Drainage of proximal cholangiocarcinoma

Proximity of proximal cholangiocarcinoma for surgical treatment of extrahepatic biliary tract cancer. Treating diseases: cholangiocarcinoma Indication Proximal cholangiocarcinoma drainage is applicable to: 1, the upper end of the bile duct cancer, there has been extrahepatic metastasis, obstructive jaundice is serious, it is not appropriate to undergo radical resection. 2, the patient's condition can still undergo surgery. 3, patients who are undergoing radical resection, surgical exploration found that can not be radical resection, can be changed to drainage. Contraindications 1. At the end of the course of the disease, drainage of the bile duct does not prolong the patient's survival or improve the patient's quality of life. 2, obvious dyscrasia, a large amount of ascites. 3, the patient can not undergo surgery. 4. Obvious cirrhosis and liver damage. Preoperative preparation 1. The location and extent of biliary obstruction should be accurately estimated. It can be determined by non-invasive methods such as B-mode ultrasound, CT, MRCP, etc. If necessary, PTC and ERCP can be performed before surgery. However, care must be taken to prevent complications such as biliary infections and bile leakage. 2. If PTC and PTCD have been performed before surgery, surgery should be performed at an early stage. After 2 to 3 weeks, there may be a fatal biliary infection due to delayed surgery, and liver function cannot be achieved even after 2 to 3 weeks of drainage. restore. 3, preoperative PTCD is generally only used in patients with severe obstructive jaundice and poor general condition can not be performed in time, should be careful to avoid infection and loss of water and electrolytes under drainage. If it can be drained through the endoscope, the effect is better than PTCD. 4, patients with significant weight loss and malnutrition, 1 week before surgery began to strengthen intravenous nutritional supplements, correct low potassium, low sodium, anemia, hypoproteinemia, vitamin K11 supplement. 5. Oral bile salt preparation. 6, antibiotics intestinal preparation. 7, oral administration of ranitidine 150mg before the night. 8, gastric tube and indwelling catheter. 9, preventive application of antibiotics, in view of obstructive jaundice patients, acute renal failure may occur after surgery, should avoid the use of antibiotics such as Qingda toxins with nephrotoxicity. Surgical procedure 1. When the upper bile duct cancer or hilar cholangiocarcinoma causes severe obstructive jaundice, there must be a blockage of the left and right hepatic ducts and the common hepatic duct junction. The left and right hepatic bile duct systems are separated and do not communicate with each other. In advanced cases, the second-stage branch opening of the hepatic bile duct is often involved, so it is also separated between the segments on one side of the liver. Cancer originating from one side of the liver can cause atrophy and fibrosis of the liver, while the contralateral liver is enlarged and compensated. Therefore, according to the imaging examination, especially the CT photo, the liver with one side of the compensatory function should be used to drain the intrahepatic bile duct, instead of mis-selecting the fibrotic, atrophic side, otherwise it will not improve. Liver function, the purpose of reducing serum bilirubin levels. The surgical incision is generally a right inferior oblique incision. If the left hepatic duct is to be drained, the incision should extend to the left upper abdomen. Surgical exploration should be combined with the findings of preoperative examination to determine the location of surgical drainage. In order to achieve a more thorough drainage, it is often necessary to simultaneously drain the left hepatic duct and the right hepatic duct. 2. Left hepatic duct drainage. When the cancer is still confined to the bifurcation of the hepatic duct, the lateral section of the left hepatic duct is significantly expanded above the obstruction, and the dilated, soft, and elastic left hepatic duct can be found at the lower edge of the hepatic lobe, and attention should be paid to the portal vein. Left dry identification, simple identification method is to directly puncture with a fine needle, can extract colorless, transparent white bile juice from the bile duct, if the portal vein branch, then draw blood. Pull the lower edge of the liver lobe with a curved hook, cut the peritoneal layer at the lower edge of the lobe, and slightly separate it to reveal the left hepatic duct. The suture line is cut with a 0-wire thread and cut between the traction lines. Open the left hepatic duct, after the bile is sucked, test the left and right direction with the Bakes biliary dilator. If the obstruction is below the hepatic duct bifurcation, the probe can be probed into the right hepatic duct. If it is a bifurcation obstruction, the probe cannot by. When the obstruction is under the bifurcation, a latex or silicone tube can be placed through the left hepatic duct to the right hepatic duct to drain both hepatic bile duct systems. Another commonly used method for drainage of the left hepatic duct is to cut the lower bile duct of the left outer lobe of the liver through the round ligament of the liver (section III bile duct). 3, right hepatic duct drainage. Right hepatic duct drainage is often more difficult than left hepatic drainage, and the effect is often not ideal. The reason is: 1 the right hepatic duct is short, the average length is only 0.84cm, so the right anterior hilar cholangiocarcinoma often causes the right anterior lobe and The right posterior lobe of the hepatic duct is obstructed, and the two are in a separated state; 2 the confluent configuration of the right hepatic duct is often a split type, and there are less than half of the typical right hepatic duct trunks, causing difficulty in positioning. The most common route for drainage of the right hepatic duct is to drain the lower branch of the right anterior hepatic duct (V-segment bile duct). Whether the hepatic duct is dilated or its location can be determined based on preoperative CT photographs or B-mode ultrasonography during surgery. A common method is to puncture the inside of the neck of the gallbladder to further determine the exact position and depth of the right anterior descending hepatic duct. Then cut the peritoneal layer on the medial edge of the gallbladder liver bed, and slightly remove the left edge of the gallbladder. Generally, when the gallbladder bed is cut 1.0-1.5 cm, the right anterior hepatic duct branch can be reached, and the expanded right anterior lower branch liver can be incised. After the tube, extend into the angionic vascular clamp as a guide, expand the incision on the bile duct in the direction of the hepatic gate until it reaches the obstruction of the tumor, and then probe upwards, sometimes into the opening of the right posterior hepatic duct, and then pass a drainage tube to the right front The lower hepatic duct is placed into the right posterior hepatic duct, and the liver tissue around the drain tube is sutured and sutured. If the right posterior hepatic duct opening has been blocked, such as in the split right hepatic duct, the right posterior hepatic duct is open at the confluence of the left and right hepatic ducts. Since the right posterior hepatic duct is located at the deep side of the right anterior hepatic duct, the distance is very high. Near, it can be puncture through the posterior wall of the right anterior hepatic duct, after determining the position of the right posterior hepatic duct, directly incision, drainage through the right anterior hepatic duct, generally a straight tube or a short T-shaped tube can be used. complication 1, bile leakage and biliary peritonitis. 2. Bleeding in the abdominal cavity or in the drainage tube. 3. Intra-abdominal infection. 4. A large amount of bile loss and electrolyte imbalance. 5. Severe patients may have liver failure and/or renal failure. 6, acute cholangitis.