110例成人型胆管扩张症的临床诊治分析

Clinical diagnosis and treatment of 110 adults with biliary dilatation

目的分析成人型胆管扩张症临床分型对手术方式选择的意义,探讨影响胆管扩张症手术疗效的因素。方法回顾性分析2005年6月至2017年9月上海交通大学医学院附属仁济医院收治并手术的110例成人型胆管扩张症病人的临床资料,评价董氏分型与Todani分型对术式选择的指导作用。比较腹腔镜、机器人与开腹手术对董氏C型(即TodaniⅠ型)胆管扩张症的手术疗效。通过门诊、电话等方式随访该110例病人的远期疗效,随访时间截至2018年7月。结果 110例病人按董氏分型,B型1例,行肝切除术;C型92例,均行胆管囊肿切除+胆肠Roux-en-Y吻合术;D型17例(D1型10例,D2型7例),在10例D1型病人中行胆管囊肿切除术9例,行肝切除术1例,在7例D2型病人中行肝切除术5例,行肝移植术1例,另1例行胆管囊肿切除术。本组110例病人的实际手术方式与董氏分型推荐的手术方式基本一致。9例行胆管囊肿切除的董氏D1型病人中,3例病人术后肝内扩张病变胆管残留,1例病人术后继发胆管结石。本组的胆漏发生率为6.4%,其中董氏D型的胆漏发生率为23.5%,明显高于C型的3.3%(P<0.05);胰漏发生率为16.4%,其中董氏C2型的胰漏发生率为54.2%,明显高于C1型的4.4%(P<0.01);胃排空障碍发生率为10.9%,所有胃排空障碍事件均出现于术后有胆漏或胰漏的病人中,两者之间存在正相关(r=0.681,P<0.01)。机器人手术的术中出血量明显少于开放手术与腹腔镜手术(P<0.05),机器人手术与腹腔镜手术的住院时间明显短于开放手术(P<0.05),两组术后疼痛评分明显低于开放手术(P<0.05),三组的术后恢复进食时间及并发症发生率差异无统计学意义(P>0.05)。结论 (1)董氏D型病人术后易发生胆漏,董氏C2型病人术后易发生胰漏,胰漏、胆漏是术后发生胃排空障碍的主要原因;(2)董氏分型对于手术方式选择的指导和并发症的预判作用优于Todani分型;(3)对于董氏D1型病人,应用围肝门技术能彻底切除肝内病变胆管,可降低远期病变胆管癌变与成石的风险;(4)对于董氏C型胆管扩张症病人,尤其是董氏C1型病人,微创治疗是安全、可行的,能减轻病人术后疼痛,缩短住院时间。

Objective To analyze the significance of clinical classification for surgical procedure of adult biliary dilatation（BD）and explore the factors influencing the curative effect of BD.Methods The clinical data of 110 patients with adult BD who were admitted at and operated by Shanghai Renji Hospital from June 2005 to September 2017 were retrospectively analyzed.The guiding effect of Dong＇s and Todani classification on the selection of procedure was evaluated.The operation effects of laparoscopic,robotic and open surgery of BD patients with Dong type C（Todani Type I）were compared.The long-term curative effect of 110 BD patients were followed up via out-patient examination and telephone interview till July 2018.Results According to the Dong＇s classification,among the 110 patients in our group,1 patient of type B received hepatectomy.All 92 cases of type C were treated with choledochal cyst excision.Among 17 type D cases（D1 10,and D2 7）,9 of 10 D1 type patients underwent resection of the choledochal cyst excision,and 1 underwent hepatectomy;5 of 7 D2 type patients underwent hepatectomy,1 underwent liver transplantation and 1 received choledochal cyst excision.The actual surgical methods of the 110 patients in this group were basically the same as those recommended by Dong＇s classification.There were 3 patients with residual cyst and 1 patient with cholangiolithiasis in 9 patients with Dong type D1 who underwent choledochal cyst excision.The incidence of bile leakage in this group was 6.4%.The incidence of bile leakage of Dong type D was 23.5%,which was significantly higher than that of type C.The incidence of pancreatic leakage was 16.4%.The incidence of pancreatic leakage of Dong type C2 was 54.2%,which was significantly higher than that of type C1.The incidence of delayed gastric emptying was 10.9%,which all appeared in patients with biliary leakage or pancreatic leakage,and there was a positive correlation between two events.The intraoperative blood loss of robotic surgery was significantly less than that of laparoscopic surgery and open surgery.The duration of hospitalization in the robotic surgery and laparoscopic surgery was significantly shorter than that in open surgery,and postoperative pain score significantly lower than that in open surgery.There was no significant difference in postoperative feeding time and complication rate among the three groups.Conclusions（1）The BD patients with Dong type D are prone to biliary leakage,and patients with Dong type C are prone to pancreatic leakage.Biliary leakage and pancreatic leakage are the main causes of postoperative delayed gastric emptying.（2）Dong＇s classification for BD patients plays a better role in the guiding choice of surgical procedure and prejudge complications compared with Todani classification.（3）It is able to obtain radical resection of bile duct cyst by means of perihilar technique for BD patients with Dong type D1 and reducing the risk of malignant transformation or lithogenic tendency.（4）For BD patients with Dong type C,particularly Dong type C1,minimally invasive treatment is safe and feasible.