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THE LONG-TERM OPERATIVE RESULTS OF CONGENITAL CHOLEDOCHAL CYST

目的 探讨先天性胆总管囊肿(congenital choledochal cyst,CCC)术式选择与疗效的关系。方法 对1989年至1998年间38例CCC手术治疗病例进行回顾性研究。结果 38例中行胆肠Roux-Y吻合术20例，肝总管十二指肠高位大口吻合术18例。术后随机获随访31例。13例胆肠Roux-Y吻合术后随访3～7年，发现5例并发十二指肠溃疡，3例并发胆道逆行感染。18例肝总管十二指肠高位大口吻合术后随访2～5年，发现1例并发胆道逆行感染，无1例并发十二指肠溃疡。结论 由于肝总管十二指肠高位大口吻合术后远期并发十二指肠溃疡发生率较低，其与胆肠Roux-Y吻合术相比，是提高CCC患儿术后远期生活质量较理想的术式。

Efficacy analysis of primary closure with two or three endoscopes through cystic duct for treatment of gallbladder stone with secondary common bile duct stones

ObjectiveTo investigate clinical efficacy and advantages and disadvantages of primary closure with two endoscopes (1aparoscope+choledochoscope) or three endoscopes (laparoscope+choledochoscope+duodenoscope) through the cystic duct for treatment of gallbladder stone with secondary common bile duct (CBD) stones.MethodsThe clinical data of 83 patients with gallbladder stones with secondary CBD stones treated by two or three endoscopes combined with CBD exploration and lithotomy and primary closure through cystic duct from January 2017 to December 2018 in the Chengdu Second People’s Hospital were collected retrospectively. Among them, 41 patients were treated by two endoscopes mode (two endoscopes group), 42 cases were treated by three endoscopes mode (three endoscopes group).ResultsThere were no significant differences in the general conditions such as the gender, age, preoperative diameter of CBD, chronic diseases, etc. between the two and three endoscopes group (P>0.05). All 83 cases underwent the operations successfully and recovered well. The success rate of operation, stone clearance rate, drainage volume of abdominal drainage tube on day 1 after the operation, time of abdominal drainage tube removal after the operation, and hospitalization time had no significant differences between these two groups (P>0.05). The time of operation, intraoperative bleeding volume, and the postoperative pancreatitis rate in the three endoscopes group were significantly more (or higher) than those in the two endoscopes group (P<0.05), but the condition of liver function recovered after the operation was better than that in the two endoscopes group (P<0.05).ConclusionsWith the strict control of the operation indications, it is safe and feasible to use two or three endoscopes through the cystic duct pathway and primary closure of CBD for treatment of gallbladder stone with secondary CBD stones. However, the choice of operative methods of two or three endoscopes should be based on the general situation of the patients before and during the operation.

Application of Laparoscope in Biliary Reoperation

目的探讨腹腔镜胆道再次手术的适应证、手术方法及临床效果。方法回顾性分析我院2003年2月至2010年11月期间46例腹腔镜胆道再次手术患者的临床资料，对术中及术后结果进行总结。结果本组45例在腹腔镜下完成手术，1例中转开腹。手术时间为45～270 min(平均120 min)，残株胆囊切除时间为(40±10) min，胆总管切开取石+T管引流时间为(150±50) min，胆总管切开取石+等离子碎石+T管引流时间为(180±40) min，术后出血及漏胆腹腔镜探查术时间为（40±15）min。结石一次性取尽23例，术后残余结石2例，住院4～21 d，平均8.6 d。胆管残余结石患者在术后1个月后经T管瘘道用胆道镜取石。术中十二指肠球部损伤3例，及时发现修补; 术后出现右侧胸腔积液4例、肺部感染2例和漏胆1例，均经非手术治疗痊愈。术后电话随访6～24个月（平均15个月），未见异常。结论腹腔镜胆道再次手术可行，并具有创伤小、恢复快等优点，但术前应严格掌握手术适应证，对手术医生的技术要求也较高。

