彩色多普勒超声引导下肾盂穿刺造瘘术治疗儿童腹腔镜肾盂成形术后吻合口漏的效果

Efficacy of color Doppler ultrasound-guided percutaneous nephrostomy in the treatment of anastomotic leakage after laparoscopic pyeloplasty in children

目的探讨彩色多普勒超声引导下肾孟穿刺造瘘术治疗儿童腹腔镜肾盂成形术(LP)术后吻合口漏的疗效。方法回顾性分析2018年1月至2023年1月郑州大学第一附属医院收治的15例LP术后出现腹膜刺激征患儿的病例资料,其中10例为吻合口漏,5例为肾孟内血凝块。男12例,女3例。年龄(4.2±2.7)岁。病变位于左侧11例,右侧4例。15例均有不同程度恶心、呕吐、腹痛等症状。查体:患儿均呈痛苦面容、腹肌紧张。15例肾盂穿刺造瘘术前疼痛评分为9.5(8,10)分。15例超声检查提示肾盂分离前后径为(34.93±4.86)mm,肾孟分离前后径/肾实质厚度15.66±1.02,肾动态核素显像检查示患侧分肾功能(29.69±1.71)%。13例为拔除腹腔引流管前出现上述症状,出现症状的时间为术后(3.3±1.1)d,其中8例为腹腔引流量大量增多,彩色多普勒超声检查提示腹腔内肠间隙有大量积液(约500ml);5例腹腔引流量未增多,彩色多普勒超声检查提示肾孟内有强回声,考虑血凝块。13例均在局麻下取俯卧位,行彩色多普勒超声引导下肾孟穿刺造瘘术。余2例术后第3天拔除腹腔引流管,分别于术后第4、6天出现腹膜刺激征。彩色多普勒超声检查提示腹腔内肠间隙有大量积液,于局麻下平卧位行彩色多普勒超声引导下腹腔穿刺引流术+俯卧位肾孟穿刺造瘘术。15例的腹腔穿刺引流液生化分析结果证实为吻合口漏尿。记录15例腹腔穿刺引流管和肾盂造瘘管的引流量、尿量,记录患儿肾孟穿刺造瘘术后恶心、呕吐症状缓解情况和术后疼痛程度评分。比较造瘘术前后肾积水和肾功能变化情况。结果本研究15例肾盂穿刺造瘘术时间为(16.8±1.9)min。术后恶心、呕吐症状消失,术后2h和12h疼痛程度评分分别为3.2(2,4)分和0.4(0,2)分,与术前比较差异均有统计学意义(P<0.01)。13例单纯肾孟穿刺造瘘术患儿,造瘘术后(3.6±0.8)d拔除腹腔引流管,(8.6±1.0)d拔除肾孟造瘘管;2例腹腔穿刺引流术+肾盂穿刺造瘘术患儿,造瘘术后3d拔除腹腔引流管,8d拔除肾孟造瘘管。15例LP术后3、6、12个月彩色多普勒超声检查示肾孟分离前后径分别为(10.87±4.05)、(10.13±3.50)、(9.13±3.11)mm,与术前比较差异均有统计学意义(P<0.01);术后24个月复查肾盂分离前后径为(7.60±2.86)mm,肾盂分离前后径/肾实质厚度为1.97±0.22,肾动态核素显像检查示患侧分肾功能为(39.23±2.66)%,与术前比较差异均有统计学意义(P<0.01)。结论儿童LP术后出现吻合口漏或肾盂内沉积物并发症时行彩色多普勒超声引导下肾孟穿刺造瘘术可在早期有效缓解症状,有利于输尿管吻合口的愈合,且创伤小、操作简便,手术时间短。

Objective To investigate the efficacy of color Doppler ultrasound-guided percutaneous nephrostomy in the treatment of anastomotic leakage after laparoscopic pyeloplasty.Methods A retrospective analysis was performed for the data of 15 children with peritoneal irritation after LP who were admitted to the First Affiliated Hospital of Zhengzhou University from January 2018 to January 2023,of which 10 cases were anastomotic leaks and 5 cases were with renal pelvic blood clots.There were 12 males and 3 females.Age(4.2±2.7)years.The lesions were located on the left side of 11 cases and on the right side of 4 cases.All 15 cases had varying degrees of nausea,vomiting,abdominal pain and other symptoms.Physical examination:the children all showed painful faces and tense abdominal muscles.15 patients had a preoperative pain score of 9.5(8,10).Ultrasound examination showed that the anterior and posterior diameters of renal pelvis separation were(34.93±4.86)mm,the anterior and posterior diameter/renal parenchymal thickness of renal pelvis separation was 15.66±1.02,renal dynamic nuclear imaging shows the renal function of the affected side was(29.69±1.71)%.Thirteen cases had the above symptoms before the abdominal drainage tube was removed,and the time of symptom onset was(3.3±1.1)days after surgery,of which 8 cases had a large increase in abdominal drainage,and color Doppler ultrasonography showed a large amount of fluid in the intra-abdominal intestinal space(about 500 ml).In 5 cases,the intraperitoneal drainage volume did not increase,and color Doppler ultrasonography showed strong echo in the renal pelvis,and blood clots were considered.All 13 patients were placed in the prone position under local anesthesia and underwent color Doppler ultrasound-guided percutaneous nephrostomy.The remaining 2 cases had abdominal drainage tube removed on the 3rd day after surgery,and peritoneal irritation signs appeared on the 4th and 6th days after surgery,respectively.Color Doppler ultrasonography showed that there was a large amount of fluid in the intra-abdominal intestinal space,and color Doppler ultrasound-guided peritoneal puncture and drainage+prone percutaneous nephrostomy was performed in the supine position under local anesthesia,and the biochemical analysis of the peritoneal puncture drainage fluid was confirmed to be anastomotic urine leakage.The drainage volume and urine output of 15 cases of peritoneal puncture drainage and pyelostomy were recorded,and the relief of nausea and vomiting symptoms and the score of postoperative pain after percutaneous nephrostomy were recorded.The changes of hydronephrosis and renal function before and after percutaneous nephrostomy were compared.Results In this study,15 patients underwent percutaneous nephrostomy with a duration of(16.8±1.9)min.The symptoms of nausea and vomiting disappeared after operation,and the pain scores were 3.2(2,4)and 0.4(0,2)at 2 h and 12 h after operation,respectively,which were statistically significant compared with those before operation(P<0.01).In 13 children with simple percutaneous nephrostomy,the abdominal drainage tube was removed on(3.6±0.8)days and(8.6±1.0)days after percutaneous nephrostomy.In 2 children with peritoneal puncture and drainage plus percutaneous nephrostomy,the abdominal drainage tube was removed 3 days after the fistula operation,and the pyelostomy tube was removed 8 days after the fistula operation.The anterior and posterior diameters of renal pelvis separation were(10.87±4.05),(10.13±3.50)and(9.13±3.11)mm by color Doppler ultrasound at 3,6 and 12 months after LP operation,respectively,and there were statistically significant differences compared with preoperative comparisons(P<0.01).The diameter before and after renal pelvis separation was(7.60±2.86)mm,the diameter before and after renal pelvic separation/renal parenchymal thickness was 1.97±0.22,and the renal function was(39.23±2.66)%at 24 months after operation,which was statistically significant compared with that before operation(P<0.01).Conclusions Color Doppler ultrasound-guided percutaneous nephrostomy can effectively alleviate symptoms in the early stage,which could help to the healing of ureteral anastomosis,and has less trauma and short operation course.