小儿胆总管囊肿超声诊断的临床要求

目的 探索超声作为胆总管囊肿诊断常规方法的临床价值。方法 总结近十年手术治疗的胆总管囊肿５８例,分析术前超声检查的准确性和完整性。结果 术前测量的囊肿大小和肝内胆管扩张与临床结果符合,胆道结石和胆道蛔虫的诊断准确率为５３％。超声提示２６例肝肿大和肝回声改变,３例严重肝病漏报;Ｂ超诊断１１例胰腺病变,９例正常,而其余未描述。     

假性胰腺囊肿的外科治疗

自１９９２年１月至１９９８年１月对假性胰腺囊肿２５例行外科手术治疗,现报告如下。一、临床资料１－一般资料：本组２５例,男９例,女１６例,年龄２１～６８岁,平均为５０－８岁。病因包括胆源性胰腺炎１５例,酒精性胰腺炎１例,外伤５例,原因不明４例。２－临床表现：上腹胀痛２０例,发热４例,恶心呕吐１１例,腹部包块２１例,腹水１例,黄疸２例。血淀粉酶升高１０例,尿淀粉酶升高７例,囊液淀粉酶升高１５例,腹水淀粉酶升高１例,血糖升高２例。全组病例术前经Ｂ型超声或ＣＴ确定囊肿部位、大小及与周围脏器的关系。３－治…     

经腹腔镜治疗非扩张性胰胆合流异常

目的探讨经腹腔镜治疗非扩张性胰胆合流异常的效果。方法 2003年2月～2009年1月,13例不合并胆总管囊肿的胰胆合流异常患儿,年龄4～12岁,中位年龄5岁,男5例,女8例。均有腹痛病史,反复胆管炎发作3例,反复梗阻性黄疸病史8例,胰腺炎病史3例。术前超声检查肝内外胆管无扩张,总胆红素(TBIL)34～120μmol/L,直接胆红素(DBIL)18.4～70.8μmol/L。6例转氨酶升高,天冬氨酸转氨酶(AST)38.7～89IU/L,丙氨酸转氨酶(ALT)45～81IU/L。4例血淀粉酶升高,147～198U/L。4例术前ERCP检查发现胰胆合流异常。13例均经术中胆道造影证实存在胰胆合流异常,然后实施胆总管切除、肝管空肠Roux-en-Y吻合术。2例合并肝外胆管结石,首先以3mm镜头用作胆道镜探查,然后用8号尿管以生理盐水冲洗,或用小儿尿道镜将结石勾出或冲出。4例合并蛋白栓处理方法与并发结石者基本相同,但相对容易。结果全部手术均获成功。术中胆道造影显示Komi分型Ⅰ型10例、Ⅱ型3例;共同管长度5～12mm,中位数7.0mm,无中转开腹。手术时间152～216min,中位数170min。术中出血5～10ml,无需输血病例,无脏器损伤,无胆漏、肠漏。术后住院4～7天。TBIL、DBIL术后3周均恢复至正常范围。6例AST、ALT升高者在术后4个月内恢复正常,4例淀粉酶升高者术后3周内恢复正常。术后随访6～50个月,中位数28个月。患儿生长发育良好,无腹痛、黄疸、发热等。肝胆系统超声无胆管扩张、肝硬化表现。结论经腹腔镜治疗伴有反复腹痛、黄疸、胰腺炎等并发症的非扩张性胰胆合流异常效果良好。     

