hilar cholangioplasty

Hepatic hilar cholangioplasty is used for the surgical treatment of hepatolithiasis with hepatic bile duct stricture. Hepatobiliary stenosis, often associated with hepatolithiasis, and exacerbated each other. This stenosis is often annular and forms thickened scars around the bile duct, varying in length. Hepatobiliary stenosis can be single-shot, and it is most common in the first and second branch openings of the left hepatic duct. It can also be multiple, with the most common hepatic hilar ducts, namely the left and right hepatic ducts and the common hepatic duct opening. Due to the narrowing, the fibrosis, atrophy and compensatory hyperplasia of the liver tissue of the liver are irregular hepatic enlargement, which is called atrophic hyperplasia. The major hepatic bile duct stenosis, together with hepatolithiasis, is often the leading cause of severe biliary purulent infection, resulting in patient death and repeated or multiple surgery. For the bile duct stenosis of the hilar, bile duct angioplasty is theoretically feasible. However, there is not much chance that plastic suture can be performed when hepatic bile duct stones are combined with stenosis. Because hepatic bile duct stenosis is caused by acute suppurative cholangitis and hepatic duct ulcer and fibrous tissue hyperplasia, inflammation is not limited to the bile duct itself, and it is often surrounded by the liver tube, and the location of the ulcer is the heaviest and narrow. Around the hepatic duct, the degree of fibrous scarring is generally heavier. At this time, not only the lumen of the bile duct is reduced, but also blocked, and the hepatic duct and the surrounding tissue are also difficult to loose due to adhesion and fixation of the scar. Moreover, the intrahepatic stones remain in the stenosis, and it is often difficult to cut along the longitudinal section of the hepatic duct. There is an opportunity to complete a satisfactory lateral suture to restore the lumen inner diameter. There are many chances of failure in surgery, and the proportion of recurrence and reoperation is also high, and it is easy to have stone blockage again. Therefore, there is very little chance of successful orthopedic surgery during hepatolithiasis surgery. Treatment of diseases: benign biliary stricture Indication Hepatic hilar biliary angioplasty is applied to the annular stenosis mainly at the left hepatic duct opening. The lesion is limited, the range is small, the surrounding scar tissue is less, there is no liver fibrosis, atrophy, and the intrahepatic calculi have been cleared above the stenosis. Preoperative preparation Hepatolithiasis, hepatobiliary stenosis, especially those with recurrent seizures of severe cholangitis, long-term obstructive jaundice and biliary fistula, local and general conditions are often poor, and should be carried out at the same time as various examinations and diagnoses Thoughtful preoperative preparation. 1. Replenish blood volume, maintain water and salt metabolism and acid-base balance, especially pay attention to the correction of chronic water loss and hypokalemia. 2. Strengthen and improve the systemic nutritional status of patients. Give a high-protein, low-fat diet and add enough calories and vitamins. Patients with obstructive jaundice should be injected with vitamin K11. Some patients also need fluid replacement and blood transfusion. In patients with complete biliary fistula and hepatic insufficiency, intravenous nutritional support is often required. 3. Check the coagulation mechanism and correct any abnormalities that may occur. Comprehensive analysis was performed together with the results of liver function tests to evaluate liver reserve and metabolic function. 4. Pay attention to protecting liver function. Repeated episodes of biliary tract infection and prolonged obstructive jaundice often cause varying degrees of liver damage. If you have biliary cirrhosis, you should pay attention to active liver protection. Patients with long-term external drainage tube, if the daily bile flow is many and the color is light, it is often a sign of liver dysfunction. The inversion of the ratio of white and globulin indicates that the compensatory function of the whole liver is in an unfavorable condition. If you have splenomegaly and ascites, you should first do liver protection treatment. After you have improved, consider the staged treatment. 5. Investigation of bile bacteriology and antibiotic susceptibility testing in order to use antibiotics more rationally. In some complicated cases, it is often necessary to start systemic application of antibiotics 2 to 3 days before surgery to help prevent surgery or angiography and stimulate cholangitis. If the operation is performed during the onset of cholangitis, penicillin or metronidazole (metidazole) should be administered to control the mixed infection of anaerobic bacteria. 6. Protect and support the body's emergency response ability to help smooth the trauma response after surgery. These patients have been repeatedly attacked by biliary tract infections and multiple operations, often with physical depletion; and most of them have a history of treatment with different degrees of glucocorticoids, systemic response is low, should pay attention to support and protection. In the operation, hydrocortisone 100 ~ 200mg was intravenously instilled, and 50-100 mg per day can be instilled within 2 days after surgery, which often receives good results. 7. For patients with external drainage tubes, the preparation of the skin of the mouth should be carried out as soon as possible. For excessively long granulation tissue, it should be cut off. For local inflammation and skin erosion, the dressing should be changed frequently and wet if necessary. For mouthwashes with digestive juices, apply zinc oxide paste coating protection. Keep your mouth clean and perform surgery when your skin is healthy. Deworming should be routinely performed after admission. Stomach tubes and catheters should be placed before surgery. Surgical procedure 1. Incision: The oblique incision under the right upper abdomen is the best choice for incision. Followed by the right upper rectus abdominis incision, but not as good as the right upper abdomen rib oblique incision, the room for maneuver is small. 2. Exposing the hilar bile duct is the key to this operation. Care should be taken to separate the adhesion of the hepatoduodenal ligament to the hilar. And pull the liver up. 3. Separate the outer sheath of the left hepatic bile duct, and fully dissociate the upper, lower and front sides of the left hepatic duct. 4, from the stenosis of the common hepatic duct to do all the mouth, and cut the stenosis ring along the longitudinal axis of the left hepatic duct, and cut a part of the enlarged left hepatic duct, the incision to explore the right hepatic duct, left hepatic duct, caudate lobe The liver tube and try to remove the stones. 5. The left hepatic duct wall of the upper and lower stenosis rings was sutured transversely with a 3-0 absorbable line, and the longitudinal left incision of the cut left hepatic duct was sutured to enlarge the narrow left hepatic lumen. 6, in the common bile duct to make a longitudinal incision, and explore the common bile duct, take the distal stone. Then, the short arm of the T-shaped tube is placed in the left and right hepatic ducts by the incision to support the drainage and suture the incision of the common bile duct.