Portoenterostomy

Hepatic portal anastomosis for the surgical treatment of inoperable orthostatic bile duct atresia. Congenital biliary atresia is a congenital or partial atresia or absence of the bile duct system. The cause is still unclear and may be the result of cholecystectomy in embryonic development. In recent years, some people think that this disease is closely related to neonatal hepatitis. Both can exist at the same time, or first develop into bile duct atresia for giant cell hepatitis. It is also believed that due to infectious, vascular or chemical causes of the embryo, the bile duct system is harmed, and the bile duct is occluded, hardened or partially disappeared. This course of disease can continue from the time of embryonic development to the time of birth. Bile duct atresia can be divided into intrahepatic type and extrahepatic type, in which intrahepatic type is intrahepatic bile duct system atresia, there are only irregular small bile ducts in the liver with stenosis or atresia, and there is no good treatment method; extrahepatic bile duct The lock can be divided into VI type according to the position of the lock. Among them, type I-III is a type, accounting for 80%-90% of extrahepatic bile duct atresia, which is called non-correctable type; type IV-VI is another type, which can be corrected, with a good prognosis, accounting for about 10%~ 20%. Operational hepatic portal anastomosis for non-surgical correction of bile duct atresia was designed by Japanese scholar Kasai in 1968. The authors have studied through a series of studies that unresectable extrahepatic bile duct atresia is carefully removed and the liver is removed. After the fibrous tissue block at the door, some of the sick children have small bile ducts in the hilar section. The hepatic portal of the bile duct is anastomosed to the intestine, and in about 30% of cases, persistent bile flow can be obtained, and the jaundice is reduced to normal. The sick child can be cured. However, some of the children who have recently received bile drainage have an up-and-down cholangitis due to reflux after the hepatic jejunum anastomosis, and thus the bile flow is interrupted, and even liver failure, secondary sepsis and death. In order to prevent ascending cholangitis, the ascending branch of the jejunum is first made into a stoma, and the stoma is closed 1 to 3 months after the operation. Some scholars do jejunal ascending anti-reflux rectangular valve, intussusception and anti-reflux surgery to prevent ascending cholangitis. It is reported that there is a certain anti-reflux effect. Treatment of diseases: congenital biliary atresia Indication Hepatic portal anastomosis is suitable for type I, II, and III inoperable biliary atresia. Contraindications More than 3 months of biliary atresia, due to irreversible cirrhosis, should be listed as a relative contraindication for the operation, even if the surgery to obtain bile drainage, the sick child will die of cirrhosis. Preoperative preparation 1. Quickly correct anemia and hypoproteinemia in sick children. A small amount of multiple blood transfusions and plasma. 2. Intramuscular injection of vitamin K, while supplementing a large amount of vitamin B1 and vitamin C. 3. Liver treatment is given when liver function is impaired. It can be given a high protein, high sugar, high vitamin diet and low fat diet. Surgical procedure 1. Take the oblique incision of the right costal margin, and do the anatomy of the hilar after opening the abdomen. If the gallbladder exists, it can be performed by gallbladder catheterization. When the structure of the extrahepatic bile duct is confirmed, the gallbladder is separated from the gallbladder bed, and then in the twelve The upper edge of the intestine cuts the hepatoduo duodenal ligament and is always dissected to the hilar. Properly protect the hepatic artery and portal vein. 2. The connective tissue mass was separated into the hilar, and the connective tissue mass was removed together with the enlarged lymph node, and carefully separated into the liver parenchyma by 1 cm. 3. Cut the jejunum and jejunum membrane 10 to 15 cm below the duodenal jejunum (Treitz ligament). The blind end of the cut jejunum is sutured and sealed. 4. Hepatic jejunum end-to-side anastomosis. A longitudinal incision is made at a distance of 5 cm from the blind end of the jejunum, which is 1.5 to 2 cm long. The posterior margin of the fibrous connective tissue section of the jejunum and hepatic portal was sutured in the entire posterior wall with a 4-0 absorbable suture. The same method is used to match the anterior wall to complete the anastomosis between the hilum and the jejunum 5. At the 30cm from the anastomosis of the hilar jejunum, the proximal jejunal margin and the ascending jejunum were used for end-to-side anastomosis. 6. Close the transverse mesenteric hiatus and jejunal mesenteric hiatus, and then close the abdomen layer by layer. complication 1. Hepatic damage is aggravated In children with extrahepatic biliary atresia, such as failure to effectively relieve biliary obstruction during surgery, postoperative jaundice will gradually deepen, and cirrhosis and liver function damage will continue to increase. Sometimes complications such as hepatic coma, ascites, and upper gastrointestinal bleeding are combined, which is the main cause of death in sick children. 2. Anastomotic opening It is a serious complication. The reason for the occurrence is that there is local tension after the anastomosis, which affects the blood vessel to cause cracking; in addition, due to the small field of view and the depth of the operation, it is often impossible to satisfactorily perform the inversion suture. In addition, the children with high jaundice, liver dysfunction, hypoproteinemia have a certain degree of impact on healing. When the anastomosis is ruptured, the sick child often has a sudden high fever and increased drainage. The method of treatment is to fully drain, strengthen the supportive therapy, wait for it to heal itself or form a chronic sinus, and elective fistula resection. 3. Incision cracking Often occurs within 5 to 10 days after surgery. The main cause is abdominal distension, severe liver damage, malnutrition, ascites, abdominal or incisional infection. The clinical manifestation is that a large amount of bloody exudate suddenly flows out of the early wound. In severe cases, the incision suture cuts the skin, and the internal organs (mainly the small intestine) come out of the incision. When the incision is opened, the intestine should be immediately removed to the operating room for suturing the incision under general anesthesia. If necessary, the suture should be sutured, and anti-infection and supportive therapy should be strengthened after surgery. 4. Ascending cholangitis This is another serious complication after hepatic portal anastomosis. Clinical manifestations of high fever, deepening of jaundice, white stool, high mortality. In the hepatic jejunostomy, the distal end of the jejunum is made into a stoma, which can greatly reduce the occurrence of reflux and ascending cholangitis. Other authors have made a series of improvements to prevent reflux, such as rectangular petals, intussusception, artificial nipple anti-reflux, etc., can play a different degree of anti-reflux. Some people advocate that reflux cholangitis after hepatic portal anastomosis, jaundice deepening, should be surgically explored the anastomosis, timely release of anastomotic obstruction factors, is important to reduce death, regain bile flow.