Lal Richa, Behari Anu, Hari Ranjit Hari Vijaya, Sikora Sadiq S, Yachha Surender Kumar, Kapoor Vinay Kumar
Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226014, India.
Pediatr Surg Int. 2013 Aug;29(8):777-86. doi: 10.1007/s00383-013-3333-5. Epub 2013 Jun 22.
An aberrant biliary ductal and vascular anatomy presents a technical challenge for choledochal cyst (CDC) surgery. Mismanagement may have unfavourable implications. This study highlights the spectrum, approach to their identification and management.
Forty of 117 (34 %) cases were identified to have an aberrant biliary ductal (n = 17) or arterial (n = 26) anatomy; 3 had both. The pancreaticobiliary anatomy was defined by an intraoperative cholangiogram (IOC) before January 2005 and a preoperative magnetic resonance cholangiopancreatogram (MRCP) subsequently.
IOC missed 3 of 4 aberrant biliary ducts, while an MRCP accurately delineated 10 of 13 aberrant bile ducts. The significant biliary anomalies were: an aberrant right sectoral/segmental duct joining the common hepatic duct (CHD) or the cyst itself (n = 14), cystic duct (n = 1) and cystic duct-CHD junction (n = 1). The aberrant duct was incorporated into the biliary-enteric anastomosis (B-EA) by: (i) double ostia B-EA (n = 1), (ii) ductoplasty with single ostium B-EA for aberrant duct and CHD (n = 2), and (iii) transection of the CHD/cyst distal to the aberrant duct orifice with a single ostium B-EA (n = 13). The arterial anomalies were (i) replaced or accessory right hepatic artery (RHA) (n = 11) and (ii) RHA crossing anterior to the cyst (n = 15), which was repositioned posterior to the B-EA.
It is important to consciously look for, appropriately identify and manage aberrant biliovascular anatomy. MRCP facilitates accurate preoperative delineation of aberrant duct anatomy. All major aberrant ducts need to be incorporated into the B-EA and aberrant arteries should not be ligated.
异常的胆管和血管解剖结构给胆总管囊肿（CDC）手术带来了技术挑战。处理不当可能会产生不利影响。本研究着重介绍了其范围、识别方法及处理措施。
117例患者中有40例（34%）被确定存在异常胆管（n = 17）或动脉（n = 26）解剖结构；3例两者均有。2005年1月前通过术中胆管造影（IOC）确定胰胆管解剖结构，之后则通过术前磁共振胰胆管造影（MRCP）确定。
IOC漏诊了4条异常胆管中的3条，而MRCP准确描绘出了13条异常胆管中的10条。主要的胆管异常包括：异常的右叶/段胆管汇入肝总管（CHD）或囊肿本身（n = 14）、胆囊管（n = 1）以及胆囊管 - CHD汇合处（n = 1）。异常胆管通过以下方式纳入胆肠吻合术（B - EA）：（i）双开口B - EA（n = 1），（ii）对异常胆管和CHD采用单开口B - EA的胆管成形术（n = 2），以及（iii）在异常胆管开口远端切断CHD/囊肿并采用单开口B - EA（n = 13）。动脉异常包括：（i）替代或副右肝动脉（RHA）（n = 11）和（ii）RHA从囊肿前方穿过（n = 15），后者被重新定位到B - EA后方。
有意识地寻找、正确识别并处理异常的胆血管解剖结构很重要。MRCP有助于术前准确描绘异常胆管解剖结构。所有主要的异常胆管都需要纳入B - EA，且不应结扎异常动脉。