肝总管直径≤5mm顿挫型胆总管囊肿行腹腔镜胆肠吻合的方法初探

目的:总结为肝总管直径≤5 mm的胆总管囊肿患儿行腹腔镜囊肿切除+肝总管空肠Roux-en-Y吻合术中胆肠吻合的临床经验。方法:回顾分析2018年1月至2019年4月腹腔镜胆总管囊肿根治术中发现的6例肝总管直径≤5 mm的顿挫型胆总管囊肿患儿的临床资料,其中男1例,女5例。患儿9个月～4岁,平均(25.5±14.7)个月。术前转氨酶升高5例,胆红素升高2例,囊肿感染2例,合并胰腺炎1例。肝总管与肠管后壁用5-0可吸收缝线连续缝合,前壁间断缝合,缝合完毕后依次打结。统计手术前后转氨酶、胆红素、淀粉酶等指标,观察术中胆肠吻合时间、术后胆漏、吻合口狭窄、胆管结石及肝管扩张情况。结果:6例患儿中2例肝总管直径4 mm, 4例5 mm,均成功完成肝总管空肠吻合,胆肠吻合时间20～30 min,术后无胆漏发生,随访17～34个月,平均(22.7±6.2)个月,患儿转氨酶、胆红素、淀粉酶均恢复正常。术后随访,B超检查示无吻合口狭窄、胆管结石及肝管扩张发生。结论:肝总管直径≤5 mm的顿挫型胆总管囊肿行腹腔镜根治手术时,采用可吸收缝线连续缝合肝总管后壁与空肠、间断缝合前壁,然后依次打结是安全、可行的。     

严重胰腺损伤的诊治

目的 探讨严重胰腺损伤的诊断与外科治疗方法。方法 回顾分析我院近20年32例3～5级胰腺损伤的临床资料。结果 术前腹腔穿刺液淀粉酶升高占50％，血淀粉酶升高者占60％(12／20)。B超检查10例，3例提示诊断。CT检查8例，3例提示诊断。术前诊断胰腺损伤仅10例。32例均手术治疗，术中证实胰腺损伤属3级者20例，4级10例，5级2例。治愈25例，死亡7例，死亡率21．9％。并发症有腹腔脓肿、胰瘘、胰腺假性囊肿等。结论 严重胰腺损伤合并伤多，术前诊断困难，术后并发症多和死亡率高。早期确诊、术中仔细探查，合理的手术方式是关键。术中B超和术中造影有助于诊断。生长激素和生长抑素的应用有较好的治疗效果。     

胰腺包虫致慢性胰腺炎1例

胰腺包虫致慢性胰腺炎１例胡文龙患者女，５４岁。因反复上腹部胀痛伴恶心，呕吐１年余入院。体查：皮肤、巩膜无黄染，腹平软，未触及包块，剑突下压痛明显。血常规、血、尿淀粉酶均正常。Ｂ超示：胰腺假性囊肿。ＣＴ示：①胰腺尾部包虫囊肿，多子囊并感染；②慢性胰腺炎...     

结石性胆囊炎术中胆总管探查阴性10例报告

我科于1993年7月~2004年10月对胆囊结石、胆囊炎者施行胆囊切除术,术中行胆总管切开探查阴性10例。报告如下。临床资料本组10例,男2例,女8例;年龄27~72岁,平均47.5岁。均为择期手术。腹痛9例,皮肤黄染、尿色黄1例,发热3例,畏寒1例。术前体检发现黄疸4例。既往有黄疸病史3例,胰腺炎病史1例。WBC>10.0×109/L者1例,血、尿淀粉酶升高1例,胆红素升高2例,-γGT升高4例,SGPT升高4例。术前B型超声检查发现胆总管中上段占位1例,CT检查提示肝总管及胆囊颈壁增厚伴梗阻性胆道扩张,考虑为胆管癌。B型超声检查发现胆总管结石6例,胆道蛔虫1例,胆总…     

8例异位胰腺诊治分析

我院于 1991年 8月～ 2 0 0 1年 8月共收治异位胰腺 8例 ,均经病理确诊。现就其临床特点和诊治情况进行分析。临床资料　　本组男 5例 ,女 3例。年龄 2～ 78岁 ,中位年龄 5 0 .9岁。胰腺异位位置 :十二指肠乳头上方肠壁一例 ,小肠 4例 ,胃 2例 ,胆总管一例。诊断及合并其他疾病 :残胃癌、直肠癌、胆总管平滑肌肉瘤、胆石症一例和空肠憩室各一例 ,胆管癌 2例。实验室检查 :术前ＡＬＰ、ＧＧＴ升高 4例 ,术后均有不同程度下降 ,ＨＧＢ降低 5例 ,血糖升高 4例 ,果糖胺异常 2例 ,曾测 2例血淀粉酶 ,但均正常 ;尿糖升高一例 ,尿胆原升高一例 ,尿…     

