Cystectomy and Interposition of Jejunocholangioenterostomy

Cystectomy and jejunal bile duct anastomosis for the treatment of choledochal cysts. At present, choledochal cysts have been collectively referred to as bile duct dilatation, which is a common congenital malformation in children with biliary system. The dilated bile duct is spherical and fusiform, which can affect the common hepatic duct and even the intrahepatic bile duct. Most experts tend to think that abnormal pancreaticobiliary flow is an important cause of the disease. The common bile duct and the pancreatic duct meet in advance before entering the duodenal wall. Due to the lack of Oddi sphincter, the high pressure pancreatic juice flows back to the low pressure bile duct, and the reflux pancreatic juice acts under the action of trypsin. The wall gradually expands to form a bile duct dilatation. In addition, the lower end of the common bile duct congenital stenosis or distortion, the development of the common bile duct wall, may also be the cause of choledochal cyst. Common cysts of the common bile duct are accompanied by inflammatory changes, and in severe cases, there are purulent exudates. Sometimes the bile duct wall has bile pigment stones attached. Due to the fall of the cyst, the distal bile duct can be distorted, combined with its own stenosis and degeneration, sometimes difficult to find during surgery. The cystic duct and gallbladder at the proximal end of the cyst are passively dilated. The common hepatic duct and intrahepatic bile duct can sometimes undergo different degrees of expansion. The liver has cholestasis, biliary cirrhosis can occur in severe cases, and cancer can occur in a few cases. The type of common bile duct dilatation can be divided into 3 types: 1 extrahepatic type; 2 mixed type; 3 intrahepatic type. Resection of the common bile duct cyst and bile duct anastomosis is the most reasonable treatment. Me Whorler first reported cyst drainage in 1924, but this surgery was not promoted due to the high surgical trauma and high mortality. It was not until 1959 that Alonro-lej was successfully treated with a cystectomy. In 1970, Kasai reported that 14 cases of cystectomy and jejunal Roux-Y anastomosis achieved good results, and the operation was promoted around the world. In view of the hemorrhage of cystectomy, especially in cases of inflammation, the cyst wall and the portal vein are widely adhered, difficult to separate, and easily cause massive bleeding during anatomy. To solve this problem, Todani reported in 1977 and Lilly in 1979 that the outer and inner layers of the capsule wall were separated, and then the inner wall was removed, leaving the outer wall to prevent damage to the portal vein and hepatic artery. In the lower end of the free inner wall of the capsule, it should be carefully separated, try to find the lower end of the common bile duct and properly ligature, but should prevent the abnormal confluence of the pancreatic duct. The biliary anastomosis is achieved by the interposition of the jejunum, which makes the treatment of choledochal cysts a step forward. Treatment of diseases: choledochal cysts, congenital choledochal cysts in children Indication 1. This operation is suitable for infants with common bile duct cysts, no history of cyst infection, and cases of sick children are generally better. 2. After the first-stage palliative operation, the infection is controlled, and the sick child is generally better. It is better than the first operation for more than 3 months. Surgical procedure 1. The right upper abdomen of the incision is a straight rectus incision or a oblique oblique incision. 2. After the laparotomy, the cyst is revealed, the peritoneum is cut open, the cyst wall is bluntly separated by the vascular clamp, and the portal vein and the hepatic artery are carefully separated to prevent damage during the separation process. At the same time remove the gallbladder. 3. Separation of the cyst should be carried out close to the cyst wall, and attention should be paid to the underside of the cyst to protect and protect the junction of the distal end of the common bile duct and the pancreatic duct to prevent injury. In the process of separating the cyst, it should be noted that sometimes the cyst is large, and the lower end of the common bile duct is not necessarily located at the lower end of the cyst due to gravity. 4. Cut at 0.5cm at the lower end of the common bile duct, completely remove the cyst, and remove the gallbladder and cyst together. 5. Cut the jejunum and mesangium from the duodenal jejunum 10cm, take 10~20cm jejunum, and the mesangial blood vessels are dragged to the hilar part through the transverse mesenteric hiatus. The proximal end is end-to-end with the total hepatic duct. Match two layers. The distal end of the jejunum was anastomosed to the descending part of the duodenum. In order to prevent reflux, an artificial nipple anti-backflow flap is made at the distal end of the intervening jejunum. complication 1. If the infection occurs repeatedly before surgery, the bile in the cyst has more bacteria. The open biliary anastomosis or cystectomy may contaminate the surgical field, and the abdominal cavity or wound infection may occur after operation. Therefore, preoperative and postoperative preventive Apply antibiotics and stop bleeding during surgery. Postoperative sick children with long-term fever, may have subgingival infections, may also be intracapsular infection, should be carefully examined, if necessary, X-ray abdominal plain film, B-ultrasound or CT examination, clear underarm infection, should be promptly drained. 2. The external drainage tube is dislodged or distorted, which is manifested by a sudden decrease in bile drainage. At this time, the stoma tube should be inspected, and a small amount of physiological saline can be injected to check whether the stoma tube is unobstructed. If necessary, inject 3 ml of diatrizoate 10 ml, and observe whether the contrast agent flows into the bile duct or into the free abdominal cavity under fluoroscopy. If the latter is the case, the stoma tube is detached and the bile is continuously flowing into the abdominal cavity. The stoma should be repaired immediately and the stoma can be repositioned. 3. The external drainage sick child loses a lot of bile, which can cause serious electrolyte disorder for a long time, should be promptly tested and supplemented. 4. After the biliary formation is removed, a large amount of bile flows out. The drainage port is unhealed for a long time. It is often indicated that there is obstruction at the distal end of the bile duct. Immediately, an angiographic examination should be performed. If necessary, the laparotomy should be performed again to relieve the obstruction. 5. Reflux cholangitis is mostly caused by food reflux, sometimes secondary to anastomotic stricture. The method of prevention is to prevent the backflow flap during surgery.