Applied Research Of Roux-en-Y And Uncut Roux-en-Y Cholangiojejunostomy For Congenital Biliary Dilatation

[Background]Congenital Biliary Dilatation(CBD),also known as Congenital Choledochal Cyst(CCC),is a common congenital malformation of the biliary system,and its main first symptoms are abdominal pain,jaundice,vomiting,fever and abdominal masses,etc.According to reports in the literature,the cancer rate of choledochal cysts is 2.5%to 26%,and increases with age.Therefore,once diagnosed,it is advisable to fight for complete cystectomy.The most commonly used digestive tract reconstruction after cystectomy is Roux-en-Y cholangiojejunostomy.This operation allows a longer jejunum below the bile duct to be used to transport bile.The chyme flows back into the bile duct for a long distance,so there is a less opportunity to cause biliary tract infection,which is the biggest advantage of this surgery.However,such surgical procedures are complicated and time consuming.In order to solve this problem,people are constantly exploring an improved method of biliary anastomosis.In 1965,Australian surgeon Warren reported a case of biliary jejunal anastomosis.This procedure does not require cutting the jejunum.The operation is relatively simple,but the procedure can not prevent the chyme from passing through the biliary anastomosis and is prone to cause reflux cholangitis.Later,the procedure was improved on this basis,the input intestine between the biliary anastomosis and the jejunal anastomosis was uncut with a silk thread,which kept the continuity of the jejunum and prevented food passing through the biliary anastomosis,this also provides a feasible solution to solve such problems.Compared with the traditional Roux-en-Y cholangiojejunostomy,the Uncut Roux-en-Y cholangiojejunstomy does not cut the jejunum,retains the normal anatomical structure and electrophysiological integrity of the jejunum,simplifies the surgical procedure,and has a smaller surgical trauma,less intraoperative bleeding loss,quicker recovery after surgery and other advantages.In addition to the rapid development of laparoscopic surgery and minimally invasive concepts in recent years,the Uncut Roux-en-Y cholangiojejunstomy has also been used more and more widely.This study used retrospective analysis to collect general clinical data,surgical status,postoperative complications,and postoperative recovery in patients who underwent both Uncut Roux-en-Y and Roux-en-Y cholangiojejunstomy.And inductive analysis to explore whether Uncut Roux-en-Y cholangiojejunstomy is safe,reliable and feasible,whether it is worth promoting and discussing its application value in laparoscopic surgery.[Objective]Study on the advantages of Uncut Roux-en-Y cholangiojejunstomy in the treatment of biliary dilatation compared to conventional Roux-en-Y cholangiojejunstomy,whether it is safe,reliable,feasible,and worth promoting;The value of Uncut Roux-en-Y cholangiojejunstomy in the treatment of biliary dilatation by laparoscopic minimally invasive surgery;To explore the limitations of Uncut Roux-en-Y cholangiojejunstomy in laparoscopic surgery for CBD,to provide clinicians with experience in diagnosis and treatment,and to improve the the understanding of surgical options for this disease,and to provide a reasonable choice of surgical methods,so that patients can get satisfactory treatment results and rapid recovery.[Methods]This study retrospectively analyzed the clinical data of 74 patients diagnosed with congenital biliary dilatation who were admitted to the Department of General Surgery,Qilu Hospital of Shandong University from January 2013 to November 2018.They were divided into three groups according to their surgical methods:RY group:Cholecystectomy,choledochal cyst resection,Roux-en-Y cholangiojejunostomy group;URY group:Cholecystectomy,choledochal cyst resection,Uncut Roux-en-Y cholangiojejunostomy group;LURY group:Laparoscopic cholecystectomy,choledochal cyst resection,Uncut Roux-en-Y cholangiojejunostomy group.Among them,30 patients in the RY group,24 patients in the URY group,and 20 patients in the LURY group.By collecting and arranging the general data and medical history of each group of patients(including patient gender,age,duration of disease,initial symptoms,clinical classification of lesions,choledochal cyst size,preoperative auxiliary examination and laboratory examination indicators,preoperative biliary puncture and drainage therapy,etc),and surgical related indicators(including operative time,intraoperative blood loss,postoperative gastrointestinal decompression time,continuous abdominal drainage time,volume of total abdominal drainage,postoperative hospital stay,postoperative intestinal function recovery time,postoperative feeding time,etc.),and perioperative complications(including anastomotic leakage,pancreatic leakage,bile leakage,ascites,wound infection,reflux cholangitis,etc.).Compare and analyze the surgery and clinical procedures of the three groups of patients undergoing different surgical method,to verify the safety and effectiveness of Uncut Roux-en-Y cholangiojejunostomy,and its application value and limitations in laparoscopic minimally invasive surgery.