成人先天性胆总管囊肿的二次手术分析

Analysis on Re-operation for Congenital Cyst of Common Bile Duct in Adult Patients

目的探讨成人先天性胆总管囊肿二次手术的原因及治疗对策。方法回顾性分析2010年9月-2015年12月我科7例先天性胆总管囊肿接受二次手术的临床资料。3例第1次手术囊肿残留未处理,4例第1次手术行囊肿切除及胆肠吻合（其中1例囊肿部分残余伴结石,其余3例吻合口狭窄伴结石）。二次手术以囊肿完全切除、胆肠吻合口重建为首选手术方式,1例Ⅳ型囊肿加做左半肝切除。二次手术中1例选择腹腔镜手术。结果 7例手术顺利,手术时间203-466min,平均338.7 min;术中出血量50-500 ml,平均178.6 ml;术后住院时间7-20 d,平均10.7 d。1例二次手术后34个月复发肝内胆管结石,局麻下行盲襻切开、胆道镜取石;其余6例术后恢复顺利,无结石及胆管炎复发。结论成人先天性胆总管囊肿二次手术以首次手术术式选择不当[单纯改道和（或）囊肿切除不全]、胆管结石、吻合口狭窄等为常见原因,再次治疗以囊肿完整切除和（或）肝脏部分切除、胆管（肝管）-空肠Roux-en-Y吻合手术为首选;对于合并肝内胆管结石复发患者,二次手术可皮下埋置空肠盲襻,便于再次处理复发的胆道结石。

Objective To investigate the causes and treatment of re-operation for congenital common bile duct cyst in adult patients. Methods Seven patients with congenital biliary duct cyst in our department from September 2010 to December 2015 were retrospectively analyzed. In the first operation,the bile duct cysts were kept untreated in 3 patients,while cyst resection and biliary enteric anastomosis was performed in the other 4 patients. Among the 4 patients,3 unfortunately suffered anastomotic stenosis and intra-hepatic bile duct stones,and 1 patient suffered residual cyst. The cyst resection with biliary enteric anastomosis was considered as the best choice for the second surgery. The left half liver resection was conducted in 1 patient with type Ⅳ cyst. The laparoscopic surgery was carried out in 1 patient. Results All the operations were successful. The operative duration was 203- 466 min（ mean,338. 7 min）. The intraoperative blood loss was 50- 500 ml（ mean,178. 6 ml）. All the patients were discharged 7- 20 days（ mean,10. 7 days） after the second surgery. One case suffered recurrence of intra-hepatic biliary stone 34 months after the second surgery,who received cholangioscopic lithotomy through jejunal loop. The rest of the patients recovered smoothly without calculus and recurrent cholangitis. Conclusions The causes of re-operation for congenital choledochal cyst include improper treatment in the first operation（ including simple bypass and/or incomplete cyst resection）,bile duct calculus,and anastomotic stenosis. The total cyst resection and / or liver partial resection,and bile duct（ hepatic duct） jejunum Roux-en-Y anastomosis are considered as the best choice in the second surgery. Subcutaneous jejunal blind loop can be used in patients with intrahepatic bile duct stones,which can be utilized to treat the recurrent biliary calculi.