To compare the different hepatic portal exposure techniques in Kasai surgery during their different perioperative periods / 中华肝胆外科杂志

Objective:To compare the impact of different portal exposure techniques in the Kasai surgery on children with type Ⅲ. biliary atresia during their different perioperative periods.Methods:A retrospective study was performed on the data of children with type Ⅲ. biliary atresia who underwent Kasai surgery at Fujian Children's Hospital from January 2017 to October 2020. Of 45 children enrolled in this study, there were 24 males and 21 females, aged (71.3±21.0) days. Patients who had left and right branches of the portal vein and the left and right hepatic arteries in the portal area being completely freed and elastically stretched during the Kasai operation were included into the free group ( n=22) and the remaining patients were included in the control group ( n=23). Postoperative hospital stay, postoperative direct bilirubin levels, postoperative complications and transplant-free survival after the Kasai operation were compared between the 2 groups. Results:Postoperative hospital stay of (17.1±4.4) d in the free group was significantly lower than that in the control group (20.1±5.4) d, ( t=2.07, P=0.044). The direct bilirubin level at 3 months after surgery for the control group was 30.0 (109, 108.0)μmol/L, which was significantly higher than that of 14.5 (4.0, 37.5) μmol/L in the free group ( Z=-2.16, P=0.031). Twenty-one patients (91.3%) in the control group had frequent attacks of postoperative cholangitis, compared with 13 patients (59.1%) in the free group. The difference was statistically significant (χ 2=4.69, P=0.030). Eleven surviving patients (47.8%) in the control group did not undergo liver transplantation at one year after surgery, compared with 15 patients (68.2%) in the free group. At two years after surgery, 7 surviving patients (30.4%) in the control group did not undergo liver transplantation compared with 10 patients (45.5%) in the free group. Conclusion:For children with type Ⅲ. biliary atresia, completely freeing the left and right branches of portal vein, and left and right hepatic arteries in the liver portal area, and elastically stretching these vessels to expose the portal area of the liver during Kasai surgery increased surgical safety and reduced hospital stay.

Analysis of risk factors of postoperative biliary leakage in patients with perihilar cholangiocarcinoma / 中华肝胆外科杂志

Objective:To analyse the risk factors of biliary leakage after surgical resection in patients with perihilar cholangiocarcinoma (PHCC).Methods:The medical data on 179 patients who underwent surgical resection for PHCC at the Department of Hepatopancreatobiliary Surgery, Ningbo Medical Centre Lihuili Hospital, Ningbo University from April 2000 to April 2020 were collected, and 160 patients were finally enrolled into this study. There were 86 males and 74 females, aged (63.4±10.8) years. The 44 patients with class B biliary leakage and the 5 patients with class C biliary leakage were classified into the biliary leakage group, while the remaining 111 patients were classified into the control group. Risk factors of biliary leakage were analysed by univariate and multivariate logistic regression analyses.Results:Operation time ≥360 min, resection and reconstruction of hepatic hilar vessels on the preserved side of liver and number of bile duct openings of >3 in remnant liver were significantly higher in the biliary leakage than the control group (all P<0.05). Multivariate analysis showed that resection and reconstruction of hepatic hilar vessels on the preserved side ( OR=2.322, 95% CI: 1.078-5.002, P=0.028) and 3 or more bile duct openings in the remnant liver ( OR=2.656, 95% CI: 1.198-5.892, P=0.016) were significantly associated with biliary leakage. Conclusion:Resection and reconstruction of hepatic hilar vessels on the preserved side of liver and 3 or more bile duct openings in remnant liver were independent risk factors for biliary leakage after PHCC resection.

