腹腔镜与开放Kasai手术治疗Ⅲ型胆道闭锁疗效的前瞻性对比研究

Laparoscopic versus open Kasai portoenterostomy in infants with type Ⅲ biliary atresia： a prospective study

目的应用大样本的前瞻性临床对比研究来评价腹腔镜Kasai手术治疗先天性胆道闭锁的疗效。方法2009年9月至2011年8月共95例Ⅲ型胆道闭锁患儿在我院接受手术治疗。术前随机分为2组：腹腔镜手术组（LP组）48例和开放手术组（OP组）47例。LP组中4例患儿中转开放手术，其余44例LP组患儿及47例OP组患儿进入研究。两组患儿手术年龄及性别均无统计学差异。通过对比术中出血量、手术持续时间、术后住院时间、术后恢复进食时间、手术前后肝功能变化情况、术后黄疸消退情况、胆管炎等各种并发症发生率以及生存率，评价两组的疗效。结果LP组手术时间（172．32±29．00）min长于OP组（149．66±27．91）min（P〈0．01），LP组手术出血量（8．07±3．09）ml较OP组（17．55±3．59）ml少（P〈0．01），LP组术后进食时间（2．80±1．36）d较0P组早（3．47±0．65）d（P=0．02），但两组患儿的术后住院时间差异无统计学意义[-LP组（12．55±3．92）d，OP组（13．57±3．03）d，P=0．16]。LP组术后中位随访时间为16个月，OP组为17个月。术后退黄率（LP组43．18％，OP组51．06％，P=0．45）、胆管炎发病率（LP组59．09％，OP组59．57％，P=0．96）、病死率（术后6个月LP组18．18％，OP组14．89％，P=0．67；术后1年LP组21．88％，OP组27．78％，P=0．58）及术后肝功能恢复情况均无统计学差异。结论腹腔镜Kasai手术的术后肝功能恢复情况、退黄率、胆管炎发病率及病死率均不优于开放手术，而且术后效果不佳的患儿仍需要肝移植，微创手术优势不能体现出来。因此，Ⅲ型胆道闭锁的治疗需要慎重选择腹腔镜Kasai手术。

Objective To compare the clinical outcomes in laparoscopic versus conventional Ka- sai portoenterostomy in patients with type Ⅲ biliary atresia. Methods Ninety-five patients with type Ⅲ biliary atresia underwent Kasai operation in the Capital Pediatric Institution between September 2009 and August 2011. They were randomized assigned into 2 groups according to the surgical proce- dures： laparoscopic Kasai portoenterostomy group （LP group, n = 48） and open Kasai portoenterosto- my group （OP group,n = 47）. In LP group, 4 patients were converted to open surgery during opera- tion. The rest 44 cases of the LP group and 47 cases of OP group were recruited in this study. The clinical data including intraoperative blood loss, operation time, postoperative hospital stay, start of food intake, liver function improvement, jaundice clearance rate, incidence of cholangitis, postopera- tive complications and mortality were analyzed. Results There were no significant differences of pa- tients gender and age at operation between the LP group and the OP groups. Compared with those un- derwent open surgery, the patients underwent laparoscopic Kasai procedure had a longer operation time （172. 32 ＋ 29 min vs. 149. 66 ± 27. 91 min,P〈0. 01）, less intraoperative blood loss （8. 07 - 3. 09 ml vs. 17. 55 ＋ 3. 59ml, P〈0. 01）, and earlier start of food intake after surgery （2. 80 ＋ 1.36 days vs. 3. 47 ± 0. 65 days, P = 0. 02）. However, no statistical difference of postoperative hospital stay was found between these 2 groups （LP 12. 55 ＋3.92 days vs. OP 13. 57＋3.03 days, P=0. 16）. The me- dian follow-up period was 16 months of the LP group and 17 months of the OP group. There are no significant differences between these 2 groups in postoperative jaundice clearance rate （LP 43.18 % vs. OP 51.06%, P = 0. 45）, incidence of cholangitis （LP 59. 09% vs. OP 59. 57%, P = 0. 96）, mortality（6 months after surgery： LP 18. 18~ vs. OP 14. 89%,P = 0. 67; 1 year after surgery： LP 21.88% vs. OP 27.78%, P = 0. 58）, and liver function improvement after operation. Conclusions This pro- spective study shows the laparoscopic Kasai procedure for biliary atresia is technically feasible. How- ever, laparoscopic Kasai portoenterostomy is not superior to open surgery in the improvement of native liver survival.