Objective To explore primary surgical treatment experience of typeⅣ hilar cholangiocarcinoma. Methods From April 2008 to April 2011，20 patients with type Ⅳ hilar cholangiocarcinoma were enrolled into the same surgical group in Department of Hepatobiliary and Pancreatic Surgery of West China Hospital of Sichuan University.The intra- and post-operative results were analyzed.Results The total resection rate was 75%，which was consisted of 10 cases of radical excision and 5 cases of non-radical excision.Seven patients received left hepatic trisegmentectomy and caudate lobe resection including anterior and posterior right hepatic duct reconstruction，hepatojejunostomy，and Roux-en-Y jejunojejunostomy.Six patients received enlarged left hepatic trisegmentectomy and caudate lobe resection including left intrahepatic and extrahepatic duct reconstruction，hepatojejunostomy，and Roux-en-Y jejunojejunostomy. Two patients received quadrate lobe resection including two cholangioenterostomies after anterior and posterior right hepatic duct reconstruction，and left intrahepatic and extrahepatic duct reconstruction.After percutaneous transhepatic cholangial drainage （PTCD） and portal vein embolization （PVE），two patients with total bilirubins ＞400 mmol/L received radical excision and non-radical excision，respectively.Three patients only received PTCD during operation due to wide liver and distant metastasis，and two patients received T tube drainage during operation and postoperative PTCD due to left and right portal vein involvement. All 15 patients who received lesion resection survived more than one year， whereas another five patients whose lesions can not been resec ted only survived from 3 to 6 months with the mean of 4.2 months.No death occurred during the perioperative period. Conclusions For patients with type Ⅳ hilar cholangiocarcinoma， preoperative evaluation and tumor resection shall conducted so as to relieve obstruction of biliary tract，otherwise PTCD and PVE prior to the final lesion resection shall be performed.
Objective To investigate the best management in treating relapsed biliary calculi after endoscopic sphincterotomy (EST).Methods The clinical data of 96 patients with relapsed biliary calculi after EST in our hospital from February 1999 to February 2009 were retrospectively analysed. The patients were grouped into two groups by the size of calculi under magnetic resonance cholangiopancreatography: surgical group (the size of calculi was bigger than 1.0 cm) in 79 cases and non-surgical group (the size of stone was smaller than 1.0 cm and the patients were performed EST again) in 17 cases. The relapsed biliary calculi rate between two groups were compared. Results In the surgical group, the 79 patients (82.29%) were performed common bile duct exploration, transected common bile duct and choledochojejunostomy with Roux-en-Y anastomosis. In the non-surgical group, the 17 patients (17.17%) were performed EST again. The relapsed biliary calculi rate was 2.63% in the surgical group, 70.59% in the non-surgical group. There was marked difference in the relapsed biliary calculi rate between surgical group and non-surgical group (Plt;0.05). Conclusion The operation treatment is the best way for relapsed biliary calculi after EST, and has good curative effect. The best manner of operation treatment is common bile duct exploration, transected common bile duct and choledochojejunostomy with Roux-en-Y anastomosis.
Objective To evaluate the application of a surgical method in pancreaticoduodenectomy. Methods All the 211 cases of purse-string invaginated pancreaticojejunostomy performed from Dec.1985 to Dec.2007 were reviewed. Firstly, an accordant plastic tube was put and fastened in main pancreatic duct, and pancreas was ligated at 2-3 cm apart from the pancreatic stump to let secretin flow far away. Furthermore, invaginated pancreaticojejunostomy was performed to get closer between pancreas and jejunum. Results Pancreatic fistula and perioperative death didn’t occur among these 211 cases. The complications included 2 cases of incision dehiscence, 4 cases of biliary fistula and 1 case of scission of superior mesentric artery. Conclusion Purse-string invaginated double-layer anastomosis of pancreaticojejunal would be feasible for pancreaticoduodenectomy preventing pancreatic fistula.
