间置空肠和皮下盲袢间置空肠胆管十二指肠吻合术的若干技术细节

间置空肠和皮下盲袢间置空肠胆管十二指肠吻合术(下称间置术和盲袢间置术)是我院1980年开始开展的一种新的胆肠内引流术。由于它有:①可避免肠胆返流及由此引起的胆管炎;②可保持正常的胃肠消化吸收功能;③可保持胃肠道正常酸碱度,防止术后溃疡病;④可便于术后复查胆道;⑤可便于治疗残余和复发结石等优点,因而近年已被广泛采用。现将本术的若干技术细节进一步介绍,供参考。术式简介本术特点是在处理胆道病变后,根据病情切断胆总管或肝总管,远端缝合关闭,近端与胆肠吻合。在屈氏韧带下20cm左右,切取带蒂空肠袢约70cm,近端缝合关闭后钳夹4只银夹留作日后X线下定位标志,并置于皮下。距关闭端约10～15cm与胆管残端做端侧吻合。带蒂空肠的远端再与十二指肠第二部近第三部处做端侧吻合(图1)。     

胆道与空肠吻合术的改进

目的 探讨胆道与空肠吻合的手术方式以及远期疗效.方法 对2006年10月至2009年10月问施行胆肠袢式吻合和胆肠间隔袢式吻合术27例的病例作回顾性分析.结果 27例中11例肝总管横断的病人行胆肠袢式吻合术,16例未横断胆总管的病人行胆肠间隔袢式吻合术,其中26例顺利恢复出院;术后18例获得随访,随访时间12～24个...     

经胃后短袢间置空肠胆管十二指肠吻合术

经胃后短袢间置空肠胆管十二指肠吻合术山东菏泽地区医院普外科（２７４０３１）韩要法应用胆肠吻合治疗胆管疾患的术式很多，且各有优缺点。近几年来时兴的间置空肠胆管十二指肠吻合术治疗肝胆管结石已日趋普遍（１～３）。自１９８６年以来，我院也开展了间置空肠胆管十...     

胆肠吻合术的现代应用

胆肠吻合术（choledochojejunostomy,CJ）是于修复胆道损伤、肝外胆管病变切除后及治疗胆管结石的胆道重建常用手术方式，基本术式包括：Oddi括约肌切开成形术，胆总管十二指肠吻合术，间置空肠胆管十二指肠吻合术，胆管空肠Roux-Y吻合术，胆肠袢式吻合术。     

空肠皮下盲袢在治疗肝内胆管结石中的地位

肝内胆管结石是外科常见病 ,某些病例处理较为困难。我科于 1987年 3月至 2 0 0 1年 5月利用空肠皮下盲袢型胆肠吻合术处理 2 7例此类病人 ,效果良好 ,报告如下。临床资料本组 2 7例 ,男 14例 ,女 13例。年龄 2 7～ 67岁。以往手术 :胆囊切除 10例 ,胆总管切开取石 10例 ,附加肝左外叶切除 2例 ,胆肠内引流术 5例。 2次以上胆道手术 12例。本组皮下盲袢切开胆道取石 5例 ,胆道止血 1例。皮下盲袢长度 (自胆肠吻合口至盲袢顶端 ) 8～ 10ｃｍ。置于右上腹 2 6例 ,左上腹 1例。全组无并发症及死亡。讨　　论1.传统的胆肠Ｒｏｕｘ Ｙ内引流 ,希…     

皮下盲袢型胆肠吻合术治疗肝门部胆管狭窄合并肝内胆管结石

目的总结皮下自袢型胆肠吻合术治疗肝门部胆管狭窄合并肝内胆管结石的经验及治疗效果。方法肝门部胆管狭窄合并肝内胆管结石53例，采取皮下盲袢型胆肠吻合，其中皮下盲袢Roux—ell—Y型33例（62．3％）；皮下盲袢间置卒肠型5例（9．4％）；皮下奇袢间置窑肠胆道腹壁型15例（28．3％）．、结果术后发生近期并发症6例：胆漏2例，胆道出血1例，切口感染3例；远期并发症5例：反流性慢性胆管炎2例，胆肠吻合口狭窄2例，吻合口癌1例。残石率13．2％，优良率88．6％，结石复发率6．8％。术后经皮下盲袢行胆道镜取石10例（残余结石7例，复发结石3例），扩张吻合口狭窄2例，活检1例．结论皮下盲袢型胆肠吻合术是治疗肝门部胆管狭窄合并肝内胆管结石的有效手段。     

