总结先天性胆总管囊肿术后吻合口狭窄/肝内胆管结石的原因、腹腔镜再手术经验及手术效果。

回顾首都医科大学附属北京儿童医院普外科2021年6月至2023年6月收治的17例先天性胆总管囊肿术后吻合口狭窄/肝内胆管结石患儿的病例资料，总结吻合口狭窄/肝内胆管结石发生原因、腹腔镜再手术经验，对比再手术前后生化检查结果，并进行随访。

17例患儿平均再手术年龄124.4±11.9个月，与前次根治手术的平均间隔时间73.9±11.4个月。原始胆总管囊肿Todani分型Ⅳa型11例(64.7%)，Ⅰa型5例(29.4%)，Ⅰc型1例(5.9%)。本次临床表现包括腹痛、发热、梗阻性黄疸、肝内胆管结石。再手术方式均为腹腔镜下手术，其中吻合口瘢痕狭窄9例(吻合口重建8例，吻合口扩大成形1例)，肝总管先天性狭窄4例(吻合口重建2例，吻合口扩大成形2例)，肝右动脉骑跨压迫肝总管2例(动脉前方吻合口重建)，胆支肠襻粘连梗阻1例(粘连松解)，先天性肝管膜状狭窄1例(隔膜切除后吻合口扩大重建)。再手术后1个月较术前中位丙氨酸氨基转移酶(21.6 vs. 118.3 U/L，P<0.001)、门冬氨酸氨基转移酶(18.9 vs. 162.0 U/L，P<0.001)、谷氨酰转肽酶(21.2 vs. 418.9 U/L，P<0.001)、总胆红素(11.4 vs. 27.3 μmol/L，P＝0.002)、总胆汁酸(6.4 vs. 43.1 μmol/L，P＝0.002)水平均有明显下降。中位随访15.8个月，全部患儿均无临床症状复发、肝内胆管结石或肝功能异常。

腹腔镜下手术可有效治疗先天性胆总管囊肿术后吻合口狭窄/肝内胆管结石，再手术策略是解除病因并重建宽阔平整的高位胆肠吻合口。

To summarize our laparoscopic surgical experience of redo surgery for jejunohepatic anastomotic stricture/intrahepatic cholelithiasis after primary surgery in children with congenital choledochal cyst, and to determine the surgical efficacy.

During Jun. 2021 to Jun. 2023, 17 children diagnosed as jejunohepatic anastomotic stricture/intrahepatic cholelithiasis after primary congenital choledochal cyst surgery were included. Data were collected to summarize the cause and surgical experience. Pre- and post-operative biochemical results were compared, and follow-ups were performed.

The mean age at redo surgery was 124.4±11.9 months, and the mean interval after primary surgery was 73.9±11.4 months. The primary types of congenital choledochal cysts included 11Ⅳa (64.7%), 5Ⅰa (29.4%), 1Ⅰc (5.9%). Clinical presentation included abdominal pain, fever, obstructive jaundice and intrahepatic cholelithiasis. Redo surgeries were all performed under laparoscope, including 9 anastomotic stricture (8 anastomotic reconstruction and 1 anastomotic plasty), 4 congenital hepatic duct stenosis (2 anastomotic reconstruction and 1 anastomotic plasty with enlarged caliber), 2 crossing right hepatic artery (replace of artery under common hepatic duct with anastomotic reconstruction), 1 ascending loop adhesive obstruction (adhesion lysis), and 1 congenital membranous stenosis of left hepatic duct (membranectomy with enlarged anastomotic reconstruction). The level of post-operative ALT (21.6 vs. 118.3 U/L, P<0.001), AST (18.9 vs. 162.0 U/L, P<0.001), GGT (21.2 vs. 418.9 U/L, P<0.001), TBIL (11.4 vs. 27.3 μmol/L, P=0.002) and TBA (6.4 vs. 43.1 μmol/L, P=0.002) were significantly lower than preoperative level. With median follow-ups of 15.8 months, there were no symptom or intrahepatic cholelithiasis recurrence, and all liver panels were normal.

Laparoscopic redo surgery is effective in treating jejunohepatic anastomotic stricture/intrahepatic cholelithiasis after primary surgery in children with congenital choledochal cyst, and the surgical strategy is resolve the etiology and create a wide soomth jejunohepatic anastomosis at the level of porta hepatis.