先天性胆总管囊肿术后吻合口狭窄/肝内胆管结石的腹腔镜再手术经验

Laparoscopic surgical experience of redo surgery for jejunohepatic anastomotic stricture/intrahepatic cholelithiasis after primary surgery in children with congenital choledochal cyst

目的总结先天性胆总管囊肿术后吻合口狭窄/肝内胆管结石的原因、腹腔镜再手术经验及手术效果。方法回顾首都医科大学附属北京儿童医院普外科2021年6月至2023年6月收治的17例先天性胆总管囊肿术后吻合口狭窄/肝内胆管结石患儿的病例资料,总结吻合口狭窄/肝内胆管结石发生原因、腹腔镜再手术经验,对比再手术前后生化检查结果,并进行随访。结果17例患儿平均再手术年龄124.4±11.9个月,与前次根治手术的平均间隔时间73.9±11.4个月。原始胆总管囊肿Todani分型Ⅳa型11例(64.7%),Ⅰa型5例(29.4%),Ⅰc型1例(5.9%)。本次临床表现包括腹痛、发热、梗阻性黄疸、肝内胆管结石。再手术方式均为腹腔镜下手术,其中吻合口瘢痕狭窄9例(吻合口重建8例,吻合口扩大成形1例),肝总管先天性狭窄4例(吻合口重建2例,吻合口扩大成形2例),肝右动脉骑跨压迫肝总管2例(动脉前方吻合口重建),胆支肠襻粘连梗阻1例(粘连松解),先天性肝管膜状狭窄1例(隔膜切除后吻合口扩大重建)。再手术后1个月较术前中位丙氨酸氨基转移酶(21.6 vs.118.3 U/L,P<0.001)、门冬氨酸氨基转移酶(18.9 vs.162.0 U/L,P<0.001)、谷氨酰转肽酶(21.2 vs.418.9 U/L,P<0.001)、总胆红素(11.4 vs.27.3μmol/L,P=0.002)、总胆汁酸(6.4 vs.43.1μmol/L,P=0.002)水平均有明显下降。中位随访15.8个月,全部患儿均无临床症状复发、肝内胆管结石或肝功能异常。结论腹腔镜下手术可有效治疗先天性胆总管囊肿术后吻合口狭窄/肝内胆管结石,再手术策略是解除病因并重建宽阔平整的高位胆肠吻合口。

Objective To summarize our laparoscopic surgical experience of redo surgery for jejunohepatic anastomotic stricture/intrahepatic cholelithiasis after primary surgery in children with congenital choledochal cyst,and to determine the surgical efficacy.Methods During Jun.2021 to Jun.2023,17 children diagnosed as jejunohepatic anastomotic stricture/intrahepatic cholelithiasis after primary congenital choledochal cyst surgery were included.Data were collected to summarize the cause and surgical experience.Pre-and post-operative biochemical results were compared,and follow-ups were performed.Results The mean age at redo surgery was 124.4±11.9 months,and the mean interval after primary surgery was 73.9±11.4 months.The primary types of congenital choledochal cysts included 11Ⅳa(64.7%),5Ⅰa(29.4%),1Ⅰc(5.9%).Clinical presentation included abdominal pain,fever,obstructive jaundice and intrahepatic cholelithiasis.Redo surgeries were all performed under laparoscope,including 9 anastomotic stricture(8 anastomotic reconstruction and 1 anastomotic plasty),4 congenital hepatic duct stenosis(2 anastomotic reconstruction and 1 anastomotic plasty with enlarged caliber),2 crossing right hepatic artery(replace of artery under common hepatic duct with anastomotic reconstruction),1 ascending loop adhesive obstruction(adhesion lysis),and 1 congenital membranous stenosis of left hepatic duct(membranectomy with enlarged anastomotic reconstruction).The level of post-operative ALT(21.6 vs.118.3 U/L,P<0.001),AST(18.9 vs.162.0 U/L,P<0.001),GGT(21.2 vs.418.9 U/L,P<0.001),TBIL(11.4 vs.27.3μmol/L,P=0.002)and TBA(6.4 vs.43.1μmol/L,P=0.002)were significantly lower than preoperative level.With median follow-ups of 15.8 months,there were no symptom or intrahepatic cholelithiasis recurrence,and all liver panels were normal.Conclusion Laparoscopic redo surgery is effective in treating jejunohepatic anastomotic stricture/intrahepatic cholelithiasis after primary surgery in children with congenital choledochal cyst,and the surgical strategy is resolve the etiology and create a wide soomth jejunohepatic anastomosis at the level of porta hepatis.