成人先天性胆管囊肿的诊治体会

成人先天性胆总管囊肿较为少见 ,有关诊治方面内容的报导也不多 ,我们近 1 5年来收治 7例 ,现将诊治方面的体会讨论如下。1　临床资料本组患者 7例 ,男性 1例 ,女性 6例 ,年龄 1 6- 42岁 ,平均年龄 2 7.5岁。临床表现为间歇性发热、黄疸、腹部绞痛或持续性钝痛、血淀粉酶升高 ,其中右上腹包块 1例 ,B超或 CT检查提示胆总管梭形扩张 ,术前均诊断为先天性胆总管囊肿。术中探查可见胆总管囊肿呈梭形 ,横向直径 4～ 1 2 cm,胆囊管开口于囊肿 ,其中合并囊内结石 5例。术后病理诊断 :先天性胆总管囊肿 ,其中囊壁上皮化生 3例。采用囊肿切除、肝…     

胆源性胰腺炎的诊断和外科治疗

目的：探讨胆源性胰腺炎的诊断和外科治疗方法。方法：对１９８６￣１９９６年急诊收治１４６例胆源性胰腺炎进行总结。结果：本组主要诊断方法为胆道感染的临床征象，如左上腹压痛范围广泛，血、尿淀粉酶明显升高，Ｂ超、ＣＴ显示有胆道结石和胰腺病变。结果非手术治疗５７例，手术治疗８９例，死亡１１例，病死率７．５％。结论：根据胆道、胰腺病变的具体情况，采用“个体化原则”选择手术时间，用非手术治疗或去尽胆道结石，畅     

小儿先天性胆总管囊肿自发性穿孔的临床分析

目的：探讨先天性胆总管囊肿自发性穿孔的诊断方法和手术方式。方法：回顾性分析16例先天性胆总管囊肿自发性穿孔患儿的临床资料。结果：本组16例患儿年龄均小于4岁，平均年龄23个月。临床表现为胆胀，腹痛，呕吐及发热，同时有全腹压痛，10例术前经腹腔穿刺明确胆道自发性穿孔的诊断，其中5例经B超或CT检查证实有胆总管囊肿，采用囊肿外引流加腹腔引流治疗。16例患儿术后均恢复良好，3个月左右再地囊肿切除加胆道重建。结论：先天性胆总管囊肿穿孔与胆道梗阻有关，对小婴儿有腹膜炎表现，全腹压痛并以右上腹为著者，应常规行腹腔穿刺检查，急诊治疗宜选择囊肿外引流术，而后再行囊肿切除和胆道重建。     

婴幼儿先天性胆总管囊肿自发穿孔的诊治

目的探讨先天性胆总管囊肿自发性穿孔的诊断和治疗。方法回顾性分析11例婴幼儿先天性胆总管囊肿自发性穿孔患儿的临床资料。结果本组8例经术前腹腔穿刺确诊胆道自发性穿孔,其中5例经B超或CT诊断胆总管囊肿。3例行一期胆总管囊肿切除加胆道重建术(胆总管空肠Roux-Y吻合术);6例行胆道外引流加腹腔引流术,2例行胆囊置管引流加腹腔引流术,3~6个月后行胆总管囊肿切除加胆道重建术。11例患儿治疗后均恢复良好。结论婴幼儿胆总管囊肿自发穿孔容易误诊,掌握其临床特点、提高诊断意识以及根据患儿具体情况选择合理的手术方式是提高术前诊断率和减少术后并发症的关键。     

Clinical and operative findings of choledochal cysts in neonates and infants differ from those in older children

