Chang Xiaopan,Tang Shaotao,Cao Guoqing,et al.Laparoscopic widened-porta embedding anastomosis for choledochal cysts with a narrow portal bile duct[J].Journal of Clinical Pediatric Surgery,2019,18(07):552-558.[doi:10.3969/j.issn.1671-6353.2019.07.007]
腹腔镜扩大肝门埋入空肠吻合术治疗上端开口过小胆总管囊肿的可行性和有效性探讨
- Title:
- Laparoscopic widened-porta embedding anastomosis for choledochal cysts with a narrow portal bile duct
- Keywords:
- Laparoscopes; Choledochal Cyst; Choledechojejunostomy
- 分类号:
- R726;R616.5;R575.7
- 摘要:
- 目的 通过动物实验和病例观察两方面的结果探讨腹腔镜扩大肝门埋入空肠吻合术预防吻合口狭窄的可行性和有效性。方法 动物实验部分遵循相关的实验设计原则，构建巴马小型猪模型，并将其随机分为2组接受不同的干预方案。两组胆总管直径均<6 mm。A组（n=12）行胆总管套入式吻合，模拟肝门包入空肠吻合术；B组（n=12）行胆总管空肠吻合，模拟经典肝管空肠吻合术；比较两组吻合口局部组织学特点。病例观察部分选取2012年1月至2018年1月于华中科技大学同济医学院附属协和医院小儿外科接受腹腔镜肝门扩大埋入空肠吻合术的肝门胆管狭窄胆总管囊肿患儿47例并进行随访，初步总结手术治疗经验。结果 A组实验动物术后无一例发生吻合口狭窄，B组中有5只小型猪出现狭窄；B组狭窄吻合口组织表现为炎性细胞浸润严重、粗大的胶原纤维排列紊乱以及遍布吻合口全层，促纤维化因子表达水平较A组显著增高（P<0.05）。47例患儿腹腔镜肝门扩大埋入空肠吻合手术过程均顺利，手术时长（165±15）min，住院时间（9±2）d。随访（31±18）个月，无一例并发胆管炎、胆管结石及吻合口狭窄。结论 对于肝门胆管直径<6 mm的胆总管囊肿，腹腔镜肝门扩大埋入空肠吻合术能有效地预防术后吻合口狭窄的发生。
- Abstract:
- Objective To explore the laparoscopic widened-porta embedding anastomosis for preventing stricture in choledochal cysts(CCs) with a narrow hilar duct.Methods An anastomosis was created around the transected end of common bile duct in 12 minipigs(group A) while another 12 minipigs(group B) underwent conventional cholangiojejunostomy.Anastomotic diameter measurements and cholangiography were conducted at different timepoints.The expression levels of TGF-β1 and type I collagen were detected by real-time quantitative polymerase chain reaction(PCR).Between January 2012 and January 2018,laparoscopic excision of cyst and ductoplasty plus widened portoenterostomy were performed for 47 children with confirmed CCs with a narrow portal bile duct.The follow-up period was 15-83 months.Results Group A survived well without obstruction.Mild inflammation and fibrotic tissue were confined to bile duct periphery.In Group B,5 pigs developed stricture.Severe inflammation and diffuse fibrosis affected the whole layer of anastomosis.Fibrotic biomarkers were significantly higher postoperatively in Group B.Clinically,47 children exhibited satisfactory outcomes.The operative duration was(165±15) min and hospitalization length(9±2) days.No anastomotic stricture has been observed during a follow-up period of(31±18) months.Conclusion Laparoscopic widened-porta embedding anastomosis may be a superior option of preventing anastomotic stricture in CCs with an anastomosis <6 mm in diameter.
参考文献/References:
1 Senthilnathan P,Patel ND,Nair AS,et al.Laparoscopic management of choledochal cyst-technical modifications and outcome analysis[J].World J Surg,2015,39(10):2550-2556.
