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THE LONG-TERM OPERATIVE RESULTS OF CONGENITAL CHOLEDOCHAL CYST

目的 探讨先天性胆总管囊肿(congenital choledochal cyst,CCC)术式选择与疗效的关系。方法 对1989年至1998年间38例CCC手术治疗病例进行回顾性研究。结果 38例中行胆肠Roux-Y吻合术20例，肝总管十二指肠高位大口吻合术18例。术后随机获随访31例。13例胆肠Roux-Y吻合术后随访3～7年，发现5例并发十二指肠溃疡，3例并发胆道逆行感染。18例肝总管十二指肠高位大口吻合术后随访2～5年，发现1例并发胆道逆行感染，无1例并发十二指肠溃疡。结论 由于肝总管十二指肠高位大口吻合术后远期并发十二指肠溃疡发生率较低，其与胆肠Roux-Y吻合术相比，是提高CCC患儿术后远期生活质量较理想的术式。

PATHOGEN BASED MANAGEMENT OF BENIGN HILAR STRICTURE OF BILE DUCT

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.

先天性胆管囊肿并发胆系癌肿10例报告

USE OF FIBRIN GLUE IN THE PREVENTION OF SECONDARY ANASTOMOTIC STENOSIS FROM REPAIR AND RECONSTRUCTION OF THE INJURY OF THE BILE DUCT

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.

Treatment of Recurrent Hepatolithiasis after Choledochojejunostomy by Choledochofiberscope Through The Biliary Duct Marked with Silver Clip

目的 探讨金属银夹标记胆道通道，利用胆道镜技术治疗胆肠吻合术后肝胆管结石复发的可行性、安全性和有效性。方法 回顾性分析大连市友谊医院47例胆管结石行胆肠Roux-en-Y吻合术患者的资料，在空肠盲袢或输出袢处使用银夹作标志，术后通过胆道镜行胆管残留结石或复发结石或狭窄的治疗。结果 11例术后胆管残留结石和5例残留结石合并胆管狭窄者经T管窦道行胆道镜探查、取石及肝胆管狭窄的治疗而治愈。2例结石复发的患者根据空肠的金属银夹标记物，在数字减影血管造影（DSA）下进行穿刺置管建立胆道镜通道，通过胆道镜成功取出了结石，避免了再手术。结论 发挥胆道镜技术治疗肝胆管结石的优势，经以银夹标志的胆道通道，可望成为治疗胆肠吻合术后复发结石手段的有益补充。

Reoperation on Recurrent and Residual Hepatic Calculus after Surgery: Report of 128 Cases

目的探讨胆管残余和复发结石的原因、特点和处理经验。方法回顾性分析128例胆管残余和复发结石再手术临床资料。 结果残余或复发结石位于肝外胆管68例，肝内胆管48例，肝内、外胆管12例。再手术行残株胆囊切除术2例（1.5%）， 胆总管探查、T管引流术64例（50.0%），肝左外叶切除或肝左叶切除术+胆总管切开取石29例（22.7%），肝右叶、段切除加胆总管切开取石6例（4.7%），同时行狭窄胆管切开整形胆管空肠吻合术13例（10.2%），单独或联合行胆管空肠Roux-en-Y吻合术14例（10.9%）。术后痊愈出院124例，自动出院2例，死亡2例。 术后出现并发症18例（14.1%），其中切口感染 10例，胸腔积液3例，胆肠瘘3例，上消化道出血2例，均经保守治疗治愈。出院的124例中117例获随访1～2年，89例（76.1%）恢复满意，18例（15.4%）恢复较好， 10例（8.5%）经B超、CT、MRCP等检查证实再次复发胆管结石，其中6例经再次手术治愈，4例经中西医结合药物治疗好转。 结论术前全面了解病情，选择合适的手术时机，术中认真仔细的探查确认，并结合术中造影、胆道镜以及术者的经验技术，术后有效的治疗，是降低残石、结石复发及再手术的关键因素。

The Selection of Choleenterostomy Type in Benign Diseases of Biliary Tract

Objective To investigate the choleenterostomy type and the longterm results in treatment of benign diseases of biliary tract. MethodsA total of 614 cases of choleenterostomy from January 1981 to December 2000 were followed up and analysed. The original diseases: 321 were original hepatolithiasis and/or bileduct stricture (52.3%)， 106 congenital cyst of common bile duct (17.3%), 151 iatrogenic bile duct injury (24.6%) and others 36 cases (5.9%). Choledochoduodenostomy was performed in 89 cases and choledochojejunostomy in 525 cases. Five hundred and twentyfour cases have been followed up for 1 to 20 years. The rate of followup was 87.9%. ResultsIn 84.5% of the cases, excellent or good longterm results were achieved. Reoperation rate were 49.4% in cases of choledochoduodenostomy or cystoduodenostomy, 14.2% in sideside (cyst) cholangiojejunostomy and 4.4% in endside cholangiojejunostomy, respectively. Conclusion The choledochoduodenostomy should be abolished. The endside cholangiojejunostomy shoud be the best choice when it is needed to perform choledochojejunostomy in benign bile duct diseases and can promise a satisfactory longterm result.