Surgical Treatment of Congenital Choledochal Cyst (Report of 145 Cases)

Objective To present the surgical treatment experiences of congenital choledochal cyst (CCC). MethodsOne hundred and fortyfive patients in 152 CCC were analyzed retrospectively and followed in west China hospital of Sichuan university from 1964 to 1999. ResultsOne hundred and fortyfive cases underwent operation and 6 of them died after operation. The incidence of hepatocirrhosis within first year after birth is higher than those over one year old （P＜0.05）. Thirtynine cases underwent cystoduodenostomy or cystojejunostomy. One hundred and six children underwent cyst resection and biliary tract reconstruction (with single RouxY hepaticojejunostomy 48 cases, intussusceptive valve and rectangular valve to the line of RouxY hepaticojejunostomy 37 and 21 cases respectively). Seventyseven patients were followedup (means 4.68 years). Two of 3 cases with ascending cholangitis after single RouxY hepaticojejunostomy underwent reoperations with an intussusceptive valve added to the line of RouxY hepaticojejunostomy and the symptoms disappeared. All of them have a good outcome. Conclusion The younger the patients, the less severe the liver damaged, and its prognosis are better. The procedure that cyst resection totally and an intussusceptive valve added to the line of RouxY hepaticojejunostomy should be carried out early as soon as possible.

The Effects of Apoptosis and Proliferation on Choledochal Cyst

ObjectiveTo observe apoptosis and proliferation of choledochus wall epithelial cell and fibrocyte, to understand the effects of apoptosis and proliferation on choledochal cyst development.MethodsThirty two cases of cystic dilatation,35 cases of cylindrical dilatation，and 25 cases of cholangiectasis caused by choledocholith were collected. All specimens were offered by department of hepatobiliarypediatric surgery. The apoptosis related index (bcl2 and bax) and cell proliferation index (PCNA) were detected by the immunohistochemical technique; Apoptosis was detected by TUNEL method. ResultsThere was serious mucosal epithelial cell damage in cystic dilatation group. In cylindrical dilatation group there was a damage similar to that of the cystis dilatation group, but the damage was not serious. In control group there was little damage in the duct wall, but there was a low positive rate of apoptosis of 〔epithelium cell (2.74±1.00)% and fibroblast (2.95±0.87）%〕, and a low bcl2 and bax’s expression rate, and a high PCNA’s expression rate 〔epithelium cell (3.74±1.00)%, fibroblast (3.71±1.77)%〕. There was no obvious difference between cylindrical dilatation group and cystic dilatation group (Pgt;0.05): the PCNA’s expression rate was low 〔(0.99±0.51)% and (0.90±0.38)% respectively〕, the bax expression rate was high in remaining epithelial cell, and the positive rate of bax was apparently higher than that of bcl2 (P＜0.05), the positive rate of the apoptosis cell was high 〔(13.94±4.77)%, (7.51±3.46)%〕; the expression rate PCNA were high 〔(9.91±2.91)%,(9.70±3.18)%〕, and expression rate of bax’s was low in the fibre tissue, the positive rate of bcl2 was markedly higher than that of bax, and the positive rate of the apoptosis cell was low 〔(3.74±2.12)%,(4.46±2.41)%〕. There were no marked difference between the two groups (Pgt;0.05). The expression of bcl2 and bax had marked difference both in cylindrical dilatation group and cystic dilatation group and as compared to control group (P＜0.05). ConclusionApoptosis has certain promoting effect in the course of choledochal cyst formation.

