Recurrence of biliary tract obstructions after primary laparoscopic hepaticojejunostomy in children with choledochal cysts
Recurrence of biliary tract obstructions after primary laparoscopic hepaticojejunostomy in children with choledochal cysts
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DOI：
10.1007/s00464-015-4697-5
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发表时间：
2016-09-01
影响因子：
3.1
通讯作者：
Cheng, Wei
中科院分区：
文献类型：
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作者：
Diao, Mei;Li, Long;Cheng, Wei
本研究的目的是探讨胆总管囊肿（CDC）患儿行初次腹腔镜肝总管空肠吻合术后复发性胆道梗阻的原因并制定治疗策略。（平均年龄：7.15岁，范围：8个月-24岁，女性/男性：22/8）2006年1月至2008年12月期间，我院收治了112例腹腔镜肝管空肠吻合术后复发性胆道梗阻患者和2014年6月。所有患者均行再次肝管空肠吻合+/- A胆管成形+/- A迷走肝右动脉复位术，术后1个月~ 7年均出现复发性胆管炎或持续性肝功能异常。肝活检病理证实56.7%（17/30）的患者存在I-IV级肝纤维化。我们确定了一个以前未报告的胆道梗阻原因，即，术后胆道梗阻复发的患者中，迷走肝右动脉前穿肝总管近端的比例较高（7/30，23.3%）。再次行肝管空肠吻合时，将肝动脉重新置于Roux袢后。其余患者中，9例（30%）患者有相关的肝管狭窄，并接受了胆管成形术和广泛的肝管空肠吻合术。14例（46.7%）患者发生吻合口狭窄，并接受了再次肝管空肠吻合术。中位随访期为62个月（14-115个月）。迄今为止，未观察到复发性胆道梗阻或胆管炎。肝功能恢复正常，肝动脉迷走、未解决的肝管狭窄以及吻合技术差都可能导致初次腹腔镜肝管空肠吻合术后胆道梗阻复发。主张早期手术矫正，以尽量减少肝损伤。
The aim of the current study was to investigate the cause and develop a management strategy for recurrent biliary obstructions after primary laparoscopic hepaticojejunostomy in children with choledochal cyst (CDC).Thirty CDC patients (mean age: 7.15 years, range 8 months-24 years, F/M: 22/8) who suffered from recurrent biliary obstructions after primary laparoscopic hepaticojejunostomies were referred to our hospital between January 2006 and June 2014. All patients underwent redo hepaticojejunostomy +/- A ductoplasty +/- A reposition of aberrant right hepatic arteries.All patients developed recurrent cholangitis or persistent abnormal liver function 1 month to 7 years postoperatively. Liver biopsy pathology verified that 56.7 % (17/30) of patients had grades I-IV of liver fibrosis. We identified a previously unreported cause of biliary obstruction, i.e., aberrant right hepatic arteries crossing anteriorly to the proximal common hepatic duct in high percentage of the patients who suffered from postoperative recurrent biliary obstructions (7/30, 23.3 %). The hepatic arteries were repositioned behind Roux loop during the redo hepaticojejunostomies. Of remaining patients, nine (30 %) patients had associated hepatic duct strictures and underwent ductoplasties and wide hepaticojejunostomies. Fourteen (46.7 %) patients had anastomotic strictures and underwent redo hepaticojejunostomies. The median follow-up period was 62 months (14-115 months). No recurrent biliary obstruction or cholangitis was observed up to date. Liver functions were normalized.Aberrant hepatic artery, unsolved hepatic duct stricture, as well as poor anastomotic technique, can all contribute to recurrent biliary obstructions after the primary laparoscopic hepaticojejunostomies. Early surgical correction is advocated to minimize liver damage.