ObjectiveTo prospectively study the effect of preventing postoperative reflux esophagitis with esophagogastrostomy and RouxenY gastrojejunostomy after proximal subtotal gastrectomy.MethodsTwentysix cases of carcinoma of the gastric fundus and cardia were allocated randomly to 2 groups (the control group with 12 cases and the experimental group with 14 cases) according to odd or even number of the admission number.After proximal subtotal gastrectomy and esophagogastrostomy, the control group underwent pyloroplasty while the experimental group with pyloruspreserving RouxenY gastrojejunostomy.The inflammatory reaction of the tissue obtained at the esophagogastric junction using a fiber gastroscope was observed after half year of postoperative followup in the two groups.An examination of gastric emptying of a radionuclidelabeled test meal were performed.According to the Visick score of followup data,the effects of operation were evaluated.The 5year survival rate was also evaluated.ResultsThe postoperative gastrointestinal symptoms in the experimental group were slighter than those in the control group.The examination of gastric emptying of a radionuclidelabeled test meal showed that the gastric emptying time of a half dose,gastric remains rates of radionuclide after 10 min and 60 min in the experimental group were similar to those in the control healthy people group.But in the control group,the gastric emptying time of a half dose delayed,and the gastric remains rate of radionuclide after 10 min and 60 min were higher than the other groups.The biopsy study of the esophagogastric junction showed that the inflammatory reaction in the experimental group was slighter than that in the control group.There was no significant difference between the two groups in the survival rate.ConclusionFor patients with carcinoma of the gastric fundus and cardia, after proximal subtotal gastrectomy and esophagogastrostomy,compared with pyloroplasty,pyloruspreserving RouxenY gastrojejunostomy can decrease the reflux esophagitis,and relieve the postoperative gastrointestinal symptoms.
Objective To evaluate the linkage between the proxmal as well as long term outcome and choice of therapeutical modality for benign hilar stricture of bile duct prospectively. Methods 25 patients have been catergorized into 4 groups according to different pathogen and the proxmal as well as long term outcome after pathogen based management have been studied prospectively. Results The hepatic portal cholangio-jejunostomy applied for iatrogenic hilar stricture of bile duct has been proved to be effective and the incidence of refulux cholangitis is only 10%(1/10). Hepatic hilar plasty procedures keep the physiological entitity of bile duct and the vital, sufficient autologous repair materials as well as reliable operation design are needed. Resection of atrophic right liver lobe bearing hepatolithiasis combined hepatic hilar plasty has reached both elimination of liver focus and maintaining the physiological entitity of bile duct. The ballon dilation for mild ring-like hilar stricture of bile duct is valide but not for hilar tubular stricture of secondary sclerosing cholangitis.Conclusion The strategy of individualized management (pathogen based management) for benign hilar stricture of bile duct has proved to be reliable and effective.
Objective To explore the diagnostic and treating scheme of primary sclerotic cholangitis. Methods 24 cases of primary sclerotic cholangitis identified by radiological and pathological examinations from 1972 to 1998 were analysed retrospectively. According to Thompson, 1 case was classified as type Ⅰ, 5 cases were type Ⅱ, 10 cases were type Ⅲ and 8 cases were type Ⅳ. The operation were as follows,resection of gallbladder plus T tube drainage in 8 cases, plus Roux-en-Y anastomosis of bile duct and jejunum in 12 cases, plus U tube stent and drainage in 4 cases. Results The total mortality rate was 25% (6/24) in 2～18 years follow-up after operation. Conclusion Early diagnosis and operation may resolve the drainage of bile into the jejunum. When serious lesions and worse liver functions exist, liver transplantation should be considered.
Twenty one cases of hepatocholelithiasis treated through hepatic round ligament approach for hepaticojejunostomy is reported. Of them 5 were introgenic injury to the biliary tract， 8 were left hepatolithiasis (7 complicated with bile duct stricture), 2 were intrahepatic sandy stone with acute suppurative cholangeitis, and 3 were residual stone in left hepatic duct with cystlike dilatation after T-tube drainage; while traumatic injury to the biliary passages, previous multiple biliary tract operations and left hepatic duct stone with acute hemorrhage were present in one of case individually 75.9% each. The ages of the patients were between 32 to 50 years. Clinical follw-up in this series was satisfactory. The authors consider that this approach gives good exposure with little injury to the liver and no liver resection needed. The indication for this approach mode of anastomosis and some operative details are discussed.
