| BackgroundCholedochojejunostomy is one of the most commonly way of biliary reconstruction and is an important mean to treat the diseases of biliary tract, pancreas and duodenum. Choledochojejunostomy brings a certein percentage of complications while treating the diseases, including a common complication of postoperative anastomotic stenosis. The incidence of anastomotic stenosis is even higher for those bile ducts with no obvious expansion or small diameter. It was reported that, the incidence of anastomotic stenosis reached51.7%after choledochojejunostomy of iatrogenic bile duct injury and benign bile duct stricture and it is higher for small bile ducts’ choledochojejunostomy in living donor liver transplantation. Anastomotic stenosis can cause reversal abdominal pain, fever, jaundice or even shock and long-term bile duct inflammation can also cause the canceration.It’s treatments are difficult and the effect is poor. Therefore, the prevention of postoperative anastomotic stenosis has been the difficult Problems of general Interest in hepatobiliary surgery.It is poor to prevent anastomotic stenosis of small bile duct in current. The integration of bile duct to enlarge anastomotic stoma and using biliary supporting tube for long time are the common ways to prevent anastomotic stenosis of small bile duct’s choledochojejunostomy presently. But the integration of bile is only used in hilar Bile duct stricture those bile duct can be integrated. It needs to anastomose after cutting and joining the bile duct. The complications of biliary reflux, bile leakage and the obstruction caused by bile duct’s distorting or contracturing may easily to occur because the bile duct is hard to anastomose in this condition. Placing supporting tube for long time may cause the complications of bile duct mucosal necrosis, biliary infection, biliary stricture, and biliary stones. Drainaging bile out of body will cause the lost of digestive enzymes, loss of appetite, electrolyte disorder and will affect patient’s work and life, caused great economic and psychological burden to patient. So it is uncertain about the advantages and disadvantages for placing supporting tube for long time.It is also poor in the research of the mechanism of anastomotic stenosis after choledochojejunostomy, and its mechanism was unclear at present. Some scholars believed that persistent inflammation caused by anastomotic suture and the damage of bile leakage in pinhole and fit clearance and the excessive proliferation and scar contracture cause by active proliferation of fibroblasts in the broken ends of bile duct are important factors of anastomotic stenosis after choledochojejunostomy. In addition, because the intestinal mucosa cells also have the ability to repair, intestinal mucosa cells proliferated towards the center of anastomotic stoma would cause the anastomotic stenosis of small bile duct.ObjectivesThis study devised a new way of anastomosis for rabbits’small bile duct, named pull-in choledochojejunostomy. The bile duct was directly pulled into the intestinal to anastomosis and the anastomtic stoma was without suture and the broken ends of bile duct. Theoretically, this surgery can avoid the persistent inflammation caused by suture and the damage of bile leakage in pinhole and fit clearance and avoid the excessive proliferation cause by active proliferation of fibroblasts in the broken ends, and the hyperplasia of intestinal mucosa cells toward the center of anastomosis may be inhabited by the pull-in bile duct. The purpose of this study is to observe the effect of pull-in choledochojejunostomy on prevention of anastomosis stenosis for rabbits’ Small bile duct construction and to investigate its possible mechanism by examining the inflammation and the proliferation through pathological observation and immunohistochemistry of ki67in the anastomtic stoma. It aims to offer some beneficial effect in preventing anastomotic stenosis in choledochojejunostomy in clinical.Methods 1, A total of21SPF rabbits weighted2.15-2.58kg, average2.29kg, provided by navy general hospital animal laboratory were randomly assigned to three groups (n=7).Group A underwent a simple laparotomy surgery (SL), group B Roux-en-Y choledochojejunostomy (CJ) and group C Pull-in choledochojejunostomy(PCJ).2, Operation steps:(1) Blended new Speed Sleep Ⅱ injection and Ketamine Hydrochloride injectionl.5ml and then intramuscular injected with the concentration of1ml/kg. Fixed rabbits on the operation panel, made skin in the center of the abdomen prepared, sterilizated then placed sterile drapes.