完全腹腔镜下Roux—en—Y胆管空肠吻合术在胆系疾病中的应用

目的报道完全腹腔镜下Roux—en—Y吻合术的手术方法，探讨腹腔镜下Roux—en—Y吻合术在胆系疾病手术中的应用价值。方法对103例患者行完全腹腔镜下胆肠Roux—en—Y吻合术，其中多次手术取石后，胆总管结石再发合并胆管狭窄28例，医源性胆道损伤3例，胆总管囊肿24例，肝门部胆管癌36例，胰头癌及壶腹癌12例。所有手术均采用5个Trocar进行操作。首先在腹腔镜下处理胆道病变，即切开胆总管、取净结石；修整并切开损伤胆总管；切除扩张的胆总管；切除肿瘤部位胆管或者纵行切开恶性黄疸患者胆总管引流等；同时为胆肠吻合前做好肝管断端的准备。然后更换腹腔镜位置，于镜下切断空肠及其系膜，行空肠间侧侧吻合。将腹腔镜位置复位，镜下将Roux—en—Y胆支空肠襻牵拉至肝门处行胆肠侧侧或者端侧吻合。最后留置腹腔引流管。结果全组病例均成功完成手术，残余胆（肝）管直径0．4～3．2锄，平均0．9Gin。术后胆汁漏3例，经腹腔引流1周～1个月治愈。2例胆道损伤伴阻塞性黄疸患者，术后均出现应激性溃疡及腹腔内出血，1例腹腔内出血经再次腹腔镜手术止血治愈，另1例经腹腔引流、抑酸及止血药物治疗2d后治愈。95例患者获随访，随访率92．2％（95／103），随访时间4～93个月，平均48-3个月。胰头、壶腹癌及上段胆管癌患者，随访期间14个月内因转移及消耗死亡，均无手术并发症发生；3例胆总管结石患者分别于术后2、3、5年发生反流性胆管炎，来院经抗炎对症治疗后痊愈出院；其余患者随访期间均无胆道、胆肠吻合口狭窄等并发症发生。结论完全腹腔镜下胆肠Roux—en—Y吻合术是胆道疾病需行胆肠吻合手术治疗的最佳、首选术式，但术者需具有丰富的腹腔镜手术经验。

Application of total laparoscopic Roux-en-Y cholangiojejunostomy in treating biliary tract diseases

Objective To report the surgical procedure of total laparoscopic Roux-en-Y cholangiojejunostomy （TLRCJS）, and clinical evaluate the value of TLRCJS in treating biliary tract diseases. Methods We performed TLRCJS on 103 patients. Twenty-eight of them had recurrent common bile duct （CBD） stones with stricture after several times of CBD stones extractions, 3 patients were diagnosed with iatrogenic bile duct injury, 24 patients had choledochalcyst, 36 patients had hepatic portal cholangiocareinoma and 12 patients had pancreatic head cancer or periampullary cancer. M1 surgeries were performed by 5 ports. At first, we treated CBD accordingly. In choledoeholithiasis patients, we performed choledochotomy and extracted all stones possible. In iatrogenic injury patients, the injured CBD was cut open and repaired. Dilated CBD or CBD with tumor were transected. Malignant jaundice patients had their CBD cut open longitudinally for bile drainage. During this procedure, the residue bile duct was also prepared for cholangiojejunostomy. Secondly, the position of the laparoscope was altered. Then, the jejunal mesentery and jejunum were transected laparoscopically, and side-to-side jejunojejunostomy （JJS） was performed. Finally, the Roux-en-Y biliary limb was lifted close to residual bile duct and laparoscopic side- to-side or end-to-side choledochojejunostomy （CJS） were performed. An abdominal drainage tube was placed after that. Results All of the surgeries were performed successfully. The residual bile duct caliber ranged from 0.4 to 3.2cm, averagely 0.9cm. Bile leakage happened in three patients and were cured by abdominal drainage 1 weeks- 1 mouths postoperatively. Two patients with biliary tract injury combined with obstructive jaundice had intraperitoneal hemorrhage and stress ulcer of the stomach. One of the intraperitoneal hemorrhage was cured by another laparoscopic surgery. The other patient was cured after 2 days＂ abdominal drainage, antiacids and hemostatic drug therapy. The follow-up duration of 95 patients （92.2% =95/103） were 4~93m, averagely 48.3m. Patients with pancreatic head, ampullary cancer and upper cholangiocarcinoma died of metastasis or cachexia during 14 months＂ follow-up without having postoperative complication. Reflux cholangitis happened in 3 patients 2, 3, 5 years postoperatively, respectively. All of them were cured by anti- inflammatory and symptomatic treatment. Stricture of bile duct or anastomosis was found in no patient. Conclusions For patients with biliary tract diseases who need biliary-jejunal anastomosis, TLRCJS should be the first and best consideration. While, the surgeon should have a good master of laparoscopic surgeries.