PURPOSE: Significant differences in the clinical and pathological presentation of choledochal cysts between infants and older children have been noted. We developed a new management strategy according to these differences. METHODS: Between 1990 and 2001, we managed 34 cases of type I choledochal cyst. Nineteen patients were more than 1 year old. Fifteen patients underwent surgery before the age of 1 year, and eight before the age of 2 months. One patient was diagnosed prenatally. All patients underwent choledochal cyst excision and hepaticojejunostomy. Symptoms and signs, and findings from physical examination, laboratory tests, and pathology were recorded and analysed. Follow-up periods ranged from 6 months to 11 years. RESULTS: Eight cases who were less than 1 year old suffered from painless jaundice, and choledochal cysts in this group usually ended as a blind pouch. Their cystic amylase and lipase concentrations were within normal limits. Biliary cirrhosis was diagnosed by liver biopsy in three of these patients. In contrast, 17 of the 19 patients who were more than 1 year old had abdominal pain, and 15 of their cysts were connected to the pancreatic duct. Cystic amylase and lipase concentrations were often elevated. All patients had an excellent outcome. CONCLUSION: Diseases with different pathogeneses may cause different clinical manifestations and pathology of choledochal cysts in infants and older children. Some patients develop biliary cirrhosis in the early months of life. Our findings show that it is safe and imperative to treat neonates and infants with choledochal cysts as soon as possible, as delayed surgery may cause severe complications.     

Choledochal cyst associated with duodenal obstruction

The association between congenital duodenal obstruction and concomitant choledochal cyst has not been reported, although duodenal obstruction is known to be associated with many other anomalies. The authors describe 2 patients with choledochal cyst with duodenal obstruction. In 1 patient, a diverticulum type of choledochal cyst was found within an annular pancreas. Cyst excision, choledochojejunostomy, and side-to-side duodeno-duodenostomy were performed. The other patient showed separated duodenal atresia and other multiple anomalies including imperforate anus. A choledochal cyst was noted at the time of duodeno-duodenostomy and sigmoid colostomy. Cyst-enterostomy was performed at the age of 8 months, but the patient died of multiple anomalies. Intraoperative cholangiography indicated an anomalous pancreatobiliary ductal junction (APBDJ). In both patients the bile in the cyst contained high levels of amylase, suggesting the presence of an APBDJ. An APBDJ is considered to play an etiologic role in the development of the choledochal cysts associated with duodenal obstruction.     

Enteric duplication cyst of the pancreas with duplicated pancreatic duct

Enteric duplication cyst is one of the rarest forms of cystic lesion of the pancreas. We report a unique case of an enteric duplication cyst of the pancreas that was communicating with a duplicated pancreatic duct. A 7-year-old girl with severe acute abdominal pain was found to have a large cyst that was smoothly communicating with the dilated pancreatic duct in the pancreatic tail. Analysis of cyst fluid showed elevated levels of amylase, carcinoembryonic antigen (CEA) and CA 19-9, and no epithelial cells. Intraoperative cyst pancreatography revealed that the pancreatic duct was duplicated in the tail: 1 duct was communicating with the cyst, and the other was dilated within the pancreatic tail. The patient underwent spleen-preserving distal pancreatectomy and complete cyst excision without complication. Because preoperative diagnosis of duplication cyst of the pancreas is difficult, this condition should be considered during differential diagnosis of atypical cystic lesions of the pancreas. Complete excision is desirable for the management of duplication cyst of the pancreas.     

先天性胆总管囊肿癌变20例报告

目的总结先天性胆总管囊肿癌变的防治经验。方法回顾性分析1981-2006年间收治的先天性胆总管囊肿癌变20例的临床资料。结果原发癌变9例,内引流术后癌变11例。临床表现为非特异性,其中15例表现为化脓性胆管炎,5例为上腹部包块,均伴乏力、消瘦。原发胆总管囊肿癌变9例中7例行ERCP检查,其中6例合并胆胰管合流异常。手术方式包括剖腹活检术4例,T管引流4例,囊肿切除加胰十二指肠切除术6例,囊肿部分切除、肝左外叶切除2例,囊肿切除、肝管空肠Roux-en-Y吻合术4例。癌变主要位于囊壁18例,术后病理结果16例(16/20)为腺癌。术后生存期为4~31个月,平均12.7个月。结论胆胰管合流异常是先天性胆总管囊肿癌变的病因之一,临床表现不典型,术前诊断困难,预后极差,先天性胆总管囊肿行内引流术后更易癌变,对先天性胆管囊肿病人推荐行新的预防癌变的手术方式,术中冰冻切片检查有助于确诊,对侵及胰腺的病例考虑行囊肿切除及胰十二指肠切除术。     

