Chen Dexing, Zhu Andong, Zhang Zhibo
Qianwei Hospital of Jilin Province, Changchun, China.
JSLS. 2013 Apr-Jun;17(2):178-87. doi: 10.4293/108680813X13654754535232. Epub 2013 Jun 25.
Roux-en-Y cholangiojejunostomy (RCJS) has been widely used in biliary bypass surgeries, but in most reported literature, an assisted miniincision was needed, and studies reporting total laparoscopic Roux-en-Y cholangiojejunostomy (TLRCJS) are rare. The goal of this study was to investigate how to treat hepatic portal bile duct diseases and perform jejunojejunostomy and cholangiojejunostomy totally laparoscopically. We evaluated the feasibility of TLRCJS in treating biliary tract diseases.
TLRCJS were performed in 103 patients from January 2000 to August 2011. There were 28 cases of recurrent choledocholithiasis combined with stricture of the common bile duct (CBD) after several stone extractions, 3 patients with iatrogenic bile duct injury, 24 patients with choledochal cyst, 36 patients with hepatic portal cholangiocarcinoma, and 12 patients with cancer of the pancreatic head and periampullary cancer. All surgeries were performed through 5 trocars. First, laparoscopic surgery on the CBD was performed according to the original disease. The CBD was opened and stones were extracted in choledocholithiasis patients. In iatrogenic injury patients, strictured CBD was resected and repaired. Dilated CBD or choledochal cyst with tumor was transected. In patients with malignant jaundice, the CBD was opened longitudinally. At the same time, the bile duct was prepared for cholangiojejunostomy. Second, the positions of the laparoscope and surgeons were altered. The jejunal mesentery and jejunum were transected, and side-to-side jejunojejunostomy (JJS) was performed. The laparoscope and surgeon positions were exchanged again; the Rouxen-Y biliary limb was lifted close to the residual bile duct; and side-to-side or end-to-side choledochojejunostomy (CJS) was performed. Finally, an abdominal drainage tube was placed.
All the surgeries were performed successfully. The diameter of the residual bile duct ranged from 0.4 to 3.2 cm (average, 0.9 cm). Three patients had postoperative bile leakage and were treated from 1 week to approximately 1 month with abdominal drainage. Postoperative intraperitoneal hemorrhage and stress ulcer of the stomach occurred in 2 patients with biliary tract injury combined with obstructive jaundice. One with intraperitoneal hemorrhage was cured by another laparoscopic surgery. The other patient was cured after 2 days of abdominal drainage, antacids, and hemostatic drug therapy. The follow-up duration of 95 patients was 4 to 93 months (average, 48.3 months). The follow-up rate was 92.2% (95/103). Patients with cancer died of metastasis or cachexia during 14-month follow-up with no postoperative complication. Reflux cholangitis occurred in 3 patients 2, 3, and 5 years after the operation, respectively. No anastomotic stricture or other complication was found in other patients during the follow-up.
TLRCJS is the best and first choice for patients with biliary tract diseases that need biliary-jejunal anastomosis. But it is essential that the surgeon has proficiency in laparoscopic surgeries.
Roux-en-Y胆管空肠吻合术（RCJS）已广泛应用于胆道搭桥手术，但在大多数报道的文献中，需要辅助小切口，而报道完全腹腔镜下Roux-en-Y胆管空肠吻合术（TLRCJS）的研究很少。本研究的目的是探讨如何完全腹腔镜下治疗肝门部胆管疾病并进行空肠吻合和胆管空肠吻合。我们评估了TLRCJS治疗胆道疾病的可行性。
2000年1月至2011年8月，对103例患者实施了TLRCJS。其中，28例为多次取石后复发性胆总管结石合并胆总管狭窄，3例为医源性胆管损伤，24例为胆总管囊肿，36例为肝门部胆管癌，12例为胰头癌和壶腹周围癌。所有手术均通过5个套管针进行。首先，根据原发病进行胆总管的腹腔镜手术。在胆总管结石患者中，切开胆总管并取出结石。在医源性损伤患者中，切除并修复狭窄的胆总管。切除扩张的胆总管或合并肿瘤的胆总管囊肿。在恶性黄疸患者中，纵向切开胆总管。同时，准备胆管空肠吻合的胆管。其次，改变腹腔镜和手术医生的位置。切断空肠系膜和空肠，进行空肠侧侧吻合（JJS）。再次交换腹腔镜和手术医生的位置；提起Roux-en-Y胆支靠近残留胆管；进行侧侧或端侧胆管空肠吻合（CJS）。最后，放置腹腔引流管。
所有手术均成功完成。残留胆管直径为0.4至3.2 cm（平均0.9 cm）。3例患者术后发生胆漏，经腹腔引流治疗1周左右至1个月。2例胆道损伤合并梗阻性黄疸患者术后发生腹腔内出血和胃应激性溃疡。1例腹腔内出血患者通过再次腹腔镜手术治愈。另1例患者经2天腹腔引流、抗酸剂和止血药物治疗后治愈。95例患者的随访时间为4至93个月（平均48.3个月）。随访率为92.2%（95/103）。癌症患者在14个月的随访期间死于转移或恶病质，无术后并发症。3例患者分别在术后2年、3年和5年发生反流性胆管炎。随访期间其他患者未发现吻合口狭窄或其他并发症。
TLRCJS是需要胆肠吻合的胆道疾病患者的最佳首选方法。但手术医生必须熟练掌握腹腔镜手术。
