本文選題：先天性膽總管囊腫　切入點：穿孔　出處：《重慶醫(yī)科大學》2016年碩士論文　論文類型：學位論文

【摘要】：目的:總結(jié)先天性膽總管囊腫穿孔患兒的臨床資料,提高疾病認識,優(yōu)化疾病診治方案。方法:收集重慶醫(yī)科大學附屬兒童醫(yī)院2008年3月至2015年8年收治的膽總管囊腫穿孔患兒38例�；仡櫡治瞿懣偣苣夷[穿孔患兒癥狀、發(fā)病年齡、性別分布、輔助檢查、手術(shù)方案的選擇。結(jié)果:1.發(fā)生膽總管囊腫穿孔患兒共38例,總的穿孔率為4.5%,其中男童7例,女童31例,男女之比約為1:4.4。年齡7天至6歲2個月,中位數(shù)14個月,≤1歲者共15例,占39.5%,≤3歲者共33例,占86.8%。2.膽道穿孔患兒主要癥狀:腹痛47.4%、腹脹42.1%、發(fā)熱44.7%、嘔吐73.7%、黃疸23.7%,白陶土樣大便13.2%、腹部包塊15.8%、尿色加深21.1%、腹瀉7.9%。3.膽道穿孔患兒輔助檢查以腹腔穿刺抽液、腹部超聲、MRCP檢查診斷準確率較高。4.早期誤診率達34.2%(13/38),發(fā)生于≤1歲的嬰兒有7例,占該年齡段的46.7%(7/15),發(fā)生于1歲幼兒有6例,占該年齡段的26.1%(6/23)。誤診為多為其他腹部疾病及支氣管肺炎并發(fā)胸水。5.膽總管囊腫穿孔患兒腹水淀粉酶升高占81.6%;膽道穿孔部分最常發(fā)生于膽總管與膽囊管交界處;不同膽總管擴張類型的發(fā)生率不同,其中囊狀擴張:梭狀擴張約為2.2:1,且囊狀擴張組術(shù)前膽紅素水平較梭狀擴張組高。6.38例穿孔患兒均采用分期手術(shù),Ⅰ期行引流術(shù),1-4月后完成Ⅱ期囊腫切除+肝總管空腸roux-en-y吻合術(shù)。(1)Ⅰ期行引流術(shù)后未出現(xiàn)引流管逆行感染、肺部感染、出血等并發(fā)癥。平均術(shù)后11天出院,男性患兒較女性患兒術(shù)后恢復時間長,采用非單純腹腔引流的囊腫外引流、t管引流或腹腔引流+t管引流較單純腹腔引流術(shù)后患兒體溫恢復正常所需時間短。隨訪中,3例患兒于術(shù)后兩月發(fā)生膽道感染,予以感染控制后出院,1月后來院行Ⅱ期根治術(shù)。(2)Ⅱ期手術(shù)術(shù)后恢復可,無出血、感染等并發(fā)癥。平均術(shù)后10天出院。術(shù)后3月隨訪無膽瘺、黃疸發(fā)生。7.38例膽道穿孔患兒均使用三代頭孢+奧硝唑或甲硝唑的抗感染方案,其中16例加用1種對β-內(nèi)酰胺酶穩(wěn)定的抗生素,集中于術(shù)后1-3天體溫恢復正常。使用阿拓莫蘭、美能或阿拓莫蘭+美能的保肝方案,術(shù)后轉(zhuǎn)氨酶恢復約需1-3天。結(jié)論:1.年齡對穿孔發(fā)生有影響,嬰幼兒發(fā)生率高于較大年齡兒,符合自幼起病特點。2.膽總管囊腫穿孔主要癥狀為腹痛、腹脹、發(fā)熱、嘔吐,典型“黃疸、腹痛、發(fā)熱”三聯(lián)征出現(xiàn)率低。3.年齡小(≤1歲)的患兒更易發(fā)生早期誤診,借助于腹部b超及腹腔穿刺抽液穿出膽汁樣液體是確診膽總管囊腫穿孔的方便、可靠的辦法。4.胰膽管合流異常、膽總管囊腫或膽總管遠端阻塞、膽總管遠端神經(jīng)肌肉發(fā)育不良、膽總管局部缺血等均為膽總管囊狀穿孔發(fā)生的病因。5.先天性膽總管囊腫穿孔采用分期手術(shù)方式,安全且療效確切。Ⅰ期引流術(shù)中腹腔引流可作為輔助引流方式,不適于單獨使用。6.術(shù)后抗使用生素、保肝藥,營養(yǎng)、維生素支持對術(shù)后恢復十分重要。
[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，

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