Xie Ting,Zhou Chonggao.Prospects of laparoscopic surgery for biliary atresia[J].Journal of Clinical Pediatric Surgery,2024,(08):701-705.[doi:10.3760/cma.j.cn101785-202406003-001]
腹腔镜下Kasai手术治疗胆道闭锁展望
- Title:
- Prospects of laparoscopic surgery for biliary atresia
- Keywords:
- Biliary Atresia; Surgical Procedures; Operative; Laparoscopy
- 摘要:
- 胆道闭锁是婴儿胆汁淤积常见的病因。患儿随着年龄增长,会逐渐出现肝纤维化、肝硬化,如未及时手术,最终发展为肝衰竭。Kasai手术是胆道闭锁的首选手术方式,腹腔镜下Kasai手术具有视野更清晰、更利于手术操作的优势,但在胆道闭锁患儿中的应用仍然存在争议。早期腹腔镜下Kasai手术后患儿黄疸清除率、自体肝生存率并不理想,后经手术技术的不断改进以及经验的积累,疗效日益提高,患儿短中期自体肝生存率已经与开放手术相当,在提高黄疸清除率及减少术后腹腔粘连方面较开放手术更具优势。本文通过文献复习,结合作者多年临床实践,对胆道闭锁腹腔镜下Kasai手术疗效进行综合评价,认为腹腔镜下Kasai手术虽然可以获得与开放手术相近的临床效果,但手术操作难度大、学习曲线长,仅适合在部分有条件的医疗中心谨慎开展。
- Abstract:
- Biliary atresia is a common cause of cholestasis in infants.As children grow,they may develop progressive liver fibrosis and cirrhosis,which,if not addressed promptly,can ultimately lead to liver failure.The Kasai procedure is the preferred surgical treatment for biliary atresia.While laparoscopic Kasai surgery offers advantages such as clearer visualization and improved maneuverability,its application in the treatment of biliary atresia remains controversial.Early laparoscopic Kasai procedures had suboptimal outcomes in terms of jaundice clearance rates and native liver survival.However,with ongoing advancements in surgical techniques,the efficacy of laparoscopic Kasai surgery has significantly improved.The short-to medium-term native liver survival rates now match those of open surgery,and laparoscopic techniques may offer advantages in jaundice clearance and reduction of postoperative abdominal adhesions.This review,based on literature and authors’ extensive clinical experience,discusses the development and prospects of laparoscopic Kasai surgery for biliary atresia.It concludes that while laparoscopic Kasai surgery can achieve clinical outcomes comparable to open surgery,it is technically challenging and has a steep learning curve,making it suitable only for carefully selected medical centers.
参考文献/References:
[1] 王天有,申昆玲,沈颖.诸福棠实用儿科学[M].第9版.北京:人民卫生出版社,2022:1629. Wang TY,Shen KL,Shen Y.Zhu futang practice of pediatrics[M].9th ed.Beijing:People’s Medical Publishing House,2022,1629.
[2] Sutton H,Karpen SJ,Kamath BM.Pediatric cholestatic diseases:common and unique pathogenic mechanisms[J].Annu Rev Pathol,2024,19:319-344.DOI:10.1146/annurev-pathmechdis-031521-025623.
[3] 蔡威,张潍平,魏光辉.小儿外科学[M].第6版.北京:人民卫生出版社,2020:434. Cai W,Zhang WP,Wei GH.Pediatric surgery[M].6th ed.Beijing:People’s Medical Publishing House,2020,434.
[4] Hsiao CH,Chang MH,Chen HL,et al.Universal screening for biliary atresia using an infant stool color card in Taiwan[J].Hepatology,2008,47(4):1233-1240.DOI:10.1002/hep.22182.
[5] Zhu JJ,Yang YF,Dong R,et al.Biliatresone:progress in biliary atresia study[J].World J Pediatr,2023,19(5):417-424.DOI:10.1007/s12519-022-00619-0.
[6] Sundaram SS,Mack CL,Feldman AG,et al.Biliary atresia:Indications and timing of liver transplantation and optimization of pretransplant care[J].Liver Transpl,2017,23(1):96-109.https://doi.org/10.1002/lt.24640.
[7] Jain V,Burford C,Alexander EC,et al.Prognostic markers at adolescence in patients requiring liver transplantation for biliary atresia in adulthood[J].J Hepatol,2019,71(1):71-77.DOI:10.1016/j.jhep.2019.03.005.
[8] Chardot C.Biliary atresia[J].Orphanet J Rare Dis,2006,1:28.DOI:10.1186/1750-1172-1-28.
[9] Hartley JL,Davenport M,Kelly DA.Biliary atresia[J].Lancet,2009,374(9702):1704-1713.DOI:10.1016/S0140-6736(09)60946-6.