胆肠吻合术中留置皮下空肠盲袢的分析总结

目的 总结分析术中留置皮下空肠盲袢的改良胆肠吻合术（choledochoduodenstomy）的临床应用。方法 回顾性分析我院肝胆胰外科2014年2月至2016年4月100例肝胆管结石患者临床资料,患者分别行Roux-Y胆肠吻合术（对照组,46例）及Roux-Y胆肠吻合术加置长约8~12 cm空肠作为盲袢（改良组,54例）,对比分析两组的术后疗效。结果 改良组与对照组相比,术中出血量、肛门排气时间无统计学差异（P>0.05）;改良组手术时间较对照组长,但住院时间短、住院费用低、术后并发症发生率低,均具有统计学差异（P<0.05）。另外,改良组术后出现的并发症及再发胆管结石均可通过盲袢得到处理。结论 胆肠吻合术中留置皮下空肠盲袢该改良术式相比于传统术式有着术后并发症少、住院时间短、住院费用低等优势,且可对术后并发症及再发胆管结石进行再次非手术处理,值得在临床上推广应用。     

胆管空肠吻合活瓣成形术

胆肠吻合术后肠内容物可返流入胆道引起胆管炎。１９８１年７月－１９９４年６月，作者采用胆管空肠吻合民形术１１６例。该术式分Ｙ形法，袢式法和间置法三种，于肠肠吻合口处附加活瓣成形术，旨在将肠内容物于返流的起始部即于阻断。     

胆肠吻合术后再手术原因及处理

目的探讨胆肠吻合术后再手术的原因及处理方法. 方法回顾性分析我院1999年1月～2004年12月21例胆肠吻合术后再手术患者的临床资料. 结果 21例中初次手术行胆总管囊肿肠吻合6例,胆肠侧侧吻合7例,胆肠端侧吻合7例,胆肠侧端吻合1例.术后19例结石复发或残留,14例吻合口狭窄.再手术方法:全组均行规范胆管空肠Roux-en-Y式端侧吻合术,加行左肝外叶切除4例,其中1例行左肝管、肝门部胆管与空肠双口端侧吻合. 结论原发胆道病未能根治或复发及胆肠吻合口狭窄是再手术的主要原因,其次是术式选择不当,手术不规范.再手术应遵循"去除病灶、解除梗阻、通畅引流"的原则,选择正确术式,规范操作,避免手术技术缺陷.     

袢式胆管-空肠端侧吻合术在恶性梗阻性黄疸治疗中的应用

目的评价袢式胆管-空肠端侧吻合术在恶性梗阻性黄疸治疗中的价值。方法将袢式胆管-空肠吻合术应用于18例恶性梗阻性黄疸患者,并与同期22例应用Roux-en-Y胆肠吻合术的患者进行比较,判定两种术式对减黄效果等的影响。结果与Roux-en-Y胆肠吻合术相比,袢式胆管-空肠吻合术患者血清总胆红素、胆系感染发病率和术后住院时间均明显下降(P0.05)。两种术式术后患者生存率无差别(P0.05)。结论袢式胆管-空肠端侧吻合术简单、安全、减黄效果好,可选作恶性梗阻型黄疸患者姑息治疗的方法。     

近端胃大部切除“P”型袢空肠间置术式的临床研究

为探讨近端胃大部切除后,在重建胃肠道中能有效地抗返流性食管炎的术式,1995年5月至1997年6月,前瞻性对9例贲门癌病人,作近端胃大部切除,采用带血管蒂“P”型袢空肠段,间置于食管下段与残胃之间。术后3个月,应用食管pH监测仪作24h定位测定和纤维胃镜检查及1年的临床生活质量随访。结果表明,该术式的食管下端与“P”型袢空肠间置的吻合周围PH处于弱碱性稳定状态,未见有反酸性炎症反应,饮食状况良好。     

Canine intestinal myoelectric activity after total gastrectomy with jejunal interposition

