Surgical paper XVI

A case of plastic tube foreign body in the bladder

Patient Information

• Gender: Male
• Age: 20
• Occupation: Farmer
• Hospital Admission Number: 16318

History

On April 5, 1990, out of curiosity and playfulness, the patient self-inserted a 35-cm hollow plastic tube designed for hair-tying into his bladder via the urethra and was unable to remove it. He subsequently developed symptoms of lower urinary tract irritation, including frequent urination, urgency, and painful urination. Local hospital urine tests revealed pyuria (++), but a plain film of the bladder was reported as negative. Due to the concealment of this medical history, treatments for cystitis were ineffective. The patient was admitted to the hospital on December 3, 1990.

Physical Examination

General conditions were normal. Urinalysis showed red blood cells (++) and pyuria (x10). B-mode ultrasound revealed a hyperechoic mass within the bladder. A plain film of the bladder showed a circled mass (Figure 1). The diagnosis was a foreign body in the bladder accompanied by stone formation.

Surgical Intervention

On an unspecified day in December 1990, the patient underwent a cystotomy under continuous epidural anesthesia. A solid foreign body, measuring 2×2.5×3.0 cm and weighing 5.5 grams, was removed (Figure 2). It consisted of five loops of the plastic tube, folded upon themselves, with extensive urine salt deposition.

Insights and Reflections

This case underscores the importance of a detailed medical history for accurate diagnosis. After the operation, we conducted a simulation using a hollow plastic tube similar to the one in the patient's case and found that if the conditions are right and the films are read carefully, the foreign body could indeed be identified. However, in the early stages of this case, the local hospital misinterpreted a bladder plain film as negative and incorrectly treated the patient for cystitis. This not only prolonged the symptoms but also led to the deposition of urine salts around the foreign body, turning it into a calcified mass. Essentially, this became a case of secondary bladder calculus.

Interestingly, because the foreign body served as the core around which salts aggregated, it did not readily cause obstruction during urination. Thus, symptoms like interrupted urine flow or "staccato" urination were absent. Instead, the patient continued to experience pain and symptoms of bladder irritation. The correct diagnosis was eventually made based on the patient’s medical history, B-mode ultrasound, and X-ray examinations.

Given the specific circumstances of this case, attempting to break and remove the stone via the urethra seemed implausible and would likely result in remnants. Complete surgical removal of the mass proved to be the most effective treatment approach.

(1991/10/05), Changhang Hospital, Li Mingjie & Shi Lianghui

from 膀胱内塑料管异物一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XV

Recurrent stones in common bile duct with suture as core 

A report of 6 cases

Introduction

Between 1975 and 1980, we reviewed a group of 70 patients who had undergone reoperations for recurrent cholelithiasis, representing 19% (70/368) of cholelithiasis surgeries during the same period. Of these 70 cases, six had recurrent stones formed around the surgical suture used in their previous operations. This report aims to discuss these specific six cases due to their implications for improving surgical techniques.

Case Summaries

Case 1

• Gender: Male
• Age: 37
• Hospital No.: 1047
• Date of Admission: February 13, 1976
• Medical History: Underwent cholecystectomy, choledocholithotomy, and T-tube external drainage at our hospital a year prior.
• Symptoms: Began experiencing frequent right upper abdominal pain and occasional fever six months after discharge.
• Intraoperative Findings: Discovered a 2cm diameter muddy stone mass formed around a surgical suture in the common bile duct.
• Outcome: Stone removed, T-tube placed, and the patient was discharged 14 days post-op. No recurrence at three-year follow-up.

Case 2

• Gender: Female
• Age: 28
• Hospital No.: 4893
• Date of Admission: October 6, 1977
• Medical History: Had cholecystectomy, left hepatic lobectomy, and T-tube external drainage two years earlier.
• Symptoms: Upper right abdominal pain, fever, and jaundice half a month prior.
• Intraoperative Findings: Two pieces of 7cm and 4cm sutures were found in the common bile duct, around which loose stone masses of 3cm and 2cm in diameter had formed.
• Outcome: Stones removed, patient was hospitalized for 15 days and discharged. However, the patient died a year later due to intrahepatic stones and severe infection, leading to shock.

