).Results The median duration of the operations was 3.0 hours (range:2.6 to 3.2 hours).There was no intraoperative complication.The blood loss was 15 tO 30 ml No blood transfusion was required.The paitents passed flatus 26 hours post-operatively(median) (range:1 8 to 50 hours),resumed oral intake in 32 hours(range,from 24 to 52 hours)postoperative,bile stained stools were passed on day 3(range,from 2 to 4 days)postoperatively.Jaundice started to subside on day 12(range,from 7 to 24 days)postoperatively.The post-operative course was unevent-ful with the mean hospital stay of 10 days(range,from 8 to 14 days).No complication was detected during the followed-up visits.Conclusions Re-operation and bile duct dilatation in post-Kasai biliary atresia patients with recurrent hyperbilirubinemia is feasible,safe and effective.