Roux-en-Y cholangiojejunostomy

Roux-en-Y biliary jejunostomy is used for drainage in the biliary tract. The designer of Roux-en-Y jejunum is Cesar Roux (1893), which was originally used for gastrojejunostomy and was widely used in biliary and pancreatic surgery and biliary and digestive anastomosis. It was used in China after the 1960s. widely used. Because Roux-en-Y jejunum has a complete vascular supply, there is sufficient length to transfer long distances, and the intestines that are anastomosed with the bile duct are smooth and easy to prevent reflux. Based on these characteristics, Roux-en-Y common bile duct jejunostomy Surgery is a common procedure in biliary surgery. The main role of biliary drainage is to relieve cholestasis. In the proximal side of the bile duct obstruction, a discharge channel is created for the continuously secreted bile, so that the jaundice is regressed, and a series of pathophysiological changes caused by obstructive jaundice are gradually restored. Primary bile duct stones can also be discharged through the anastomosis to the intestine. The technical point of Roux-en-Y biliary jejunostomy is to ensure the smoothness of the bile duct jejunostomy, to avoid anastomotic stenosis, and to make the Roux-en-Y jejunum have an appropriate length, which can prevent the intestinal contents from flowing backwards and not being placed. The jejunum is too long. In order to meet the first requirement, a sufficient length of the common bile duct is first revealed to have a large opening in the obstructed upper bile duct. In the lower end of the common bile duct obstruction, the common bile duct is mostly dilated, and it is generally difficult to separate the common bile duct. The problem is that the common bile duct and the jejunum are combined in four modes, namely: side-side, side-- End, end-to-side and end-end anastomosis. We believe that the large-diameter bile duct jejunum side-to-side anastomosis is superior to other types of anastomosis. The anastomosis of the common bile duct wall is limited by the size of the common bile duct lumen. The incision on the bile duct can start from the confluence of the left and right hepatic ducts. Direct access to the full length of the extrahepatic bile duct on the duodenum, such a large anastomosis is conducive to bile drainage, gallstone discharge, and maintain long-term patency of the anastomosis, reducing the chance of formation of restenosis, as long as the anastomosis is large enough, the position is low enough, The so-called "funnel syndrome" caused by the retention of stones or food debris at the lower end of the common bile duct is unlikely. The common bile duct and the jejunum end-to-side anastomosis still need to be applied when the extrahepatic bile duct injury and the continuity of the bile duct are destroyed. The bile duct end is used for anastomosis. When the original diameter of the bile duct is not thick enough, the anastomotic stenosis is very likely to occur after the operation. In order to avoid the anastomotic stenosis, there are two points to be noted: First, do not damage the bile duct when separating the common bile duct. The blood supply to the broken end, otherwise the chance of bile duct stricture after surgery increases due to tissue ischemia. Through the study of vascular cast, the arterial supply of the extrahepatic bile duct was observed. The upper part was from the right hepatic artery and the gallbladder artery, and the lower part was from the posterior duodenal artery. It was longitudinally oriented, and the main blood vessels flowed at 3 o'clock and 9 o'clock. To the hepatic hilum, there is still a posterior portal vein artery that runs behind the common bile duct, originating from the superior mesenteric artery, branching to the bile duct wall, and participating in the formation of the vascular network around the common bile duct. From the vascular plexus around the common bile duct to the submucosa, the mucosal capillary network of the bile duct is formed. Due to the characteristics of the blood supply of the common bile duct, bile duct anastomosis is more likely to cause bile duct tissue ischemia. In addition, the common bile duct wall above the duodenum is mainly composed of fibrous elastic tissue, containing a small amount of smooth muscle fibers, but does not form a muscular layer, no peristalsis, and fibrous tissue is formed during the healing process. Local blood supply and bile duct wall tissue characteristics determine the anastomotic stenosis in the postoperative period of biliary