Case 3

• Gender: Female
• Age: 52
• Hospital No.: 5105
• Date of Admission: October 20, 1977
• Medical History: Cholecystectomy and common bile duct T-tube drainage 14 months ago.
• Symptoms: Recurrence of symptoms 8 months post-op, leading to admission 10 hours after the onset.
• Intraoperative Findings: A 4x3x3 cm sand-mud stone mass was found, with the suture from the previous surgery serving as the core.
• Outcome: The patient died of toxic shock 10 hours post-operation.

Note: Three additional cases had similar intraoperative findings and outcomes. All were successfully treated and had no recurrence after a follow-up period of 1 to 3 years.

Discussion

The recurrence rate of primary hepatobiliary pigmented stones after surgery is high, reaching 19% according to our data. The fundamental cause is metabolic dysfunction in bile composition. However, improper surgical procedures or the retention of foreign objects can also lead to early recurrence of stones. In this report, all six cases of recurrent stones had sutures from previous surgeries as their core. The absence of these sutures could have potentially prevented the recurrence or at least recent postoperative recurrence. Case 3 in our series tragically passed away due to this issue, serving as a serious lesson.

Although we have only identified six such cases, the actual number may be higher. Not every stone removed in reoperations is crushed for examination. Therefore, it is possible that the actual number of such cases is higher. Furthermore, in most reoperations, the original sutures from previous surgeries on the common bile duct were not found. We speculate that once these sutures penetrate into the lumen, the body's natural rejection mechanisms could expel them into the intestine through the common bile duct, thereby averting harm. However, before being expelled into the intestine, could these sutures serve as a nucleus for stone formation or even cause symptoms? This warrants further investigation. It might also be one of the reasons contributing to the so-called "post-cholecystectomy syndrome," another aspect deserving attention. Further systematic endoscopic or radiographic studies are needed to draw scientific conclusions.

In our hospital, the common practice for suturing the common bile duct incision involves using non-absorbable No.0 or No.1 silk threads for full-layer continuous suturing, starting from the upper edge of the incision and moving downwards. While this method ensures tight closure and is time-efficient, it has a downside. During the removal of the T-tube, part of the duct wall is inevitably damaged, exposing the suture to the lumen. This can lead to a natural rejection response, causing the suture to adhere to bile sediments before being fully expelled into the intestine, sometimes leading to symptoms. Therefore, we recommend abandoning this suturing method and instead using thinner sutures for submucosal interrupted sutures to prevent the suture from being exposed to the lumen.

Case 3 demonstrated that even the thicker sutures used for the hepatic section can fall into the lumen, illuminating the body's natural rejection instinct. This is a rare but instructive instance.

Originally published in the Proceedings of the Second Annual Surgical Conference of Anhui Province, 1988; 87; presented at he Yangtze River Full-Line Biliary Surgery Seminar, No. 23. (1987/02/24), Changhang Hospital, Li Mingjie

from 以缝线为核心的总胆管复发结石6例报告

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XIV

Successful primary repair of congenital omphalocele 

A Case Report

Case Presentation

The patient, a male newborn named Shao, was born at home on May 14, 1983. He was brought to the emergency department four hours post-birth due to the presence of an omphalocele, a condition where part of his abdominal organs were protruding out of the abdomen, enclosed in a transparent membranous sac.

Clinical Examination

Upon examination, the infant weighed 3010 grams and had no other associated congenital malformations. The umbilical cord was ligated at a distance of 10 cm. The transparent sac contained portions of the liver, the majority of the stomach, and sections of the small and transverse intestines. There were no signs of strangulation or vascular compromise. The sac was intact and not discolored, and the abdominal wall defect at the umbilicus measured 6 cm (Figures 1 and 2).

Surgical Intervention

The surgery was performed under local anesthesia. The omphalocele sac was excised, and the skin edges were trimmed and dissected laterally. Successful herniation of the protruding organs was achieved, followed by layered suturing (Figure 3). The patient experienced neither respiratory distress nor circulatory complications. He passed gas and stool on the evening following surgery, and sutures were removed as scheduled. The wound healed without complications.

Follow-up

One-and-a-half years post-surgery, the child displayed normal development, stable gait, and no intellectual disabilities. He had begun to recognize and call out to people.

