单中心胆道闭锁Kasai术后早期肠道并发症诊治分析

Diagnosis and treatment of early intestinal complications after Kasai operation: experiences from a single center

目的分析胆道闭锁术后早期肠道并发症的发生情况,探讨诊治策略及预后情况。方法2009年1月至2016年6月我院普外科共收治胆道闭锁患儿行Kasai手术治疗358例。随访资料完整、到达随访终点患儿310例,失访48例,10例出现术后早期肠道并发症。对出现术后并发症的10例患儿相关临床资料进行统计分析,并进行随访。结果Kasai术后出现早期肠道并发症患儿男6例,女4例,本中心Kasai术后早期肠道并发症发生率为2.79%(10/358)。术后均表现为呕吐腹胀,症状出现时间为术后(4±1.7)d,时间范围2~7 d。其中3例患儿呕吐黄绿色液体,其余呕吐胃液;此外还有腹引流管引流血性腹水1例,血便1例。立位腹平片均提示肠梗阻,其中6例伴有腹腔游离气。二次手术时间为Kasai术后(6.2±3.6) d,时间范围3~16 d。术中证实为粘连性肠梗阻9例,小肠套叠1例;其中6例气腹患儿均存在空肠Roux-Y端侧吻合口漏,行修补术;另有6例患儿存在肠管坏死,行肠管切除吻合。有2例患儿分别因肠穿孔、Roux-Y端侧吻合口漏行3次手术治疗,分别为肠造瘘术及吻合口漏修补术。住院时间(33.9±28.3) d,范围16~99 d。较我院标准住院时间14 d明显延长。经随访,10例患儿中有5例出现Kasai术后早期胆管炎(术后1个月内),较本中心既往胆管炎发病率9.9%明显升高。10例早期肠道并发症患儿术后3个月有2例黄疸清除,术后6个月有3例黄疸清除,术后1年自肝生存4例。结论胆道闭锁患儿Kasai术后早期肠道并发症表现为腹胀、呕吐,多发生于术后1周内,多为粘连性肠梗阻,容易引起梗阻点近端的空肠端侧吻合口漏,宜尽早手术解除梗阻。Kasai术后早期肠道并发症对远期自肝生存情况有不良影响。

Objective To analyze clinical data of early intestinal complications after Kasai operation in biliary atresia (BA) infants,and to summarize diagnostic and therapeutic strategy as well as follow-up results.Methods From January 2009 to June 2016,a total of 358 BA patients were admitted for Kasai operation.Early intestinal complications occurred in 10 patients.And 310 of them had complete clinical follow-up data.Statistical analysis was performed.Results Early intestinal complications occurred at a rate of 2.79%(10/358) in 6 boys and 4 girls.Vomiting and abdominal distension on days 2 to 7 postoperatively (mean 4±1.7 days).There were green-yellowish vomit (n=3),blood-stained ascitis (n=1) and bloody stool (n=1).Standing abdominal radiography hinted at bowel obstruction with pneumoperitoneum (n=6).Re-operations were performed on Days 3 to 16 after Kasai’s operation (mean 6.2±3.6 days).During re-operations,adhesive bowel obstruction (n=9) and intestinal intussusception (n=1) were confirmed and jejunal end-to-side anastomotic leakage was detected in 6 pneumoperitoneal children.For 6 children with intestinal necrosis,resections with anastomosis were performed.A third operation was performed with enterostomy and anastomotic resuture due to bowel perforation (n=1) and anastomotic leakage (n=1).The mean hospitalization stay was (33.9±28.3)(16-99) days and it was longer than a standard of 14 days.Five patients had an early onset cholangitis (within 1 months after Kasai’s operation).And it was higher than our previous cholangitis rate of 9.9%.The 3/6-month postoperative jaundice clearance rates of 10 intestinal complication patients were 20%(2/10) and 30%(3/10) and both were lower than 39.7%(119/300) and 65.7%(197/300) for the remainder from the same period respectively.The 1-year native liver survival rate of intestinal complication children was 40%(4/10) and it was lower than 68.7%(206/300) of the remainder from the same period.Conclusions BA children after Kasai’s operation with early intestinal complications present usually with vomiting and abdominal distension within 1 week post-operation.Adhesive bowel obstruction is a leading cause for jejunal end-to-side anastomotic leakage.Timely surgery is preferred for resolving the obstruction.Early intestinal complications after Kasai’s operation have adverse effects on native liver survival in BA children.