Jejunojejunostomy with artificial nipple

Roux-en-Y bile duct jejunostomy is the most commonly used biliary anastomosis in biliary surgery. Especially in China, primary bile duct stones and intrahepatic bile duct stones are still very common. Therefore, the application of cholangioenterostomy is also very widely. According to a national survey of surgical treatment of intrahepatic bile duct stones, 44% of 4197 patients were treated with various types of cholangioenterostomy. In addition, 74% of 728 patients treated with hepatectomy were also Different types of cholangioenterostomy are used. The main problems of the most commonly used Roux-en-Y bile duct jejunostomy are: 1 still fails to effectively solve the reflux of intestinal contents; 2 the pathophysiological changes of the digestive tract caused by the excessive upper jejunum segment. The results of clinical observations and animal experiments have confirmed that the usual Y-shaped jejunum-jejunum end-to-side anastomosis still inevitably has a reflux of intestinal contents. Intrahepatic bile duct gas accumulation is a common phenomenon after general anastomosis of the biliary anastomosis. . Some people think that if the retroperitoneal stenosis of the jejunum is about 25cm in length, it may effectively prevent reflux, but it is not. In order to reduce the reflux, there have been many measures and surgical methods. The most common one is to extend it. The length of the reverse creep is 5050 to 60 cm. Long-term peristalsis may bring two problems: one is similar to blind syndrome, and the other is similar to short bowel syndrome. Treatment of diseases: pancreatic cancer Indication Artificial nipple placement of jejunal common bile duct jejunostomy is applicable to: 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. Surgical procedure 1. The surgical procedure until the treatment of jejunal fistula is the same as that of the common bile duct jejunum. 2. Reconstruction of jejunum continuity with jejunal common jejunal anastomosis. 3. Reverse peristaltic jejunum, artificial nipple formation and insertion-matching method: Mucosal papillary flap: This procedure uses a thin, soft jejunal mucosa and submucosa to create a one-way mucosal papillary flap to prevent reflux. (1) About 4 cm away from the distal end of the free jejunal segment, circularly cut the sarcoplasmic layer of the jejunum, and pay attention to preserve the integrity of the mucosa. The incision should be inclined to the side edge of the mesentery, so that the mucosal flap is inserted into the intestinal lumen and becomes an angle of <90°. (2) Separate and remove the muscle layer within 4cm of the intestine by sharp method, and preserve the intestinal mucosa and the submucosa. This layer is thin. Although it is not too small, sometimes it is inevitable that there are small holes, but generally not It affects the operation because the valgus mucosa will be placed in the intestinal lumen. If ischemic necrosis occurs in the mucosal layer, the excess should be removed. The corresponding part of the margin of the mucosa and the margin of the pulp muscle layer is fixed by 4 fixed stitches, generally with a 3-0 suture. (3) The mucosal layer reversal and the pulp muscle layer cutting edge are aligned with the 3-0 line suture. In this step, the foreskin skin is reversely sutured when circumcision is performed. After the suture is completed, the jejunal end is an extravagant protruding mucosal layer, which is 2.0 cm long. Because the mucous membrane is soft, the tip end tends to be closed. The nipple insertion site is about 10 cm from the distal end of the jejunal anastomosis to the mesenteric margin. The incision on the jejunum still emphasizes the transverse incision to preserve the ring muscle of the intestinal wall, and simultaneously sutures the intestine and the jejunum in a distance of about 5 cm to enhance the anti-reflux effect of the nipple flap. 4. The intervening jejunal artificial nipple can be inserted into the second segment of the duodenum, the third segment of the duodenum and the upper part of the jejunum. It is mainly selected according to actual needs and pathological conditions. The results can be obtained by different surgical methods. complication Complications of general biliary surgery Acute attack of cholangitis Mainly due to repeated long-term exploration or stone removal, inappropriate biliary flushing and other irritations, cholangitis attacks, and even septic shock. 2. Bile leakage May be due to: 1 bile duct incision or T-shaped tube is not tightly sutured; 2 reactive edema, spasm, and excretion after distal exit of bile duct; 3 intrahepatic bile duct stones or residual extrahepatic bile duct stones, distal bile duct obstruction . The former two are treated in a short period of time, and most of them can be eliminated; the latter often cannot be pinched, and it is still necessary to perform fiberoptic choledochoscopy after taking an angiographic observation to remove stones and relieve obstruction. If the distal stone is incarcerated, the tube cannot be removed until it is effectively treated. 