腹腔镜下再次胆肠吻合治疗良性胆肠吻合口狭窄探讨

目的 探讨腹腔镜下再次胆肠吻合在治疗良性胆肠吻合口狭窄（BBEAS）中的可行性和有效性。方法 采用回顾性病例对照研究。2017年1月至2019年6月,11例行开放手术后BBEAS病人再行腹腔镜下再次胆肠吻合术治疗（腹腔镜组）,同期有13例BBEAS病人接受经皮经肝穿刺胆道引流（PTCD）+球囊扩张治疗（PTCD组）。对比两组病人一般资料、治疗相关参数及随访结果。结果 腹腔镜组诊断BBEAS时间晚于PTCD组,余术前资料两组类似。两种方式治疗BBEAS的成功率（10/11 vs. 12/13,χ2=0.15,P=0.9）及相关并发症发生率（1/10 vs. 11/57,χ2=0.5,P=0.48）类似,但腹腔镜组在治疗所需中位时间（14 d vs. 161 d,Z=-3.5,P=0）、所需平均治疗次数（1.0次/例 vs. 4.4次/例,T=-6.4,P=0）明显少于PTCD组。术后随访26.0±10.8个月,两组吻合口狭窄复发比例（1/10 vs. 4/12,χ2=1.7,P=0.19）差异无统计学意义。结论 腹腔镜下再次胆肠吻合术治疗良性胆肠吻合口狭窄安全、效果良好。     

胆道镜联合放射介入治疗胆肠吻合术后吻合口狭窄

胆肠吻合术后吻合口狭窄常引起胆道梗阻、胆管炎、再生结石，反复发作可导致胆汁淤积性肝硬化。再次手术处理较困难、术后可能再发狭窄，是一个较难处理的问题。胆肠Roux-en-Y吻合术后吻合口内留置的T管，常是为支撑吻合口、治疗残余结石所用；皮下留置空肠盲襻常是为治疗再生结石。通过T管窦道、皮下盲襻用胆道镜治疗肝内胆管残余及再生结石已广泛用于临床，并取得了良好的疗效。放射介入治疗对恶性病变引起的狭窄，可经皮经肝穿刺胆道引流（PTCD）途径置金属支架治疗，但不能同时处理合并的结石；对良性瘢痕性狭窄，PTCD途径不能提供足够粗的窦道来置放内径0．5-0．8cm的硬塑管支撑狭窄。     

胆肠吻合术后吻合口狭窄的非手术治疗

目的：探讨胆肠吻合口狭窄非手术治疗的方法和疗效。方法：8例经皮下盲袢、13例经T管窦道进入胆道镜，先气囊扩张狭窄，再取狭窄上方结石，瘢痕性狭窄置硬塑管支撑3-6个月；恶性狭窄胆道镜引导置金属支架。12例行PTCD；恶性狭窄不伴结石，放射介入置金属支架；如有结石或瘢痕狭窄，先扩张窦、后经PTCS取石或置金属支架、硬塑管。全组气囊扩张19例、置硬塑管5例、置金属支架9例。结果：33例中24例良性狭窄，扩张19例、置硬塑管5例均解除梗阻，9例恶性狭窄8例置金属支架解除梗阻。15例伴有结石取净结石。全组无严重并发症。结论：借助胆道镜的非手术方法在治疗胆肠吻合术后吻合口狭窄中创伤小、副损伤少、疗效确切。     

胆肠吻合术后吻合口狭窄的非手术治疗

目的 探讨胆肠吻合口狭窄非手术治疗的方法和疗效。方法8例经皮下盲袢、13例经T管窦道进入胆道镜,先气囊扩张狭窄,再取狭窄上方结石,瘢痕性狭窄置硬塑管支撑3-6个月;恶性狭窄胆道镜引导置金属支架。12例行PTCD;恶性狭窄不伴结石,放射介入置金属支架;如有结石或瘢痕狭窄,先扩张窦道、后经PTCS取石或置金属支架。硬塑管。全组气囊扩张19例、置硬塑管5例、置金属支架9例。结果33例中24例良性狭窄,扩张19例、置硬塑管5例均解除梗阻,9例恶性狭窄8例置金属支架解除梗附。15例伴有结石者取净结石。全组无严重并发症。结论 借助胆道镜的非手术方法在治疗胆肠吻合术后吻合口狭窄中创伤小、副损伤少、疗效确切。     

腹腔镜手术治疗微创胰十二指肠切除术后胆肠吻合口狭窄7例报道

目的:探讨腹腔镜手术治疗微创胰十二指肠切除术后胆肠吻合口狭窄的可行性及安全性。方法:回顾性分析2019年8月至2021年7月浙江省人民医院胃肠胰外科收治的微创胰十二指肠切除术后发生胆肠吻合口狭窄再次行腹腔镜手术治疗的7例患者临床资料,其中男性3例,女性4例,年龄(41.7±4.3)岁,年龄范围27~54岁。分析再次手术...     

