腹腔镜与开放胆总管囊肿术后胆道梗阻二次手术的对比研究

Comparison of laparoscopic versus open redo hepaticojejunostomy for children with choledochal cysts

目的本研究旨在比较腹腔镜和开放胆总管囊肿二次手术术后长期疗效。方法2006年1月至2016年5月间49例患儿在外院接受胆总管囊肿根治术后出现胆道梗阻，转入我院成功行腹腔镜二次手术。术中根据梗阻原因进行相应处理：异位前置肝右动脉压迫肝管空肠吻合口近端肝总管，将异位肝右动脉重置于近端肝总管后方解除梗阻；初次手术未解决伴发的单一或多处肝管狭窄，行肝管扩大成型＋肝管空肠再吻合；吻合口狭窄，行肝管空肠再吻合。评估手术时间，术后恢复和并发症，和2001年10月至2005年12月间在我中心行开放胆总管囊肿二次手术的17例患儿进行疗效对比。结果两组患儿年龄差异无统计学意义。平均手术时间相似（腹腔镜组2.3 h，开放手术组2.1 h，P＝0.1）。腹腔镜组平均术后住院时间5.5 d，术后恢复进食时间2.1 d，放置腹腔引流时间3.2 d，明显短于开放手术组（平均术后住院时间7.4 d，术后恢复进食时间3.3 d，放置腹腔引流时间4.5 d，P〈0.001）。中位随访时间腹腔镜组为50个月（1～123个月），开放手术组142个月（123～173个月）。两组均无一例发生胆道再梗阻，胆管炎，肝内胆管结石或癌变。腹腔镜组无一例输血，开放手术组1例患儿因术后出血予止血和输血治疗3 d后自愈。开放手术组2例患儿发生伤口裂开，行手术修补。腹腔镜组无一例出现伤口并发症。开放手术组1例患儿发生初次手术腹壁伤口下粘连肠管损伤，腹腔镜组无一例发生。腹腔镜二次手术早期1例患儿发生胆漏，术后引流7 d后自愈。腹腔镜组并发症发生率明显低于开放手术组（2%比23.5%，P〈0.05）。两组肝功能均于二次术后1个月至2年恢复正常。 结论腹腔镜胆总管囊肿二次手术安全可行，长期疗效可与开放手术相媲美，甚至优于开放手术。

ObjectiveTo compare the efficacy of laparoscopic （LRH） versus open redo hepaticojejunostomy （ORH） for children with cholecochal cysts （CDC）. MethodsFrom January 2006 to May 2016, 49 CDC children with biliary re-obstructions after primary definitive surgeries underwent LRH successfully. Hepatic arteries were repositioned behind Roux loop. Ductoplasties and wide hepaticojejunostomies were performed. Operative duration, postoperative recovery and complications were compared with our open redo hepaticojejunostomy （ORH, n=17） from October 2001 to December 2005. ResultsNo significant inter-group difference existed in age at surgery. Mean operative duration was 2.3 hours in LRH group and it did not differ from 2.1 hours in ORH group （P=0.1）. Average postoperative hospital stay, resumption of full diet and duration of drainage were 5.5, 2.1 and 3.2 days in LRH group and they were significantly shorter than 7.4, 3.3 and 4.5 days in ORH group （all P〈0.001）. The median follow-up period was 50 （1-123） months in LRH group versus 142 （123-173） months in ORH group. There was no instance of recurrent biliary obstruction, cholangitis, intrahepatic stone formation or carcinoma. No blood transfusion was required in LRH group while one patient in ORH group received 3-day hemostatic treatment and blood transfusion for postoperative bleeding. Two patients in ORH group who developed wound dehiscence required surgical repairing. One patient in ORH group had injury of intestine adherence to primary abdominal scar. In LRH group, one patient with bile leak was spontaneously cured after 7-day drainage. Overall morbidities were 2.0% （1/49） in LRH group, significantly less than 23.5% （3/17） in ORH group （P〈0.05）. Liver function parameters were normalized in both groups. ConclusionsNormally LRH requires no open surgery. The outcomes of LRH group are comparable or even superior to those of ORH group.