(2) Group A:cut abdominal wall layer-by-layer and closed abdominal cavity directly with4-0suture.(3) Group B:cut abdominal wall got into the abdominal cavity, cut off the jejunum about15cm distal of the ligament of Traitz, got20cm jejunum in distal jejunum as Y jejunum arm, end-side anastomosed proximal jejunum to distal jejunum about20cm under the residual of Y jejunum arm and Closed the residual of Y jejunum arm. isolated bile duct bluntly, ligatured it with5-0suture adjacent to the duodenum and then cut off it. Opened a small hole at1.5cm away from the residual of Y jejunum arm and then end-side and mucosa-mucosa anastomosed bile duct to this hole with8-0absorbable suture. closed abdominal cavity with4-0suture layer-by-layer.(4) Group C:cut abdominal wall got into the abdominal cavity, cut off the jejunum about15cm distal of the ligament of Traitz, got20cm jejunum in distal jejunum as Y jejunum arm, end-side anastomosed proximal jejunum to distal jejunum about20cm under the residual of Y jejunum arm and Closed the residual of Y jejunum arm. isolated bile duct bluntly, ligatured it with5-0suture adjacent to the duodenum and then cut off it. ligatured the end of bile duct with5-0suture and cut off a single tail.Opened a about3mm small hole at1.5cm away from the residual of Y jejunum arm and another about8mm hole at3cm away from the residual of Y jejunum arm.Pull the bile duct into Y jejunum arm from the3mm hole and got out from the8mm hole. longitudinally cut the bile duct about1.5mm about5mm away from the end of bile duct to drainage bile. threaded a needle with the reserved single tail and fixed the bile duct to the Intestinal wall,then closed the8mm hole.closed abdominal cavity with4-0suture layer-by-layer.(5)ambrosiaed for48hours and Intravenously injected with glucose and sodium chloride injection plus cefazolin sodium for injection with with the concentration of0.25g/a rabbit/day for1week.3, The testing, Hemateineosin, and Immunohistochemistry:The time and the complications of Operation. The total bilirubin and direct bilirubin biochemically were tested in2,4,8weeks After surgery by drawing blood from the artery of rabbits’ ear. The tissue of bile duct and anastomotic stoma were collected after rabbits was killed in8weeks. The diameter of bile duct lumen, anastomotic stoma and the thickness of bile duct were measured respectively. Pathological changes of anastomotic stoma were observed after The tissue of anastomotic stoma was made into HemateinEosin. Ki67immunohistochemical staining was made by EnVision after antigen repairing. calculated the percentage of the positive expression cells on every section as ki67index by selecting10section per slice in the400times the microscopic view and counting100cells each view.4, Statistical analysis:Statistical software SPSS13.0were used to analyze experimental data expressing with x±s. Repeated measurement factor one way ANOVA were usded to analysis the data. It was statistically significant when P≤0.05.Results:1, The general situation:Operation time, group B (2.0+0.3) h> group C (1.4+0.2) h> group A h (0.2+0.0)(P<0.01) and the time of Roux-en-Y was longer than pull-in choledochojejunostomy. Two rabbits died in group B because of bile leakage in the perioperative period while one rabbit died because of intestinal leakage and another died because of bile leakage in group C.Rabbits in group B were started to loss of appetite with yellow color urine in2weeks after the surgery. one rabbit in group B died in7weeks after surgery because of hepatic failure.All the dead animals well supplied by surgery. The rabbits in Roux-en-Y choledochojejunostomy appeared to be obstructive jaundice and higher mortality than pull-in choledochojejunostomy. The texture and color were nomal in group A and group C after animals were killed,while cholestasis liver cirrhosis in group B with yellow, shrinkage, and hard texture liver. 