Biliary dilatation secondary to lithiasis in a child affected by Langerhans' cell histiocytosis

Langerhans' cell histiocytosis (LCH) is a disease of unknown pathogenesis, caused by clonal proliferation of Langerhans' cells. Liver involvement results in a cholangiopathy, which has the radiologic appearance of sclerosing cholangitis. Only 1 case of obstructive jaundice due to common bile duct stone in a patient with LCH has been described. We present a case of a 31‐month‐old child with LCH and liver involvement on the waiting list for liver transplantation. During the follow‐up, there was a rapid onset of jaundice due to sludge and lithiasis. The patient was treated first with an endoscopic biliary plastic stent and then with percutaneous biliary drainage and bilioenteric anastomosis. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound 2009     

快速康复外科理念在胆肠吻合术中的临床应用效果分析

目的探讨快速康复外科(FTS)理念在胆肠吻合术中应用的临床效果。方法选择72例经评估可耐受并必须实施胆肠吻合术的患者,随机实施分组,即FTS组(n=36)和对照组(n=36),比较两组麻醉苏醒时间、术后离床活动时间、通气时间、住院天数及住院费用、术后并发症的差别。结果快速康复外科组术后麻醉苏醒时间、术后离床活动时间、通气时间、住院天数及住院费用显著降低(P<0.01),两组麻醉苏醒时间比较差异无统计学意义(P>0.05)。结论快速康复外科理念对胆肠吻合手术有较好的临床应用价值,可明显加快患者的康复速度,缩短住院日程,节省同类手术的住院费用。     

应用可降解腔内支架的无缝合吻合术在狗胆肠吻合模型的实验研究

目的 传统的手工缝合行胆肠吻合术操作困难、费时,尤其在小胆管吻合和腹腔镜手术时明显。为简化和改良手术操作,我们设计了一种新的应用可降解腔内支架的无缝合胆肠吻合术。本文拟在狗胆总管十二指肠吻合模型中评估该无缝合方法的可行性和安全性。方法 为无缝合胆总管十二指肠吻合术设计一种腔内吻合支架管,这种专利支架管直径3mm和4mm,材料为可降解聚乳酸。38条毕格犬随机分为支架组（SG n=20）和对照组（CG n=18）。SG组应用无缝合支架法行胆总管十二指肠端侧吻合,CG组行传统可吸收缝线间断一层胆总管十二指肠端侧吻合。动物分术后1、3、6、12月4个亚组,比较两组术中吻合手术时间、术中吻合口耐受压、胆漏发生率、术后吻合口爆破压差异,观察两组术后胆红素和肝酶变化、术后1,3,6,12月取材的吻合口组织病理形态学改变,包括HE染色和Masson染色,比较两组吻合口羟脯氨酸含量,观察两组吻合口疤痕纤维组织增生状况。MRCP了解术后6月,12月两组吻合口状况。结果 手术均顺利完成,支架组吻合时间明显小于对照组(SG19.2±4.3min VS CG29.2±7.1min, P 0.000);两组各有1例胆漏并死亡（SG5.0% VS CG 5.6%,P=0.695)。两组间术中吻合口耐受压、术后胆漏发生率、术后各时期吻合口爆破压、吻合口羟脯氨酸含量、胆红素和肝酶测定均无显著性差异。MRCP检查及病理检查未发现吻合口狭窄和梗阻。结论 在狗胆总管十二指肠吻合模型中,无缝合腔内可降解支架胆吻合方法具有可行性和安全性。     

Development of a novel reflux-free bilioenteric anastomosis procedure by using a bioabsorbable polymer tube

Background

Bilioenteric anastomosis allows reflux of bowel fluid into bile ducts, resulting in reflux cholangitis. We sought to develop a reflux-free procedure of bilioenteric anastomosis endowed using an artificial bile duct (ABD).

Methods

The study was performed in four groups of pigs. In Group A, end-to-side choledochoduodenostomy using the interposed ABD with its distal end wrapped by the duodenal seromuscular layer was performed. In Group B, conventional end-to-side choledochoduodenostomy using the ABD was performed. In Group C, conventional end-to-side choledochoduodenostomy was performed. In Group D, sham operation was performed. In each groups, 12 weeks later, animals were evaluated.

Results

Bile amylase levels were significantly lower in Group A (36.9 ± 21.7 U/L) compared with Group B (469 ± 140.9 U/L). No significant differences were observed in bile amylase levels between Groups A and D or between Groups B and C. On histology, the neo-bile duct in Group A was covered with the duodenal muscular layer at the orifice into the intestinal tract.

Conclusion

This study suggests that the ABD is useful in the regeneration of extrahepatic bile ducts and that to bury the ABD in the duodenum can be a preventive measure against reflux of bowel fluid to bile ducts.     