anastomosis, especially after end-to-end, side-end or end-to-end anastomosis of the bile duct jejunum, especially in When determining the implementation of cholangioenterostomy, these characteristics should be remembered when choosing a biliary anastomosis. Second, increase the anastomotic diameter of the bile duct end to avoid re-stenosis of the anastomosis. For the bile duct with a small degree of expansion, when the bile duct is transversely cut, the anterior wall of the bile duct is cut open to the confluence of the left and right hepatic ducts or the anterior wall is V-shaped and cut, and a considerable anastomosis can be made. When bile duct jejunostomy is used, it is generally not recommended to use the bile duct side wall to make anastomosis with the jejunal end. This is because this method of anastomosis often leads to anastomotic stenosis at the later stage, and the end of bile duct stones or food residue remains due to poor bile drainage of the anastomosis. This is the occurrence of the so-called "funnel syndrome" and repeated bile duct infections. End-to-end bile duct jejunostomy and contralateral anastomosis with bile duct end-to-end anastomosis, due to the possibility of late anastomotic stenosis, should be avoided. In order to prevent the Roux-en-Y jejunal anastomosis from being discharged above the anastomosis, the second requirement is reached. The method used is as follows: 1 lengthening the length of the jejunum, the initial length is generally 25-30 cm. So far, it has increased to 50cm and even some people use 100cm of the intestine. In the early years, it was considered that the length of the Roux-en-Y jejunum was 25 cm, which prevented the reflux, but in fact, the extension of the length of the jejunum reached 50-60 cm. However, a long period of jejunum segmentation occurs, but a series of pathophysiological changes occur. First, the number of bacteria in the jejunum is significantly increased, and the anaerobic genus is dominant; the second is the gastrointestinal endocrine regulation disorder, and the increase of gastric acid secretion may be related to the reduction of intestinal gastric peptide (GIP). In recent years, studies have indicated that increased gastric acid secretion is caused by decreased synthesis and secretion of somatostatin. The incidence of duodenal ulcers in the late stage of surgery is high, ranging from 2% to 22%. Despite these many problems, the results of such surgery depend to a large extent on the primary lesions. For example, the effect of intra-biliary drainage after intra-biliary bile stone removal is different from that of simple bile duct lesions. The former often has a poor effect due to the presence of lesions above the anastomosis. When there is stenosis in the intrahepatic bile duct, it should be classified as a contraindication for cholangiojejunostomy. 2 The proximal jejunum and the jejunum are anastomosed to form a Y shape. This is an improvement of Zeng Xianjiu's surgical procedure through clinical research. He proposed the proximal end. The jejunum and the transverse ileum of the distal jejunum were end-to-end anastomosis, and the jejunum was sutured in a parallel position 6 to 8 cm long. The chyme of the proximal jejunum could be squirmed into the distal jejunum. This method is simple and widely used in clinical practice. In order to solve the adverse effects of intestinal contents, there are bile duct-intermediate jejunum-duodenal anastomosis; bile duct-intermediate jejunal papillary formation-duodenal anastomosis; jejunum segmental jejunum for artificial jejunal intussusception, etc. Introduced in the relevant section. Treatment of diseases: benign bile duct cholangiocarcinoma Indication Roux-en-Y biliary jejunostomy is suitable for: 1. Benign extrahepatic bile duct stricture. Benign bile duct stricture below the common hepatic duct is mostly associated with injury. After surgery (laparoscopic cholecystectomy or open cholecystectomy), extrahepatic bile duct stenosis accounts for 80% to 90% of extrahepatic bile ducts during surgery. Secondary inflammation, infection and ischemia secondary to bile duct after surgery are only 10%~ 20%. 2. The end of the common bile duct is narrow. Inflammatory scar stenosis at the end of the bile duct, inflammatory changes in the biliary tract can be seen, and the sphincter is incomplete. At this time, although the 8mm probe can be passed, due to sphincter dysfunction, there is still bile stagnation. Caused by stones at the end of the bile duct. Chronic pancreatitis can also cause narrowing of the end of the bile duct. 3. Duodenal nipple opening diverticulum, which causes repeated pancreatitis and cholangitis. 