Discussion

Congenital omphalocele is an embryonic developmental disorder resulting from the failure of synchronous development between the abdominal cavity and viscera. Approximately 40% of cases present with additional congenital malformations. The condition is relatively rare, occurring in 1 in 7,000 births. The literature contains limited case reports, with one study reporting only 22 instances. Delayed surgical intervention can result in desiccation, necrosis, and rupture of the omphalocele sac, exposing the organs to infection and significantly increasing mortality risk. The surgical approach, either primary or staged repair, depends on the size of the omphalocele and the developmental status of the abdominal cavity. Our case, although categorized as a "giant" omphalocele due to the 6 cm abdominal wall defect and involvement of multiple organs, was successfully managed through primary repair owing to the absence of other deformities and favorable overall development.

References

• She Yaxiong: Pediatric Surgery. 1979; p. 296

Figures: Embryonal Omphalocele

• Figure 1: External appearance of the omphalocele with a 6 cm abdominal wall defect at the umbilical pedicle.

• Figure 2: Organs involved in the omphalocele: liver, stomach, small intestine, and transverse colon.

• Figure 3: Appearance following successful primary repair.

1988/04/01
Changhang Hospital, Li Mingjie

from 先天性脐膨出一期修补成功一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XII

Adult retroperitoneal teratoma infection complicated with chronic purulent fistula 

A Case Report

Introduction

A 53-year-old female patient presented with a history of left waist swelling, pain, fever, and pus discharge that occurred 12 years ago and reportedly "self-healed" within a few months. Six years prior to the current consultation, she developed an abscess on the medial aspect of her left thigh, which was incised to create a fistula but never fully healed.

Clinical Examination

Upon examination, the patient appeared to be suffering from chronic consumptive anemia. She had purulent fistulas in both the right lumbar and left femoral regions, discharging yellowish fluid and some pus. Radiographic evaluations showed no abnormalities in the spine, pelvis, or hip joints. However, the shadow of the left psoas muscle appeared indistinct. No evidence of an intestinal fistula was found through contrast studies. A 4.5 cm irregular residual barium shadow was noted near the second and third lumbar vertebrae, appearing potato-like. Biopsy of the fistula tissue revealed inflammatory granulation.

Surgical Findings

Immediate surgical exploration was carried out, confirming that the fistula tract led into the left psoas muscle. Upon injecting methylene blue into the fistula and subsequently incising the muscle, thin pus was drained. The abscess cavity was spindle-shaped, measuring approximately 20x5x4 cm. Tracking the cavity upwards led to the discovery of a 6x5x4 cm encapsulated mass near the second and third lumbar vertebrae. The mass was easily excised. It was adherent to and penetrated the psoas major muscle. The intramuscular abscess was fully incised, its inner wall scraped clean of granulation tissue, washed, and hemostasis was achieved through compression.

Pathological Diagnosis

The pathological examination confirmed a benign cystic teratoma complicated by infection, leading to the formation of a left psoas muscle abscess and an external fistula.

This article was originally published in Journal of Transportation Medicine,1993；Vol.7, fourth (368)
Changhang Hospital, Li Mingjie

from 成人腹膜后畸胎瘤感染并发慢性脓瘘1例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XIII

Ingested lighter as a foreign body in the stomach

A Case Report

Case presentation

A 22-year-old male, generally in good health, intentionally ingested a wire resistance lighter two months prior to admission. He manually forced the object through his pharynx, facilitating its smooth passage into the stomach without experiencing obstruction, bleeding, or esophageal injury. Despite consuming a large quantity of leeks that evening, the foreign body was not naturally expelled and he experienced no immediate discomfort. One month later, he began experiencing abdominal pain on an empty stomach, which was alleviated by eating. An abdominal X-ray at our institution confirmed the object's retention in the stomach. Surgical intervention was deferred until two months later, given the absence of acute symptoms.

Clinical Examination

Upon physical examination, the patient appeared generally well, with no upper abdominal tenderness. Abdominal X-ray and B-type ultrasonic gastric perfusion examination confirmed the presence of the foreign body within the stomach.

Surgical Procedure

On July 4, 1991, under epidural anesthesia, a 3.5 cm gastric incision was made. The gastric mucosa appeared slightly congested, but there were no signs of ulceration or hyperplasia. The foreign object, not adhered to the gastric wall, was successfully retrieved under direct visualization and the stomach was subsequently repaired. The postoperative course was uneventful, with sutures removed on day seven.

