儿童鞘膜积液发病机制的临床研究

Clinical research progress in the pathogenesis of congenital hydrocele in children

目的传统观念认为,儿童非交通性鞘膜积液患儿内环口处鞘状突均处于闭合状态,鞘膜囊内液体主要来源于囊壁自身分泌。本研究旨在探讨儿童先天性鞘膜积液(尤其非交通性鞘膜积液)的发病机制。方法 2002年1月至2015年12月由本院收治395例年龄大于2岁先天性鞘膜积液患儿,其中交通性鞘膜积液134例,非交通性鞘膜积液261例;均予腹腔镜手术探查,了解鞘状突闭合情况,术后长期随访鞘状突结扎后疗效;对其中25例接受腹腔镜手术的患儿通过在内环口水平向未闭合的鞘状突内滴注美兰液,了解鞘膜积液的液体可能来源。同期选择传统开放手术患儿34例,术中切取少许鞘膜囊囊壁组织送病理检查,了解囊壁的组织学特征。结果 (1)34例开放手术患儿组织病理学检查发现:患儿鞘膜囊壁内膜主要由单层扁平间皮细胞构成,分泌功能非常弱。(2)134例交通性鞘膜积液患儿内环口处鞘状突均未闭合,经2~3 cm的鞘状突管直接连通睾丸鞘膜腔,挤压阴囊鞘膜囊可见清亮液体经内环口流入腹腔;261例非交通鞘膜积液患儿内环口处鞘状突仍呈开放状态,经鞘状突管与精索或睾丸鞘膜囊腔相连,挤压鞘膜囊可见少量液体从其顶部小孔渗出。经内环口向未闭合鞘状突管滴注美兰液,30 min后用细针经皮穿刺交通性和非交通性鞘膜积液囊,均可抽取美兰淡染囊液。(3)395例腹腔镜下手术患儿,术后平均随访时间均超过1年,仅6例于术后1~3个月患侧复发,一期治愈率98.5%。结论与传统观念不同,本研究发现鞘状突发育过程中未闭合是儿童先天性鞘膜积液发病的主要因素,鞘膜囊壁内膜主要由单层扁平间皮细胞构成,囊内积液不是囊壁自身分泌,而是来源于腹腔的正常腹水。非交通性鞘膜积液鞘膜囊顶部小孔处可能存在单向瓣膜样结构,阻止囊内液倒流入腹腔。

Objective Pediatric processus vaginalis of uncommunicating hydrocele is perceived to stay in a closed state at inner ring and fluid in sac is derived from the secretion of sac wall itself. The present study was intended to explore the possible pathogenesis of congenital hydrocele （ esp. uncommunicating hydrocele）. Methods Between January 2002 and December 2015,395 boys aged 〉2 years with congenital hydrocele un-derwent laparoscopy for exploring the closure of sheath of inguinal inner ring. Within the same period, 34 pa-tients voluntarily opting for traditional open surgery were selected for histological study to investigate the struc-ture of cyst wall. Then methylthionine chloride was injected into processus vaginalis of 25 laparoscopic patients to understand the possible source of fluid in congenital hydrocele. After mini-invasive laparoscopic high-liga-tions of processus vaginalis at internal inguinal ring,percutaneous puncture,aspiration of sac and postoperative follow-ups were performed for evaluating the therapeutic efficacies. Results Pathological research of 34 pa-tients with open surgery revealed that sac of hydrocele was composed predominantly of a monolayer of flat epi-thelial cells and secretion function was rather weak. According to the changes in cyst size in 395 laparoscopic patients,the preoperative diagnosis was communicating hydrocele （ n = 134） and uncommunicating hydrocele （7i =261） . Under laparoscope, open processus vaginalis with communicating hydrocele was observed at internal inguinal ring. Processus vaginalis communicated with cavity of periorchium by a tube of 2 - 3 cm. Transparent liquids flew into peritoneal cavity through internal inguinal ring when pressing sac of hydrocele; For 261 patients with uncommunicating hydrocele,open processus vaginalis was observed at internal inguinal ring. Proces- sus vaginalis communicated with sac of uncommunicating hydrocele by a tube. A small amount of liquid exudated through connecting hole in sac roof of hydrocele when pressing sac of hydrocele. After an injection of raeth- ylthionine chloride into open processus vaginalis, methylthionine chloride was aspirated by a puncture in com-municating hydrocele or uncommunicating hydrocele 30 min later. The postoperative mean follow-up of 395 children was over 1 year after laparoscopic high ligation of sheath. Only 6 children had the postoperative unilat-eral recurrence rate of 1 -3 months and a curative rate of 98.5%. Conclusion In contrast to the traditional concept,the developmental failure of closure of processus vaginalis is a major pathogenic factor for congenital hydrocele. Sac of hydrocele is composed predominantly cf a monolayer flat epithelial cells. And capsular fluid is not secreted by wall itself but derived from normal ascites of abdominal cavity. One-way valve structure may exist in connecting hole in sac roof of hydrocele and it prevents a reflux of liquid into peritoneal cavity.