[10] Buskens CJ,Sahami S,Tanis PJ,et al.The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis:a review of current evidence[J].Best Pract Res Clin Gastroenterol,2014,28(1):19-27.DOI:10.1016/j.bpg.2013.11.007.
[11] Buia A,Stockhausen F,Hanisch E.Laparoscopic surgery:a qualified systematic review[J].World J Methodol,2015,5(4):238-254.DOI:10.5662/wjm.v5.i4.238.
[12] Esteves E,Clemente Neto E,Ottaiano Neto M,et al.Laparoscopic Kasai portoenterostomy for biliary atresia[J].Pediatr Surg Int,2002,18(8):737-740.DOI:10.1007/s00383-002-0791-6.
[13] Chan KWE,Lee KH,Tsui SYB,et al.Laparoscopic versus open Kasai portoenterostomy in infant with biliary atresia:a retrospective review on the 5-year native liver survival[J].Pediatr Surg Int,2012,28(11):1109-1113.DOI:10.1007/s00383-012-3172-9.
[14] Tomaszewski JJ,Casella DP,Turner RM 2nd,et al.Pediatric laparoscopic and robot-assisted laparoscopic surgery:technical considerations[J].J Endourol,2012,26(6):602-613.DOI:10.1089/end.2011.0252.
[15] Lishuang M,Zhen C,Guoliang Q,et al.Laparoscopic portoenterostomy versus open portoenterostomy for the treatment of biliary atresia:a systematic review and meta-analysis of comparative studies[J].Pediatr Surg Int,2015,31(3):261-269.DOI:10.1007/s00383-015-3662-7.
[16] 李龙,刘树立.第16届国际小儿腔镜外科学术大会纪要[J].中华小儿外科杂志,2008,29(2):124-125.DOI:10.3760/cma.j.issn.0253-3006.2008.02.019. Li L,Liu SL.Summary of the 16th international conference on pediatric endoscopic surgery[J].Chin J Pediatr Surg,2008,29(2):124-125.DOI:10.3760/cma.j.issn.0253-3006.2008.02.019.
[17] Koga H,Miyano G,Takahashi T,et al.Laparoscopic portoenterostomy for uncorrectable biliary atresia using Kasai’s original technique[J].J Laparoendosc Adv Surg Tech A,2011,21(3):291-294.DOI:10.1089/lap.2010.0162.
[18] Wada M,Nakamura H,Koga H,et al.Experience of treating biliary atresia with three types of portoenterostomy at a single institution:extended,modified Kasai,and laparoscopic modified Kasai[J].Pediatr Surg Int,2014,30(9):863-870.DOI:10.1007/s00383-014-3551-5.
[19] Yamataka A,Lane GJ,Koga H,et al.Role of laparoscopy during surgery at the porta hepatis[J].S Afr Med J,2014,104(11):820-824.DOI:10.7196/samj.8921.
[20] Ure BM,Kuebler JF,Schukfeh N,et al.Survival with the native liver after laparoscopic versus conventional kasai portoenterostomy in infants with biliary atresia:a prospective trial[J].Ann Surg,2011,253(4):826-30.DOI:10.1097/SLA.0b013e318211d7d8.
[21] Wong KKY,Chung PHY,Chan KL,et al.Should open Kasai portoenterostomy be performed for biliary atresia in the era of laparoscopy?[J].Pediatr Surg Int,2008,24(8):931-933.DOI:10.1007/s00383-008-2190-0.
[22] Oetzmann von Sochaczewski C,Petersen C,Ure BM,et al.Laparoscopic versus conventional Kasai portoenterostomy does not facilitate subsequent liver transplantation in infants with biliary atresia[J].J Laparoendosc Adv Surg Tech A,2012,22(4):408-411.DOI:10.1089/lap.2012.0077.
[23] Chen Y,Nah SA,Chiang L,et al.Postoperative steroid therapy for biliary atresia:systematic review and meta-analysis[J].J Pediatr Surg,2015,50(9):1590-1594.DOI:10.1016/j.jpedsurg.2015.05.016.
[24] Murase N,Uchida H,Ono Y,et al.A new era of laparoscopic revision of Kasai portoenterostomy for the treatment of biliary atresia[J].Biomed Res Int,2015,2015:173014.DOI:10.1155/2015/173014.
[25] Li YN,Gan JR,Wang C,et al.Comparison of laparoscopic portoenterostomy and open portoenterostomy for the treatment of biliary atresia[J].Surg Endosc,2019,33(10):3143-3152.DOI:10.1007/s00464-019-06905-9.
[26] Nakamura H,Koga H,Cazares J,et al.Comprehensive assessment of prognosis after laparoscopic portoenterostomy for biliary atresia[J].Pediatr Surg Int,2016,32(2):109-112.DOI:10.1007/s00383-015-3820-y.
[27] Li YN,Xiang B,Wu Y,et al.Medium-term outcome of laparoscopic Kasai portoenterostomy for biliary atresia with 49 cases[J].J Pediatr Gastroenterol Nutr,2018,66(6):857-860.DOI:10.1097/MPG.0000000000001934.