Changes of intestinal myoelectric activities after total gastrectomy with jejunal interposition were studied in three conscious dogs. Under general anesthesia a total gastrectomy was performed and intestinal continuity was reestablished by a 15 cm jejunal segment interposed between the esophagus and the duodenum. Two electrodes were sown each to the serosal surface of the interposed segment of the jejunum, duodenum, and distal potion of the jejunum, respectively. After recovery from the surgery, the myoelectric activities were recorded for 8 to 12 hours during fasting and after feeding a 200 ml liquid meal. In each segment, total gastrectomy did not alter the initiation of the migrating myoelectric complex (MMC) during fasting. Total gastrectomy also changed neither the postprandial inhibition of the enteric MMC nor the induction of the fed myoelectric pattern after feeding. The way of MMC propagation along the small intestine, however, showed various patterns. Each of three segments generated its own MMCs. Some complexes migrated to the next segment or had an effect on initiating new MMCs of the next segment. Although MMCs occurring in the segment of the interposed jejunum hardly migrated to the adjacent duodenum, some jumped to the distal jejunum. These results suggest that there are no coordinated activities between the interposed jejunum and the duodenum after total gastrectomy with jejunal interposition.     

Gastric Bypass Distal Roux-en-Y with Jejunal Interposition

Gastric bypass with jejunal interposition is a version of the distal Roux-en-Y. Ninety cm of the jejunum is interposed between the gastric stoma and the ileum. This new procedure initially was used in super-obese patients mainly to facilitate the gastric anastomosis.     

Esophagojejunal anastomoses with the EEA stapler after total gastrectomy. Technic and immediate results apropos of a recent series of 32 cases

32 consecutive total gastrectomies for cancer (20 extended total gastrectomies) were carried out through an abdominal approach. Reconstruction using a Rouxen-Y loop (28 cases) or an interposed jejunal loop (four cases) was done with an EEA stapled oesophago jejunostomy: 25 end to side and 5 end to end anastomosis were performed and two technical failures led to complete manual anastomosis. All patients have had post-operative X-ray examination: there was no anastomotic leakage in this series, even in the 3 patients (10%) who have died during the post-operative course. A critical study of this series and eight others one from elsewhere is presented: it is concluded that the stapling device allows an easier and safer oesophagojejunostomy than manual procedure, when great care is taken of technical details.     

Retrosternal pedicled jejunum interposition: an alternative for reconstruction after total esophago-gastrectomy.

OBJECTIVE: If the colon cannot be used for reconstruction after total esophago-gastrectomy, alternatives have to be sought. METHODS: From 1990 to 2001, retrosternal jejunum loop interposition was performed in 35 patients (male/female: 29:6; mean age 59.2, range 16-83 years) due to cancer in 32 cases and to esophageal perforation in three cases. In all patients reconstruction with stomach or colon, respectively, was impossible on behalf of the underlying histology, of previous resection of the stomach and impedient colonic diseases. A jejunal segment with abundant arcades was chosen, preserving a strong, distal arteriovenous mesenteric pedicle, while 2-3 proximal mesenteric vessels were severed. The loop was pulled up retrosternally, establishing a cervical end-to-side esophagojejunostomy. A Roux-en-Y anastomosis was done in a convenient position. RESULTS: Two patients died perioperatively due to mediastinitis and consecutive multiorgan failure (one Boerhaave's syndrome, one suicidal ingestion of acid). In one case the oral part of the loop developed venous congestion and was replaced by a free jejunal transplant. The perioperative course of 32 patients was uneventful. Seventeen patients are up and well (1-8.5 years). Sixteen patients died of metastatic disease. The functional results are satisfactory. In about 50% of patients recurrent dilatations became necessary due to anastomotic scars. However, none of the patients complained about severe dysphagia. CONCLUSION: In cases of impedient colonic diseases, the pedicled, retrosternal jejunal loop with cervical anastomosis is an alternative for reconstruction after total esophagogastrectomy.     

两种减压管放置方法对胰十二指肠切除术后胰瘘的影响分析

目的:探讨胰十二指肠切除术(PD)后减压管的两种放置方法对术后胰瘘发生的影响。方法:回顾性分析2012年1月—2014年10月期间收治的125例行胰十二指肠切除术患者的临床资料。其中68例于主胰管放置引流管减压(胰管组),57例于胰肠吻合口盲端远端置引流管减压(盲襻组),比较两组术后胰瘘发生率及其他临床指标。结果:全组共发生胰瘘9例(7.2%),其中盲襻组1例(1.8%),胰管组8例(11.8%),所有患者均经过保守治疗治愈出院,盲襻组胰瘘发生率明显低于胰管组(P0.05),其他并发症发生率两组间差异均无统计学意义(均P0.05);盲襻组住院时间(20.38dvs.27.46d)及住院费用(5.642万元vs.6.602万元)均少于胰管组(均P0.05);两组患者术后1年肿瘤复发率、生存率差异无统计学意义(均P0.05)。结论:PD术中盲攀减压管的放置能有效降低术后胰瘘的发生。     