Efficacy of percutaneous jejunal drainage in treatment of hepatolithiasis after choledochojejunostomy / 中华肝胆外科杂志

Objective:To study the feasibility and safety of percutaneous jejunal drainage in treatment of hepatolithiasis after choledochojejunostomy.Methods:The clinical data of 24 patients with hepatolithiasis after choledochojejunostomy treated by percutaneous jejunal drainage at the Cholelithiasis Center, Shanghai East Hospital Affiliated to Tongji University from May 2021 to May 2022 were retrospectively analyzed. There were 16 males and 8 females, aged (50.46±10.89) years old. Ultrasound and X ray guided percutaneous jejunography was performed under local anesthesia for patients with hepatolithiasis after choledochojejunostomy. Then the fistula was directly dilated to 16.0Fr, and percutaneous jejunal choledochoscopy was performed 3 days later. The success rate, complication rate and stone removal rate were analysed.Results:Twenty-four patients were treated with percutaneous jejunography, with a success rate of 79.2%(19/24), including 19 patients after anterior colonic cholangiojejunostomy with a success rate of 94.7%(18/19), and 5 patients after retrocolonic cholangiojejunostomy with a success rate of 20.0%(1/5). There was no complication including bleeding, intestinal leakage and bile leakage. In 19 patients with successful percutaneous jejunography, the success rate of fistula dilation was 100%(19/19), and there was no complication. Five patients with failed percutaneous jejunography underwent open choledocholithotomy through the jejunal output-loop, and bile leakage occurred in one patient. Thirteen patients with anastomotic stenosis, 5 with intrahepatic biliary strictures, and 6 with anastomotic and intrahepatic biliary strictures were diagnosed by choledochoscopy and selective cholangiography in these 24 patients. After choledochoscopic electrotomy, cylindrical balloon dilation, stone removal, stenting and other treatments, the stenosis relief rate was 100%(24/24), and the clearance rate of intrahepatic bile duct stones was 91.7%(22/24).Conclusion:Percutaneous jejunal drainage was a feasible, safe and minimally invasive method for treatment of hepatolithiasis after choledochojejunostomy. The procedure was especially suitable for patients with anterior colonic cholangiojejunostomy.

Comparative study of two biliary drainage strategies in perioperative period of cholangiojejunostomy / 国际外科学杂志

Objective:To evaluate the clinical efficacy of PTCD and ERCP combined with T tube in the perioperative period of biliary anastomosis in patients with moderate to severe obstructive jaundice.Methods:The data of 93 patients with moderate obstructive jaundice who met the inclusion criteria and planned to undergo cholangiojejunostomy (including reconstruction after pancreaticoduodenectomy) in Shuguang Hospital Affiliated to Shanghai University of traditional Chinese medicine from March 2015 to December 2021 were collected. According to the perioperative drainage strategy, 54 cases were divided into PTCD group and 39 cases were divided into ERCP combined with intraoperative T-tube drainage group. Retrospective cohort method was used to analyze the bile duct diameter, postoperative hospital stay, operation cost, time of jaundice reduction, degree of jaundice reduction, average postoperative bile loss, postoperative bile leakage, abdominal infection of the two groups. The measurement data were expressed as mean ± standard deviation( ± s), and t test was used for comparison between groups. The data of skewed distribution were represented by M( Q1, Q3), and nonparametric rank sum test was used. Chi-square test was used for counting data. Results:The preoperative yellowing reduction time, operation cost, mean bile loss 7 days after operation, time to remove biliary drainage tube, and postoperative hospital stay in PTCD group were (5.9±3.1) d, (59 846.3±9 129.7) yuan, 210.0(170.0, 325.0) mL/d, (18.4±5.6) d, and(10.7±4.4) d, respectively, while those in ERCP group were (9.5±4.4) d, (77 833.1±12 164.5) yuan, 285.0(225.0, 370.0) mL/d, (41.4±17.2) d and(15.3±5.6) d, respectively. The difference between the two groups was statistically significant ( P<0.05). There was no significant difference between the two groups in general condition before drainage, cholangitis and hemorrhage after drainage, degree of jaundice reduction, bile leakage after surgery, abdominal infection, etc. Conclusions:When performing biliary enterostomy in patients with moderate or above obstructive jaundice, PTCD and ERCP combined with intraoperative T-tube drainage are effective means to improve the safety of perioperative period. PTCD has some advantages in reducing jaundice efficiency, operation cost and rapid postoperative rehabilitation.