Hepatic portal venous gas associated with cholangitis following pancreaticoduodenectomy: Report of a case

A 63-year-old man developmented fever and shock 2 weeks after undergoing a pancreaticoduodenectomy for carcinoma of the gallbladder with duodenal involvement. Computed tomography (CT) of the abdomen showed transient hepatic portal venous gas in the right lobe of the liver, which had probably been induced by obstruction of the bilioenteric anastomosis by the biliary drain. The gas and bacteria, both of which are commonly observed in cases of bilioenteric anastomosis, may have been diffused through the sinusoid into the portal venous system. Thus, hepatic portal venous gas could be a serious sign when it develops in patients with cholangitis following bilioenteric anastomosis.     

Repair of benign bile duct stricture

Cases of benign bile duct stricture treated during the past ten years were reviewed in reference to the location of the bile duct stricture, the method of repair and their long-term results. Common hepatic duct was the most frequent site of bile duct involved. Bilioenteric anastomosis in the form of retrocolic hepaticojejunostomy (Roux-Y) was the method of repair most frequently used. Brief survey was made on the current literatures concerning the methods of repair of benign bile duct stricture.     

Repair of bile duct injuries with gore-tex vascular grafts: Experimental study in dogs

Bile duct injury is the most feared complication related to biliary tract operations. The goal of this investigation was to offer an alternative treatment that might prevent this complication. Twelve mongrel dogs, thin-walled FEP-ringed Gore-Tex vascular grafts, and Gore-Tex sutures were used in this study. The dogs were randomized into three groups of four according to the length of time of graft implantation: group 1 = 1 month; group 2 = 2 months; and group 3 = 3 months. During the first part of the study, a biliary injury was induced by ligating the middle choledocus after performing a conventional cholecystectomy. During the second part of the study, biliodigestive and biliobiliary anastomosis were performed using Gore-Tex vascular grafts prior to resection of the stenotic area. Initially, an increase in serum bilirubin and alkaline phosphatase levels was noted. Two weeks later, after implantation of the grafts, these values returned to normal. Thin-walled FEP-ringed Gore-Tex vascular grafts were found to be useful in the repair of bile duct injuries, especially in complete transections of the common bile duct. The ductility and flexibility of the material allows any type of anastomosis to be performed, especially when bile duct-gut anastomosis is technically difficult. Presented at the Third Americas Congress of the American Hepato-Pancreato-Biliary Association, Miami, Fla., Feb. 22–25, 2001.     

不能切除的胆管癌的胆道引流术（附80例临床分析）

目的：了解胆道引流治疗不能切除的胆管癌的治疗效果。方法：分析经胆道引流手术治疗的不能切除的胆管癌80例的临床资料及生存情况，其中肝门部胆管癌49例（61.3％），胆总管中上段癌9例（11．2％），胆总管下段癌22例（27．5％）.手术方式包括胆肠吻合的内引流术，U或T管外引流，或两者联用。结果：15％的病例术后早期出现并发症，手术死亡率为10％。术后随访：肝门部胆管癌、胆总管中上段癌及胆总管下段癌中位生存期分别为6．10、5．50和9．50个月。胆总管中上段癌无1年以上生存者，肝门部胆管癌和胆总管下段癌1、2、3年生存率分别为27．39％、38．54％，6．59％、8．97％和2．10％、0。结论：胆道引流手术是治疗不能切除胆管癌的一种重要方法，可获良好的姑息治疗效果。     

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。     

Bilioenteric anastomotic stricture in patients with benign and malignant tumors: prevalence,risk factors and treatment

BACKGROUND:Stricture formation at the bilioenteric anastomosis is a rare but important postoperative complication.However,information on this complication is lacking in the literature.In the present study,we aimed to assess its prevalence and predictive factors,and report our experience in managing bilioenteric anastomotic strictures over a ten-year period.METHODS:A total of 420 patients who had undergone bilioenteric anastomosis due to benign or malignant tumors between February 2001 and December 2011 were retrospectively reviewed.Univariate and multivariate modalities were used to identify predictive factors for anastomotic stricture occurrence.Furthermore,the treatment of anastomotic stricture was analyzed.RESULTS:Twenty-one patients(5.0%) were diagnosed with bilioenteric anastomotic stricture.There were 12 males and 9 females with a mean age of 61.6 years.The median time after operation to anastomotic stricture was 13.6 months(range,1 month to 5 years).Multivariate analysis identified that surgeon volume(≤30 cases)(odds ratio:-1.860;P=0.044) was associated with the anastomotic stricture while bile duct size(6 mm)(odds ratio:2.871;P=0.0002) had a negative association.Balloon dilation was performed in 18 patients,biliary stenting in 6 patients,and reoperation in 4 patients.Five patients died of tumor recurrence,and one of heart disease.CONCLUSIONS:Bilioenteric anastomotic stricture is an uncommon complication that can be treated primarily by interventional procedures.Bilioenteric anastomosis may be performed by a surgeon in his earlier training period under the guidance of an experienced surgeon.Bile duct size6 mm may play a protective role.