Pathological Findings

The retrieved foreign body was identified as a wire resistance lighter, measuring 7x3x1.5 cm and weighing 18 grams. It was composed of a blend of plastic and metal. Erosion was evident on its metal shell, and part of the plastic had been stripped away.

Discussion

The smooth passage of a rigid foreign body with a 3 cm transverse diameter through the pharynx and esophagus without injury is notable. However, the object remained in the stomach for an extended period, unable to pass through the pylorus. Stomach acid had corroded both the metal and plastic components of the lighter, although it remained largely intact due to its composite nature. Endoscopic retrieval was considered but deemed risky due to the potential for iatrogenic injury. Surgical removal proved to be a safe and effective approach, with a favorable prognosis confirmed at a three-month follow-up.

1991/10/15
Changhang Hospital, Li Mingjie & Wang Yisheng

from 胃内打火机异物一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XI

Misdiagnosis of subacute perforated peritonitis in gastric malignant lymphoma 

A Case Report

Case Presentation

A 71-year-old female patient, with the medical record number 13520, experienced intermittent periumbilical abdominal pain for 10 days, without accompanying diarrhea, hematochezia, or fever. She was admitted to the Affiliated Hospital of Anhui Medical University on March 22, 1987, with severe colic in the right lower abdomen and vomiting lasting for two days. She was initially suspected to have appendiceal perforation.

Clinical Examination

Upon admission, the patient had a temperature of 35.5°C, a pulse rate of 84 beats/min, and a blood pressure of 120/80 mmHg. She appeared acutely dehydrated with general nutrition. No lymphadenopathy or jaundice was observed. Physical examination revealed tenderness and rebound tenderness throughout the abdomen, especially in the right lower quadrant. Laboratory tests showed decreased hemoglobin levels (9 g/mm3), RBC count of 3.8 million/mm3, and a WBC count of 19,700/mm3 with 91% neutrophils and 9% lymphocytes. Urine amylase was 16 units/Winsler.

Surgical Findings

The patient underwent emergency surgery on the day of admission for suspected acute appendicitis with peritonitis. During the procedure, a small amount of intra-abdominal exudate was found, but no obvious purulent fluid was observed. The appendix, gallbladder, liver, spleen, and pancreas appeared normal. However, a 5x6 cm mass was discovered on the anterior wall of the gastric antrum, with a soft texture and focal necrosis at its center.

Histopathology and Postoperative Care

Histopathological examination confirmed the diagnosis of malignant lymphoma of the gastric antrum. The patient was discharged after 12 days of hospitalization and showed no signs of recurrence during the one-year follow-up.

Discussion

Gastric malignant lymphoma accounts for 80% of gastric sarcomas and often presents with insidious and non-specific symptoms, making preoperative diagnosis challenging—only 10% are accurately diagnosed before surgery. These tumors may result in peritonitis due to necrosis and exudation, often misleadingly presenting as appendicitis.

For patients with a prolonged history of symptoms but no localized inflammatory mass, the possibility of this rare condition should be considered. Excision of sufficient gastric tissue and omentum generally leads to a more favorable prognosis than gastric cancer, with a 5-year survival rate up to 50%. In this case, the patient remained symptom-free at the one-year follow-up.

References

Waltar LJ, et al. Cancer Management. New York, 1977; p.269.

This article was originally published in Proceedings of First Health Conference of the Yangtze River Shipping Company,1988；4:1
Changhang Hospital, Li Mingjie

from 胃恶性淋巴瘤亚急性穿孔腹膜炎误诊一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper IX

Several special problems in diagnosis and treatment of biliary tract surgery

Abstract

In the realm of biliary surgery, unique anatomical deviations and pathological transformations often necessitate unconventional approaches to achieve therapeutic success and minimize unintended harm. This article delves into the surgical procedures and outcomes of a curated selection of cases from a pool of 456 biliary surgeries. Through a retrospective evaluation, this study seeks to enhance both the diagnostic and therapeutic strategies for managing biliary disorders.

