空肠肠襻固定在胆肠吻合口狭窄再手术中的应用

Jejunal loop fixation in the reoperation for stricture of cholangiojejunostomy

目的探讨再次手术治疗胆肠吻合口狭窄同时行空肠肠襻固定的治疗效果及意义.方法回顾性分析2016年1月~2020年1月治疗的15例胆肠吻合口狭窄患者,全部病例均切除原吻合口重新行胆肠Roux-en-Y吻合,同时行空肠肠襻固定.肠襻固定方式分为两种,一种为胆肠吻合口近端预留10~15 cm的盲襻,并与剑突下腹壁标记固定,一种在胆肠吻合口远端10 cm左右空肠侧壁与右侧腹壁标记固定.同时经固定肠管壁中央在肠道内留置T管.结果共行盲襻固定5例,侧壁固定10例,3例发生术后并发症,其中胆瘘1例,切口感染1例,腹腔出血1例,经保守治疗后治愈,无围手术期死亡.术后随访1例发生吻合口狭窄,局麻下空肠穿刺窦道扩张,经胆道镜治疗后治愈.结论吻合口狭窄再手术时,应该考虑到术后再次狭窄的可能,术中可以固定并标记空肠肠襻.再发狭窄时可以经固定肠襻穿刺扩张行胆道镜治疗,避免再次开腹手术.

Objective To investigate the effect of jejunal loop fixation in the reoperation for anastomotic stricture after cholangiojejunostomy.Methods From Jan 2016 to Jan 2020,clinical data of 15 patients undergoing reoperations for anastomotic stenosis was analyzed retrospectively.Original anastomosis was removed and Roux-en-Y cholangiojejunostomy and jejunal loop fixation were performed in all cases.Two different types of jejunal loop fixation were used.One with a blind loop of 10-15 cm at the proximal side of the anastomosis,which is fixed with a mark of the abdominal wall under the xiphoid process.The second is to mark and fix the jejunal side wall and the right abdominal wall about 10 cm from the distal side of the anastomosis.A T tube is placed in the intestine through the central part of the fixed intestinal wall.Results Five cases underwent blind loop fixation,10 cases underwent lateral wall fixation.There were 3 complications after operation,including I case of bile fistula,I case of incision infection,I case of abdominal hemorrhage,all were cured by conservative treatment,and there was no perioperative death.One case had postoperative anastomotic stenosis in the follow-up.The patient underwent jejunal puncture under local anesthesia,and was cured by percutaneous choledochoscopy.Conclusions The possibility of restenosis should be considered in the reoperation of anastomotic stenosis.The jejunal loop should be fixed and marked during the operation in high risk patients.Once the anastomotic stricture recuiTed,choledochoscopy could be performed by puncture and dilation of fixed loop of intestine to avoid reopen surgery.