胰胃吻合术治疗胰十二指肠切除术后胰肠吻合口狭窄3例疗效分析

目的 观察胰胃吻合术治疗胰十二指肠切除术后胰肠吻合口狭窄的临床疗效。方法 回顾性分析2010年5月至2017年12月收治的3例内镜治疗失败的胰十二指肠切除术后胰肠吻合口狭窄病人的临床资料。通过开腹探查、切除胰肠吻合口,采用单层捆绑式胰管胃黏膜吻合术进行残胰消化道重建。观察术中和术后情况。结果 从胰肠吻合至诊断胰肠吻合口狭窄的时间分别为72、37 和21个月。3例病人手术均顺利完成,手术时间为137、210、120 min,出血量为 210、350、180 mL。术后未出现胰瘘、出血、感染等并发症。术后症状缓解,术后随访23、58和15个月未再发作。结论 对于内镜治疗失败的胰十二指肠切除术后胰肠吻合口狭窄病人,胰胃吻合术特别是单层捆绑式胰管胃黏膜吻合术是可考虑采取的手术方案。     

肝方叶切除联合大口径胆肠吻合治疗高位胆肠吻合口良性狭窄32例临床分析

目的:探讨肝方叶切除联合大口径胆肠吻合治疗高位胆肠吻合口良性狭窄的临床疗效。方法:回顾性分析32例肝方叶切除联合大口径胆肠吻合患者的临床资料,分析该术式的胆汁引流效果和术后并发症,并对比不同大小胆肠吻合口的临床疗效。结果:术后最常见的近期并发症为胆管炎（9.4%）和胆漏（9.4%）,最常见远期并发症为反流性胆管炎（15...     

胆肠吻合术后并发症的内镜治疗

胆肠吻合术被广泛用于胆道良恶性疾病的外科治疗,术后相关并发症的发生并不少见。以往对于胆肠吻合术后相关并发症的治疗一般以再次手术为主要方式,随着内镜技术的发展,特别是内镜逆行胆胰管造影（ERCP）技术的出现及应用,使胆肠吻合术后并发症的治疗有了更好的选择。     

胆肠吻合术后吻合口狭窄45例临床分析和再处理

目的探讨胆肠吻合术后胆肠吻合口狭窄的原因,以提高外科治疗水平。方法回顾性分析2000～2006年收集的45例病人行胆肠内引流手术发生胆肠吻合口狭窄再手术的资料,总结临床经验教训。结果45例病人中41例再手术治疗,其中39例行胆管空肠端侧Roux-en-Y吻合,1例行带蒂空肠瓣胆道修补重建术,1例更换U管;3例采取非手术治疗(其中1例为肝移植术后),1例家属放弃治疗(肝门部胆管癌复发),随访0.5～5年,5例(5/41)病人出现胆道感染症状,其中1例(1/41)为右肝残余结石。结论胆肠吻合术后吻合口狭窄主要原因首先为吻合方式不当,其次是病灶未能很好清除、引流不畅,再者应为吻合技术欠佳及使用材料不当。     

胆道损伤行胆肠Roux-en-Y吻合后胆道再次狭窄的处理

目的探讨胆道损伤经胆肠Roux-en-Y吻合后胆道再次发生狭窄的手术时机和方法。方法回顾性分析2005年11月至2006年10月间,上海交通大学医学院附属瑞金医院外科收治的胆道损伤经胆肠Roux-en-Y吻合后发生再次狭窄的7例临床资料。结果胆道损伤均由胆囊切除所造成,其中6例为腹腔镜胆囊切除术,1例为小切口胆囊切除术。发生胆道损伤的类型,按Strasberg分型:E11例、E23例、E32例和E41例。6例接受了再次高位胆肠Roux-en-Y吻合,其中1例施行了二期右半肝切除术,另1例施行了胆道外引流术,所有病人恢复基本良好。结论胆肠Roux-en-Y吻合是修复胆道损伤的主要治疗方法,尤其对于再次胆肠Roux-en-Y吻合的病例,手术时机和手术方式的合理选择、手术技术的精益求精是成功的关键。     

Salvage reoperation for complications after ileal pouch-anal anastomosis

BACKGROUND: Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis. METHODS: Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients. RESULTS: A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent. CONCLUSION: Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.     

Continuous vertical hemimattress suture for biliary-enteric anastomosis

The continuous hemivertical mattress suture technique for biliary-enteric anastomosis has not been well reported in the literature. We used the technique with a double-armed monofilament absorbable suture (Glycomer 631) for 32 anastomoses in 31 patients. There was one anastomotic leakage (3.1%). The mean follow-up period was 683 days, during which time no patient developed anastomotic stenosis or cholangitis. The technique provided satisfactory results with lower cost than one-layer interrupted sutures.     