4. Congenital biliary malformations, such as congenital cystic dilatation of the common bile duct, biliary reconstruction after cystectomy. 5. Biliary digestive tract stenosis. 6. Unresectable cholangiocarcinoma and pancreatic head cancer. Contraindications If the intrahepatic stenosis or stones above the common bile duct are not treated, the common bile duct jejunostomy should not be performed. Otherwise, the postoperative not only can not play a therapeutic role, but can increase the intrahepatic bile duct infection and further worsen the condition. Preoperative preparation 1. Patients with jaundice or recurrent episodes of cholangitis, or have had biliary tract surgery once or several times, must make a correct evaluation of the patient's general condition, and elderly patients should be carefully examined for the function of various organs of the body. Perform the necessary treatment. 2. Correct malnutrition, anemia and hypoproteinemia. Hemoglobin is above 100g/L, and plasma albumin protein is safer than 30g/L. 3. Patients with jaundice should check the original time of prothrombin before surgery. If prothrombin is prolonged, 20 mg of vitamin K11 per day is injected, and prothrombin time cannot be restored to near normal, or liver enzymology If there is a significant abnormality, if it is not an emergency operation, the application of Chinese and Western medicine treatment, after the situation has improved, immediate surgery, lifting the obstruction of jaundice. 4. Recently, the choledochitis was applied to the antibiotics 1 day before surgery, and continued to be applied for 3 to 5 days during and after surgery. The elderly should be routinely applied antibiotics before and during surgery. The patient should be used once a day for 1 day. The dosage should be determined according to the condition. At the same time, the liver and kidney function should be noted. The amount of renal insufficiency can be less than that of the average adult. 3. 5. For elective surgery, the following checks should be made: (1) Liver function tests: including transaminase, alkaline phosphatase, transpeptidase, bilirubin, plasma protein, prothrombin time and activity, blood glucose, serum triacylglycerol, cholesterol. (2) renal function test: blood urea nitrogen, creatinine. (3) Electrocardiogram examination, elderly or patients with heart disease should do echocardiography or 24h dynamic electrocardiogram. (4) Pulmonary function test: general patients undergo chest X-ray or chest X-ray examination, elderly patients or those with respiratory diseases should perform lung function tests and blood gas analysis. (5) Serum electrolyte examination. (6) Iodine allergy test. (7) Fasting water in the morning of surgery and placing the stomach tube. (8) Infected with aphids, stools found in the stool, should be treated with mites before surgery. Surgical procedure Incision Incision under the right margin. Generally take 3cm under the right costal margin, the midline of the abdomen starts to the front of the iliac crest, and the right rectus abdominis and abdominal white line are cut off. Electric knife cutting takes less time. The advantage of this incision is that most of the operation is mainly performed on the transverse colon and its mesentery. Postoperative intestinal adhesion obstruction rarely occurs. For elderly patients, there is very little chance of incision. 2. Exploring The abdominal cavity should be fully explored after laparotomy. Determine the peritoneal exudate, omental adhesion, liver, gallbladder, spleen, pancreas, kidney and gastrointestinal, pelvic cavity must be checked. Focus on the liver and biliary tract, combined with the results of preoperative imaging studies to further clarify the nature and extent of the lesion, especially the presence or absence of lesions in the intrahepatic bile duct, and the nature of the lesions in the lower end of the bile duct, especially when the lower end of the bile duct and bile duct cancer coexist, not Only satisfied with bile duct stones and neglect the existence of cancer. If retrograde cholangiopancreatography is performed before surgery, the duodenal ampulla has undergone endoscopic direct examination or histopathological examination, which will be very helpful for exploration and judgment during surgery. of. The probe can also provide the presence or absence of liver fibrosis and long-term bile stasis due to bile duct lesions. In