纤维板块内小胆管分布与葛西手术预后关系的研究  

Correlation of fibrous renmant of porta hepatis and postoperative prognosis of patients with biliary atresia

作　　者：魏楠楠 杨继鑫[1] 易斌 詹江华[2] 冯杰雄[1] 

机构地区：[1]华中科技大学同济医学院附属同济医院小儿外科,武汉430030 [2]天津市儿童医院

出　　处：《中华小儿外科杂志》2018年第2期116-120,共5页Chinese Journal of Pediatric Surgery

基　　金：国家自然科学基金青年项目（81401240）;国家自然科学基金面上项目（81571478）;天津市卫生行业重点局攻关项目（14KG129）

摘　　要：目的通过对胆道闭锁患儿肝门部纤维板块的组织病理学研究，探索肝门部增生小胆管的数量及空间分布的特点，并依此判断胆道闭锁患儿葛西手术的预后，为改良葛西手术方式提供理论依据。方法收集2015年10月至2016年10月于我院行葛西手术的患儿肝门部纤维板块标本共21例，其中男10例，女11例，术中均确诊为Ⅲ型胆道闭锁。从纤维板块近端切缘开始连续切片，采用CK-19免疫组化染色技术，光镜下观察组织切片，将近端切缘切片分为左、中、右三部分，观察并统计各部分增生小胆管的数量及分布情况。根据随机视野下平均增生小胆管的数量将标本分为A组（≥5个/视野）和B两组（〈5个/视野）：A组小胆管较多组（8例），B组小胆管较少（或无）组（13例）。术后通过门诊、电话对所有患儿进行1年随访，内容包括术后1个月内胆管炎发生率、术后6个月内黄疸消退率及术后1年自体肝存活率。结果在21例标本中，有4例未见小胆管结构；其余17例中，左侧与右侧相比较无统计学意义，P〉0.05；左侧及右侧与中部相比差异均存在统计学意义，P〈0.05。距标本近端切缘约2 mm处，小胆管数量开始显著下降（P〈0.05）。两组术后1个月内胆管炎发生率差异无统计学意义（P〉0.05），但术后6个月内黄疸消退率及术后1年自体肝存活率A组均显著高于B组（P〈0.05）。结论胆道闭锁患儿肝门部增生小胆管数量及手术方式与葛西手术的预后紧密相关。增生小胆管大多分布于纤维板块左右两侧，印证了胆道闭锁胆管的演变过程。因此，解剖纤维板时，应向左右两侧分离至门静脉分支外缘，深度应达肝门静脉分叉之上靠近肝实质，以显露更多的小胆管，从而达到更好的胆汁引流效果。ObjectiveTo perform a histopathological study of fibrous remnants in porta hepatis of biliary atresia （BA） to examine the distribution of micro biliary ducts in fibrous remnants and provide theoretical rationales for modified Kasai’s operation.MethodsWe collected 16 fibrous remnants of BA after Kasai＇s operation from type III BA patients. The sections were observed under light microscope. And the numbers of micro biliary ducts were counted in left, right and middle parts. They were divided into groups A and B based on the amount of micro ductules. The postoperative follow-up period was up to 1 year.ResultsNo statistically significant difference existed between left and right parts （P〉0.05） while the difference existed in left/right part compared to middle part （P〈0.05）. No significant inter-group difference existed in the incidence of cholangitis at postoperation 1 month （P〉0.05）. In group A, jaundice disappearance rate at postoperation 6 months and survival rate with native liver at postoperation 1 year were both higher than those in group B （P〈0.05）. As compared with transection of fibrous remnants, the reduction of micro biliary ducts in fibrous remnants had a significant difference in a distance of 2 mm from transection.ConclusionsThere is a close relation between the number of micro biliary ducts in fibrous remnants and the prognosis of BA after Kasai＇s operation. Micro biliary ducts are predominantly distributed in left or right part of fibrous remnants. And it confirms the etiology of BA. While stripping fibrous remnants during Kasai＇s operation, a surgeon may extend far to outer edge of portal vein. And the deepest point should reach above portal vein bifurcation close to liver parenchyma to expose more of micro biliary ducts and achieve optimal bile drainage.

关 键 词：胆道闭锁 葛西手术 胆管 预后 

分 类 号：R726.5[医药卫生—儿科]