[Results]Through the inductive analysis of the case data of the center,the following results were obtained:Overall,74 patients in all samples successfully completed choledochal cyst resection and biliary reconstruction,including 30 patients in the RY group and 24 patients in the URY group and 20 patients in the LURY group.There were 23 males(31.08%)and 51 females(68.92%).The age ranged from 12 to 80 years,with an average of 45.78±18.74 years.First symptoms:39 cases(52.70%)with abdominal pain,6 cases(8.11%)with nausea and vomiting,13 cases(17.57%)with jaundice,0 cases(0%)with abdominal mass,and 16 cases(21.62%)with other symptoms.Clinical classification of lesions:according to Todani classification:63 cases(85.14%)of type I;11 cases(14.86%)of type IV.In terms of general patient data and medical history:between the three study samples,the gender of the patients,clinical classification of the lesion(Todani classification),initial symptoms,choledochal cyst size,preoperative tumor markers and other laboratory tests,whether preoperatively puncture the bile duct and drainage,whether accompanied by cholangitis or pancreatitis,there were no statistically significant differences in these factors,so the influence of the above factors on the study was excluded.In terms of mean age,the mean age of the RY group was 45.23±17.34 years,the mean age of the URY group was 50.67±17.78 years,the mean age of the LURY group was 37.6±16.76 years;the mean age of the LURY group was lower than that of the URY group,and there was a statistically significant difference in age between them,and there was no statistically significant difference in age between the URY group and the RY group.In terms of duration of disease,the mean duration of disease in the RY group was 916.17±1718.36 days,the mean duration of disease in the URY group was 954.75±1409.16 days,and the mean duration of disease in the LURY group was 36.5±66.35 days;the mean duration of disease of the LURY group was shorter than that of the URY group,and there was a statistically significant difference,and there was no statistically significant difference in the duration of disease between the URY group and the RY group.In terms of surgical related indicators:including intraoperative blood loss,continuous abdominal drainage time,volume of total abdominal drainage,length of bile outflow tract,Uncut ligature distance,anterior/posterior colon anastomosis,intraoperative choledochoscopy examination,cholangiography examination,amylase,etc.There was no statistical difference in these factors.Among them,the URY group was shorter than RY group in the blow factors:during operation time(183.29±29.93 mins<216 ±141.84 mins),postoperative gastrointestinal decompression/drainage time(2±0.93 days<3.23±1.43 days),postoperative intestinal peristalsis recovery time(3.13±0.74 days<4.07±1.17 days),banned diet time(3.13±0.54 days<4.031±1.07 days),and there were statistically significant differences.The during operation time of the URY group(183.29±29.93min)was shorter than that of the LURY group(330.25±102.59min),and there was a statistically significant differences;The LURY group was less than the URY group in terms of postoperative intestinal peristalsis recovery time(2.35?0.75 days<3.13?0.74 days)and postoperative hospital stay(8.70±1.38 days<11.21±5.64 days),with statistically significant difference.There were no statistical differences in the remaining aspects.In the perioperative complication rate:there were 6 cases in the RY group,the complication rate was 20%;5 cases in the URY group,the complication rate was 20.83%;4 cases in the LURY group,the complication rate was 20%.In the three groups of patients,there was no statistical difference in the total complication rate.There were no statistical differences in the types of complications as well.[Conclusions]1.Uncut Roux-en-Y cholangiojejunostomy is a safe,reliable and feasible surgical method.Compared with Roux-en-Y cholangiojejunostomy,it can achieve the same satisfactory surgical results,and it has smaller trauma,shorter postoperative recovery time and other advantages,it is worth promoting.2.Uncut Roux-en-Y cholangiojejunostomy can simplify the operation process.The operation procedure is relatively simple and time-saving.It has important application value in laparoscopic minimally invasive surgery for congenital biliary dilatation.3.Laparoscopic minimally invasive surgery for congenital biliary dilatation is less traumatic than open surgery,quick recovery after surgery,short hospital stay,But laparoscopic surgery is difficult,requires high experience and skill for the surgeon,mainly applicable to patients without recurrent cholangitis or pancreatitis.4.By using a reasonable first-stage minimally invasive bile drainage for patients with critical congenital biliary dilatation,conditions can be created for surgical resection.