儿童腹腔镜肾盂成形术并发症的分析及处理  

Analysis and management of complications of laparoscopic pyeloplasty in children

作　　者：赵敏利 田广超 苑思彤 张胜利[1] 李泸平[1] 范应中[1] Zhao Minli;Tian Guangchao;Yuan Sitong;Zhang Shengli;Li Luping;Fan Yingzhong(Department of Pediatric Surgery,First Affiliated Hospital,Zhengzhou University,Zhengzhou 450052,China)

机构地区：[1]郑州大学第一附属医院小儿外科,450052

出　　处：《中华小儿外科杂志》2020年第9期813-818,共6页Chinese Journal of Pediatric Surgery

摘　　要：目的探讨腹腔镜肾盂成形术(laparoscopic pyeloplasty,LP)治疗肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)常见并发症的危险因素及处理。方法回顾性分析2015年1月至2018年12月郑州大学第一附属医院小儿外科收治的243例行LP治疗UPJO患儿的临床资料。其中,男207例,女36例;年龄<12月龄46例,≥12月龄197例;体重<10 kg者55例,≥10 kg者188例;梗阻部位位于左侧206例,右侧37例。按术后有无并发症,将患儿分为并发症组(34例)和非并发症组(209例)进行对比分析,寻找发生术后并发症的危险因素,并建立临床模型预测小儿LP术后发生并发症的危险,同时对术后并发症的处理方式进行探讨。结果本组术后并发症发生率为14.0%(34/243)。按Clavien-Dindo分级系统分级:Ⅰ级12例(4.9%),Ⅱ级4例(1.6%),Ⅲa级9例(3.7%),Ⅲb级9例(3.7%)。Ⅰ级12例术后引流量较多,延迟拔除引流管。Ⅱ级4例术后出现泌尿系统感染,给予头孢类药物治疗。Ⅲa级9例中,5例拔除引流管后出现腹痛、恶心呕吐,腹部及泌尿系统彩色超声检查提示有腹腔积液及肾周积液,予行超声引导下腹部及肾盂穿刺置管;2例引流管未拔除期间出现腹痛,考虑引流管引流不畅,给予超声引导下调整引流管位置后症状缓解;2例拔除D-J管后出现腹腔积液,给予肾盂造瘘及腹腔穿刺置管引流。Ⅲb级9例中,6例术后复查确诊为再梗阻,再次行手术治疗;2例术后拔除D-J管时,进入膀胱镜发现输尿管末端水肿,D-J管未进入膀胱内,更换新D-J管,6周后再次返院拔除D-J管;1例术后肠管经原引流管位置膨出,紧急行全身麻醉下肠管还纳术。并发症组术前分肾功能<40%者占65.4%(17/26),≥40%者占34.6%(9/26);非并发症组分肾功能<40%者占73.6%(103/140),≥40%者占26.4%(37/140),两组术前分肾功能比较,差异有统计学意义(χ2=15.160,P<0.001)。并发症组术中有吻合口张力者占50.0%(17/34),无吻合口张力者�Objective To explore the risk factors and managements of common complications of laparoscopic pyeloplasty(LP)in children with ureteropelvic junction obstruction(UPJO).Methods From January 2015 to December 2018,retrospective analysis was performed for clinical data of 243 UPJO children undergoing LP.There were 207 boys and 36 girls with an age range of<12 months(n=46)and≥12 months(n=197)and a body weight of<10 kg(n=55)and≥10 kg(n=188).The involved side was left(n=206)and right(n=37).According to the postoperative complications,they were divided into complication group(n=34)and non-complication group(n=209).The risk factors for postoperative complications and counter-measures were analyzed.Results The incidence of postoperative complications was 14.0%(34/243)in this cohort.According to the Clavien-Dindo grading system,there were large postoperative drainage and delayed removal of drainage tube(grade I,n=12,4.9%),postoperative urinary tract infection&using cephalosporins(gradeⅡ,n=4,1.6%)and abdominal pain,nausea and vomiting occurred after a removal of drainage tube(gradeⅢa/b,n=9,3.7%).Abdominal and urinary color ultrasonography showed peritoneal and perirenal effusion.Ultrasound-guided puncture and catheterization of lower abdomen and renal pelvis were performed.Abdominal pain occurred in 2 cases during the implantation of drainage tube.Considering the poor drainage of drainage tube,the symptoms were relieved after adjusting the position of drainage tube under ultrasonic guidance.After removing double J tube,2 cases of peritoneal effusion underwent pyelostomy and abdominal puncture and drainage.Six cases of gradeⅢb(n=9,3.7%)were diagnosed as re-obstruction and underwent re-operation.Upon a removal of double J stent,edema of urethra end was detected under cystoscope in 2 cases and double J stent did not enter bladder.A new double J stent was replaced and removed after 6 weeks.After operation,intestinal canal was dilated through the original drainage tube in 1 case and intestinal tube was returned immediate

关 键 词：儿童 肾积水 肾盂输尿管连接部梗阻 腹腔镜肾盂成形术 

分 类 号：R726.9[医药卫生—儿科]