Traditional approaches to biliary surgery, well-versed among surgeons, have been progressively refined to better manage conditions like intrahepatic stones and biliary strictures [1]. However, the nature of challenges that arise during such procedures can be incredibly diverse, and not all can be addressed through standard methodologies or by adhering to a one-size-fits-all surgical protocol. The eventual outcome of the intervention holds significant implications for patient prognosis. This study delves into an array of unique challenges encountered in a collection of 456 biliary surgical cases [2]. It aims to shed light on their pathological underpinnings, surgical strategies employed, and the resulting clinical outcomes, serving as a repository of insights and lessons for future reference.

Case Introduction

Case 1:

The patient is a 42-year-old female farmer, medical record No. 13317, who has been experiencing recurrent right upper abdominal colic for eight years. B-ultrasound indicated the presence of gallstones and stones at the left hepatic margin. She underwent surgery in our hospital on December 2, 1986. The surgical findings aligned with the B-ultrasound report. Intraoperative cholangiography displayed normal and unobstructed grade 1 to 3 biliary ducts but failed to reveal clusters of stones on the lower margin of the liver's left outer lobe. The surgical approach included a cholecystectomy and a partial hepatectomy for stone removal, capped off with sub-hepatic drainage. Bile duct exploration and drainage were not performed, and the patient recovered smoothly without the need for a blood transfusion. She was discharged 12 days post-surgery, fully recovered.

Key Takeaways

The insights from this case underscore the utility of combining B-ultrasound and intraoperative cholangiography for a more nuanced understanding of the pathology, thereby aiding in the selection of the most appropriate surgical technique. The chosen procedure in this case was minimally invasive and effectively addressed the lesion.

While pre-operative examinations like PTC and ERCP are invaluable, their absence can make it challenging to fully comprehend the intrahepatic bile duct conditions, even when bile duct exploration is performed during the surgery, including choledochoscopy. Intraoperative cholangiography delivers direct imaging of the biliary tree, thus providing valuable guidance and mitigating some of the operative uncertainties.

In this specific case, however, the intrahepatic stones weren't visualized in the cholangiography. This could have been due to the patient's positioning during the imaging or perhaps due to obstruction caused by a narrow biliary tract. Thankfully, the diagnosis was confirmed through liver surface palpation, emphasizing the need for a comprehensive evaluation in similar cases.

Case 2:

The patient is a 64-year-old male worker, medical record No. 12928. He was diagnosed with the pentalogy of ACST and underwent emergency surgery in our hospital on April 18, 1986. During the operation, the common bile duct was opened and a pigmented gallstone with a diameter of 2 cm was removed. Microscopic analysis of the bile revealed pus cells, and a culture indicated the presence of E. coli. The gallbladder was found to be atrophic, measuring 3 cm in diameter, and containing 23 mixed stones along with some white mucus. The cystic duct was occluded. Remarkably, the gallbladder had an internal fistula of 0.3 cm with the common hepatic duct, which was patent. To simplify the procedure, separate choledochotomy and cholecystostomy were performed. Angiography on the 19th day post-operation showed normal intrahepatic and extrahepatic bile and pancreatic ducts, and the gallbladder-common hepatic duct fistula was also patent. The patient recovered well and had no symptoms upon a 10-month follow-up.

Key Experience

This was a high-risk case that required immediate surgical intervention, primarily focused on relieving biliary obstruction and draining infectious materials. The operation was straightforward, but the condition of the gallbladder—non-functioning and a disease focal point—posed a dilemma: to remove or not to remove.

The authors argue that the presence of a patent internal fistula would ensure proper drainage, essentially serving as a biliary diverticulum. This is considered harmless, especially given the emergency nature of the surgery and the complexities of the local anatomy that could potentially lead to additional complications, such as stenosis of the main bile duct or biliary leakage. Therefore, opting not to remove the gallbladder was deemed appropriate. Although the gallbladder could have been repaired, the recent inflammation and edema were inhibitory to proper drainage. As a safety precaution, a cholecystostomy was performed instead.

Case 3:

The patient is a 64-year-old female teacher, with medical record No. 4417. She was diagnosed with gallstones based on her medical history and B-ultrasound. A cholecystectomy was performed on October 16, 1984. During the surgery, 23 cholesterol gallstones were discovered in the gallbladder. The common bile duct, measuring 0.7 cm, appeared normal upon inspection and matched the B-ultrasound report. Since there was no history of jaundice, the common bile duct was neither explored nor puncture-confirmed. While removing the gallbladder, a cystic duct of 0.3 cm was found, which gradually tapered and extended away from the hepatic pedicle. The duct was ligated, and attention was then turned to the gallbladder artery. After 75 minutes, the surgery was successfully completed with no postoperative bile leakage and grade A incision healing. However, on the third postoperative day, progressive jaundice was observed. Serum bilirubin levels rose to 8.8 mg% on the 20th postoperative day, suggesting obstructive jaundice.