Larparoscopy Combined with Choledochoscopy for Common BileDuct Exploration in Treatment Bile Duct Calculus

胆总管末端结石64例分析

Clinical Application of Fast Track Surgery in Treatment for Cholecystolithiasis Combined with Calculus of Common Bile Duct by Combination of Laparoscope and Duodenoscope

Objective　To evaluate the use of fast track surgery （FTS） in the treatment for cholecystolithiasis combined with calculus of common bile duct （CBD） by combination of laparoscope and duodenoscope. Methods　One hundred and twenty patients with cholecystolithiasis combined with calculus of CBD underwent laparoscopic cholecyst-ectomy （LC） and endoscopic retrograde cholangiopancreatography （ERCP） were divided into FTS group （n=55） and conventional group （n=65），which were accepted the perioperative therapy of FTS or conventional therapy，respectively. After operation，the incision pain，nausea and vomiting，infusion time，loss of body weight，out-of-bed time，dieting time，postoperative hospitalization，hospital costs，and complications were compared in two groups. Results　Compared with the conventional group，the postoperative infusion time，dieting time，out-of-bed time，and postoperative hospitali-zation were shorter，the incidence rates of pulmonary infection，and urinary systems infection，pancreatitis，nausea and vomiting， and incision pain were lower，the loss of body weight was lower in the FTS group （P＜0.05），but the differences of WBC and serum amylase at 24 h after operation were not significant between the FTS group and conventional group（P＞0.05）. Conclusion　The FTS is safe，economic，and effective in the treatment for cholecystolithiasis combined with calculus of CBD by combination of laparoscope and duodenoscope.

THE STUDY ON THE FAT SOLUBLE VITAMINS ABSORPTIONS AFTER OPERATIVE TREATMENT OF THE CONGENITAL BILIARY DILATATION

In order to observe the absorption of the fat solube vitamine afer operative treatment of the congenital biliary dilation(CBD),the plasma fat soluble vitamin A,D and E were determined in 57 cases of CBD at the postoperative stage and 51 cases of normal children as control.The normal values of vitamin A,D and E was 576.25±170.93ng/ml,13.21±2.20ng/ml and 7.34±1.96ng/ml respectively in control group versus 501.59±120.64ng/ml, 11.66±1.81ng/ml and 6.16±1.18ng/ml respectively in the postoperative group of CBD.The differences were significant for a long period of about 10 years,and gradually disappear after that to approach or near the normal level.Therefor,the radical operation of CBD may affect the absorption of the fat soluble vitamins.

Report of Two Cases of Type Ⅴb of Double Common Bile Duct and Review of The Literature

Object　To evaluate the significance of double common bile duct （DCBD） in hepatobiliary surgery. Metheds　The data of diagnosis and treatment of two patients with DCBD in our hospital between Jul. to Dec. 2010 were analyzed retrospective， and the related literatures were reviewed. Results　The right hepatic bile duct of DCBD due to mistaking it for cystic duct in 1 case was accidental injuried during laparoscopic cholecystectomy. Another example，the DCBD was confirmed by intraoperative exploration and choledochoscopic examination， at the same time with chole-dochal cyst， anomalous pancreaticobiliary ductal junction （APBDJ）， primary hepatolithus， and choledocholith， and then operation was performed. Two cases were typeⅤb of DCBD. A total of 32 English literatures were reviewed. Since the beginning of 1932 English literature had reported 100 cases of DCBD. The type Ⅱand typeⅢwere the most common type of DCBD， and the typeⅤonly 10 cases. There were 27 cases of DCBD in twenty-five Chinese articles from 1994 to 2012. The typeⅤwas the most common type of DCBD. The accessory common bile duct （ACBD） opening in the duod-enum， gastric， and pancreatic duct were the most common. The common complications included stone， APBDJ， choled-ochal cyst， tumor etc. Conclusions　DCBD is a very rare anatomic variation of extrahepatic bile duct， often accompanied by calculus of bile duct and common bile duct cyst， APBDJ， and other biliary anatomy abnormality， and potentially carci-nogenic potential. The existence of DCBD may increase the risk of iatrogenic bile duct injury and complexity of biliary operation. In view of this， this abnormality of extrahepatic duct should be paid with close attention during operation.