Feng Jun,Wang Huanmin,Qin Hong,et al.Diagnosis and treatment of postoperative biliary fistula in children with hepatoblastoma[J].Journal of Clinical Pediatric Surgery,2020,19(09):794-799.[doi:10.3969/j.issn.1671-6353.2020.09.007]
儿童肝母细胞瘤手术后胆瘘的诊断与治疗分析
- Title:
- Diagnosis and treatment of postoperative biliary fistula in children with hepatoblastoma
- 分类号:
- R729;R735.7
- 摘要:
- 目的 总结儿童肝母细胞瘤手术后胆瘘的诊断及治疗经验，以提高医者对该病的临床认识及诊疗水平。方法 收集2016年5月至2020年3月于首都医科大学附属北京儿童医院肿瘤外科接受治疗的12例肝母细胞瘤术后胆瘘患儿临床资料，包括一般信息、临床特征、相关影像学检查结果、手术情况、胆瘘临床表现、胆瘘并发症以及胆瘘治疗措施。结果 12例中，男7例，女5例，中位发病年龄为2（1，2.3）岁。原发肿瘤10例，复发肿瘤2例。7例（58.3%）为PRETEXT Ⅲ至Ⅳ期，8例（66.7%）肿瘤与第一肝门关系密切，11例（91.7%）肿瘤手术过程涉及肝中叶。术后出现胆瘘的中位时间为术后第7（7，8.3）天，胆瘘患儿接受治疗的中位时间为3.5（1.5，7.1）个月。胆瘘可通过检测腹腔引流液的胆红素浓度、超声引导下穿刺抽液、腹腔穿刺或手术诊断。腹腔引流液的颜色可随胆瘘量的增加而加深。9例（75%）伴有包裹性积液，其他并发症包括局部感染（3例）、电解质紊乱（1例）、全身感染（2例）、梗阻性黄疸（1例）、肝硬度升高（1例）、胆汁性腹膜炎（1例）以及肠梗阻（1例）。10例（83.3%）可通过非手术方法（单纯腹腔外引流或超声引导下穿刺抽液）治愈；2例（16.7%）患儿经过非手术治疗后，胆瘘量仍持续超过100 mL，且合并严重并发症，后经胆道重建手术治愈。结论 胆瘘多发生在PRETEXT Ⅲ期至Ⅳ期及肿瘤累及肝中叶的患儿中，手术涉及肝叶越多、手术部位越靠近胆道主干，术后出现胆瘘的可能性越大。胆瘘多出现在术后1周左右，应常规检测腹腔引流液中胆红素浓度，对术后有包裹性积液的患儿应定期监测，大多数胆瘘患儿不伴有严重并发症，胆瘘量<100 mL，非手术治疗是首选治疗方法；若患儿经非手术治疗后胆瘘量仍持续>100 mL或出现严重并发症，应尽早行胆道重建手术。
- Abstract:
- Objective To summarize the experiences of diagnosing and treating postoperative biliary fistula in children with hepatoblastoma. Methods For 12 children with biliary fistula after hepatoblastoma surgery from May 2016 to March 2020,general profiles,clinical features,related imaging examinations,intraoperative findings,clinical manifestations,secondary complications and treatments were reviewed. Results Among 12 children with biliary fistula,there were 7 boys and 5 girls with a median onset age of 2(1-2.3) years.The tumors were primary (n=10) and recurrent (n=2).And 58.3% (n=7) of children were from PRETEXT Ⅲ-Ⅳ,66.7% (n=8) of tumors closely related to the first hepatic hilum and 91.7% (n=11) of tumors involving middle hepatic lobe.The median time of postoperative biliary fistula was 7(7-8.3) days and the median time of biliary fistula treatment 3.5(1.5-7.1) months.Biliary fistula might be diagnosed by detecting the concentration of bilirubin in abdominal drainage fluid,ultrasound-guided puncture,abdominal puncture or operation.The color of abdominal drainage deepened with a greater volume of biliary fistula.And 75% (n=9) were accompanied with encapsulated effusion and other complications included local infection (n=3),electrolyte disturbance (n=1),systemic infection (n=2),obstructive jaundice (n=1),greater liver hardness (n=1),biliary peritonitis (n=1) and intestinal obstruction (n=1).And 83.3% (n=10) could be cured by non-operative methods (simple abdominal drainage or ultrasound-guided puncture).16.7%(n=2) by biliary reconstruction surgery after non-operative treatment.The volume of abdominal drainage remained >100 ml and there were serious complications. Conclusion Biliary fistula often occurs in children with stage PRETEXT Ⅲ-Ⅳ and tumors involve middle hepatic lobe.The more hepatic lobes are involved,the closer operative site is to main biliary tract and the greater the possibility of postoperative biliary fistula.Biliary fistula often occurs at 1 week after operation.Bilirubin concentration of abdominal drainage fluid should be measured routinely.Children with encapsulated effusion after operation should be monitored regularly.Most cases of biliary fistula are not accompanied by serious complications.If drainage volume is <100 ml,non-operative treatment is a first choice; if drainage volume is >100 ml or serious complications occur after non-operative treatment,biliary tract reconstruction should be performed as soon as possible.
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备注/Memo
收稿日期:2020-04-13。
基金项目:中国工程院咨询研究课题（编号：2019—XY—34）
通讯作者:王焕民,Email:wanghuanmin@bch.com.cn