带蒂脐静脉瓣胆道修复术与远期疗效

目的 总结带蒂脐静脉瓣胆道重建的临床经验和远期随访结果。方法 第一种术式，胆管上下端后壁对端吻合，前壁纵行切开，其缺损以带蒂脐静脉瓣修复22例；第二种术式，胆管狭窄切开、整形，胆管缺损以带蒂脐静脉瓣修复19例。结果 本组无死亡病例，术后达7年以上25例，其中再手术3例，术后7—12年ERCP10例，MRCP和双剂量静脉胆道造影各1例，胆道显影均正常；轻度胆管炎2例；另8例无任何胆道感染症状，B超胆道未见异常。结论 带蒂脐静脉瓣胆道重建是一种理想的胆道修复手术。     

带蒂脐静脉瓣胆道修复

目的进一步总结带蒂脐静脉瓣胆道修复的临床经验和远期随访结果。方法第一种术式，胆管上下端后壁对端吻合，前壁纵行切开，其缺损以带蒂脐静脉瓣修复21例；第二种术式，胆管狭窄切开、整形，胆管缺损以带蒂脐静脉瓣修复18例。结果本组无死亡病例。术后达7年以上25例，其中再手术3例，术后7～12年ERCP9例，双剂量静脉胆道造影1例，胆道显影均正常；轻度胆管炎2例；另10例无任何症状，B超胆道未见异常。结论带蒂脐静脉瓣胆道修复是一种理想的胆道修复手术。     

带蒂脐静脉瓣修复Mirizzi综合征胆管缺损35例体会

目的 总结带蒂脐静脉瓣修复Mirizzi综合征胆管缺损的经验。方法 回顾性分析35例采用带蒂脐静脉瓣修复Mirizzi综合征（Ⅱ型19例、Ⅲ型15例,Ⅳ型1例）的临床资料。结果全组无死亡病例,术后发生胆漏5例,经1～3周引流后痊愈。全部病例拔管后均获6个月的随访,有27例随访达3年,未见明显胆道并发症发生。结论利用带蒂脐静脉瓣修复Mirizzi综合征胆管缺损方法简单、效果较好。     

带蒂脐静脉或胆囊瓣修复胆管狭窄和缺损(附6例报告)

目的　评价利用带蒂脐静脉瓣和胆囊瓣修复胆管狭窄和缺损的疗效。方法　对 6例利用带蒂脐静脉瓣和胆囊瓣修复后的病人进行随访并小结。其中男 2例 ,女 4例。年龄 1 2～ 84岁。医源性胆总管狭窄 1例 ,右肝管环形狭窄 2例 ,Mirrizi综合征 2例 ,胆总管十二指肠瘘 1例。缺损范围均在胆总管直径的 1 / 2以上。结果　用带蒂脐静脉瓣修复 4例 ,带蒂胆囊瓣修复 2例。本组无手术死亡和并发症。 5例随访 3年以上 ,无明显临床症状 ,长期疗效佳。结论　利用自体带蒂脐静脉瓣或胆囊瓣修复胆管狭窄和缺损 ,是治疗良性胆管狭窄和缺损的有效方法。     

带蒂脐静脉瓣修复肝外胆管缺损的临床应用

应用带蒂脐静脉瓣为3例肝外胆管良性狭窄及缺损的患者进行了胆管的重建修复，取得了较为满意的效果，并利用动态摄影及组织学检查对修补胆管的带蒂脐静脉壁的适应性改变作了研究观察。认为带蒂脐静脉是修复胆管缺损比较理想的自体生物材料，利用带蒂脐静脉修复肝外胆管良性缺损或狭窄是一种符合生理条件的治疗方法。     

胆道修复手术在Mirizzi综合征大范围胆管缺损中的应用

目的 探讨修复手术在伴有大范围胆管缺损Mirizzi综合征中的应用.方法 回顾分析2008年7月至2011年11月作者所在单位采用带血管蒂胃瓣修补治疗的3例伴有大范围胆管缺损者的Mirizzi综合征患者的临床资料.检索国内2001年1月至2011年1月,10年间有关修复方法治疗Mirizzi综合征的报道5篇,对检出的159例病例资料按Csendes分类,对其外科治疗方法进行统计分析.结果 3例胃瓣修复病例中,CsendesⅢ型2例,Ⅳ型1例.手术过程顺利.术后分别随访2年、3年、1年,平均随访2.5年,无胆管狭窄及胆管炎症等并发症发生.国内文献检索159例中,CsendesⅠ型93例,采用单纯胆囊切除58例,胆囊大部切除+剩余黏膜电凝消融35例;Ⅱ型40例,瘘口直接修补29例,带血管蒂胆囊瓣修补9例,脐静脉瓣修补2例;Ⅲ型20例,带血管蒂胆囊瓣修补9例,脐静脉瓣修补1例,带血管蒂胃瓣修补3例,胆管空肠Roux -en-Y吻合7例:Ⅳ型5例,均采用胆管空肠Roux-en-Y吻合,术后胆瘘1例,消化道出血1例,胆管狭窄1例,均治愈.结论 对于存在胆囊胆管内瘘的Mirizzi综合征患者,应根据瘘口大小及修复材料,进行个体化的修复治疗.对于伴有较大缺损的胆管损伤,采用带血管蒂胃瓣修复胆道疗效确切,宜作为首选.     

