Cholangiojejunostomy for multiple biliary ducts in living donor liver transplantation: A case report

BACKGROUND Laparoscopic living donor hepatectomy(LLDH)has been successfully carried out in several transplant centers.Biliary reconstruction is key in living donor liver transplantation(LDLT).Reliable biliary reconstruction can effectively prevent postoperative biliary stricture and leakage.Although preoperative magnetic resonance cholangiopancreatography and intraoperative indocyanine green cholangiography have been shown to be helpful in determining optimal division points,biliary variability and limitations associated with LLDH,multiple biliary tracts are often encountered during surgery,which inhibits biliary reconstruction.A reliable cholangiojejunostomy for multiple biliary ducts has been utilized in LDLT.This procedure provides a reference for multiple biliary reconstructions after LLDH.CASE SUMMARY A 2-year-old girl diagnosed with ornithine transcarbamylase deficiency required liver transplantation.Due to the scarcity of deceased donors,she was put on the waiting list for LDLT.Her father was a suitable donor;however,after a rigorous evaluation,preoperative magnetic resonance cholangiopancreatography examination of the donor indicated the possibility of multivessel variation in the biliary tract.Therefore,a laparoscopic left lateral section was performed on the donor,which met the estimated graft-to-recipient weight ratio.Under intraoperative indocyanine green cholangiography,4 biliary tracts were confirmed in the graft.It was difficult to reform the intrahepatic bile ducts due to their openings of more than 5 mm.A reliable cholangiojejunostomy was,therefore,utilized:Suture of the jejunum to the adjacent liver was performed around the bile duct openings with 6/0 absorbable sutures.At the last follow-up(1 year after surgery),the patient was complication-free.CONCLUSION Intrahepatic cholangiojejunostomy is reliable for multiple biliary ducts after LLDH in LDLT.

CHANGES OF GASTRIC ACID SECRETION AND SOMATOSTATIN AFTER ROUX-EN-Y CHOLANGIOJEJUNOSTOMY

The authors studied the changes of gastric acid secretion and determined the levels of somatostatin(SS) and gastrin (Gn)in blood, gastric jujce and

Comparatively lower postoperative hepatolithiasis risk with hepaticocholedochostomy versus hepaticojejunostomy

BACKGROUND: Optimal surgical technique plays a key role in preventing the postoperative recurrence of hepatolithiasis. Tian et al developed the subcutaneous tunnel and hepatocholangioplasty using the gallbladder (STHG) technique and applied it in hepatolithiasis patients who had an approximately normal gallbladder and sphincter of Oddi. However, the technique is controversial. In the present study, a canine model was established for hepatocholangioplasty (HC) and hepaticojejunostomy (HJ) to simulate STHG and Roux-en-Y cholangiojejunostomy in the clinic, respectively. Then, the alterations of bile components in the vicinity of the anastomosis were compared. This may provide an experimental guide for choosing an optimal technique for the treatment of hepatolithiasis in the clinic. METHODS: The animals were randomly separated into a control group (5 dogs) and a model group (stenosis of the common bile duct; 24 dogs). The 24 dogs in the model group were randomly divided into an HC group and an HJ group (12/group). Bile was collected from the bile duct at I and 5 months after the operation, and the bile components were determined. RESULTS: The levels of total bile acid, cholesterol, total bilirubin, and phospholipid in the HC group were higher than those in the HJ group (P<0.05). However, no statistical difference was seen in unconjugated bilirubin and calcium ions. The mucin level in bile in the HC group was lower than that in the HJ group at 5 months after the operation (P<0.05). The postoperative lipid peroxidation level was remarkably lower than that in the HJ group (P<0.05). However, the superoxide dismutase level was remarkably higher than that in the HJ group (P<0.05). Finally, a significant difference was found in the positive bacterial culture rate in bile between the groups. CONCLUSION: Changes of bile components near the anastomosis after HC might be more preferable for preventing hepatolithiasis formation than HJ.

Healing of Stoma After Magnetic Biliary-Enteric Anastomosis in Canine Peritonitis Models

Objective To assese the healing of stoma after magnetic anastomosis for the reconstruction of biliary-enteric continuity under severe inflammation. Methods Acute bile duct injury was constructed as a bile peritonitis model in mongrel dogs(n=32). Magnetic anastomosis(group A, n=16) and traditional suture anastomosis(group B, n=16) were performed to reconstruct the biliary-enteric continuity in one stage. Half of the dogs in each group were euthanized on the 30 th postoperative day, and the other half on the 90 th postoperative day to harvest the stoma region. The healing conditions of the stoma after the 2 anastomotic approaches were observed with naked eyes, under light microscope and scanning electron microscope. Results The stoma leakage rate(50% versus 0% on the 30 th postoperative day, 37.5% versus 12.5% on the 90 th postoperative day, both P<0.05) and stenosis degree(13.9%±0.3% versus 7.1%±0.3% on the 30 th postoperative day, 17.2%±0.4% versus 9.4%±0.4% on the 90 th postoperative day, both P<0.01) were significantly higher in group B than in group A. Compared with traditional manual anastomoses, the histological analysis under light and electron microscope showed a more continuous stoma with more regular epithelium proliferation and collagen arrangement, less inflammation in group A. Conclusions Magnetic anastomosis stent ensures better healing of the stoma even under the circumstance of severe inflammation.

