38例先天性胆总管囊肿穿孔临床分析

发布时间：2018-03-09 04:25

  本文选题：先天性胆总管囊肿　切入点：穿孔　出处：《重庆医科大学》2016年硕士论文　论文类型：学位论文

【摘要】：目的:总结先天性胆总管囊肿穿孔患儿的临床资料,提高疾病认识,优化疾病诊治方案。方法:收集重庆医科大学附属儿童医院2008年3月至2015年8年收治的胆总管囊肿穿孔患儿38例。回顾分析胆总管囊肿穿孔患儿症状、发病年龄、性别分布、辅助检查、手术方案的选择。结果:1.发生胆总管囊肿穿孔患儿共38例,总的穿孔率为4.5%,其中男童7例,女童31例,男女之比约为1:4.4。年龄7天至6岁2个月,中位数14个月,≤1岁者共15例,占39.5%,≤3岁者共33例,占86.8%。2.胆道穿孔患儿主要症状:腹痛47.4%、腹胀42.1%、发热44.7%、呕吐73.7%、黄疸23.7%,白陶土样大便13.2%、腹部包块15.8%、尿色加深21.1%、腹泻7.9%。3.胆道穿孔患儿辅助检查以腹腔穿刺抽液、腹部超声、MRCP检查诊断准确率较高。4.早期误诊率达34.2%(13/38),发生于≤1岁的婴儿有7例,占该年龄段的46.7%(7/15),发生于1岁幼儿有6例,占该年龄段的26.1%(6/23)。误诊为多为其他腹部疾病及支气管肺炎并发胸水。5.胆总管囊肿穿孔患儿腹水淀粉酶升高占81.6%;胆道穿孔部分最常发生于胆总管与胆囊管交界处;不同胆总管扩张类型的发生率不同,其中囊状扩张:梭状扩张约为2.2:1,且囊状扩张组术前胆红素水平较梭状扩张组高。6.38例穿孔患儿均采用分期手术,Ⅰ期行引流术,1-4月后完成Ⅱ期囊肿切除+肝总管空肠roux-en-y吻合术。(1)Ⅰ期行引流术后未出现引流管逆行感染、肺部感染、出血等并发症。平均术后11天出院,男性患儿较女性患儿术后恢复时间长,采用非单纯腹腔引流的囊肿外引流、t管引流或腹腔引流+t管引流较单纯腹腔引流术后患儿体温恢复正常所需时间短。随访中,3例患儿于术后两月发生胆道感染,予以感染控制后出院,1月后来院行Ⅱ期根治术。(2)Ⅱ期手术术后恢复可,无出血、感染等并发症。平均术后10天出院。术后3月随访无胆瘘、黄疸发生。7.38例胆道穿孔患儿均使用三代头孢+奥硝唑或甲硝唑的抗感染方案,其中16例加用1种对β-内酰胺酶稳定的抗生素,集中于术后1-3天体温恢复正常。使用阿拓莫兰、美能或阿拓莫兰+美能的保肝方案,术后转氨酶恢复约需1-3天。结论:1.年龄对穿孔发生有影响,婴幼儿发生率高于较大年龄儿,符合自幼起病特点。2.胆总管囊肿穿孔主要症状为腹痛、腹胀、发热、呕吐,典型“黄疸、腹痛、发热”三联征出现率低。3.年龄小(≤1岁)的患儿更易发生早期误诊,借助于腹部b超及腹腔穿刺抽液穿出胆汁样液体是确诊胆总管囊肿穿孔的方便、可靠的办法。4.胰胆管合流异常、胆总管囊肿或胆总管远端阻塞、胆总管远端神经肌肉发育不良、胆总管局部缺血等均为胆总管囊状穿孔发生的病因。5.先天性胆总管囊肿穿孔采用分期手术方式,安全且疗效确切。Ⅰ期引流术中腹腔引流可作为辅助引流方式,不适于单独使用。6.术后抗使用生素、保肝药,营养、维生素支持对术后恢复十分重要。
[Abstract]:Objective: To summarize the clinical data of congenital choledochal cyst with perforation, raise awareness of the disease, disease diagnosis and treatment plan optimization. Methods: 38 cases of children with cysts collected at children's Hospital Affiliated to Medical University Of Chongqing in March 2008 to 2015 8 years were retrospectively analyzed. Common bile duct perforation perforation of choledochal cyst in children with symptoms, onset age, gender distribution, auxiliary examination, surgery the choice of the program. Results: 1. a total of 38 cases of children with choledochal cyst perforation, the total perforation rate was 4.5%, of which 7 were boys, 31 were girls, male and female ratio is about 1:4.4. the age of 7 days to 6 years 2 months, median 14 months, less than 1 years old were 15 cases, accounted for less than 39.5%. At the age of 3, there were 33 cases, accounting for 86.8%.2. of biliary tract perforation in children: 47.4% main symptoms of abdominal pain, abdominal distension 42.1%, 44.7% fever, vomiting in 73.7%, jaundice in 23.7%, 13.2% clay colored stools, abdominal mass 15.8%, urine 21.1%, diarrhea 7.9%.3. biliary tract perforation with auxiliary Check to paracentesis, abdominal ultrasound, MRCP diagnostic accuracy of high.4. rate of misdiagnosis was 34.2% (13/38), occurs in less than 1 years old baby in 7 cases, accounting for the age of 46.7% (7/15), occurred in 1 years old children in 6 cases, accounting for the age of 26.1% (6/23). The misdiagnosis as other abdominal diseases and bronchial pneumonia complicated with pleural.5. choledochal cyst with perforation of ascites amylase increased 81.6%; biliary tract perforation part most often occurs in the common bile duct and cystic duct junction; bile duct dilatation rate of different types, including: cystic dilatation of fusiform expansion is about 2.2:1. Group and cystic dilatation of preoperative serum bilirubin level was fusiform dilatation group.6.38 cases of perforation patients were treated with surgical staging, drainage of phase I, phase II complete cyst excision and Roux-en-Y hepaticojejunostomy after 1-4 months. (1) drainage stage line does not appear after the drainage of retrograde infection, lung Department of infection, bleeding and other complications. An average of 11 days after discharge, male patients than in female children with postoperative recovery time is long, the non simple peritoneal drainage cyst drainage and T tube drainage or abdominal drainage and +t tube drainage is simple peritoneal drainage in children after the temperature returned to normal time. Short follow-up, 3 cases two months after operation in children occurred biliary tract infection, and was discharged after controlling infection, January later underwent radical resection of stage II. (2) second stage surgery postoperative recovery, no bleeding, infection and other complications. The average discharge 10 days after operation. Postoperative follow-up in March without biliary fistula, the anti infective Huang Danfa.7.38 cases biliary tract perforation patients were treated with three generation cephalosporins + ornidazole or metronidazole, 16 cases with 1 kinds of beta lactamase stable antibiotic which focused on the 1-3 day after operation. The use of the body temperature to restore the normal Atomolan, beauty or o extension Mo Fang LAN + liver case of postoperative beauty. Transamination 閰舵仮澶嶇害闇，

本文编号：1586991