腹腔镜Kasai手术在Ⅲ型胆道闭锁中的临床应用评价

Clinical evaluations of laparoscopic Kasai portoenterostomy for type Ⅲ biliary atresia

目的对腹腔镜Kasai手术治疗Ⅲ型胆道闭锁的疗效及其对肝移植影响进行临床评价。方法对2014年1月至2018年1月在广西医科大学第一附属医院接受Kasai手术的Ⅲ型胆道闭锁病例进行回顾性分析,根据不同手术方式分为腹腔镜组(laparoscopic portoenterostomy,LPE)与开放组(open portoenterostomy,OPE),将组内行肝移植的病例分为LPE后肝移植亚组(liver transplantation after laparoscopic portoenterostomy,LTLPE)与OPE后肝移植亚组(liver transplantation after open portoenterostomy,LTOPE),收集各组术前、术中、术后临床资料进行对比分析。随访截止时间为2020年1月1日。结果全组病例115例,LPE组54例,OPE组61例。两组间比较手术年龄、体重、术中出血量,术前及术后1个月、3个月、6个月TBIL、ALT,术后胆管炎发生率、黄疸清除率差异无统计学意义(P>0.05)。手术时间LPE组长于OPE组(229 min vs.126 min,P<0.001);术后首次进食时间LPE组短于OPE组(2 d vs.3 d,P<0.001);住院天数LPE组短于OPE组(19 d vs.21 d,P<0.001)。LPE组与OPE组1年自体肝生存率(survival rate of native liver,SNL)分别为79.6%和72.1%(P=0.35);2年SNL分别为70.4%和57.4%(P=0.149),4年SNL分别为63.0%和55.7%(P=0.432)。LPE组与OPE组1年生存率分别为83.3%和75.4%(P=0.297),2年生存率分别为74.1%和62.3%(P=0.177),4年生存率分别为72.2%和60.7%(P=0.191)。Kasai手术后肝移植9例,LTLPE亚组5例,LTOPE亚组4例。两组受者移植手术年龄、体重、术前儿童终末期肝病模型(pediatric end-stage liver disease,PELD)评分差异无统计学意义(P>0.05),腹腔粘连评分LTLPE亚组低于LTOPE亚组(3分vs.10分,P=0.024)、肝移植手术时间LTLPE亚组短于LTOPE亚组(587 min vs.844 min,P=0.027)、病肝切除时间LTLPE亚组短于LTOPE亚组(132 min vs.278 min,P=0.037)、出血量LTLPE亚组少于LTOPE亚组(430 mL vs.947.5 mL,P=0.027)。结论腹腔镜Kasai手术治疗Ⅲ型胆道闭锁的效果与开放手术相当,有利于肝移植实施。

Objective To evaluate the efficacy of laparoscopic Kasai portoenterostomy for type Ⅲ biliary atresia(BA)and examine its effect on liver transplantation.Methods Clinical data were retrospectively analyzed for 115 type Ⅲ BA patients undergoing Kasai surgery from January 2014 to January 2018.They were divided into laparoscopic portoenterostomy group(LPE,n=54)and open portoenterostomy group(OPE,n=61).Patients undergong liver transplantation were divided into two subgroups of liver transplantation after laparoscopic portoenterostomy subgroup(LTLPE)and liver transplantation after open portoenterostomy subgroup(LTOPE).The perioperative data were compared and analyzed.The following-up cut-off time was January 1,2020.Results No statistically significant inter-group differences existed in operative age,weight,intraoperative blood loss,episodes of cholangitis or jaundice clearance rate(P>0.05).TBIL and ALT of pre-operation and at Month 1/3/6 post-operation showed no statistical difference(P>0.05).The operative duration of LPE was significantly longer than that of OPE(229 vs.126 min,P=0.001),the first feeding time of LPE significantly shorter than that of OPE(2 vs.3 days,P=0.001)and hospitalization length of LPE were significantly shorter than that of OPE(19 vs.21 days,P=0.001).The 1-year survival rate of native liver of LPE and OPE were 79.6% and 72.1%(P=0.35),the 2-year survival rate of native liver 70.4% and 57.4%(P=0.149)and the 4-year survival rate of native liver 63.0% and 55.7% respectively(P=0.432).And the 1-year survival rate of two groups were 83.3% and 75.4%(P=0.297),the 2-year survival rate 74.1% and 62.3%(P=0.177)and the 4-year survival rate 72.2% and 60.7% respectively(P=0.191).The clinical data of 9 patients undergoing Kasai postoperative liver transplantation were retrospectively analyzed.There were LTLPE(n=5)and LTOPE(n=4)subgroups.No statistically significant difference existed in age,weight or PELD score(P>0.05).However,LTLPE had a lower score of abdominal cavity adhesion(3 vs.10,P=0.024),shorter operative duration(587 vs.844 min,P=0.027),shorter liver resection time(132 vs.278 min,P=0.037)and less bleeding(430 vs.947.5 mL,P=0.027).Conclusion Laparoscopic Kasai portoenterostomy has a similar efficacy to open Kasai portoenterostomy for type Ⅲ BA.And it is conducive to the implementation of liver transplantation.