儿童腔镜辅助胆总管囊肿切除术胆肠吻合处理策略研究

Strategy of choledochoenterostomy in laparoscopic assisted choledochal cyst excision in children

目的探索儿童微创胆总管囊肿切除术中胆肠吻合的手术处理策略并进行经验分享。方法回顾性分析2020年1月至2022年12月四川大学华西医院小儿外科接受腹腔镜或达芬奇机器人辅助胆总管囊肿切除的患儿临床资料,收集并分析数据包括流行病学资料(年龄、体重、性别等)、影像学资料(囊肿分型、直径等)、术中情况(手术时间、出血量、胆肠吻合口直径、内引流支撑管置入情况、吻合口前后壁缝合方式等)、术后并发症(胆漏、胆肠吻合口狭窄等)。结果本研究共纳入261例胆总管囊肿患儿,其中男性67例,女性194例,121例接受机器人手术,140例接受腹腔镜手术。其中Ia型129例,Ic型98例,Ⅳ型34例。平均手术时间为210.10±34.16 min,术中出血量约为21.81±11.17 ml。吻合口直径≥8 mm者209例,前后壁连续缝合,吻合口均未放置内引流支撑管;直径5~8 mm者46例,前壁间断缝合,后壁连续缝合,吻合口放置内引流支撑管者5例;直径<5 mm者6例,前后壁均行间断缝合,均放置内引流支撑管。术后平均随访时间为(14.75±1.52)个月,放置内引流支撑管的11例患儿,其中8例于术后3个月复查彩超显示支撑管已脱落,3例于术后6个月复查彩超时示已脱落。术后发生胆漏2例,保守治疗后治愈,胆肠吻合口狭窄3例,均行经皮肝穿刺胆道引流术(percutaneous transhepatic cholangial drainage,PTCD)支架置入后治愈,术后门诊随诊恢复良好。结论腔镜辅助儿童胆总管囊肿切除术中胆肠吻合口的处理策略在预防术后吻合口漏及狭窄中发挥重要作用,根据具体情况选择不同的吻合策略和内引流支撑管放置可降低手术风险,减少胆道并发症的发生。

Objective To explore the surgical strategy of choledochoenterostomy in minimally invasive choledochal cyst excision in children and share our experience.Methods The clinical data of children undergoing choledochal cyst excision assisted by laparoscopy or da Vinci robot in the Department of Pediatric Surgery,West China Hospital of Sichuan University from Jan.2020 to Dec.2022 were analyzed retrospectively.The data were collected and analyzed,including epidemiological data(age,body weight,sex,etc.),imaging data(cyst classification,diameter,etc.),intraoperative conditions(operation time,blood loss,anastomotic diameter,biliary stents,suture of the anterior and posterior wall of the anastomosis,etc.),postoperative complications(bile leakage,anastomotic stricture,etc).Results A total of 261 children with choledochal cyst were included in this study,including 67 males and 194 females,121 received robotic-assisted surgery and 140 received laparoscopic-assisted surgery.There were 129 children for type Ia,98 for type Ic and 34 for type IV.The average operation time was(210.10±34.16)min,and the intraoperative blood loss was(21.81±11.17)ml.209 cases had a diameter of≥8 mm at the anastomosis,and the anterior and posterior walls were continuously sutured without biliary stents;46 cases had a diameter of 5-8 mm,used intermittent sutures on the anterior wall and continuous sutures on the posterior wall,5 cases with biliary stents;There were 6 cases with a diameter less than 5 mm,and the anterior and posterior walls were sutured intermittently,all with biliary stents.The average follow-up time was(14.75±1.52)months.Among the 11 children with biliary stents,8 cases showed that the biliary stents had fallen off 3 months after operation,and 3 cases′biliary stents had fallen off at 6 months after operation.Bile leakage occurred in 2 cases,which was cured by conservative treatment.3 cases of anastomotic stricture were cured by planting biliary stents through percutaneous transhepatic cholangial drainage(PTCD),recovering well in follow-up.Conclusion The management strategy of choledochoenterostomy in endoscope-assisted choledochal cystectomy in children plays an important role in preventing anastomotic leakage and stricture after operation.choosing different anastomosis strategies and placement of biliary stents according to specific conditions can reduce the risk of operation and the occurrence of biliary complications.