3. Under the liver or underarm abscess Mainly because the perihepatic effusion, hemorrhage and bile were not absorbed before the closure of the abdomen; no drainage or drainage failure was left. This situation, as long as it is noted, is generally less common. The nipple formation of biliary anastomosis still has: 1 jejunal vascular pedicle damage caused by intestinal wall blood circulation disorder, mostly for technical reasons. 2 duodenal anastomotic fistula, rare. 3 a large number of reflux, mostly occurred in the distal obstructive factors, such as small intestinal adhesions, partial intestinal obstruction. 4 internal hemorrhoids, the gap between the free intestinal mesenteric and the transverse mesenteric membrane is not blocked or re-cleaved. Artificial nipple placement of jejunal duodenal anastomosis can theoretically achieve: 1 short intestinal fistula, generally within 15cm, an average of about 10cm; 2 preserve the natural circulation path of bile; 3 has a certain resistance to backflow. This theoretical advantage is also supported by clinical and experimental. In the Third Military Medical University of the Chinese People's Liberation Army, 11 cases were performed from 1982 to 1984. No cases of intestinal fluid flowed out from the T-shaped drainage tube after all cases. The amylase content in the metacarpal jejunum was measured, except for one case. In addition, the rest are in the normal range, indicating no duodenal reflux; the intraductal pressure is 10-15 cmH2O, the jejunum and duodenal pressure is 9-12 cmH2O; the tincture duodenum is in the head low In the duodenum, no sputum was observed in the jejunum segment and biliary tract reflux; 2 patients underwent duodenal endoscopy 1 month after surgery, and the artificial nipple was located outside the duodenum. The wall is slightly larger than the original medial nipple, and there is no obvious edema. It can be seen that the bile is intermittently discharged through the artificial nipple. The 187th hospital of the Chinese People's Liberation Army used the intestine to reverse the formation of the nipple and partially narrow the nipple outlet. It was proved in animal experiments that it can resist the pressure above 30cmH2O in the intestine. 19 cases underwent fiberoptic duodenaloscopy to directly observe the nipple. See that it is semicircular into the intestine cavity about 1.0cm, the surface is smooth and tidy, the color is consistent with the duodenal mucosa, and the bile is discharged in a burst-like spray. From the clinical efficacy, the effect is positive. The one-way flap formed by the artificial intussusception method is similar in configuration to the nipple flap, but the fundamental difference is that it depends on the function of the intestinal wall. In the late post-operative period, the one-way flap is ineffective due to the atrophy and thinning of the intestinal wall and the degeneration of the folded intestinal wall. Therefore, some authors have proposed so-called double nested flaps, but their long-term results may be similar. The difference in the nipple flap is that the nipple protrudes into the intestine, and endoscopic observation after surgery proves that it still preserves the shape and function of the nipple. As for the long-term changes, there is currently insufficient information. However, according to recent data, the results are positive. In the Second Central Hospital of Tianjin, 120 cases of jejunal artificial nipple bile duct duodenal anastomosis were treated, 106 cases were followed up for 1 to 5 years, and 12 cases were treated with fiber duodenoscopy during 2 to 5 years after operation. Examination, see the artificial nipples that protrude into the twelve fingers are still full without atrophy. In the cases of different periods of 2 to 5 years after operation, there is no obvious change in the color of the nipple, and there is no inflammatory change. It can be seen that the bile flows out from the nipple. In the General Hospital of the Guangzhou Military Region of the Chinese People's Liberation Army, 79 patients were followed up for 0.5 to 3.5 years after surgery. Only 3 patients found that the sputum was invaded into the jejunum when the lower stomach was pressurized. In the 187th hospital of the Chinese People's Liberation Army, 98 cases were followed up for 0.5 to 5 years, and 72 cases of phagocytosis were found in the nipple examination for 1 to 5 years. The bacteriological investigation of the artificial nipple jejunum found that the detection rate of postoperative anaerobic bacteria (83.33%) was significantly higher than the detection rate of bile during surgery. Shortening the length of the interstitial fistula may be a way to reduce infection. When the bile duct is inferior, the intestinal fistula can be shortened to about 5 cm.

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