Twenty-Five Year Experience with Laparoscopic Cholecystectomy in the Pediatric Population-From 10 mm Clips to Indocyanine Green Fluorescence Technology: Long-Term Results and Technical Considerations
Twenty-Five Year Experience with Laparoscopic Cholecystectomy in the Pediatric Population-From 10 mm Clips to Indocyanine Green Fluorescence Technology: Long-Term Results and Technical Considerations
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DOI：
10.1089/lap.2019.0254
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发表时间：
2019-06-14
影响因子：
1.3
通讯作者：
Escolino, Maria
中科院分区：
文献类型：
--
作者：
Esposito, Ciro;Corcione, Francesco;Escolino, Maria
背景：本研究旨在回顾我们25年的儿童腹腔镜胆囊切除术（LC）经验，以评估其长期结局。材料与方法：回顾性分析了过去25年（1993-2018年）接受LC的215名儿童（127名女孩和88名男孩）的记录。所有患者均有症状性胆石症。原发性胆石症185例（86%），继发性胆石症30例（14%）。采用四套管技术，前35例（16.3%）采用10 mm夹闭胆囊管和胆囊动脉，后180例（83.7%）采用5 mm夹闭胆囊管和胆囊动脉。后15例术中采用吲哚菁绿色（ICG）增强荧光，以更好地显示胆囊和胆管树的解剖结构。结果：平均手术时间为69分钟，在引入ICG荧光后降至52分钟（P = .001）。共发现解剖异常15例（6.9%），其中胆管5例，胆囊动脉10例。6例（2.8%）报告术中技术问题。我们记录了4例术后Clavien IIIb并发症（1.9%）：1例胆囊动脉出血，1例胆囊管夹脱位，2例医源性主胆管损伤，1例采用胆肠吻合术，2例采用支架上胆管缝合术。我们还记录了3例脐肉芽肿（1.4%）（Clavien II）。结论：LC是一种标准化和有效的程序，在儿童进行。我们25年的经验表明，即使在经验丰富的外科医生手中，也可能发生严重并发症（Clavien IIIb）。在我们的研究中，年龄、体重和术前胆囊炎与胆管损伤的风险显著相关。考虑到其多功能性和安全性，我们认为ICG荧光技术可以在每一个LC中采用，以减轻剥离和减少并发症的可能性。
Background: This study aimed to review our 25-year experience with pediatric laparoscopic cholecystectomy (LC) to assess its long-term outcome. Materials and Methods: The records of 215 children (127 girls and 88 boys) who underwent LC for the past 25 years (1993-2018) were retrospectively reviewed. All patients had a symptomatic cholelithiasis. The cholelithiasis was idiopathic in 185 patients (86%) and secondary in 30 patients (14%). A four-trocar technique was always adopted and cystic duct and cystic artery were clipped using 10-mm clips in the first 35 cases (16.3%) and 5-mm clips in the following 180 patients (83.7%). In the last 15 cases, indocyanine green (ICG)-enhanced fluorescence was adopted intraoperatively for a better identification of the anatomy of gallbladder and biliary tree. Results: The average operative time was 69 minutes and fell down to 52 minutes after introduction of ICG fluorescence (P = .001). Fifteen anatomic anomalies (6.9%), involving bile duct in 5 cases and cystic artery in 10 cases, were recorded. Technical problems were reported intraoperatively in 6 cases (2.8%). We recorded 4 postoperative Clavien IIIb complications (1.9%): 1 bleeding from the cystic artery, 1 dislocation of the clips on the cystic duct, and 2 iatrogenic injuries to the main bile duct managed with choledojejunostomy in 1 case and suture of the choleducus over a stent in the second case. We also recorded 3 umbilical granulomas (1.4%) (Clavien II). Conclusions: LC is a standardized and effective procedure to perform in children. Our 25-year experience showed that major complications (Clavien IIIb) can occur even in experienced surgeons' hands. Age, weight, and preoperative cholecystitis were significantly associated with the risk of bile duct injury in our series. Considering its versatility and safety, we believe that ICG fluorescence technology may be adopted in every LC to ease the dissection and reduce the likelihood of complications.