[28] Hinojosa-Gonzalez DE,Bueno LC,Roblesgil-Medrano A,et al.Laparoscopic vs open portoenterostomy in biliary atresia:a systematic review and meta-analysis[J].Pediatr Surg Int,2021,37(11):1477-1487.DOI:10.1007/s00383-021-04964-5.
[29] Shirota C,Murase N,Tanaka Y,et al.Laparoscopic Kasai portoenterostomy is advantageous over open Kasai portoenterostomy in subsequent liver transplantation[J].Surg Endosc,2020,34(8):3375-3381.DOI:10.1007/s00464-019-07108-y.
[30] Huang SY,Yeh CM,Chen HC,et al.Reconsideration of laparoscopic Kasai operation for biliary atresia[J].J Laparoendosc Adv Surg Tech A,2018,28(2):229-234.DOI:10.1089/lap.2017.0535.
[31] Laje P,Clark FH,Friedman JR,et al.Increased susceptibility to liver damage from pneumoperitoneum in a murine model of biliary atresia[J].J Pediatr Surg,2010,45(9):1791-1796.DOI:10.1016/j.jpedsurg.2010.02.117.
[32] Mogilner JG,Bitterman H,Hayari L,et al.Effect of elevated intra-abdominal pressure and hyperoxia on portal vein blood flow,hepatocyte proliferation and apoptosis in a rat model[J].Eur J Pediatr Surg,2008,18(6):380-386.DOI:10.1055/s-2008-1038920.
[33] Nakamura H,Koga H,Okazaki T,et al.Does pneumoperitoneum adversely affect growth,development and liver function in biliary atresia patients after laparoscopic portoenterostomy?[J].Pediatr Surg Int,2015,31(1):45-51.DOI:10.1007/s00383-014-3625-4.
[34] Yamataka A,Lane GJ,Cazares J.Laparoscopic surgery for biliary atresia and choledochal cyst[J].Semin Pediatr Surg,2012,21(3):201-210.DOI:10.1053/j.sempedsurg.2012.05.011.
[35] Li B,Chen BW,Xia LS.Experience of treating biliary atresia with laparoscopic-modified Kasai and laparoscopic conventional Kasai:a cohort study[J].ANZ J Surg,2021,91(6):1170-1173.DOI:10.1111/ans.16872.
[36] Ji Y,Yang KY,Zhang XP,et al.The short-term outcome of modified laparoscopic Kasai portoenterostomy for biliary atresia[J].Surg Endosc,2021,35(3):1429-1434.DOI:10.1007/s00464-020-07530-7.
[37] Li ZH,Ye YQ,Wu ZG,et al.Learning curve analysis of laparoscopic Kasai portoenterostomy[J].J Laparoendosc Adv Surg Tech A,2017,27(9):979-982.DOI:10.1089/lap.2016.0204.
[38] Yamataka A.Laparoscopic kasai portoenterostomy for biliary atresia[J].J Hepatobiliary Pancreat Sci,2013,20(5):481-486.DOI:10.1007/s00534-013-0607-1.
[39] Cazares J,Koga H,Murakami H,et al.Laparoscopic portoenterostomy for biliary atresia:single-center experience and review of literatures[J].Pediatr Surg Int,2017,33(12):1341-1354.DOI:10.1007/s00383-017-4171-7.
[40] Ji Y,Yang KY,Zhang XP,et al.Learning curve of laparoscopic Kasai portoenterostomy for biliary atresia:report of 100 cases[J].BMC Surg,2018,18(1):107.DOI:10.1186/s12893-018-0443-y.
[41] Lorincz A,Langenburg S,Klein MD.Robotics and the pediatric surgeon[J].Curr Opin Pediatr,2003,15(3):262-266.DOI:10.1097/00008480-200306000-00006.
[42] Dutta S,Woo R,Albanese CT.Minimal access portoenterostomy:advantages and disadvantages of standard laparoscopic and robotic techniques[J].J Laparoendosc Adv Surg Tech A,2007,17(2):258-264.DOI:10.1089/lap.2006.0112.
[43] Meehan JJ,Elliott S,Sandler A.The robotic approach to complex hepatobiliary anomalies in children:preliminary report[J].J Pediatr Surg,2007,42(12):2110-2114.DOI:10.1016/j.jpedsurg.2007.08.040.
[44] Zhang MX,Cao GQ,Li XY,et al.Robotic-assisted Kasai portoenterostomy for biliary atresia[J].Surg Endosc,2023,37(5):3540-3547.DOI:10.1007/s00464-022-09855-x.
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备注/Memo
收稿日期:2024-6-6。
基金项目:国家临床重点专科重大科研专项(Z2023072)
通讯作者:周崇高,Email:zhoucg_hnch@163.com