2 Wen Z,Liang H,Liang J,et al.Evaluation of the learning curve of laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy in children:CUSUM analysis of a single surgeon’s experience[J].Surg Endosc,2017,31(2):778-787.
3 Yeung F,Chung PH,Wong KK,et al.Biliary-enteric reconstruction with hepaticoduodenostomy following laparoscopic excision of choledochal cyst is associated with better postoperative outcomes:a single-centre experience[J].Pediatr Surg Int,2015,31(2):149-153.
4 李龙,余奇志,刘刚,等.经腹腔镜行先天性胆总管囊肿切除肝管空肠Roux-Y吻合术的探讨[J].临床小儿外科杂志,2002,1(1):54-56.Li L,Yu QZ,Liu G,et al.Laparoscopic excision of choledochal cyst plus bile duct jejunum Roux-Y anastomosis[J].Journal of Clinical Pediatric Surgery,2002,1(1):54-56.
5 Diao M,Li L,Cheng W.Timing of surgery for prenatally diagnosed asymptomatic choledochal cysts:a prospective randomized study[J].J Pediatr Surg,2012,47(3):506-512.
6 Hamada Y,Ando H,Kamisawa T,et al.Diagnostic criteria for congenital biliary dilatation 2015[J].J Hepatobiliary Pancreat Sci,2016,23(6):342-346.
7 Tang ST,Yang Y,Wang Y,et al.Laparoscopic choledochal cyst excision,hepaticojejunostomy,and extracorporeal Roux-en-Y anastomosis:a technical skill and intermediate-term report in 62 cases[J].Surg Endosc,2011,25(2):416-422.
8 Farello GA,Cerofolini A,Rebonato M,et al.Congenital choledochal cyst:video-guided laparoscopic treatment[J].Surg Laparosc Endosc,1995,5(5):354-358.
9 Todani T,Watanabe Y,Urushihara N,et al.Biliary complications after excisional procedure for choledochal cyst[J].J Pediatr Surg,1995,30(3):478-481.
10 Kim JH,Choi TY,Han JH,et al.Risk factors of postoperative anastomotic stricture after excision of choledochal cysts with hepaticojejunostomy[J].J Gastrointest Surg,2008,12(5):822-828.
11 Kim JW,Moon SH,Park DH,et al.Course of choledochal cysts according to the type of treatment[J].Scand J Gastroenterol,2010,45(6):739-745.
12 Cho MJ,Hwang S,Lee YJ,et al.Surgical experience of 204 cases of adult choledochal cyst disease over 14 years[J].World J Surg,2011,35(5):1094-1102.
13 Wang DC,Liu ZP,Li ZH,et al.Surgical treatment of congenital biliary duct cyst[J].BMC Gastroenterol,2012,12:29.
14 Jung K,Han HS,Cho JY,et al.Is preoperative subclassification of type I choledochal cyst necessary?[J]Korean J Radiol,2012,13 Suppl 1:112-116.
15 Narayanan SK,Chen Y,Narasimhan KL,et al.Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst:a systematic review and meta-analysis[J].J Pediatr Surg,2013,48(11):2336-2342.
16 Qiao G,Li L,Li S,et al.Laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts in China:a multicenter study[J].Surg Endosc,2015,29(1):140-144.
17 Dutta HK.Hepatic lobectomy and mucosectomy of intrahepatic cyst for type IV-A choledochal cyst[J].J Pediatr Surg,2012,47(11):2146-2150.
18 Perdikakis E,Chryssou EG,Koulentaki M,et al.Assessment of a postoperative anastomotic stricture following correction surgery of a type Ⅳa choledochal cyst using Gd-EOB-DTPA-enhanced magnetic resonance cholangiography[J].Clin J Gastroenterol,2011,4(6):396-400.
19 Diao M,Li L,Cheng W.Recurrence of biliary tract obstructions after primary laparoscopic hepaticojejunostomy in children with choledochal cysts[J].Surg Endosc,2016,30(9):3910-3915.