The comparison of desflurane and sevoflurane on postoperative hepatic function of infant with biliary atresia undergoing Kasai operation

BACKGROUND: Biliary atresia is an extrahepatic progressive obliterate cholangiopathy that occurs in infants. Kasai procedure, a surgical method that can help re-establish bile flow from the liver into the intestine, is its first line treatment. Since infants with biliary atresia already have advanced hepatic dysfunction, all kinds of schemes should be considered to minimize further liver damage during surgery. The objective of this study was to compare the postoperative hepatic functions between the two commonly used inhalational anesthetics in infants undergoing the Kasai procedure (i.e., desflurane and sevoflurane). METHODS: This prospective, randomized, double-blind, single-center, and parallel group study included 40 children undergoing Kasai procedure. They were randomly allocated to Group S (sevoflurane) or Group D (desflurane). All the patients were anesthetized with designated anesthetic agent with the end-tidal concentration of about 0.8–1 minimum alveolar concentration. Postoperative hepatic functions were assessed by aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, prothrombin time, and total bilirubin. RESULTS: A total of 38 patients were selected for the study. In both groups, AST, ALT were increased in magnitude to the peak on postoperative day 0 and decreased to preoperative value at postoperative day 3. There were no significant differences between the groups in any laboratory results related to liver function. CONCLUSIONS: Sevoflurane and desflurane, inhalation anesthetics for maintaining anesthesia used in infants undergoing the Kasai procedure, did not show any difference in preserving postoperative hepatic function.

The effect of modified basin-forming biliary-intestinal anastomosis on recurrent stones after choledochojejunostomy / 中华普通外科杂志

Objective@#To evaluate the effect of modified basin-forming anastomosis for recurrent stones after choledochojejunostomy.@*Methods@#A total of 83 patients suffering from recurrent choledocholithiasis undergoing re-operation at our department from Jan 2013 to Dec 2017 were divided into two groups. 46 patients treated by routine choledochojejunostomy(controls), and 37 patients by modified basin-forming biliary-intestinal anastomosis(study group).@*Results@#Control vs study group: intraoperative blood loss were(262±86)ml vs(121±77)ml, blood transfusion: (139±256)ml vs(22±92)ml , and operative time: (316±75)min vs(245±73)min , the number of patients with liver resection were 8 vs 3(all P<0.05). The number of patients with fever, biliary tract infection, abdominal infection, anemia, and postoperative hospital stay were 14 vs 4, 12 vs 3, 7 vs 0, 11 vs 1, (11.5±1.8) d vs (8.5±1.9) d (all P<0.05).@*Conclusions@#The modified basin-forming biliary-intestinal anastomosis is a simple, safe and effective surgical method for recurrent choledocholithiasis after choledochojejunostomy.

The effect of modified basin-forming biliary-intestinal anastomosis on recurrent stones after choledochojejunostomy / 中华普通外科杂志

Objective To evaluate the effect of modified basin-forming anastomosis for recurrent stones after choledochojejunostomy.Methods A total of 83 patients suffering from recurrent choledocholithiasis undergoing re-operation at our department from Jan 2013 to Dec 2017 were divided into two groups.46 patients treated by routine choledochojejunostomy (controls),and 37 patients by modified basin-forming biliary-intestinal anastomosis(study group).Results Control vs study group:intraoperative blood loss were(262 ±86)ml vs(121 ±77) ml,blood transfusion:(139 ±256)ml vs(22 ± 92) ml,and operative time:(316 ± 75) min vs (245 ± 73) min,the number of patients with liver resection were 8 vs 3 (all P＜0.05).The number of patients with fever,biliary tract infection,abdominal infection,anemia,and postoperative hospital stay were 14 vs 4,12 vs 3,7 vs 0,11 vs 1,(11.5 ± 1.8) d vs (8.5 ± 1.9) d (all P ＜ 0.05).Conclusions The modified basin-forming biliary-intestinal anastomosis is a simple,safe and effective surgical method for recurrent choledocholithiasis after choledochojejunostomy.

