小儿胆总管囊肿自发性穿孔初次手术方式探讨  

Exploration of Operation Pattern at the First Time of Spontaneous Perforation of Congenital Choledochal Cyst in Children

作　　者：彭小旅[1] 董琦[1] 林海[1] 李权[1] 

机构地区：[1]海南省人民医院小儿外科,海口570311

出　　处：《实用儿科临床杂志》2008年第23期1828-1829,共2页Journal of Applied Clinical Pediatrics

摘　　要：目的探讨先天性胆总管囊肿自发性穿孔的诊断方法和初次手术方式。方法收集先天性胆总管囊肿并穿孔患儿11例。男4例,女7例;年龄6个月～5岁;病程平均4d。患儿均有突发性腹胀、腹痛、哭闹不安和发热,7例出现黄疸、5例伴呕吐。查体均有明显腹膜炎体征。8例经B超和(或)CT检查证实有胆总管囊肿。病例均行腹腔穿刺,抽到含胆汁的腹水。初次手术方法有3种:2例Ⅰ期行胆总管囊肿切除、肝总管空肠Roux-Y吻合术,3例行胆总管囊肿T管外引流术,6例行胆囊造瘘术。9例Ⅰ期行外引流手术的患儿3～6个月再次手术完成胆道重建(胆总管囊肿切除、肝总管空肠Roux-Y吻合术)。结果病例均取得满意的疗效,未出现吻合口瘘、胆道感染、胆道梗阻等严重并发症。本组5例发现穿孔位于胆总管胆囊管交界处,6例未发现穿孔灶。在Ⅱ期手术中发现,Ⅰ期行胆总管T管引流者胆总管周围黏连严重、解剖结构混乱,手术难度大、出血多(100～200mL)、耗时长(3.5～5.0h)。而Ⅰ期行胆囊造瘘术的患儿,未发现有因胆囊管梗阻而致胆汁引流不畅者,且Ⅱ期手术时胆总管周围结构较清晰,手术操作相对容易、出血少(30～50mL)、耗时短(2.5～3.0h)。结论初次手术行胆囊造瘘术对于胆总管囊肿自发穿孔后腹腔炎性反应水肿明显、黏连重、状态差的患儿是一种更合理的术式选择。Objective To explore the diagnostic methods and surgery pattern at the first time of spontaneous perforation of congenital choledochal cyst. Methods Eleven cases （4 male ,7 female） with spontaneous perforation of congenital choledochal cyst were 6 months to 5 years old, and their average course of disease were 4 days. Gustily abdominal distension, abdominal pain, crying and fever were present in all cases. Jaundice （7 cases） and emesis （5 cases） appeared. All cases were detected with physical sign of peritonitis by physical examination. Choledochal cysts were confirmed by CT or B ultrasound in 8 cases. All cases accepted abdominal paracentesis and biliary ascites was drawn. Three different operative procedures were performed ：choledochocyst excision ＆ Roux- Y choledocho- jejunostomy （2 cases）,eholedoehotomy with T- tube drainage（3 cases）, and choleeystostomy （6 cases）. Nine children receiving external drainage operation accepted a second operation to rebuild biliary tract （choledochoeyst excision ＆ Roux - Y eholedochoje - junostomy） after 3 to 6 months. Results All cases had got satisfactory therapeutic efficacy without any grave complication such as fistula of anastomotie stoma,infection of biliary tract or obstruction of biliary tract. During operation, perforations were located in the juncture of choledochus and cystic duct in 5 children and were not found in the other 6 children. In the second operation,the cases receiving choleeystostomy had less peritoneal adhesion, anatomic structure changes, haemorrbage [ （30 - 50） mL vs （ 100 - 200） mL] and operation time [ （2.5 - 3.0） h vs （3.5 - 5.0） h ] than those receiving eholedoehotomy with T - tube drainage, and did not appear inadequate drainage for cystic duct obstruction. Conclusions For children with more organ inflammatory edema and adherence and in a bad overall condition,the first - time operation of cholecystostomy is more reasonable.

关 键 词：胆道穿孔 胆总管囊肿 外科治疗 儿童 

分 类 号：R726.5[医药卫生—儿科]