20 Sheng Q,Lv Z,Xu W,et al.Reoperation after cyst excision with hepaticojejunostomy for choledochal cysts:our experience in 18 cases[J].Med Sci Monit,2017,23(12):1371-1377.
21 Urushihara N,Fukumoto K,Nouso H,et al.Hepatic ductoplasty and hepaticojejunostomy to treat narrow common hepatic duct during laparoscopic surgery for choledochal cyst[J].Pediatr Surg Int,2015,31(10):983-986.
22 Stringer MD.Wide hilar hepaticojejunostomy:the optimum method of reconstruction after choledochal cyst excision[J].Pediatr Surg Int,2007,23(6):529-532.
23 Urushihara N,Fukuzawa H,Fukumoto K,et al.Totally laparoscopic management of choledochal cyst:Roux-en-Y Jejunojejunostomy and wide hepaticojejunostomy with hilar ductoplasty[J].J Laparoendosc Adv Surg Tech A,2011,21(4):361-366.
24 Li S,Wang W,Yu Z,et al.Laparoscopically assisted extrahepatic bile duct excision with ductoplasty and a widened hepaticojejunostomy for complicated hepatobiliary dilatation[J].Pediatr Surg Int,2014,30(6):593-598.
25 Morotomi Y,Todani T,Watanabe Y,et al.Modified Kasai’s procedure for a choledochal cyst with a very narrow hilar duct[J].Pediatr Surg Int,1996,11(1):58-59.
26 Pal K,Singh VP,Mitra DK.Partial hepatectomy and total cyst excision is curative for localized type IV-a biliary duct cysts-report of four cases and review of management[J].Eur J Pediatr Surg,2009,19(3):148-152.
27 Xia HT,Liu Y,Yang T,et al.Better long-term outcomes with hilar ductoplasty and a side-to-side Roux-en-Y hepaticojejunostomy[J].J Surg Res,2017,215(1):21-27.
28 Watanabe Y,Toki A,Todani T.Bile duct cancer developed after cyst excision for choledochal cyst[J].J Hepatobiliary Pancreat Sci,1999,6(3):207-212.
29 Liu YB,Wang JW,Devkota KR,et al.Congenital choledochal cysts in adults:twenty-five-year experience[J].Chin Med J(Engl),2007,120(16):1404-1407.
30 Stringer MD.Laparoscopic management of choledochal cysts:is a keyhole view missing the big picture?[J]Pediatr Surg Int,2017,33(6):651-655.
31 Ohtsuka H,Fukase K,Yoshida H,et al.Long-term outcomes after extrahepatic excision of congenital choladocal cysts:30 years of experience at a single center[J].Hepatogastroenterology,2015,62(137):1-5.
32 Ohashi T,Wakai T,Kubota M,et al.Risk of subsequent biliary malignancy in patients undergoing cyst excision for congenital choledochal cysts[J].J Gastroenterol Hepatol,2013,28(2):243-247.
33 Sastry AV,Abbadessa B,Wayne MG,et al.What is the incidence of biliary carcinoma in choledochal cysts,when do they develop,and how should it affect management?[J]World J Surg,2015,39(2):487-492.
34 Ten Hove A,de Meijer VE,Hulscher JBF,et al.Meta-analysis of risk of developing malignancy in congenital choledochal malformation[J].Br J Surg,2018,105(5):482-490.
35 Yin L,Yang H,Li J,et al.Pig models on intestinal development and therapeutics[J].Amino acids,2017,49(12):2099-2106.
36 Lichtman MK,Otero-Vinas M,Falanga V.Transforming growth factor beta(TGF-beta)isoforms in wound healing and fibrosis[J].Wound Repair Regen,2016,24(2):215-222.
37 Klass BR,Grobbelaar AO,Rolfe KJ.Transforming growth factor beta1 signalling,wound healing and repair:a multifunctional cytokine with clinical implications for wound repair,a delicate balance[J].Postgrad Med J,2009,85(999):9-14.
