The Application Of "Inserting" Hepaticojejunostomy In Difficlut Biliary Reconstruction

Objective:To study the clinical and pathological features of the patients with difficult hepaticojejunostomy in pancreaticoduodenectomy (PD), and to assess the incidence of postoperative complications with different ways of biliary reconstruction, in-depth understanding of the pros and cons in different ways of reconstruction of biliary-enteric anastomosis.Background:In abdominal surgery, pancreaticoduodenectomy (PD), although a most difficult surgery, but it is major to surgical cure pancreatic cancer, ampullary cancer, duodenal cancer and other methods. Due to the surgical trauma, there is higher changce of postoperative pancreatic fistula, bile leakageage and other complications, which leads to longer hospital stay, higher costs. Nowadays, there have been many studies focused on how to reduce the incidence of postoperative pancreatic. Moreover, the definition and classification of pancreatic fistula have been reached a consensus, but the study of bile leakages are rare. For difficult hepaticojejunostomy, the way of biliary reconstruction remains controversial.Method:Data was retrospectively collected from January1995to December2013. Study subjects were51cases in our department who underwent PD and the diameter of the common hepatic duct is less than8mm. Patients were divided into three groups with the way of transanatomosis drainage as a criterion. The control group contained19patients with traditional hepaticojejunostomy (no tube), while15patients in one experimental group with "inserting" hepaticojejunostomy and17patients in another group with placement of T tube. Clinical data were collected, including gender, age, BMI, preoperative American Society of Anesthesiologists (ASA) score, postoperative days, diameter of common bile duct, sites of lesions and the incidence of postoperative complications. Finally statistical analysis were applied for comparison.Results:No tube group contents19patients (10males/9females,52±10years old, BMI21.5±2.6),"inserting" hepaticojejunostomy group contents15patients (M7/8females,50±9years of age, BMI20.4±2.2), T tube group contents17patients (12males/5females,54±9years of age, BMI21.4±2.9), there is no statistically significant difference (p＜0.05) between the three groups on demographic characteristics. The difference of preoperative ASA score, benign and malignant lesions, sites of lesions, diameter of common hepatic duct among the three groups is not statistically significant (p＜0.05). Mortality was not different among the groups. But three groups have significant differences in the postoperative bile leakageage, where no tube group was31%(6/19),no patients in "inserting" hepaticojejunostomy group developed bile leakageage and T tube group was35%(6/17)[P=0.037]."Inserting" hepaticojejunostomy group presented lower incidence of bile leakage than no tube group (p=0.016) and T tube group (p=0.011), while no tube group and T-tube group have no difference in the incidence of bile leakage (p=0.813). Moreover, Clavien-Dindo classification showed significant statistical differences in complications greater than grade3b among three groups [p=0.040]. Bile leakage was associated with postoperative hospital stay, mortality,hemorrhage, wound infection, pancreatic fistula, ascites, sepsis and cholangitis.7%(4/51) of patients required revisional laparotomy (no tube group21%[4/19] vs "inserting" hepaticojejunostomy group0[0/15] vs T tube group0[0/17], p=0.026). Minor T tube-associated complications occurred in12%(1/17) patients without major complication. Conclusion:"Inserting" hepaticojejunostomy can reduce the incidence of postoperative bile leakage, but the T-tube placement did not reduce the incidence of bile leakage. We believe that "inserting" hepaticojejunostomy can effectively reduce the incidence of postoperative biliary complications in difficult biliary reconstruction of PD, and improve the postoperative recovery of patients. Objective:To investigate the application and experience of "inserting" hepaticojejunostorny used in biliary reconstruction of auxiliary liver transplantation, and improve biliary reconstruction techniques.Method:From January2008to December2013,10cases of auxiliary liver transplantation biliary reconstruction cases’ clinical data were analyzed. We peformed hepaticojejunostomy in6cases (60%), while4cases (40%) with choledochocholedochostomy.The reconstruction time was25±5min. Evaluate the biliary reconstruction approach, biliary reconstruction time, postoperative biliary complications. Follow-up time was3months postoperatively.Results:No patient developed postoperative biliary complication.Conclusion:"Inserting" hepaticojejunostomy is a effective method of biliary reconstruction of auxiliary liver transplantation with advantages of less postoperative biliary complications.