Hepato-intestinal anastomosis in the treatment of complex stricture of high bile duct / 中华普通外科杂志

Objective To evaluate hepato-intestinal anastomosis in the treatment of complex stricture of high bile duct.Methods From Jan 2010 to Dec 2016,43 patients undergoing traditional biliary-intestinal anastomosis were grouped into control,45 patients undergoing hepato-intestinal anastomosis were allocated into study group.Results (1) Control vs study grounp,the operative time was (24 ±3)min vs.(15 ± 3)min,intraoperative blood loss and blood transfusion were (384 ± 51)ml vs.(280 ± 41) ml,(649 ± 3) ml vs.(454 ± 8) ml,number of patients with intraoperative blood transfusion,and liver resection were 10 vs.3,and 8 vs.3 respectively,with statistically differences (t =12.48,10.46,144.65,x2 =43.68,49.50,all P ＜ 0.05).(2) Postoperatively efficacy:fever was in 7 vs.3 cases,incision infection in 5 vs.3 cases,abdominal infection was in 5 vs.2 cases,biliary fistula was in 7 vs.3 cases,number of un-planed readmission was in 7 vs.3 cases,and postoperative hospital stay were (14.3 ± 1.5) d vs.(10.7 ± 0.7) d,respectively,between the control group and the study group,with statistically differences (x2 =52.55,58.91,62.23,52.55,52.55,t =16.28,all P ＜0.05).(3) Follow-up situation:all the 88 patients were followed-up for 6 to 96 months (median time,30 months).Biliary restenosis occurred in 5 vs.1 patients between the control group and the study group,respectively,with statistically differences (x2 =65.64,P ＜ 0.05).Conclusions Hepato-intestinal anastomosis is effective in the treatment of complex stricture of high bile duct.

Effects of three suture techniques on complications after choledochojejunostomy / 临床肝胆病杂志

ObjectiveTo observe the effects of different suture techniques on complications after choledochojejunostomy. MethodsA retrospective analysis was performed on the clinical data of 162 patients who underwent choledochojejunostomy from January 2005 to December 2014 in our hospital. The patients were divided into group A undergoing simple interrupted suture (n=68), group B undergoing simple continuous suture (n=45), and group C undergoing parachute type continuous suture (n=49). The intraoperative conditions and postoperative complications were compared between the three groups. Comparison of continuous data between the three groups was made by ANOVA and pairwise comparison between any two groups was made by LSD t-tests; comparison of categorical data between the groups was made by chi-square test. ResultsThe anastomosis time and the rate of T-tube insertion showed significant differences between the three groups (P＜0.05). Groups B and C had significantly shorter anastomosis time than group A(P＜0.001), but there was no significant difference in the anastomosis time between groups B and C (P＞0.05). Among the three groups, group A had the highest rate of T-tube insertion; group B had the second highest rate; group C had the lowest rate. Significant differences were found between any two groups in the rate of T-tube insertion by pairwise comparison (P＜0.05). However, there were no significant differences between the three groups in the incidence rates of postoperative bile leakage and choleperitonitis (P＞0.05). There was significant difference in biliary stricture between the three groups in the follow-up examination 6 months after surgery (P＜0.001) and the differences analyzed by pairwise comparison were also significant (P＜0.05). Among the three groups, the degree of biliary stricture in the group A was the highest and that in the group C was the lowest. ConclusionParachute-type continuous suture is a fine suture technique for choledochojejunostomy, which can reduce the anastomosis time, the rate of T-tube insertion, and the degree of biliary stricture.

Effects of three suture techniques on complications after choledochojejunostomy / 临床肝胆病杂志

