胆道闭锁Kasai手术的精准处理

Precise procedure of Kasai operation in biliary atresia

目的探讨胆道闭锁Kasai手术的精准操作技巧，提高术后黄疸消退率，改善胆道闭锁预后。方法回顾性分析2002年7月至2012年12月首都医科大学附属北京儿童医院普外科收治的189例Ⅲ型胆道闭锁患儿的临床资料。男117例，女72例，男女之比为1．63：1．00；年龄34—110d，平均76d。189例均用针形电刀解剖肝门部锥形纤维组织块，剪除肝门处闭锁的肝外胆道，行肝门-空肠Roux-en-Y吻合恢复胆汁引流。保证胆汁良好引流的手术要点：（1）用针形电刀解剖肝门部锥形纤维组织块，可以微创，精准到位，减少出血；（2）电凝纤维组织块深面回流至门静脉的4～6支小静脉分支，肝门部锥形纤维组织块即达到门静脉分叉以上的解剖平面；（3）组织剪剪除游离的纤维组织块，断面压迫止血，局部可加用1：100000的肾上腺素液能起到更好的止血作用；（4）肝门空肠吻合先在纤维块的背侧预留针线备用，再吻合前壁，可降低肝门空肠吻合的难度，使吻合确切、到位；（5）肝门空肠Roux—en—Y吻合的胆支长度最好在60em以上，同时行矩形瓣防返流，以防止和减少术后胆管炎的发生。结果189例患儿术后早期均有胆汁样粪便经肛门排出；术后6个月，56．7％的患儿血清总胆红素降至正常（总胆红素〈20μmol／L）。结论胆道闭锁Kasai手术的精准操作是胆道闭锁患儿良好预后的重要保证。

Objective To discuss the precise operational skill of Kasai operation in biliary atresia,in order to increase postoperative jaundice-free rate and improve proguosis. Methods The clinical data of 189 cases of type Ⅲ biliary atresia were analyzed admitted into Department of General Surgery,Beijing Children＇s Hospital,Capital Medical University ,from Jul. 2002 to Dec. 2012 retrospectively, 117 male and 72 female（ 1.63 ： 1.00）. Age at Kasai procedure ranged from 34 days to 110 days,with mean age 76 days. All of the 189 cases restored bile drainage after Kasai opera-tion; during operation dissect the cone-shaped fibrous tissue at porta hepatis with needle-shaped electrotome, then cut off impotent extrahepatic biliary tract and fibrous tissue at porta hepatis with tissue scissor, and a Roux-en-Y loop of jeju-num was anastomosed around the fibrous edges of the transected tissue, forming a portoenterostomy. The key skills which to guarantee good bile drainage during operation： （ 1 ） Use needle-shaped electrotome to dissect fibrous tissue at porta hepatis in order to obtain precise dissection, less blood loss and minimal invasion. （2） Stop the blood flow of the 4-6 small venous branches below the fibrous tissue at porta hepatis which return to portal vein with electrocoagulation, in or-der to dissect the cone-shaped fibrous tissue until above the level of portal vein branches. （3） Cut off the fibrous tissue at porta hepatis with tissue scissor,then press the transsection to stop bleeding,with local application of 1 ： 100 000 ad-renalin if necessary. （4） Prepare sutures with needles at the dorsal edge of transsection previously, then anastomose the ventral edge,which would make portoenterostomy less difficult and more precise. （5） In order to reduce the chance of postoperative cholangitis, the jejunal Roux-en-Y loop should better be more than 60 era, and antireflux valve should be done. Results All of the 189 cases achieved cholic stool soon after operation ,56.7% patients achieved janndice-free 6 months after operation（ total bilirubin 〈 20 μmol/L）. Conclusion Precise procedure of Kasai operation is the key guaranty of good prognosis for biliary atresia patients.