腹腔镜开窗术治疗非寄生虫性肝囊肿

Laparoscopic fenestration for non-parasitic hepatic cysts

目的探讨腹腔镜开窗术治疗非寄生虫性肝囊肿(NPHC)的术前评估、术中处理及预防复发策略。方法回顾性分析2010年1月至2017年12月在天津市南开医院行腹腔镜开窗术的82例NPHC患者临床资料。其中男28例,女54例;平均年龄(65±13)岁。单纯囊肿60例,合并胆囊结石7例、胆囊息肉7例、胆囊结石+胆总管结石8例。单发囊肿63例,多发囊肿19例。患者均签署知情同意书,符合医学伦理学规定。术前根据CT检查对囊肿复发风险进行评估。术中根据囊肿位置及显露情况,先行囊肿穿刺抽吸囊液,然后用高频电钩、超声刀或切割吻合器切除囊壁裸面完成囊肿开窗,应用带蒂大网膜固定填塞囊肿残腔。结果78例行一期腹腔镜开窗术,4例行二期腹腔镜开窗术,无中转开腹。平均手术时间(53±15)min,术中出血量(60±17)ml,术后住院时间(6.5±1.4)d。未发生与开窗术相关的出血、胆漏及腹腔感染等并发症。患者随访时间6.0~12.0个月,中位随访时间9.4个月,随访率88%(72/82)。术后CT检查发现囊肿复发6例,其中4例术前评估存在复发风险,术前评估准确率97%(70/72)。影像学检查囊肿复发率8%(6/72),其中肝Ⅶ、Ⅷ段复发各2例,肝Ⅳa+Ⅳb、Ⅱ段各1例。结论术前对囊肿复发风险的充分评估是腹腔镜开窗术成功治疗NPHC的前提,广泛囊壁切除、良好残腔暴露及妥善术后引流是防止囊肿复发的保障。肝Ⅳa、Ⅶ和Ⅷ段囊肿存在解剖性高复发倾向,应注意预防。

Objective To investigate the preoperative evaluation,intraoperative managements of laparoscopic fenestration for non-parasitic hepatic cysts(NPHC)and the prevention strategies for recurrence.Methods Clinical data of 82 patients with NPHC who underwent laparoscopic fenestration in Tianjin Nankai Hospital from January 2010 to December 2017 were retrospectively analyzed.Among them,28 patients were male and 54 female,aged(65±13)years on average.60 patients were diagnosed with simple cysts,7 cases complicated with cholecystolithiasis,7 cases with gallbladder polyp and 8 cases with cholecystolithiasis and choledocholithiasis.63 cases had single cysts and 19 cases had multiple cysts.The informed consents of all patients were obtained and the local ethical committee approval was received.The recurrence risk of NPHC was evaluated based on preoperative CT scan.Intraoperatively,according to the location and exposure of cysts,puncture aspiration of the cyst fluid was performed first,then the exposed surface of cyst wall was excised with high-frequency electric hook,ultrasonic scalpel or Endo-GIA to complete the cyst fenestration,and the residual cavity of cysts was fixed and filled using pedicled greater omentum.Results 78 cases underwent one-stage laparoscopic fenestration,4 cases received two-stage laparoscopic fenestration,and no case was converted to open surgery.The mean operation time was(53±15)min,the intraoperative blood loss was(60±17)ml,and the length of postoperative hospital stay was(6.5±1.4)d.No fenestration-induced complications,such as bleeding,bile leakage and abdominal infection,occurred.Postoperative follow-up was ranged from 6.0 to 12.0 months with a median of 9.4 months.The follow-up rate was 88%(72/82).NPHC recurrence was observed in 6 cases by postoperative CT scan,and 4 of them were evaluated with high-risk recurrence before operation.The accuracy rate of preoperative evaluation was calculated as 97%(70/72).Imaging examination showed that the recurrence rate of NPHC was 8%(6/72),including 2 cases of recurrence in segmentⅦandⅧ,and 1 case in segmentⅣa+Ⅳb and 1 case in segmentⅡ,respectively.Conclusions Comprehensive preoperative evaluation of the recurrence risk is the premise of successful treatment of NPHC by laparoscopic fenestration.Extensive cyst wall resection,proper exposure of residual cavity and appropriate postoperative drainage can prevent the recurrence of NPHC.The risk of anatomical recurrence is high in segmentⅣa,ⅦandⅧ,in which precautions should be noted.