38 张茜,曹国庆,汤绍涛,等.da Vinci机器人腹腔镜治疗小儿先天性胆总管囊肿[J].临床小儿外科杂志,2016,15(2):137-139.Zhang Q,Cao GQ,Tang ST,et al.Laproscopic treatment of congenital choledochal cysts in children using da Vinci robot[J].Journal of Clinical Pediatric Surgery,2016,15(2):137-139.
相似文献/References:
[1]李勇,尹强,周小渔,等.术中胆道造影在先天性胆总管囊肿手术中的应用[J].临床小儿外科杂志,2010,9(06):430.
LI Yong,YIN Qiang,ZHOU Xiao yu,et al.The clinic application experience on intraoperative cholangiography in pediatric surgery.[J].Journal of Clinical Pediatric Surgery,2010,9(07):430.
[2]王勇,汤绍涛,毛永忠,等.腔镜下手术治疗小儿膈肌疾病31例[J].临床小儿外科杂志,2010,9(06):441.
[3]唐应明,何国庆,张应,等.腹腔镜在可扪及腹股沟管内隐睾手术中的应用[J].临床小儿外科杂志,2010,9(06):445.
[4]曹国庆 汤绍涛杨瑛李时望毛永忠王勇.腹腔镜治疗直肠乙状结肠型先天性巨结肠122例疗效分析[J].临床小儿外科杂志,2011,10(01):0.
CAO Guo qing,TANG Shao tao,YANG Ying et al..The clinical analysis of laparoscopic transanal puuthrough operation for rectosigmoild Hirschsprung disease (122 cases report).[J].Journal of Clinical Pediatric Surgery,2011,10(07):0.
[5]孙驰于增文李索林李英超耿娜徐伟立.腹腔镜经脐及肛门自然腔道巨结肠根治术临床分析[J].临床小儿外科杂志,2011,10(01):0.
SUN Chi,YU Zeng wen,LI Suo lin,et al.Transumbilical single port laparoscopy hybrid transanal endorectal pullthrough for Hirschsprung’s disease.[J].Journal of Clinical Pediatric Surgery,2011,10(07):0.
[6]周辉霞孙宁马立飞孟浩谢华伟申州陶天周晓光黄澄如李宏召张旭.腹腔镜下重复肾半肾切除术手术路径探讨[J].临床小儿外科杂志,2011,10(01):0.
ZHOU Hui xia,SU Ning,MA Li fei,et al.Which laparoscopic surgery approach is better for a nonfunctioning moiety in a duplex kidney in infants and children[J].Journal of Clinical Pediatric Surgery,2011,10(07):0.
[7]寿铁军李勇马能强龚晟.腹腔镜手术治疗小儿腹股沟斜疝1582例[J].临床小儿外科杂志,2011,10(01):0.
[8]席红卫崔强强王建峰崔娆靳园园.腹腔镜下空肠隔膜狭窄手术2例[J].临床小儿外科杂志,2011,10(01):0.
[9]白东升叶辉郝春生.腹腔镜Palomo术式在小儿精索静脉曲张治疗中的应用[J].临床小儿外科杂志,2011,10(01):0.
[10]高群卢贤映潘祝彬黄河.小儿腹腔镜下阑尾切除术与开腹阑尾切除手术的对比研究[J].临床小儿外科杂志,2010,9(03):0.
[11]刁美 林海伟 明安晓 李龙 郑伟. 腹腔镜与开放性肝管空肠吻合术治疗先天性[J].临床小儿外科杂志,2011,10(05):325.
[J].Journal of Clinical Pediatric Surgery,2011,10(07):325.
[12]徐中亚,杜宝峰,易军等.腹腔镜辅助与开腹手术治疗先天性胆总管囊肿的对比研究[J].临床小儿外科杂志,2018,17(09):692.
Xu Zhongya,Du Baofeng,Yi Jun,et al.Comparative Study on laparoscopic or laparotomy total cyst excision in treating congenital choledochalcyst[J].Journal of Clinical Pediatric Surgery,2018,17(07):692.