A follow-up B-ultrasound revealed generalized dilation of both intra and extrahepatic bile ducts, with the common bile duct measuring 1.1 cm in diameter. The patient refused further tests like PTC, and a second surgery was conducted on November 9, 1984. Despite exhaustive efforts, the common bile duct was not located, and no ligated end of the bile duct was found to be enlarged. The surgery lasted six hours, and due to the length of the procedure, no additional enterohepatic drainage was attempted. A catheter was placed for external drainage from the left intrahepatic bile duct, with postoperative bile discharge measuring 150 ml per day. Unfortunately, the jaundice did not resolve significantly. A follow-up after two months showed the intrahepatic bile ducts had thinned and become branch-like. A subsequent surgery on February 10, 1985, resulted in multiple organ failure, and the patient passed away on the fifth postoperative day.

Key Experience

This case underscores the complexity and unpredictability often encountered in biliary tract surgeries. Even when initial surgeries seem successful, complications like postoperative jaundice can emerge. Multiple interventions may not always resolve the issue, emphasizing the importance of thorough preoperative evaluations and planning. The case also draws attention to the limitations of relying solely on imaging for diagnosis, particularly when surgical intervention is involved. Furthermore, the case reiterates the need for cautious decision-making, especially when surgeries stretch on for extended periods, as excessive duration can elevate the risks of complications and unfavorable outcomes.

Discussion

1. Anomalies in Extrahepatic Biliary Tract

Extrahepatic biliary variations can occur in up to 85% of cases, but the rare variation observed in this case has not been previously reported. The absence of a typical common hepatic duct and common bile duct was noted. Instead, a 0.2 cm duct entering the upper left corner of the gallbladder functioned as the common hepatic duct, and an extended 0.3 cm cystic duct served as the common bile duct. When the gallbladder was removed due to gallstones, the extrahepatic biliary tract was inadvertently damaged. Mistakes in pre- and post-operative B-ultrasound measurements, confusing the common bile duct with the portal vein, also contributed to this issue. Therefore, in such anomalies, exploration of the common bile duct is crucial, and the relationships among the three bile ducts should be thoroughly understood to avoid unnecessary damage.

2. Importance of Preoperative Testing

For surgical jaundice, it is crucial to conduct preoperative PTC and/or ERCP to obtain a clear image of both the intra- and extrahepatic bile ducts. This aids in the surgical planning. In this case, had a high-level biliary obstruction been diagnosed earlier, a lifesaving enterohepatic internal drainage could have been performed during the second surgery. However, repeated delays and long-term obstructive jaundice led to significant liver and multi-organ damage, rendering subsequent surgeries difficult and ultimately futile. This serves as a critical lesson.

3. Limitations of B-scan Ultrasonography

While B-scan ultrasonography is a relatively new and non-invasive diagnostic method, its diagnostic accuracy is 94% for gallstones and 64% for common bile duct stones. However, the modality is often prone to errors due to interference from intestinal gas and large blood vessels. Thus, clinicians should exercise caution when relying solely on B-ultrasonography for diagnosis. In this case, the two B-ultrasound images of the common bile duct were clearly incorrect, significantly contributing to the repeated diagnostic delays.

References

1. Li Mingjie: "Choledocho-Intestinal Drainage." Proceedings of Symposium on Biliary Tract Surgery, Ministry of Transportation, 37, 1987.
2. Li Mingjie: "Left Lateral Hepatectomy for Intrahepatic Calculi." Domestic Medical Abstracts, 1980; #161.
3. Wang Yu: "Journal of Practical Surgery," 1984; 4(5): 235.
4. Chief Editor of China Medical University: "Regional Anatomy." Beijing People's Publishing House, 1979; 142.
5. Liu Guoli: "Chinese Journal of Surgery," 1984; 22: 669.

