腹腔镜联合胆道镜在小婴儿胆总管远端梗阻治疗中的应用

Experience on the application of laparoscopy plus choledochoscopy in young infants with distal common bile duct obstruction

目的探讨腹腔镜经胆囊胆总管探查(laparoscopic transcystic common bile duct exploration,LTCBDE)在小婴儿(年龄<3个月)胆总管远端梗阻微创治疗中的安全性和有效性。方法收集2018年12月至2020年3月3个月以下小婴儿胆总管远端梗阻2例的临床资料、手术方式及术后治疗。2例患儿均为男孩,黄疸及无胆汁粪便,肝功能异常,经彩色多普勒超声及磁共振胰胆管造影提示胆总管结石并末端梗阻,胆管扩张,经保守治疗无效,手术日龄分别为67 d和86 d,手术时体重分别为3.33 kg和4.65 kg,采用了全身麻醉下LTCBDE。术后经留置引流管胆道冲洗,并口服利胆药,复查肝功能、彩色多普勒超声和胆道造影评价及随访。结果2例患儿均顺利完成手术,清除了胆总管结石,无中转开放手术,无手术并发症,术后黄疸消退。其中1例于术后2周直接胆红素恢复正常,术后2周引流管脱落;另1例术后8周直接胆红素恢复正常,术后10周顺利拔管。2例患儿均在随访中,目前无胆道结石复发,胆总管无扩张,胆总管远端无梗阻。结论对于小婴儿的胆石症致胆总管严重梗阻,需依据患儿的具体情况采取个体化治疗方案。腹腔镜联合胆道镜经胆囊胆总管探查术可用于小婴儿。

Objective To explore the safety and efficacy of laparoscopic transcystic common bile duct exploration(LTCBDE)for severe choledochal obstruction in infants aged under 3 months.Methods Clinical data,surgical approaches and postoperative care were reviewed for two young boys aged under 3 months with cholelithiasis plus severe common bile duct obstruction from December 2018 to March 2020.There were jaundice,bile-free stool and abnormal liver function.Ultrasound and magnetic resonance cholangiopancreatography(MRCP)indicated choledocholithiasis with terminal obstruction of common bile duct and bile duct dilatation.Conservative treatment failed.Operative age was 67 and 86 days and operative weight 3.33 and 4.65 kg respectively.LTCBDE was performed under general anesthesia.Postoperative biliary tract irrigation was performed by indwelling drainage tube and oral ursodeoxycholic,liver function,ultrasonography and cholangiography examined.Results Both cases were successfully operated.Choledocholithiasis was cleared without a conversion into open surgery.Without intraoperative complications,postoperative regression was satisfactory.Direct bilirubin normalized and drainage tube slipped off at Week 2 post-operation.Another case reverted to normal direct bilirubin at Week 8 post-operation and biliary drainage tube was removed at Week 10 post-operation.During follow-ups,there was no recurrent choledocholithiasis,dilatation of common bile duct or obstruction at distal common bile duct.Conclusion For cholelithiasis in very young infants with complete obstruction of common bile duct,individualized treatment should be adopted according to specific patient situation.LTCBD is both safe and feasible for infants aged under 3 months.