Risk factors for reoperation after relief of congenital subaortic stenosis

Background: Congenital subaortic stenosis entails a lesion spectrum, ranging from an isolated obstructive membrane, to complex tunnel narrowing of the left outflow associated with other cardiac defects. We review our experience with this anomaly, and analyze risk factors leading to restenosis requiring reoperation. Methods: From 1994 to 2006, 58 children (median age 4.3 years, range 7 days–13.7 years) underwent primary relief of subaortic stenosis. Patients were divided into simple lesions (n = 43) or complex stenosis (n = 15) associated with other major cardiac defects. Age, pre- and postoperative gradient over the left outflow, associated aortic or mitral valve insufficiency, chromosomal anomalies, arteria lusoria, and operative technique (membrane resection (22) vs associated myectomy (34) vs Konno (2)) were analyzed as risk factors for reoperation (Kaplan–Meier, Cox regression). Results: There was no operative mortality. Median follow-up spanned 2.7 years (range 0.1–10), with one late death at 4 months. Reoperation was required for recurrent stenosis in 11 patients (19%) at 2.6 years (range 0.3–7.5) after initial surgery. Risk factors for reoperation included complex subaortic stenosis (p = 0.003), younger age (p = 0.012), postoperative residual gradient (p = 0.019), and the presence of an arteria lusoria (p = 0.014). For simple lesions, no variable achieved significance for stenosis recurrence. Conclusions: Surgical relief of congenital subaortic stenosis, even with complex defects, yields excellent results. Reoperation is not infrequent, and should be anticipated with younger age at operation, complex defects, residual postoperative gradient, and an arteria lusoria. Myectomy concomitant to membrane resection, even in simple lesions, does not provide enhanced freedom from reoperation, and should be tailored to anatomic findings.     

A novel micromagnetic ring used for biliary-enteric anastomosis in rats

BackgroundTo explore the feasibility of micromagnetic ring in establishing biliary-enteric anastomosis in a rat model.MethodsA new micromagnetic ring suitable for rat biliary-enteric anastomosis model was designed and fabricated. The common bile ducts of 20 Sprague-Dawley albino rats were ligated and dilated after 2 weeks. Surgery for biliary-enteric anastomosis was completed by using micromagnetic ring. The anastomosis time, postoperative survival rate, liver function, liver histopathology, and complications were recorded. After 28 days, anastomotic specimens were obtained to observe healing with the naked eye and light microscopy.ResultsAmong the 20 Sprague-Dawley albino rats, one rat showed bile leakage and died one week after ligation of the common bile duct and another rat was removed from the experiment because there was no obvious dilatation of the common bile duct. The remaining 18 rats successfully underwent surgery for biliary-enteric anastomosis using micromagnetic ring, with an average anastomosis time of 7.10 ± 1.15 min (range, 5.17–9.50 min). The expulsion time of micromagnetic anastomosis rings was 11.94 ± 2.48 days (range, 8–17 days). The bilirubin level dropped to normal 1 week after surgery. Biliary-enteric anastomotic specimens were obtained 28 days after surgery, and microscopic observation showed that the mucosal layer of the anastomosis had good continuity and the anastomosis was smooth.ConclusionA micromagnetic ring can be used to construct a rat biliary-enteric anastomosis model, and it offers advantages, such as simple operation and reliable anastomosis effect.     

Recurrent pancreatitis after pancreaticoduodenectomy: reoperation for stenosis of the pancreaticojejunostomy

Stenosis of the pancreaticojejunostomy is a late and rarely symptomatic complication of pancreaticoduodenectomy, observed in approximately 30% of cases. Treatment of symptomatic strictures is difficult. We report a case of reoperation for stenosis of the pancreaticojejunostomy responsible for recurrent pancreatitis. The treatment strategy is discussed.     

Late bile duct cancer complicating biliary-enteric anastomosis for benign disease.

BACKGROUND: Anastomosis between the biliary tree and the intestinal tract has been, and is, a relatively common procedure. Aside from cholangitis secondary to anastomotic stricture, it is generally regarded as innocuous. METHODS: The recent experience with 3 patients who developed bile duct cancer many years after biliary-enteric anastomosis for benign disease prompted a review of whether the procedure was potentially carcinogenic. RESULTS: There have been very few reports of late cholangiocarcinoma complicating this surgery for benign disease. However, there is some experimental evidence to support the hypothesis, and the time interval between surgery and the development of malignancy may be important. CONCLUSIONS: Reflux of duodenal or small intestinal contents into the biliary tree causes changes in the biliary epithelium that may be adaptive to the new environment but also have the potential to progress to malignant transformation.     

良性疾病胆肠吻合返流液促癌活性的探讨

目的 研究良性疾病胆肠吻合术后返流液对人胆管癌细胞QBC939生长的影响,探讨胆肠内引流术与胆管癌发生和发展的关系。方法 应用四唑氮蓝(MTT)比色法检测良性疾病胆肠吻合术后返流液对QBC939增殖的影响,采用半定量逆转录-聚合酶链式反应(RT-PCR)检测QBC939环氧合酶-2(COX-2)mRNA表达水平的变化,应用流式细胞仪测定细胞周期和凋亡,采用酶联免疫吸附试验检测前列腺素 E2(PGE2)含量。结果 胆肠返流液组增殖指数(46 33±7.69)比对照组(25.57±1.03)明显上升(P=0.043),G0/G1期细胞比例(56.70±8.61)％比对照组(73.68±5.69)％明显降低(P=0.010),这种促癌活性可被COX-2选择性抑制剂Celecoxib拮抗。结论 良性疾病胆肠吻合术后返流液具有潜在的促增殖活性,这种促增殖活性依赖COX-2和PGE2途径。