the first laparotomy without abdominal adhesion, the gallbladder and common bile duct are not difficult to expose. The dilated common bile duct is easily distinguished in the shallow front of the hepatoduodenal ligament. Because of bile duct stricture, repeated suppurative cholangitis or bile duct injury, it is not easy to expose the bile duct due to surgery and inflammation adhesion. In this case, the liver should be separated first, pay attention not to damage the transverse colon and duodenum. Carefully separate the gastric and duodenum that adhere to the anterior side of the hepatoduodenal ligament and the liver and stomach ligament. If the scar tissue is very tight, sharp separation, scarring, and blunt dissection are applied. At the site of the biliary general tube, a fine needle No. 7 can be used to puncture the bile to help determine the position of the bile duct. Percussion examination of the duodenum and pancreatic head bile duct. 4. Cholecystectomy, common bile duct incision exploration. 5. Common bile duct preparation 1 common bile duct jejunum Roux-en-Y lateral-lateral anastomosis: free proximal common bile duct, cut open to the left and right hepatic duct opening, distal cut to the upper edge of the duodenum, exhaust bile, filled with dry gauze; 2 common bile duct jejunum Roux-en-Y end-to-side anastomosis: free upper bile duct to the upper edge of the duodenum, inflammation around the common bile duct, adhesion is light, can be used to bluntly separate the posterior wall of the common bile duct, with curved vascular clamp The posterior wall of the bile duct cuts the common bile duct laterally. If the adhesion is very heavy, the side is separated by the side and the bile duct is cut laterally. Remove the debris or debris from the distal end of the common bile duct, and then suture the end of the bile duct. If the common bile duct is damaged during abdominal surgery, the bile duct end should be searched, and then cut to the common hepatic duct to the hepatic hilum for anastomosis. When separating the posterior wall of the common bile duct, care should be taken not to damage the portal vein. When there is more bleeding due to inflammation, it should be clearly distinguished. Do not blindly clamp or cut. As mentioned above, the characteristics of the blood supply to the common bile duct wall, the arterial blood vessels travel mainly along the bile duct at 3 o'clock and 9 o'clock, and the blood flow from the duodenum end to the hepatic end. The hemostasis must be thorough, around Do not make too much separation to avoid affecting the blood supply to the common bile duct. 6.Roux-en-Y jejunum preparation The duodenal jejunum is about 15cm. The vaginal mesenteric vascular arch is selected well. The jejunum is cut off, the distal end of the jejunum is closed, and the suture is retained for traction. Check the jejunal end of the blood supply is good, the color is normal. The proximal jejunum was semicircular end-end anastomosis of the jejunal jejunum at a distance of 55 cm from the jejunum, and the jejunal jejunal wall was sutured to form a Y-shape. The contents of the proximal jejunum will enter the descending distal jejunum through the anastomosis and run down the peristal sinus, so that it will not flow back into the distal jejunum, thus avoiding the possibility of ascending infection. Suture the pores between the mesentery of the jejunum. 7. Place the jejunum through the colon and lift it to the hepatoduodenal ligament In the avascular region of the left mesentery of the middle cerebral artery, a small incision is made. The incision should be right-to-right, and the jejunal end of the line should be lifted from the pore. The action should be gentle. The side wall of the jejunum generally does not cause mesangial vessels. Too tight. 8. Bile duct jejunostomy 1 side-to-side anastomosis: the incision was made on the opposite side of the mesentery at the end of the jejunum 5 cm, the length was equivalent to the bile duct opening, the whole layer was sutured intermittently, the spacing was 0.3 cm, and the suture was sutured with 4-0 synthetic suture or 3- 0 shaping stitching. 2-end-side anastomosis: The specific procedure is the same side-to-side anastomosis. 9. Close the transverse mesenteric pores to prevent the formation of internal hemorrhoids. 10. Place a closed silicone tube at the back of the biliary anastomosis and poke out from the outside of the incision to prevent the formation of the incisional hernia. 11. Check the dressing and instruments and close the abdominal cavity.