Stringer Mark D
Departments of Paediatric Surgery and Child Health, Wellington Hospital & University of Otago, Wellington, New Zealand.
Pediatr Surg Int. 2017 Jun;33(6):651-655. doi: 10.1007/s00383-017-4089-0. Epub 2017 Apr 19.
In recent years, numerous articles have promoted laparoscopic surgical treatment of choledochal cysts in children. Most of these reports assert that laparoscopic excision and biliary reconstruction are as safe as open surgery and achieve equivalent or better results. However, these conclusions are based on retrospective analyses with median follow-up periods that rarely exceed 5 years. Closer scrutiny of the laparoscopic literature indicates that the optimum procedure for treating type I and most type IVa choledochal cysts, namely radical excision of the extrahepatic bile ducts and reconstruction by wide hilar hepaticoenterostomy, preferably hepaticojejunostomy, is not being carried out in most cases. Performing a less radical excision exposes patients to a greater long-term risk of a bilioenteric stricture and its complications and malignant change in residual extrahepatic bile ducts. Currently, the long-term outcomes of surgery for choledochal cysts are being eclipsed by the short-term gains of laparoscopic techniques. The prime objective in the surgical management of choledochal cysts is the long-term health of the patient; laparoscopic techniques are simply another method of performing the surgery and they should not become the standard of care unless long-term outcomes are similar to best practice open surgery.
近年来，大量文章都在推崇小儿胆总管囊肿的腹腔镜手术治疗。这些报告大多称，腹腔镜切除及胆道重建与开放手术一样安全，且能取得相当或更好的效果。然而，这些结论是基于回顾性分析得出的，中位随访期很少超过5年。对腹腔镜相关文献的进一步审视表明，在大多数情况下，治疗Ⅰ型和大多数Ⅳa型胆总管囊肿的最佳术式，即肝外胆管根治性切除并通过广泛的肝门部肝肠吻合术（最好是肝管空肠吻合术）进行重建，并未得到实施。实施不太彻底的切除会使患者面临更大的长期风险，即胆肠吻合口狭窄及其并发症以及残留肝外胆管发生恶变。目前，胆总管囊肿手术的长期疗效正被腹腔镜技术的短期优势所掩盖。胆总管囊肿手术管理的首要目标是患者的长期健康；腹腔镜技术只是实施手术的另一种方法，除非其长期疗效与最佳的开放手术相当，否则不应成为标准治疗方式。