带蒂脐静脉瓣修复肝门部胆管狭窄

目的　探讨带蒂脐静脉瓣修复肝门部胆管狭窄的效果。方法　对１９８７ 年１ 月至１９９６年１２ 月,３８ 例用带蒂脐静脉瓣修复肝门部胆管狭窄患者进行总结。采用带蒂脐静脉瓣移植修复肝门部胆管狭窄２３ 例,肝左外叶切除并脐静脉瓣修复右肝管开口狭窄１１ 例,肝方叶切除或肝中裂劈开并脐静脉瓣修复高位胆管狭窄４ 例。结果　随访率（３４／３８）为８９ ％ ,随访时间超过２．５ 年的有３２ 例,２例因胆总管结石、狭窄复发再次手术。疗效优良率为９３％ 。结论　本术式简单易行,疗效满意,是治疗肝门部胆管狭窄的有效方法。     

带血管蒂组织瓣在医源性胆道损伤中的应用

目的探讨带血管蒂组织瓣在医源性胆道损伤中的手术方式及效果。方法对于11例腹腔镜胆囊切除术后胆道损伤的患者,分别使用脐静脉瓣、胃瓣、胆囊瓣、空肠瓣以及圆韧带瓣进行修复。结果胆道修复术采用脐静脉瓣1例、胃瓣1例、胆囊瓣1例、空肠瓣4例以及圆韧带瓣4例。有1例患者术后出现胆瘘。所有患者于出院后肝功能指标及胆道影像学表现均基本正常。结论医源性胆道损伤修复手术为围肝门操作的精细手术。带血管蒂组织瓣修复重建术在恢复胆道连续性以及降低术后并发症方面具有很好的效果。     

应用带蒂自体组织修复肝门部胆管狭窄

目的总结应用带蒂自体组织修复肝门部胆管良性狭窄的经验。方法回顾性分析 1989-2003年应用带蒂胆囊壁瓣修复肝门部胆管良性狭窄38例、直用带蒂胃壁片2例及肝圆韧带脐静脉片2例修复肝总管狭窄的临床资料。结果 42例术后无明显胆瘘、出血等并发症。无手术死亡。术后T管造影显示胆道通畅无狭窄。术后随访40例6个月至14年,2例因术后胆管炎发作,经保守治疗治愈。结论应用自体组织带蒂胆囊壁瓣,肝圆韧带脐静脉片及带蒂胃壁片修复肝门部胆管良性狭窄符合生理,取材方便,操作简便,效果良好。     

带血管蒂胃壁瓣修复肝外胆管缺损

本文报道１９８５年以来采用带血管蒂胃壁瓣修复肝外胆管缺损１２例。胆胆管瘘３例，胆总管结石并穿孔２例，手术后肝外胆管狭窄经切开整形致胆管缺损７例。缺损部位在肝总管５例，胆总管７例。胆管缺损大小２．５ｃｍ×１．０ｃｍ－４．５ｃｍ×１．５ｃｍ，术后经１－１０年的随访，疗效满意，无胆道疾病的症状复发。作者认为本术式一举两得，即修复了胆管缺损，又不改变胆道、肠道原有解剖，避免了各式胆肠内引流的引起的术后并发     

肝圆韧带修复肝门部胆管治疗右肝动脉骑跨引起的胆管狭窄

目的探讨带蒂肝圆韧带修复右肝动脉骑跨引起的肝门部胆管狭窄的效果。方法回顾性分析2007年1月～2011年2月利用带蒂肝圆韧带修复右肝动脉骑跨引起的肝门部胆管狭窄5例的临床资料。胆管狭窄处直径1.5～3 mm。5例均采用离断右肝动脉,游离带蒂肝圆韧带,将肝圆韧带覆盖于胆管缺损处,自上而下,以3-0血管缝合线间断全层缝合胆管切缘与肝圆韧带,重建胆管前壁,放置T管引流的方法。结果 5例手术均获成功,手术时间90～170 min,平均120 min。肠蠕动3～4 d恢复。无围手术期死亡。T管放置3～6个月,平均4.3月。5例随访8～26个月,平均18.8月,未发生腹痛、黄疸、发热等胆管狭窄、胆管炎症状。结论利用带蒂肝圆韧带修复右肝动脉骑跨引起的肝门部胆管狭窄,能有效地避免胆管再狭窄、逆行性胆道感染等手术并发症的发生。     