Ectopic opening of the common bile duct into the duodenal bulb with recurrent choledocholithiasis: A case report

BACKGROUND Ectopic opening of the common bile duct is a condition with low incidence.Patients with an ectopic common bile duct opening have a high incidence of common bile duct stones and acute cholangitis.Patients with atypical symptoms and imaging findings are easily misdiagnosed;moreover,it is difficult to retrieve stones by endoscopic retrograde cholangiopancreatography,and common bile duct stones are prone to postsurgical recurrence.CASE SUMMARY A 45-year-old male patient presented with“intermittent upper abdominal pain and elevated liver enzymes for 1 wk”.Transabdominal ultrasound indicated dilation of the common bile duct and the presence of stones.Magnetic resonance imaging showed that the common bile duct was dilated with stones and that its opening was ectopic.Endoscopic retrograde cholangiopancreatography revealed an abnormal opening of the common bile duct into the duodenal bulb and the presence of common bile duct stones.Laparoscopic extrahepatic choledochectomy and hepatoenteric anastomosis were performed.After surgery,the patient recovered well and was discharged.The patient has been followed up for 2 years since the operation.He has not experienced stone recurrence,and his liver function and quality of life are good.CONCLUSION Improved understanding of ectopic opening of the common bile duct is needed for clinicians to provide patients with appropriate treatment.

Surgical Selection for Late Pancreatic Head Carcinoma without Gastric Outlet Obstruction

The effects of different surgical procedures for late pancreatic head carcinoma without gas- tric outlet obstruction were explored in order to provide theoretical basis to select a suitable operation for these patients. The clinical data of 441 cases of late pancreatic head carcinoma without gastric outlet obstruction were retrospectively analyzed. All patients were divided into 4 groups based on different surgical procedures： group A （101 cases） subjected to Roux-en-Y cholecystojejunostomy; group B （133 cases） undergoing Roux-en-Y choledochojejunostomy; group C （83 cases） given Roux-en-Y chole- cystojejunostomy combined with gastrojejunostomy; group D （124 cases） receiving Roux-en-Y chole- dochojejunostomy combined with gastrojejunostomy. Therapeutic efficacy in each group was evaluated comparatively. Both groups B and D had a lower rate of postoperative obstructive jaundice than groups A and C separately （P〈0.05 for all）. The data of mean life span showed that both groups B and D had a lower survival rate than groups A and C separately （P〈0.05 for all）. The incidence of postoperative gas- tric outlet obstruction in groups A and B was higher than that in groups C and D separately （P〈0.05 for all）. The gastrojejunostomy had no impacts on the mean life span, and there was no statistically signifi- cant difference in complications, average hospital stay （days） and median survival among four groups （P〉0.05）. For the late pancreatic head carcinoma without gastric outlet obstruction, Roux-en-~ chole- dochojejunostomy is effective for the reduction of icteric index and the incidence of recurrent jaundice, also offers an opportunity for prolonged survival. Combined use of prophylactic Roux-en-Y gastrojeju- nostomy during surgical biliary drainage is safe for advanced pancreatic carcinoma with obstructive jaundice, which can decrease the incidence of postoperative gastric outlet obstruction, and has important implications for improving outcomes.

Changes of gastric acid secretion after cholangioduodenostomy with artificial papilla and interposed jejunum

The changes of gastric acid secretion and the levels of gastrin(Gn) and somatostatin(SS) in the serum, gastric juice and mucous membrane of pyrolic antrum were determined in 10 cases with cholangioduodenostomy with artificial papilla and interposed jejunum(Inter-JCD) and 28 cases with cholangiojenunostomy with Roux-en-Y (CJR-Y). It was found that the secondary gastric hypersecretion did not occur and the levels of Gn and SS showed no significant changes after Inter-JCD but there was secondary high secretion of gastric acid, significant reduction of the synthesis and release of SS and significant elevation of the synthesis and release of Gn after CJR-Y. These findings indicate that Inter-JCD is superior to CJR-Y since it induces no disturbance of gastric acid secretion postoperatively.