2, The bilirubin was normal with no differentence in group A and group C in2,4,8weeks. Total bilirubin and indirect bilirubin in group were progressive rise by time and the rabbits appeared to be obstructive jaundice. It is significant different compared with A and group C (P<0.01).3, The thickness of bile duct (mm):The bile duct in Roux-en-Y choledochojejunostomy was significantly thickening while it is slightly in pull-in choledochojejunostomy. group Roux-en-Y choledochojejunostomy (2.0+0.1)> group pull-in choledochojejunostomy (0.5+0.1)> group simple laparotomy (0.3+0.1), with significant difference between three groups (P<0.01).4,The diameter of bile duct lumen (mm):The bile duct in group Roux-en-Y choledochojejunostomy was expanded and the diameter of bile duct lumen was significantly increased because of obstructive jaundice. The bile duct in group pull-in choledochojejunostomy was slightly expanded and the diameter of bile duct lumen was slightly larger than group simple laparotomy. Group Roux-en-Y choledochojejunostomy (10.7+0.8)> group pull-in choledochojejunostomy(2.8+0.3)> group simple laparotomy(1.5+0.2), with significant difference between three groups (P<0.01).5,The diameter of anastomotic stoma(mm):Anastomotic stoma in group pull-in choledochojejunostomy was larger than that in group simple laparotomy and even more than that(completely closed) in group Roux-en-Y choledochojejunostomy. group Roux-en-Y choledochojejunostomy (0.0±0.0)<group simple laparotomy (1.5±0.2)<pull-in choledochojejunostomy (12.4±4.2), with significant difference between three groups (P<0.01).6,,Hemateineosin for the tissue of anastomotic stoma The tissue of anastomotic stoma in Roux-en-Y choledochojejunostomy was thickening obviously with Inflammation. Roux-en-Y choledochojejunostomy was observed with significant infiltrated neutrophils compared with group pull-in choledochojejunostomy.7、Immunohistochemistry of Ki67(%):Group roux-en-Y choledochojejunostomy (68.9±10.7)>group pull-in choledochojejunostomy(34.4±9.2)>group simple laparotomy(12.4±4.2), with significant difference between three groups (P<0.01).Conclusion1, The operation is more simple with less time and less complications during perioperative period in group pull-in choledochojejunostomy compared with group Roux-en-Y choledochojejunostomy.2, The bilirubin was nomal and the bile duct was slightly expanded in pull-in choledochojejunostomy.It suggest that pull-in choledochojejunostomy can prevent anastomotic stoma stenosis and offer some beneficial effect for clinical.3, The pull-in choledochojejunostomy was observed with little infiltrated neutrophils with slight Inflammation.It can deduce that this way may avoid the persistent inflammation caused by anastomotic suture and the damage of bile leakage in pinhole and fit clearance without suture. The tested Ki67index was low through immunohistochemistry detection and the proliferation of Tissue cells was mild in group pull-in choledochojejunostomy. It can deduce that pull-in choledochojejunostomy may avoid the excessive proliferation cause by active proliferation of fibroblasts in the broken ends and the hyperplasia of intestinal mucosa cells toward the center of anastomosis.4,The tissue of anastomotic stoma in Roux-en-Y choledochojejunostomy was thickening obviously and was observed with significant infiltrated neutrophils.The persistent inflammation may cause by anastomotic suture and the damage of bile leakage in pinhole and fit clearance. The tissue of anastomotic stoma in group Roux-en-Y choledochojejunostomy was thickening obviously and Ki67index was significant higher through immunohistochemistry detection. Excessive proliferation appeared and the anastomotic stoma was closed.It may caused by the active fiber hyperplasia in the Bile duct fracture then scar contracture and intestinal mucosa cells proliferated towards the center of anastomotic stoma.5,This study showed that pull-in choledochojejunostomy can prevent rabbits’small duct anastomotic stoma stenosis. Its mechanism may be that it avoid the persistent inflammation caused by anastomotic suture and the damage of bile leakage in pinhole and fit clearance without suture and avoid the excessive proliferation cause by active proliferation of fibroblasts in the broken ends and the hyperplasia of intestinal mucosa cells toward the center of anastomosis by pull bile duct into intestinal. pull-in choledochojejunostomy needs further studied to offer some beneficial effect in preventing anastomotic stoma stenosis. |
PDF Full Text Request