皮下空肠盲袢胆道造口成形术治疗肝胆管结石及狭窄(附64例报告)

治疗肝胆管结石的手术方法很多，各有所长，但较普遍存在着残石率高、并发症多、再手术率高等棘手的问题。针对上述问题，作者于1988年设计了皮下空肠盲拌胆道造口成形术，并在64例肝胆管结石手术中应用，临床疗效满意，现报告如下。1材料和方法1．1临床资料本组64例，男23例，女41例，年龄21～63岁，平均39岁，27例以往做过胆道手术。术中所见：肝内胆管结石16例，肝内外胆管7例，肝外胆管结石11例。64例中并肝胆管狭窄26例，占本组40．62％，全部患者均有明显肝胆管扩张。手术方式：38例肝胆管结石行空肠盲拌胆道造口术，26例肝胆管结石井…     

A secure technique of intracorporeal Roux-Y reconstruction after laparoscopic distal gastrectomy

BACKGROUND: Laparoscopic distal gastrectomy [LDG] is a minimally invasive surgery for gastric carcinoma. The Billroth I method has been commonly employed to reconstruct alimentary tract after LDG. Conversely, Roux-Y reconstruction is employed far less commonly despite its merits. Technical difficulties, including a risk of twisting the Roux loop under limited vision through a laparoscope, have hampered Roux-Y reconstruction after LDG. METHODS: We performed LDG and intracorporeal Roux-Y reconstruction in 5 patients with early gastric cancer. The procedure included a functional end-to-end anastmosis of the stomach and jejunum, consisting of side-to-side approximation of jejunal loop to greater curvature of the gastric remnant with a laparoscopic stapling device followed by closure of the open end and simultaneous division of the jejunum with another stapler. RESULTS: Roux-Y reconstruction was successfully accomplished without torsion of the loop in all patients. CONCLUSIONS: By using the present technique, intracorporeal Roux-Y reconstruction after LDG can be accomplished without a risk of twisting the jejunal loop.     

胆管空肠吻合联合空肠盲袢固定标记在复发肝胆管结石治疗中应用研究

目的 探讨胆管空肠Roux-en-Y吻合联合腹膜下空肠盲袢固定标记法在肝胆管结石病术后及其伴随的胆管狭窄治疗中的价值。方法 回顾性分析2009年1月至2017年12月在北京大学第一医院接受胆管空肠Roux-en-Y吻合联合腹膜下空肠盲袢固定标记术的113例肝胆管结石病病人的临床资料。并对术后经肠袢胆道镜治疗肝内胆管结石和狭窄的情况进行总结。结果 113例病人全部完成胆肠吻合及盲袢固定标记术并在术后行胆道镜检查，其中79例行胆道镜取石治疗；49例行胆道镜下球囊扩张肝内胆管狭窄，7例发现有术后近期吻合口狭窄而行球囊扩张，71例证实结石取净或狭窄缓解后结束治疗。16例在治疗结束后因肝内胆管结石复发而在局麻下打开空肠盲袢，其中15例顺利完成再次治疗。结论 空肠盲袢固定标记法便于在胆管空肠Roux-en-Y吻合后进一步治疗肝内胆管结石及狭窄，并使多数复发病例避免了再次开放手术，对于易复发的肝胆管结石病是一种可供选择的治疗方法。     

一种新型胰腺空肠吻合方法——空肠浆肌层鞘捆扎法

目的介绍一种改进的胰腺空肠端端吻合方法。方法首先将空肠断端去粘膜化后形成浆肌层鞘,将胰腺断端和粘膜层进行第一层缝合。打结后将空肠浆肌层鞘套入胰腺断端,将胰腺断端和浆肌层鞘进行第二层缝合,打结前将一根捆扎丝线在第二层缝线中间包绕胰腺套入部,再进行第二层的打结,将空肠浆肌层鞘固定于胰腺上。最后将捆扎丝线打结,使浆肌层鞘和胰腺之间紧密相贴。临床应用3例,均为胰头十二指肠切除术患者。结果胰腺空肠吻合时间分别为5,8,10 min,无胰漏发生。结论空肠浆肌层鞘捆扎法简单易行,能缩短手术时间,初步结果显示无胰漏发生。