经皮经肝胆道镜碎石取石术治疗胆肠吻合术后肝胆管结石病

目的探讨经皮经肝胆道镜碎石取石术（PTCSL）必要时联合球囊扩张治疗胆肠吻合术后肝胆管结石病的可行性及安全性。方法重庆医科大学附属第二医院 2015 年 12 月至 2020 年 12 月期间共有 54 例胆肠吻合术后肝胆管结石病患者接受 PTCSL 必要时联合球囊扩张治疗（符合纳入标准）。回顾性收集患者的一般资料、手术情况、术后情况以及术后随访资料。结果54 例患者中有 52 例（96.3%）行 PTCSL 治疗成功，2 例因为胆肠吻合口完全闭塞而失败。术中出血量的中位数为 55 mL（15～520 mL）；取净结石 48 例（88.9%），结石残留 6 例（11.1%）。术后并发症发生率为 27.8%（15/54），无围手术期死亡患者。取净结石的 48 例患者获随访，中位随访时间 33 个月（2～60 个月），有 10 例结石复发，复发率为 20.8%（10/48）。结论PTCSL 必要时联合球囊扩张治疗胆肠吻合术后肝胆管结石病具有良好的安全性和可行性，但是术后需要注意预防结石复发。

Application of Jejunum Ligation in Input Loop in Cholangio-Intestinal and Pancreas-Intestinal Anastomosis

　目的　探讨输入袢空肠结扎术在胆肠和胰肠吻合中的效果。　方法　我院2006年2月至2008年3月期间共收治43例需行胆肠及胰肠吻合的患者，分别行输入袢结扎的间置空肠吻合术（观察组，n=25）和经典的Roux-en-Y吻合术（对照组，n=18），观察2组患者手术时间、住院时间、肠功能恢复时间、返流性胆管炎、胆管积气及并发症发生情况。 　结果　与经典的Roux-en-Y吻合术相比，输入袢结扎的间置空肠吻合术患者消化道重建时间、术后住院时间及肠功能恢复时间明显缩短,返流性胆管炎及胆管积气发生例数均显著减少，差异有统计学意义(Plt;0.05)。对照组2例患者出现切口感染； 观察组1例切口感染，1例肺部感染，均经对症治疗后痊愈。　结论　输入袢结扎的间置空肠吻合术操作简单、术后恢复快、并发症少，在上腹部消化道重建中有一定的应用价值。

Clinical comparison of laparoscopic magnetic compression cholangiojejunostomy to laparoscopic hand-sutured cholangiojejunostomy: single center case-control study

ObjectiveTo compare the clinical outcomes of laparoscopic magnetic compression cholangiojejunostomy (LMCCJ) with laparoscopic hand-sutured cholangiojejunostomy (LHSCJ). MethodsA retrospective case-control study was performed. From January 2019 to May 2022, 37 patients, who underwent laparoscopic treatment in this hospital, were enrolled in this study. There were 16 cases in the LMCCJ group and 21 cases in the LHSCJ group. The demographic information, procedure time to complete bilioenteric reconstruction, postoperative hospital stay, operative complications, magnets expulsion time, and follow-up results were collected and analyzed. ResultsThere were no statistical differences in the baseline data such as the gender, age, composition of primary diseases, preoperative total bilirubin, and preoperative common bile duct diameter between the two groups (P＞0.05). The outer diameter of the magnets was (10.50±0.97) mm, the expulsion time of the magnets was (49.69±37.58) d, and the expulsion rate of the magnets was 100% (16/16). There was no intestinal obstruction or gastrointestinal perforation caused by the retention of the magnets. The procedure time to complete bilioenteric reconstruction in the LMCCJ group was statistically shorter than that in the LHSCJ group [(11.31±3.40) min vs. (24.81±3.40) min, t=11.96, P＜0.01]. There was no statistical difference in the total bilirubin level at the first week after surgery between the two groups (U=142.0, P=0.80). The postoperative hospital stay in the LMCCJ group was longer than that in the LHSCJ group [(28.31±14.11) d vs. (16.19±7.56) d, t=3.36, P＜0.01]. During the perioperative period, there was no bleeding or biliary infection in the two groups, but one case of biliary leak in the LHSCJ group. In all 37 patients were followed-up for (548.8±259.2) d. During the follow-up period, the incidence rates of biliary intestinal anastomosis stenosis, tumor recurrence, and mortality had no statistical differences between the two groups (P＞0.05). ConclusionFrom the results of comparative analysis in this study, it can be concluded that LMCCJ is not only safe equally, but also easier and less time-consuming as compared with LHSCJ.