Reconstruction of the hypopharynx and cervical esophagus with free jejunal graft with double pedicle]

Free jejunal graft autotransplantation for reconstruction of pharyngoesophageal defects was performed in 27 cases between 1983 and 1990. Of 27 cases, 26 patients who had carcinoma of hypopharynx underwent pharyngo-laryngo-cervical esophagectomy and interposition of free jejunal autograft. In one case who had a small and early-staged carcinoma of the cervical esophagus underwent resection of the cervical esophagus without laryngectomy and free jejunal autotransplantation in order to preserve the continuity of the alimentary tract. In the first 5 cases, the autografts interpositioned in the neck had single pedicle and were revascularized by one artery and vein, like the applications in the literature. Two fistulas and one necrosis were observed in these patients. In the following 22 patients a new model of free graft was applied. Jejunal graft prepared with double pedicles in abdomen was interpositioned in the neck with the microvascular anastomosis of the 4 vessels (two arteries and two veins) belonging to both pedicles. It was observed that the blood supply and vitality of the double pedicled jejunal graft was better comparing to the jejunal graft with single pedicle. Also, the feasibility of +4 degrees C continuous perfusion from the second pedicle protected the grafts from warm ischaemia. Only one case developed a fistula and no necrosis was observed in the 22 cases with double pedicled free jejunal autografts. These results suggested that application of double pedicled jejunal grafts reduces the risk of fistula and necrosis, despite the total operation time is 45-60 minutes longer.     

A New Technique for Reconstruction of the Common Bile Duct by an Autologous Vein Graft and a Biodegradable Endoluminal Stent

The incidence of severe bile duct injuries has significantly increased since the introduction of laparoscopic cholecystectomy. The ideal reconstruction procedure for traumatic defects of the bile duct should be technically simple and should preserve both the physiological passage of bile and the sphincter of Oddi. In this article we describe a new technique for bile duct reconstruction in a pig model by means of an autologous vein graft that is splinted by a endoluminal biodegradable polylactate acid stent. In 12 pigs the external jugular vein was removed and used as an autologous vein graft. After performing a median laparotomy a 2-cm segment was resected from the bile duct. The common bile duct was reconstructed by a venous interponate that had been endoluminally stented by a biodegradable polylactate acid stent. For the examination of stent degradation, 2 pigs were sacrificed at 3, 4, and 5 months (stent degradation group) and the remaining 6 pigs at 6 months (survival group). All the pigs in the survival group survived for 6 months before being sacrificed. After 4 months the stent material had been completely broken down and the vein graft had been relined with bile duct epithelium. Thus, this new technique for bile duct reconstruction using an autologous vein graft with an endoluminal stent is simple to perform and reliable, and constitutes an interesting alternative to bilodigestive anastomosis due to the preservation of the papilla of Vateri.     

A new technique for reconstruction of the common bile duct by an autologous vein graft and a biodegradable endoluminal stent.

The incidence of severe bile duct injuries has significantly increased since the introduction of laparoscopic cholecystectomy. The ideal reconstruction procedure for traumatic defects of the bile duct should be technically simple and should preserve both the physiological passage of bile and the sphincter of Oddi. In this article we describe a new technique for bile duct reconstruction in a pig model by means of an autologous vein graft that is splinted by a endoluminal biodegradable polylactate acid stent. In 12 pigs the external jugular vein was removed and used as an autologous vein graft. After performing a median laparotomy a 2-cm segment was resected from the bile duct. The common bile duct was reconstructed by a venous interponate that had been endoluminally stented by a biodegradable polylactate acid stent. For the examination of stent degradation, 2 pigs were sacrificed at 3, 4, and 5 months (stent degradation group) and the remaining 6 pigs at 6 months (survival group). All the pigs in the survival group survived for 6 months before being sacrificed. After 4 months the stent material had been completely broken down and the vein graft had been relined with bile duct epithelium. Thus, this new technique for bile duct reconstruction using an autologous vein graft with an endoluminal stent is simple to perform and reliable, and constitutes an interesting alternative to bilodigestive anastomosis due to the preservation of the papilla of Vateri.     