ObjectiveTo observe the effects of different suture techniques on complications after choledochojejunostomy. MethodsA retrospective analysis was performed on the clinical data of 162 patients who underwent choledochojejunostomy from January 2005 to December 2014 in our hospital. The patients were divided into group A undergoing simple interrupted suture (n=68), group B undergoing simple continuous suture (n=45), and group C undergoing parachute type continuous suture (n=49). The intraoperative conditions and postoperative complications were compared between the three groups. Comparison of continuous data between the three groups was made by ANOVA and pairwise comparison between any two groups was made by LSD t-tests; comparison of categorical data between the groups was made by chi-square test. ResultsThe anastomosis time and the rate of T-tube insertion showed significant differences between the three groups (P＜0.05). Groups B and C had significantly shorter anastomosis time than group A(P＜0.001), but there was no significant difference in the anastomosis time between groups B and C (P＞0.05). Among the three groups, group A had the highest rate of T-tube insertion; group B had the second highest rate; group C had the lowest rate. Significant differences were found between any two groups in the rate of T-tube insertion by pairwise comparison (P＜0.05). However, there were no significant differences between the three groups in the incidence rates of postoperative bile leakage and choleperitonitis (P＞0.05). There was significant difference in biliary stricture between the three groups in the follow-up examination 6 months after surgery (P＜0.001) and the differences analyzed by pairwise comparison were also significant (P＜0.05). Among the three groups, the degree of biliary stricture in the group A was the highest and that in the group C was the lowest. ConclusionParachute-type continuous suture is a fine suture technique for choledochojejunostomy, which can reduce the anastomosis time, the rate of T-tube insertion, and the degree of biliary stricture.

Alerta amarelo: icterícia após duas semanas de vida é uma urgência pediátrica / Yellow alert: icterus after two weeks of life is equal of medical evaluation

A colestase neonatal manifesta-se clinicamente com icterícia, colúria, hipocolia ou acolia fecal. Reveste-se de grande importância, uma vez que requer propedêutica urgente e precisa, com o propósito de definir o diagnóstico e tratamento. Diante de todo recém-nascido cuja icterícia persista além dos 14 dias de vida, impõe-se a dosagem das bilirrubinas (total e fração) e a observação da coloração das fezes e urina. Uma vez confirmada a colestase, é necessário o encaminhamento urgente para umcentro de referência. Para investigação da causa da colestase, o uso de protocolo sistemático é útil para agilizar o diagnóstico. Atresia biliar, uma das principais causas de icterícia colestática, necessita de correção cirúrgica antes dos 60 dias de vida. Tal procedimento mostra-se bem-sucedido em 70 a 80% dos pacientes operados antes dessa idade. O encaminhamento tardio dos pacientes com suspeita de AB constitui um dos principais fatores para o fracasso da correção cirúrgica. Por isso, a divulgação da importância da análise da cor das fezes e da dosagem de bilirrubinas, a partir de campanhas como alerta amarelo, é necessária e deve atingir não apenas os pais, mas também os profissionais da saúde...

Neonatal cholestasis manifests clinically with jaundice, dark urine, fecal acholia or hipocholia. It is of great importance, since it requires urgent and precise propaedeutics to define diagnosis and treatment. Before every newborn whose jaundice persists beyond 14 days of life, it is necessary the dosage of bilirubin (total and fraction) and the color observation of feces and urine. Once confirmed cholestasis, it is required urgent transfer to a referral center. To investigate the cause of cholestasis, the use of systematic protocol is useful to accelerate the diagnosis. Biliary Atresia (BA), a major cause of cholestatic jaundice, requires surgical correction before 60 days of life. This procedure is successful in 70-80% of patients operated before this age.The late referral of patients with suspected BA is one of the main factors for the failure of surgical correction. Therefore,disclosure of the importance of analyzing the color of feces and the determination of bilirubin through campaigns such as yellow alert is required and must reach not only parents, but also health professionals...

