Interportal jejunoduodenal anastomosis

Interhepatic jejunal duodenal 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%. Non-surgical correction of bile duct atresia in the operation of jejunal biliary tract surgery is to cut a segment of the jejunum, with mesenteric vessels for jejunal hepatic anastomosis, distal jejunum and duodenal descending end-to-side anastomosis or end-to-side anastomosis with the jejunum . The difference between this operation and Roux-en-Y surgery is that the intervening jejunum fistula and the duodenum or jejunum are connected to the intestine but not the main channel of the digestive tract, but Roux-en-Y surgery The jejunum ascending branch is the main channel of the digestive tract. The latter is more prone to reflux. In recent years, in order to prevent reflux cholangitis, many authors advocate the addition of various anti-reflux flaps, such as rectangular flaps, artificial intussusception and artificial nipples, and some authors advocate the application of two anti-reflux measures simultaneously. For example, if a rectangular flap is applied and an intussusception is applied, the proportion of reflux caused by follow-up is decreased. In order to prevent early reflux after surgery, the intervening jejunum is generally stoma. When the gallbladder flow is smooth, the jaundice subsides, and the bilirubin drops below 51 mol/L, the stoma closure, jejunal duodenum or jejunal jejunostomy can be performed. Kasai advocates closing the stoma 2 to 4 years after surgery, but the general literature advocates closing the stoma 1 to 3 months after surgery. If a serious water-electrolyte disorder occurs after the patient develops a stoma, if it is still not effectively corrected by intravenous supplementation, the stoma should be closed in time. Treatment of diseases: congenital biliary atresia Indication Interhepatic jejunal duodenal 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. Open laparotomy, after the diagnosis, the gallbladder and hepatic portal fibrous connective tissue (including enlarged lymph nodes) were removed in one piece, and the jejunum anastomosis was performed. 2. Cut the jejunum from the 15cm and 45cm below the duodenal jejunum. Separate the corresponding jejunal mesentery to ensure adequate blood supply to the jejunal fistula. 3. The proximal end of the jejunum and the distal end of the end of the anastomosis. 4. Poke the right side of the colonic artery in the transverse mesenteric membrane, and drag the intervening jejunum to the hilum. The proximal end is sutured with 2-0 silk sutures and closed. 5. The jejunum is anastomosed at the proximal end 5 cm from the hepatic portal connective tissue cutting edge. 6. Distal jejunostomy. The cigarette is drained behind the hepatic jejunal anastomosis, and then the incision is closed layer by layer. Some authors advocate a one-stage jejunal duodenal descending end-to-side anastomosis. After 7.1 to 3 months, the jejunostomy was closed, and the jejunum duodenum (or jejunum jejunum) was anastomosed. Incision from the original abdominal wall into the abdominal cavity. When cutting the peritoneum, care should be taken that the intestine may stick to the peritoneum to prevent the intestine from being cut. Remove the jejunostomy from the abdominal wall, trim the jejunal stump, remove the scar at the stump, make an end-to-side anastomosis between the jejunum and the duodenum, or do an end-to-side anastomosis 10 cm below the anastomosis of the jejunal jejunum jejunum. . 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 hepaticojejunostomy. Clinical manifestations of high fever, deepening of jaundice, white stool, high mortality. In the hepatic portal anastomosis, 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. It is suggested that when reflux cholangitis and jaundice are deepened after hilar jejunostomy, the anastomosis should be re-explored and the anastomotic obstruction should be relieved in time to reduce death and regain bile flow.