Carcinoma Arising in the Pancreas 17 Years After Primary Excision of a Choledochal Cyst: Report of a Case

We report herein the case of a 42-year-old woman in whom a pancreatic carcinoma was found 17 years after excision of a choledochal cyst with Roux-en-Y hepaticojejunostomy. Although the incidence of biliary carcinoma associated with choledochal cyst is high, reports of cancer developing in the remaining intrapancreatic biliary tract or pancreas in patients who have previously undergone primary excision of a choledochal cyst are extremely rare. Long-term follow-up is recommended even for patients who have undergone excisional surgery for a choledochal cyst, in consideration of the possibility that cancer associated with the intrapancreatic biliary tract or pancreas may develop. Received: May 18, 2000 / Accepted: November 20, 2000     

小儿巨大胆总管囊肿11例手术体会

目的总结小儿先天性巨大胆总管囊肿的外科手术治疗经验。方法对11例先天性巨大胆总管囊肿患儿施行胆囊切除、胆总管囊肿切除术、肝管夺肠Roux—en—Y型吻合术。结果术后均痊愈出院,10例获随访3～12个月,未见胆道感染、黄疸、营养不良等并发症出现。结论常规术中胆道造影,完全地切除囊肿,合理地处理囊肿远近端胆管异常是巨大胆总管囊肿手术成功的关键。     

Cysts of the choledochus in children: experience of the Sainte-Justine hospital]

Choledochal cyst remains a rare pathology in western countries. Over the past 15 years, 18 children were diagnosed with choledochal cyst at Hospital Sainte-Justine. There were 14 girls and 4 boys with an average age of 7.4 years ranging from newborn to 15 years. Abdominal pain, jaundice and abdominal mass were present in 70%, 54% and 7% respectively. Only one patient, a 15 years old girl had all three symptoms. Abdominal ultrasonography was diagnostic in all cases and in two cases, a cystic dilatation was found in the antenatal ultrasonography. Transvesicular cholangiography was performed successfully in 11 patients and showed a detailed anatomy of the biliary tract preoperatively. Sixty-seven percent of the cysts were type I while 33% were type IV. A common channel was found in 43% of the cases. Sixteen patients underwent cyst excision followed by Roux en Y hepatico-jejunostomy, one patient with associated biliary atresia had a porto-enterostomy and one patient had a cysto-duodenostomy. The last patient had recurrent episodes of cholangitis and required reoperation while the others are doing well and free of infection. With the liberal use of ultrasonography, the diagnosis of choledochal cyst is being done earlier improving the long term prognosis. Transvesicular cholangiography is a very useful addition in the preoperative investigation of these patients. Roux en Y hepatico-jejunostomy was associated with minimal morbidity and mortality and gave excellent result.     

经腹壁ESWL治疗输尿管上段结石对胰腺的生物学效应

目的：探讨医用冲击波会否对胰腺诱发不良的生物学效应。方法：收集输尿管上段结石192例,经腹壁ESWL,术后1天（20～30h）常规检测血、尿淀粉酶,采用B超检查胰腺及周围脏器。对术后腹痛且血、尿淀粉酶增高者加以CT检查,并积极对症支持治疗;术后1周、3周、3个月、1年复查KUB、腹部B超和（或）CT及血清淀粉酶。结果：192例输尿管上段结石ESWL后1天6例出现上腹部疼痛并有血、尿淀粉酶增高．B超有2例提示为急性胰腺炎（水肿型）可能,CT有3例提示为急性胰腺炎可能,上述6例给予积极对症支持治疗后症状消失,1周、3周腹部B超和CT均未见胰腺异常影像,血清淀粉酶、尿淀粉酶逐渐恢复到正常范围,168例随访3个月、1年,腹部B超、KUB和（或）CT均未见胰腺及周围脏器异常,血清淀粉酶、尿淀粉酶均在正常范围。结论：经腹壁ESWL治疗输尿管上段结石安全有效,无严重并发症,可作为ESWL重要的补充手段之一。