The secondary anastomotic stenosis is often occured from the repair and reconstructive operation of the injured bile duct. It is difficult to treat and the outcome is serious. In order to prevent this complication, the fibrin glue instead of traditional suturing technique combined with inner support was used. Fifty-four hybrid dogs were divided into 3 groups. Group A received Roux-en-y choledochojejunostomy with fibrin glue; group B received Roux-en-y choledochojejunostomy, with a fibrin glue combined support left permanently in the bile duct and group C received Roux-en-y choledocholejejunostomy with fibrin glue combined a support left temporarily in the bile duct. The amount of collagen in the scar was measured at 3/4, 3, 6, 9, 12 months respectively after operation. The results showed: 1. the mature period of scar was shortened from 12 months to 9 months when fibrin glue instead of suture was used in choledochojejunostomy; 2. the mature period of scar was further shortened from 9 months to 6 months when fibrin glue combined with inner support instead of fibrin glue was used in choledochojejunostomy. The conclusions were as follows: 1. fibrin glue could facilitate the healing of wound by inhibiting the formation of scar and accelerrate the maturation of scar; 2. when the inner support was used with fibrin glue in the operation, the mature period of scar could be further shortened; 3. the mechanism of action of the fibrin glue included minimizing the injury, avoiding foreign-body reaction, modifying organization of hematoma, preventing formation of biliary fistular and enhancing intergration and cross-linkage of collagen.
Objective To analyze the difference in the incidence of postoperative pancreatic leakage and anasto-motic bleeding complications in various methods of pancreaticojejunostomy after pancreaticoduodenectomy （PD）. Methods The clinical data of 526 patients underwent pancreaticojejunostomy from January 2008 to September 2012 in this hospital were analyzed retrospectively. End-to-side “pancreatic duct to jejunum mucosa-to-mucosa” anastomosis （abbreviation：mucosa-to-mucosa anastomosis） was performed in 359 patients， which contained 149 patients with internal drainage， 130 patients with external drainage， and 80 patients with no drainage. End-to-side invaginated anastomosis was performedin 165 patients without drainage. In addition， side-to-side anastomosis was performed in 2 patients without drainage.Results There were 34 cases （6.46%） of pancreatic leakage， 8 cases （1.52%） of anastomotic bleeding in pancreaticoje-junostomy， and 32 cases of death （6.08%）. ① The pancreatic leakage rate of mucosa-to-mucosa anastomosis was signi-ficantly lower than that of end-to-side invaginated anastomosis 〔4.18% （15/359） versus 11.52% （19/165）， χ2=10.029， P=0.002〕. There was no significant difference of the anastomotic bleeding incidence between mucosa-to-mucosa anasto-mosis and end-to-side invaginated anastomosis 〔1.67% （6/359） versus 1.21% （2/165）， χ2=0.159， P=0.691〕. ② In the mucosa-to-mucosa anastomosis group， the pancreatic leakage rates in the ones with internal drainage and external drainage were lower than those in the ones without drainage， respectively （2.68% （4/149） versus 11.25% （9/80）， χ2=7.132， P=0.008；1.54% （2/130） versus 11.25% （9/80）， χ2=9.410， P=0.002）；which was no significant difference between the ones with internal drainage and external drainage 〔2.68% （4/149） versus 1.54% （2/130）， χ2=0.433， P=0.510〕. But there were no significant differences for both the pancreatic leakage 〔2.68% （4/149） versus 1.54% （2/130）， χ2=0.433， P=0.510〕and anastomotic bleeding incidence 〔2.68% （4/149） versus 1.54% （2/130）， χ2=0.433， P=0.510〕 between the ones with internal drainage and external drainage. Conclusions Mucosa-to-mucosa anastomosis has a lower pancreatic leakage incidence as compared with end-to-side invaginated anastomosis. However， there is no significant difference of the anast-omotic bleeding incidence. Internal or external drainage could reduce the incidence of pancreatic leakage， but have no obvious effect to the anastomotic bleeding incidence.
Objective To explore the feasibility of arch-preserved jejunum in total gastrectomy with Roux-en-Y esophagojejunostomy for adenocarcinoma of esophagogastric junction （AEG） and upper-middle gastric cancer. Methods Clinical data of 13 patients who underwent total gastrectomy with Roux-en-Y esophagojejunostomy with usage of arch-preserved jejunum to resolve the anastomosis tension problem in our hospital from Dec. 2012 to Apr. 2013 were analyzedretrospectively， and surgical experience was summarized. Results The maximal and actual extended lengths were （7.75±1.75） cm （4-10 cm） and （5.95±1.82） cm （3-9 cm） respectively， with the utilization percentage of （77.91±16.60）% （50.0%-100.0%）. These patients hadn’t suffered postoperative mortality and severe complications， such as anastomosis leakage， stenosis， hemorrhage， and so on. Besides， there were 1 case complicated with postoperative acute urinary retention and another 1 case complicated with infra-hepatic space abscess and peritoneal infection. Conclusion Arch-preserved jejunum is a practical surgical technique to handle with the anastomosis tension of esophagojejunostomy in total gastrectomy for AEG and upper-middle gastric cancer.