[13]刁美,李龙.经脐单切口腹腔镜技术治疗胆总管囊肿的手术要点及技巧[J].临床小儿外科杂志,2019,18(07):536.[doi:10.3969/j.issn.1671-6353.2019.07.003]
Diao Mei,Li Long.Surgical essentials and techniques of transumbilical single incision laparoscopy for choledochal cysts[J].Journal of Clinical Pediatric Surgery,2019,18(07):536.[doi:10.3969/j.issn.1671-6353.2019.07.003]
[14]汤绍涛,常晓盼.腹腔镜下胆总管囊肿切除术后吻合口狭窄问题[J].临床小儿外科杂志,2019,18(07):542.[doi:10.3969/j.issn.1671-6353.2019.07.004]
Tang Shaotao,Chang Xiaopan.Anastomotic stenosis after laparoscopic choledochal cyst surgery[J].Journal of Clinical Pediatric Surgery,2019,18(07):542.[doi:10.3969/j.issn.1671-6353.2019.07.004]
[15]王新宁,李索林,刘雪来,等.腹腔镜胆总管囊肿切除术中不同胆道重建方式的研究[J].临床小儿外科杂志,2019,18(07):559.[doi:10.3969/j.issn.1671-6353.2019.07.008]
Wang Xinning,Li Suolin,Liu Xuelai,et al.Different laparoscopically assisted biliary reconstructions for congenital choledochal cyst[J].Journal of Clinical Pediatric Surgery,2019,18(07):559.[doi:10.3969/j.issn.1671-6353.2019.07.008]
[16]刘斐,徐晓钢,朱德力,等.完全腹腔镜治疗小儿先天性胆总管囊肿10例临床分析[J].临床小儿外科杂志,2019,18(07):563.[doi:10.3969/j.issn.1671-6353.2019.07.009]
Liu Fei,Xu Xiaogang,Zhu Deli,et al.Total laparoscopic congenital choledochal cyst excision in children: a clinical analysis of 10 cases[J].Journal of Clinical Pediatric Surgery,2019,18(07):563.[doi:10.3969/j.issn.1671-6353.2019.07.009]
[17]蔡多特,陈青江,章立峰,等.达芬奇技术与传统腹腔镜技术在胆总管囊肿根治术中应用的对比研究[J].临床小儿外科杂志,2022,21(01):51.[doi:10.3760/cma.j.cn.101785-202012066-010]
Cai Duote,Chen Qingjiang,Zhang Lifeng,et al.Comparative study of Da Vinci technique versus traditional laparoscopic technique in the treatment of choledochal cyst[J].Journal of Clinical Pediatric Surgery,2022,21(07):51.[doi:10.3760/cma.j.cn.101785-202012066-010]
[18]刁美,李龙.腹腔镜手术治疗小儿胆总管囊肿: 并发症及防治[J].临床小儿外科杂志,2023,22(01):7.[doi:10.3760/cma.j.cn101785-202205002-002]
Diao Mei,Li Long.Laparoscopic management of choledochal cysts: causes and prevention of complications[J].Journal of Clinical Pediatric Surgery,2023,22(07):7.[doi:10.3760/cma.j.cn101785-202205002-002]
[19]刘登辉,李勇,黎明,等.直线切割吻合器在儿童腹腔镜胆总管囊肿根治术Roux-en-Y吻合中的应用[J].临床小儿外科杂志,2024,(03):238.[doi:10.3760/cma.j.cn101785-202312021-007]
Liu Denghui,Li Yong,Li Ming,et al.Application of linear cutting stapler in Roux-en-Y during laparoscopiccholedochal cyst radical surgery in children[J].Journal of Clinical Pediatric Surgery,2024,(07):238.[doi:10.3760/cma.j.cn101785-202312021-007]
备注/Memo
收稿日期:2019-6-13。
基金项目:卫计委公益性行业科研专项（编号：201402007）
通讯作者:汤绍涛,Email:tshaotao83@126.com