先天性胆总管囊肿术后系膜裂孔疝临床特点总结及诊治分析

Clinical features of postoperative transmesenteric hernia in congenital choledochal cyst patients： diagnostic and therapeutic experience from a single center

目的 总结先天性胆总管囊肿术后系膜裂孔疝患儿的临床特点,归纳诊治经验.方法 2016年12月至2017年6月,我院普外科共收治4例先天性胆总管囊肿术后系膜裂孔疝患儿,统计分析患儿临床资料、手术方法及预后情况.结果 4例患儿初次手术年龄2岁2个月至5岁2个月,既往行腹腔镜下/开腹胆总管囊肿切除肝总管空肠Roux-en-Y吻合术,系膜裂孔疝发生时间为术后2d至13个月.临床均表现为腹痛、呕吐;其中1例患儿腹腔引流管引流血性液体,另3例患儿均有特征性强迫半坐位,平卧后腹痛加重.3例患儿腹部超声结果提示Roux-en-Y代胆道肠袢旋转、系膜水肿,伴肠管积液扩张.1例患儿生化结果提示总胆红素轻微升高,3例患儿生化结果提示转氨酶轻微升高.术中探查均为小肠自代胆道肠袢下方系膜裂孔钻过,引起内疝,继发代胆道肠袢扭转.2例患儿无肠管坏死,予复位后关闭系膜裂孔;1例患儿发生长段肠坏死,经历2次手术切除吻合肠管并再次重建胆道后,呈短肠综合征状态;1例患儿发生长段肠坏死、肠吻合口瘘,经历4次手术切除坏死肠管并再次重建胆道后恢复.结论 腹腔镜下/开腹先天性胆总管囊肿切除肝总管空肠Roux-en-Y吻合手术务必严密关闭代胆道肠袢后方系膜裂孔,防止术后系膜裂孔疝发生;此种系膜裂孔疝患儿常表现出强迫体位,血生化肝功损害和腹部超声提示升枝肠管扭转伴肠管积液扩张是特征性表现;需及时手术治疗,否则可引起严重不良后果.

Objective To summarize the clinical features and diagnostic and therapeutic experiences of postoperative transmesenteric hernia in congenital choledochal cyst patients.Methods Four congenital choledochal cyst patients diagnosed as postoperative transmesenteric hernia were admitted from December 2016 to June 2017.The clinical data of surgery and prognosis were retrospectively analyzed.Results The age at initial surgery ranged from 14 months to 62 months.The surgical approaches were laparoscopic/open choledochal cystectomy with Roux-en-Y hepaticojejunostomy.The onset time of postoperative transmesenteric hernia ranged from 2 days to 13 months.All patients presented with abdominal pain and vomiting.Bloody liquid was found in drainage tube of 1 case and forced semireclining position in 3 cases.The ultrasonographic results of 3 cases showed torsion,mesenteric swelling and fluid accumulation of ascending Roux limb.The serum biochemical results showed slightly elevated total bilirubin in 1 case and a slight elevation of liver enzyme in another 3 cases.A second surgery confirmed intestinal transmesenteric hernia through ascending Roux limb mesentery defect in all cases,causing ascending Roux limb torsion at the same time.Defect closure by suturing was performed in 2 cases without intestinal necrosis.Long-segment necrotic intestine resection with anastomosis and hepaticodeudenotomy was performed in 1 case by 2 more surgeries,causing short bowel syndrome.Long-segment necrotic intestine resection with anastomosis,hepaticodeudenotomy and intestinal anastomotic leakage repair with re-anastomosis were performed by 3 more surgeries in another case.Conclusions Ascending Roux limb mesenteric defect must be strictly closed by suturing during laparoscopic/open congenital choledochal cyst surgery to prevent postoperative transmesenteric hernia.The clinical features of postoperative transmesenteric hernia in choledochal cyst include forced semireclining position,elevated liver panel and torsion with fluid accumulation of ascending Roux limb under ultrasonography.Timely urgent surgery should be performed to avoid severe complications and poor prognosis.