计算机三维重建技术在复杂肝胆管结石诊治中的临床应用

背景与目的:肝内胆管结石,特别是合并数个肝段结石或是既往合并多次胆道手术史的复杂肝胆管结石的诊断治疗是肝胆外科的难题之一,如何能够"一站式"清除结石是目前的研究热点。鉴于目前计算机三维重建可视化技术已经越来越多的被应用在肝叶切除术中,本研究探讨计算机三维重建技术在诊断和治疗复杂肝内外胆管结石诊治中的临床应用价值。方法:回顾性分析2018年1月1日—2019年7月31日期间由中国科技大学附属第一医院胆胰外科收治的术前行计算机三维重建的肝胆管结石病例的临床资料。结果:共纳入期间收治的复杂肝胆管结石19例,包括Ⅰ型9例,IIa型6例,IIb型3例,IIc型1例,合并肝外胆管结石12例,肝内胆管结石合并肝占位性病变1例,肝胆管结石合并右肝血吸虫病1例。手术方式包括行左半肝切除术3例、行右半肝切除术7例、行胆总管探查引流术9例。术前三维重建与术中符合情况:门静脉、肝动脉走行符合率均为78.95%;结石在胆管分布、肝脏体积符合率均为84.21%;总准确率为73.68%。术后胆管直接造影均未见结石残留,无术后胆管炎发作病例,无胆道损伤病例。结论:术前计算机的三维重建技术能精准描述肝内胆管结石的分布,精确测量肝脏体积,在复杂肝胆管结石的诊断、手术方案个体规划中有重要的临床应用价值,可以最大程度的达到结石的"一站式"的清除效果。     

肝门部胆管癌根治手术中联合血管切除及重建的临床疗效Meta分析

背景与目的:对于肝门部胆管癌(HCCA)而言,血管侵犯是主要的手术治疗障碍之一。联合血管切除及重建后的各个临床研究指标不一,结论也存在一定的争议,本研究通过Meta分析方法系统评价HCCA根治术中联合血管切除及重建的安全性、切除有效性及近远期疗效。方法:检索多个国内外数据库,收集HCCA根治术中联合血管切除及重建与无血管切除比较的研究,前者包括肝动脉切除及重建和门静脉切除及重建,检索起止时间均为2009年1月1日—2019年1月1日。采用Meta分析方法比较两种术式的安全性、根治效果及近远期疗效指标。结果:最终纳入18篇文献(均为回顾性研究),共3 260例患者,其中行联合血管切除及重建904例(血管切除组),未行血管切除2 356例(对照组);分亚组的研究中含肝动脉切除及重建237例(肝动脉切除亚组)与门静脉切除及重建560(门静脉切除亚组)。Meta分析结果显示,与对照组比较,血管切除组的术后总并发症(OR=1.09,95% CI=0.78～1.54,P=0.61)、肝衰竭(OR=0.84,95% CI=0.56～1.24,P=0.36)的发生率均无明显差异,但血管并发症(OR=6.79,95% CI=2.16～21.38,P=0.01)与肝脓肿(OR=7.47,95% CI=2.63～21.18,P=0.01)的发生率升高;术后病死率无统计学差异(OR=1.27,95% CI=0.84～1.93,P=0.25);术后1、3、5年的总体生存率差异均有统计学差异(OR=0.69,95% CI=0.56～0.85;OR=0.62,95% CI=0.52～0.75;OR=0.61,95% CI=0.49～0.76,均P0.05);R_0切除率无统计学差异(OR=0.96,95% CI=0.66～1.40,P=0.84)。亚组分析显示,肝动脉切除亚组和门静脉切除亚组与对照组总并发症发生率均无统计学差异(均P0.05);肝动脉切除亚组的5年总生存率低于对照组(OR=0.44,95% CI=0.30～0.67,P=0.01),但门静脉切除亚组的5年总生存率与对照组无明显差异(OR=0.89,95% CI=0.68～1.17,P=0.42)。此外,R_0切除组患者5年生存率高于R_1切除组,无淋巴结转移患者5年生存率高于有淋巴结转移患者(均P0.05)。结论:HCCA根治术中联合血管切除及重建是总体可接受的,可以一定程度上提高R_0切除率,改善患者预后。当合并门静脉侵犯时,可以行联合血管的R_0切除不增加术后并发症和死亡,也不会恶化预后。当合并肝动脉侵犯是手术R_0切除的唯一障碍时,不能简单地将其作为根治性手术的禁忌证,仍可以手术治疗,但需慎重处理,从而使患者获益。     

Biliary injury after laparoscopic cholecystectomy: end-to-end anastomosis covered with umbilical vein

The management of biliary injuries after laparoscopic surgery presents a surgical challenge. We describe a promising method of biliary reconstruction with umbilical vein covering followed by end-to-end anastomosis. In the patient reported here, the umbilical vein was identified in the pedicled ligamentum teres, transected as if it were a sheet, and sutured, then covered ventrally to the anastomosed bile duct. This procedure may be a promising reinforcement of the reconstructed site which maintains the biliary integrity; however, it can be applied, only in selected situations.