Pull-in small bile duct's choledochojejunostomy in rabbits / 中华肝胆外科杂志

Objective To investigate the effect of Pull in choledochojejunostomy which apllied in rabbits' Small bile duct construction on prevention of anastomosis stenosis and potential mechanisms.Methods A total of 21 rabbits were randomly assigned to three groups(n=7).Group A underwent a simple laparotomy (SL),group B biliary-enteric sutured by mucosa to mucosa Choledochojejunostomy (CJ) and group C Pull-in Choledochojejunostomy(PCJ).TBil and DBil were test in 2,4,8 weeks.The tissue of bile duct and anastomotic stoma were collected after Rabbits was killed in 8 weeks.The diameter of bile duct lumen,anastomotic stoma and the thickness of bile duct were measured respectively.Pathological changes of anastomotic stoma were observed and ki67 expression was studied by Immunohistochemical staining.Results (1)Bilirubin level was nomal in group A and C,but significantly higher in group B(P＜0.01).(2)Anastomotic stoma in group C was larger than that in group A and even more than that(completely closed) in group B.There was also statistically significant difference in the diameter of anastomotic stoma,C＞A＞B(P＜0.01).The diameter of bile duct lumen and the thickness of bile duct showed the similar results,B＞C＞A(P＜0.01).(3) As for the inflammatory studies,Group B was observed with significant infiltrated neutrophils compared with group C.Furthermore,cytokine studies showed that the expression of Ki67 index around anastomosis was significantly difference among three groups,B＞C＞A(P＜0.01).Conclusions The studies suggested that pull-in choledochojejunostomy which apllied in rabbits' small bile duct reconstruction could offer some beneficial effect in preventing anastomotic stoma stenosis.The mechanism might be through reducing the inflammatory reaction and restraining excessive hyperplasia in the area around anastomotic stoma.

Hepatectomy and porta-enterostomy for Bismuth type Ⅳ hilar cholangiocarcinoma / 中华普通外科杂志

Objective To investigate clinical result of hepatectomy and porta-enterostomy in the treatment of Bismuth type Ⅳ hilar cholangiocarcinoma.Methods Nine patients with Bismuth type Ⅳ hilar cholangiocarcinoma underwent accurate hilar resection(portal parecnchyma resection including about Ⅰ cm of the hilar part of the segments 5 and 4b and caudate lobe beyond the tumor),and the biliary drainage was reconstructed by Roux-en-Y portal parecnchyma-jejunum lpop anastomosis.None of the biliary radicals had to be ligated and all of them were drained into thus constructed"biliary pool".Results Hilar resection was successfully performed in all cases,and there was no postoperative mortality.Aspartate transaminase and alanine transaminase and serum bilirubin decreased evidently four weeks later.Three patients presented postoperative complications.One patient developed a transient anastomotic leakage,while one patient developed self-limiting hemobilia,wound infection occurred in one patient.All three patients were treated conservatively and recovered.The mean Karnofsky performance score was 86,with which they could carry on normal activity with minor symptoms of disease.Two patient died after 9 months and 17 months of extensive metastasis and intrahepatic metastasis respectively.The remaining seven patients are alive by a mean followup of 24.9 months after surgery without any signs of recurrence.Conclusions With accurate hilar resection and portal parecnchyma-to-enterostomy,the patients considerably benefit from the preservation of liver parenchyma and patent biliary drainage and radical resection.So the Hew technique prolongs the survival time and enhances the quality of life of the patients.

Clinical evaluation of Kasai′s procedure based on more than 5 year′s survivals after the surgery for biliary atresia / 中国普通外科杂志

Objective To evaluate factors influencing long-term survival of biliary atresia patients receiving Kasai procedure and the prevention and treatment of surgical complications.Methods Among 97 biliary atresia patients undergoing Kasai or Suruga operation from Mar 1989 to Mar 1999, 35 cases have survived over five years.These 35 cases were classified intraoperatively into type Ⅱ (4 cases) and type Ⅲ (31 cases).Procedures included hepaticojejunostomy (12 cases), Suruga operation (hepaticojejunostomy with a jejunal fistula in 21 cases), hepaticocystomy (2 cases).Six patients underwent second hepaticojejunostomy because of porta hepatis obstruction.Results (1) Eighteen patients suffered from early cholangiolitis, and four cases developed late cholangiolitis, 5-8 years after closing the ascending stoma.(2) Five cases presented upper digestive tract hemorrhage caused by portal hypertension.(3) All patients were followed up from 5 to 15 years with 2 deaths.Conclusion Conventional surgical procedures still take important part in treating biliary atresia before liver transplantation is popularized.Factors influencing long term survival of patients receiving Kasai′s operation include age at operation, pathological classification of extrahepatic bile duct, with or without cholangitis after operation, and portal hypertension.