Diao Mei, Li Long, Cheng Wei
Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, 100020, People's Republic of China.
Department of Paediatrics and Department of Surgery, Southern Medical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, 3168, Australia.
Surg Endosc. 2016 Sep;30(9):3910-5. doi: 10.1007/s00464-015-4697-5. Epub 2015 Dec 10.
The aim of the current study was to investigate the cause and develop a management strategy for recurrent biliary obstructions after primary laparoscopic hepaticojejunostomy in children with choledochal cyst (CDC).
Thirty CDC patients (mean age: 7.15 years, range 8 months-24 years, F/M: 22/8) who suffered from recurrent biliary obstructions after primary laparoscopic hepaticojejunostomies were referred to our hospital between January 2006 and June 2014. All patients underwent redo hepaticojejunostomy ± ductoplasty ± reposition of aberrant right hepatic arteries.
All patients developed recurrent cholangitis or persistent abnormal liver function 1 month to 7 years postoperatively. Liver biopsy pathology verified that 56.7 % (17/30) of patients had grades I-IV of liver fibrosis. We identified a previously unreported cause of biliary obstruction, i.e., aberrant right hepatic arteries crossing anteriorly to the proximal common hepatic duct in high percentage of the patients who suffered from postoperative recurrent biliary obstructions (7/30, 23.3 %). The hepatic arteries were repositioned behind Roux loop during the redo hepaticojejunostomies. Of remaining patients, nine (30 %) patients had associated hepatic duct strictures and underwent ductoplasties and wide hepaticojejunostomies. Fourteen (46.7 %) patients had anastomotic strictures and underwent redo hepaticojejunostomies. The median follow-up period was 62 months (14-115 months). No recurrent biliary obstruction or cholangitis was observed up to date. Liver functions were normalized.
Aberrant hepatic artery, unsolved hepatic duct stricture, as well as poor anastomotic technique, can all contribute to recurrent biliary obstructions after the primary laparoscopic hepaticojejunostomies. Early surgical correction is advocated to minimize liver damage.
本研究旨在探讨胆总管囊肿（CDC）患儿初次腹腔镜肝空肠吻合术后复发性胆道梗阻的原因并制定管理策略。
2006年1月至2014年6月期间，30例初次腹腔镜肝空肠吻合术后出现复发性胆道梗阻的CDC患者（平均年龄：7.15岁，范围8个月至24岁，女/男：22/8）被转诊至我院。所有患者均接受了再次肝空肠吻合术±胆管成形术±异常右肝动脉复位术。
所有患者术后1个月至7年出现复发性胆管炎或持续肝功能异常。肝活检病理证实56.7%（17/30）的患者有I-IV级肝纤维化。我们发现了一个此前未报道的胆道梗阻原因，即高比例术后复发性胆道梗阻患者（7/30，23.3%）的异常右肝动脉在肝总管近端前方交叉。在再次肝空肠吻合术中，将肝动脉重新置于Roux袢后方。其余患者中，9例（30%）伴有肝管狭窄，接受了胆管成形术和广泛的肝空肠吻合术。14例（46.7%）患者有吻合口狭窄，接受了再次肝空肠吻合术。中位随访期为62个月（14-115个月）。迄今为止，未观察到复发性胆道梗阻或胆管炎。肝功能恢复正常。
异常肝动脉、未解决的肝管狭窄以及吻合技术不佳，均可能导致初次腹腔镜肝空肠吻合术后复发性胆道梗阻。提倡早期手术矫正以尽量减少肝脏损害。
