【摘要】 目的评价腹腔镜胆总管囊肿切除术中不同胆道重建方式的应用及效果。方法回顾性分析河北医科大学第二医院小儿外科收治的112例腹腔镜手术治疗先天性胆总管囊肿病例资料,其中实施肝管空肠Roux-en-Y吻合术(Roux-en-Y hepaticojejunostomy,RY) 49例、不离断空肠的肝管空肠袢式吻合术(modified warren loop hepaticojejunostomy,MW) 31例及肝管十二指肠吻合术(hepaticod uodenostomy,HD) 32例,对其围手术期参数、并发症及超声随诊等情况进行对比分析。结果患儿均顺利完成腹腔镜胆总管囊肿切除及各种胆道重建手术,无一例出现术中意外及中转开腹。RY组手术时间(186. 10±19. 23) min,MW组手术时间(149. 81±23. 37) min,HD组手术时间(134. 68±21. 36) min,3组手术时间比较均有两两间的显著性差异(P <0. 05)。RY组术后肠功能恢复时间为(2. 07±1. 27) d,MW组为(1. 05±0. 97) d,HD组为(1. 02±1. 14) d,其中HJ组和HD组术后肠功能恢复时间明显短于RY组(P <0. 05)。各组术中出血量、腹腔引流管置留时间、术后住院天数和围手术期并发症发生率的差异均无统计学意义(P> 0. 05)。HD组肝内胆管反流发生率明显增高(37. 5%)、2例Ⅳ型CCC发生肝门吻合口狭窄,予以球囊扩张缓解。结论腹腔镜胆总管囊肿切除术3种胆道重建术式各有优缺点。RY术式效果较好,更适合于肝门胆管狭窄矫治后吻合重建;不离断空肠的MW手术时间较短,可维持空肠正常电生理节律、有利于术后肠功能快速恢复; HD术式可完全于腹腔镜下实施,胆汁引流更符合生理,虽操作简单、创伤小,但术后反流性胆管炎发生率较高。因此,在临床上应根据不同胆管扩张病变类型个性化选择胆道重建术式。更多还原

【Abstract】 Objective To evaluate the effectiveness of different laparoscopic biliary tract reconstructions after congenital choledochal cyst(CCC) excision involving Roux-en-Y hepaticojejunostomy(RY group),modified Warren loop hepaticojejunostomy(MW group) and hepaticoduodenostomy(HD group).Methods A total of 112 CCC children undertook laparoscopic resection of extrahepatic bile ducts plus RY(n = 49),MW(n = 31)and HD(n = 32) anastomosis respectively.Their clinical data were retrospectively summarized and analyzed,including perioperative parameters,complications and ultrasonographic follow-ups.Results Laparoscopic choledochal cyst resection and biliary-enteric reconstruction were completed successfully in all patients.There was no intraoperative accident or any conversion into open surgery.The operative duration was(186.10 ± 19.23) min in RY group,(149.81 ± 23.37) min in MW group and(134.68 ± 21.36) min in HD group(P < 0.05).The recovery time of intestinal motility was(2.07 ± 1.27) days in RY group,(1.05 ± 0.97) days in HJ group and(1.02± 1.14) days in HD group(P < 0.05).Estimated blood loss,abdominal drainage tube time,perioperative complications and hospital stay were not different among three groups(P > 0.05).Intrahepatic reflux(37.5%) was detected by ultrasonography and type IV cases with anastomotic stenosis underwent balloon dilatation in HD group.Conclusion Three biliary-enteric reconstructive procedures have both advantages and disadvantages.Roux-en-Y anastomosis is more suitable for hepatic portal biliary duct plasty.Jejunum is spared in MW so that much time is saved and normal electrophysiological rhythm preserved.It promotes recovery of postoperative intestinal peristalsis.HD anastomosis can be successfully completed under guidance of laparoscope,yet there is a higher incidence of postoperative complications.Personalized biliary-enteric reconstruction should be adopted according to different types of biliary dilation.更多还原