choledochoduodenal anastomosis

Biliary stenosis and bile duct stenosis, and some are congenital malformations, but most of them are caused by accidental injury. Bile duct defect reconstruction can be divided into two categories: one for small bile duct defects, such as partial bile duct repair, bile duct end-to-end anastomosis; the other for larger bile duct defects, such as bile duct duodenal anastomosis End-to-end anastomosis of the extrahepatic bile duct. Bile duct construction is more complicated and difficult, and the indications should be strictly controlled according to the patient's condition. Due to the difficulty in re-construction of the bile duct, it is necessary to complete the first-stage operation. It is divided into two phases only when necessary. The first stage drains the bile duct and the second stage constructs the bile duct. Treatment of diseases: cholangitis stenosis, traumatic bile duct injury, extrahepatic bile duct injury Indication 1. Fibrous stenosis at the lower end of the common bile duct. 2. Congenital atresia or stenosis at the lower end of the common bile duct. 3. Congenital choledochal cyst. 4. It is difficult to repair the lower part of the common bile duct. Contraindications Epidural anesthesia is generally used; general anesthesia is available if necessary. Preoperative preparation 1. Emergency surgery: All patients must be preoperatively prepared for 6 to 24 hours to improve the general condition and tolerate surgical treatment. (1) fasting; intestinal paralysis bloating patients with gastrointestinal decompression. (2) Intravenous infusion to correct water, electrolyte and acid and alkali balance disorders, if necessary, blood transfusion or plasma. (3) Appropriate application of broad-spectrum antibiotics. (4) Astragalus patients are injected with vitamins b1, c, and k, and those with bleeding tendency are intravenously injected with hexaamino own acid and p-carboxybenzylamine. (5) When there is toxic shock, shock should be actively rescued. 2. Selective surgery: When the patient has long-term jaundice, dehydration, liver and kidney function damage, when the general condition is bad, the patient should actively correct before surgery, improve nutritional status, and apply high blood sugar, high vitamin and other liver protection treatment. 3. The surgeon should carefully understand the medical history, physical examination, laboratory tests and various auxiliary examination data, and have sufficient analysis and estimation of the condition. 4. Patients with stones should review b-ultrasound on the morning before surgery to observe the movement of stones, in order to prevent stones from draining the biliary tract and perform surgery. Surgical procedure 1. Position: supine position. 2. Incision: right upper transabdominal rectus or median side incision. If the second operation is performed, the original incision should be avoided. 3. Separation of the duodenum: First, the liver, stomach, duodenum and pancreatic head are probed, and then the biliary system is explored to determine the anastomosis method. Carefully separate the adhesions to reveal the common bile duct and duodenum. The peritoneum was cut in the lateral edge of the duodenum, and the duodenal bulb and descending part were separated for easy anastomosis. 4. For the common bile duct and the anterior wall of the duodenum: take the anterior wall of the duodenal bulb and the anterior wall of the common bile duct as an anastomosis site, and both sides of the anterior wall of the common bile duct and the duodenum The upper edge of the front wall is used to fix the traction stitches with two needles. 5. Anastomosis: The upper part of the common bile duct is cut longitudinally 2 to 3 cm long between the traction lines to absorb bile. Further, an incision parallel to the longitudinal axis of the intestine is made on the upper edge of the duodenal bulb, and the length is equal to the common bile duct incision, and the intestinal fluid is removed at any time. Ligation of submucosal bleeding points. Using the thin wire at a distance of 0.2cm from the cutting edge, the posterior wall of the anastomosis is sutured (with or without suture), so that the midpoint of both sides of the common bile duct incision is close to the ends of the duodenal incision, and then 4- 03-0 chrome gut is used as the anastomosis of the posterior wall of the anastomosis. The inner layer of the anterior wall of the anastomosis is also used as a full-thickness varus suture with a chrome gut. The outer layer of the anterior wall of the anastomosis was sutured with a thin wire for the muscle layer. (1) 2 needle suture traction at the predetermined anastomosis; (2) after the posterior wall pulp layer is sutured, the lower bile duct and the duodenal anterior wall are cut; (3) the posterior wall of the anastomotic stoma is interrupted and interrupted. The anterior wall of the anastomosis was sutured in the anterior wall; (4) the outer layer of the anterior wall was sutured intermittently. complication 1, biliary anastomotic stenosis: common late complications, can be seen in any anastomosis, but more common in end-to-side anastomosis. Common causes include anastomotic blood flow, intraoperative anastomotic stoma making too small, excessive mucosal varus, excessive anastomotic tension, unresolved internal lesions, and retrograde infection. 2, reflux cholangitis: clinical is more common, clinical treatment is difficult, often lurking the risk of surgical failure, may be due to the defect of the anastomosis itself (not large enough, not low enough), the bile duct blind end is longer, the intestinal fistula is not enough Long and anti-reflux effects are not enough. 3, biliary and cholangioenterosal fistula: more common and serious complications, mostly due to anatomical variation, local inflammation and edema and improper operation of the surgery. 4. Peptic ulcer bleeding: After the small intestine is placed, the secretion of intestinal inhibitory peptide is reduced. After the biliary anastomosis, the bile does not flow into the duodenum, and the chyme and bile begin to contact in the jejunum. The contents of the duodenum are only neutralized by pancreatic juice, resulting in increased acidity and ulceration. 5, stone recurrence: one of the main complications in the later period. Stenosis of the biliary anastomosis or intrahepatic bile duct stricture, poor bile drainage, cholestasis, etc. are the causes of biliary infection and stone formation.