胆总管囊肿合并肝外胆管变异的诊断及腹腔镜处理

Laparoscopic management of choledochal cyst with extrahepatic bile duct anomaly

目的探讨胆总管囊肿(CC)合并肝外胆管变异术前磁共振胆胰管造影(MRCP)的诊断价值及腹腔镜手术处理策略。方法收集2010年1月至2018年9月在广州市妇女儿童医疗中心连续330例腹腔镜下CC根治术患者临床资料,对其中合并肝外胆管变异的23例患者资料进行回顾性研究,其中男性4例,女性19例,平均年龄3.2岁,年龄范围0.3~9.0岁。根据肝外胆管变异情况是否经术前MRCP诊断,将患者分为术前MRCP诊断组和术前MRCP未诊断组。评估MRCP诊断对变异胆管损伤、手术操作时间以及住院时间等指标的影响。同时分析肝外胆管变异的类型及腹腔镜处理结局。结果23例CC合并肝外胆管变异患者均经手术证实,发生率为6.97%(23/330),其中Ⅱ型副肝管(AHD)11例,Ⅲ型AHD 7例,Ⅳ型AHD 1例,交通管(CABD)4例。术前MRCP诊断组纳入14例,MRCP未诊断组纳入9例(含2例未行MRCP患者),MRCP对肝外胆管变异的术前诊断率为66.7%(14/21)。与术前MRCP诊断组相比,术前MRCP未诊断组变异胆管损伤机会更大[7.1%(1/14)比55.6%(5/9)],手术操作时间更长[(232.6±10.0)min比(278.9±22.5)min],差异均具有统计学意义(P<0.05)。23例CC合并肝外胆管变异患者,除1例Ⅱ型AHD中转开腹外,其余22例均在腹腔镜下顺利完成手术。其中11例Ⅱ型AHD及1例Ⅳ型AHD患者行变异胆管重建,7例Ⅲ型AHD患者术中注意保护变异胆管,4例CABD患者单纯结扎CABD。术后1例Ⅱ型AHD患者出现乳糜腹,经保守治疗痊愈,其余均恢复顺利。中位随访2(1~5)年,随访期内所有患者均无肝内胆管扩张及肝萎缩等并发症发生。结论MRCP检查是术前诊断CC合并肝外胆管变异的有效方法,能够避免术中变异胆管损伤,可对部分肝外变异胆管进行分型,制定相应的手术策略。绝大数患者可在腹腔镜下完成手术,术后效果良好。

Objective To discussed the diagnostic value of magnetic resonance cholangiopancreatography(MRCP),and the use of laparoscopic surgery in management of patients with choledochal cyst with extrahepatic bile duct anomaly.Methods Of 330 consecutive patients who underwent laparoscopic choledochectomy at Guangzhou Women and Children's Medical Center from January 2010 to September 2018,there were 23 patients with extrahepatic bile duct anomaly.The data of these patients were retrospectively analyzed.There were 4 males and 19 females,with an average age of 3.2(range 0.3~9.0)years.According to whether the extrahepatic bile duct anomaly was diagnosed by preoperative MRCP,these patients were divided into the preoperative MRCP diagnosis group and the preoperative MRCP undiagnosed group.The impact of MRCP in diagnosing bile duct anomaly to prevent bile duct injury,on operation time,hospital stay and the types of extrahepatic bile duct anomaly on outcomes of laparoscopic treatment were analyzed.Results All the 23 patients with choledochal cysts complicated by extrahepatic bile duct anomaly were confirmed at surgery.The incidence of extrahepatic bile duct anomaly was 6.97%(23/330).There were 47.8%of type Ⅱ AHD(11/23);36.8% of type Ⅲ AHD(7/23);4.3% of type Ⅳ AHD(1/23);17.4%(4/23)of the type with communication with accessory bile duct(CABD).The preoperative MRCP diagnosis group consisted of 14 patients,while the preoperative MRCP non-diagnosis group consisted of 9 patients,including 2 patients without MRCP.The diagnostic rate of MRCP in preoperative diagnosis of extrahepatic bile duct anomaly was 66.7%(14/21).The preoperative MRCP undiagnosed group,when compared with the preoperatives MRCP undiagnosed group,had a significantly higher bile duct injury rate[preoperative MRCP diagnosis group 7.1%(1/14),preoperative MRCP non-diagnosis group 55.6%(5/9)],and a significantly longer operation time[preoperative MRCP diagnosis group(232.6±10.0)min,preoperative MRCP undiagnosed group(278.9±22.45)min],(all P<0.05).Laparoscopic surgery was completed in 22 of 23 patients.One patient was converted to open surgery.AHD reconstruction was needed in 11 patients with type II AHD and 1 patient with type IV AHD.Seven patients with type III AHD did not require any surgical intervention for the anomaly.The 4 patients with CABD underwent simple ligation.Postoperative chyloperitoneum developed in 1 patient,who successfully responded to conservative treatment.Postoperative recovery was uneventful in the remaining patients.At a median follow-up of 2 years(range 1 to 5 years),no further complications,including intrahepatic bile duct dilatation and hepatic atrophy were detected.Conclusions MRCP was effective in preoperative diagnosis of choledochal cysts with extrahepatic bile duct anomaly.It helped to decrease intraoperation injuries to bile duct anomalies.MRCP was also useful in classifying patients with extrahepatic bile duct anomaly to better preoperatively planning of surgical treatment strategies.Laparoscopic surgery could be completed in the majority of these patients with good postoperative results.