儿童胆总管囊肿合并副肝管的诊治

Diagnosis and management of choledochal cyst with accessory hepatic ducts in children

目的总结儿童胆总管囊肿合并副肝管患儿的临床资料,探讨儿童胆总管囊肿合并副肝管的诊断和治疗决策。方法回顾性分析2013年11月至2018年6月,广州市妇女儿童医疗中心收治的14例胆总管囊肿合并副肝管患者资料。其中男性2例,女性12例,年龄4个月至3岁。所有患儿术前均行MRCP检查,其中2例行术中副肝管造影检查。结果术前MRCP诊断并术中探查证实胆总管囊肿合并副肝管7例。术前MRCP怀疑副肝管并经手术探查证实1例。术前MRCP未能诊断,但术中探查发现副肝管6例。5例III型副肝管的患儿无损伤副肝管,故常规行肝总管空肠Roux-en-Y吻合术;腹腔镜下完成副肝管吻合手术8例,开腹完成副肝管吻合1例。行副肝管成型+空肠Roux-en-Y吻合6例,行肝总管、副肝管分别和空肠吻合3例。所有患儿术后恢复顺利出院,无胆瘘、胆道梗阻等并发症。随访半年到5年,均未见黄疸出现,未见肝脏萎缩或肝脓肿发生。结论MRCP对儿童胆总管囊肿合并副肝管的术前诊断有重要参考价值,但对合并II型副肝管的诊断较为困难。对术前MRCP怀疑存在副肝管的患儿、甚至未发现副肝管的患儿,手术探查时也应注意,以提高副肝管诊断的准确率,避免误损伤。副肝管汇入部位在肝总管以下位置的患儿,胆总管囊肿一般需要行副肝管成型+空肠Roux-en-Y吻合手术。

Objective To study the diagnosis and management of choledochal cyst in children with accessory hepatic ducts (AHD). Methods From November 2013 to June 2018, 14 patients with choledochal cyst with AHD were treated in Guangzhou Women and Children's Medical Center. The patients included 2 males and 12 females, and age ranged from 4 months to 3 years (median 2 years). All patients underwent MRCP before operation, and 2 underwent operative cholangiography through the AHD. Results Seven patients with choledochal cyst and AHD were demonstrated by preoperative MRCP and intraoperative exploration. One patient was suspected by preoperative MRCP to have AHD which was confirmed by surgical exploration. Preoperative MRCP failed to diagnose, but operative exploration revealed AHD in 6 patients. Anastomosis of the AHD to jejunum was performed laparoscopically in 8 patients and by open surgery in 1 patient. Six patients had the common hepatic duct and the AHD joined together to create a common channel which was then implanted as a single duct into a Roux loop, Three patients had the common hepatic duct and the AHD anastomosed separately to a Roux loop. All the patients recovered well after operation and they were discharged home without any complication. A follow-up which ranged from 0.5 to 5 years showed no jaundice, liver atrophy or liver abscess. Conclusions MRCP was important in the preoperative diagnosis of choledochal cyst with accessory hepatic duct in children. MRCP was difficult in diagnosing type II accessory hepatic ducts. In suspected or undiagnosed cases of AHD, surgical exploration helped to improve the diagnostic accuracy, avoided injury and guided correct surgical decisions. Reconstruction of AHD required joining the AHD to the common hepatic duct, or as a separate duct to jejunal anastomosis to a Roux-y-loop.