This article was originally published in Proceedings of the Second Academic Conference on Health Care Along the Yangtze Riverthe (27), Dec. 1988；27
Changhang Hospital, Li Mingjie

from 胆道手术中几个特殊问题的诊治体会

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper VIII

Biliary enteric drainage

Literature Review and Clinical Analysis

Abstract

Between 1974 and 1980, a comprehensive review was conducted on 441 biliary duct surgical procedures, which included 81 instances (18%) of Internal Biliary-Intestinal Drainage (IDBI). This subset featured 61 cases of choledochoduodenostomy, 15 of Oddi's sphincterotomy, 2 hepatocholangiojejunostomies in the Roux-en-Y configuration, 2 Brown-type choledochojejunostomies, and one instance of U-type biliary-intestinal bridging.

The patients in this cohort generally experienced good health post-surgery, with no significant symptoms or signs of reflux. However, two exceptions were noted: one patient died due to an infection in the U-bridge, and another experienced recurrent cholelithiasis following a Finster's technique procedure, necessitating re-operation.

This paper places particular emphasis on the issue of postoperative reflux in the application of IDBI for treating biliary tract obstructions and cholelithiasis. Advances in diagnostic and therapeutic techniques, including ultrasound, CT scans, endoscopy, percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP), have considerably evolved the landscape of biliary tract disorder management.

Keywords:

Internal Biliary-Intestinal Drainage, Sump Pool Syndrome, Cholelithiasis

Introduction

Over the past six decades, advancements in various diagnostic techniques—particularly in Bus, PTC, ERCP, and CT—alongside animal clinical trials and in-depth research into biliary pathophysiology, have led to a renewed understanding of Biliary Enteric Drainage (BID). While the topic remains a subject of ongoing debate, it is clear that the field is moving along a path of increasing maturity and depth.

The concept of duodenal papillotomy has evolved significantly since its initial proposal in 1884. Despite a century of continuous exploration and advancement, a standardized surgical procedure for Biliary Enteric Drainage (BID) has yet to be established. The selection of surgical indications and technical nuances often depends on a myriad of factors—ranging from the specific clinical condition and the surgeon's individual expertise to the available equipment.

For the purposes of this study, we have reviewed a sample set comprising 441 cases of biliary surgery conducted in the Nanling region between 1974 and 1980. This data has been analyzed in conjunction with existing literature to provide a comprehensive review of BID.

Applications of Biliary-Enteric Internal Drainage (BID)

1. Restoring Normal Bile Flow

In cases where the bile-intestinal pathway is interrupted or narrowed due to tumors or injuries, BID aims to restore normal bile flow. This involves creating an artificial channel as an alternative route for bile to pass through.

2. Post-Surgical Bile Flow Management

After surgical corrections for conditions such as intrahepatic and extrahepatic bile duct stones or bile duct stenosis, BID is employed as a preventive measure. The objective is to maintain smooth bile flow, thereby preventing complications like bile stasis, recurrent infections, and further formation of stones.

On "Reflux Infections" and "Blind Bag Syndrome"

Concerns About Reflux

All Biliary-Enteric Internal Drainage (BID) procedures inherently disrupt the physiological function of the sphincter of Oddi, effectively eliminating the natural "valve" mechanism between the biliary and intestinal tracts. While the general flow direction of bile into the intestine is facilitated by factors like gravity, pressure, and peristaltic action, there are scenarios—such as a full stomach, intestinal reverse peristalsis, or posture changes—that can result in reflux from the intestine to the biliary system. This can consequently lead to infections and form a "blind bag" or "dump pool" in the residual bile ducts, causing symptoms and pathological changes of cholangitis.

Madden's Animal Experiment

In a well-known animal study by Madden in 1970, gallbladder-colon anastomosis was performed on dogs without intestinal preparation. Of 131 cases monitored with barium radiography, only one dog showed symptoms of cholangitis due to anastomotic stenosis; the rest were asymptomatic. Madden concluded that a wide and open anastomosis would not result in cholangitis. He even shifted the terminology from "ascending infection" to "descending infection," although he did not perform pathological examinations.

Follow-Up Studies

Twelve years later, a similar experiment was conducted in China by Qian Li in 1982 [1]. Pathological examinations were conducted 34-105 days post-surgery. Though all 10 dogs were asymptomatic before being sacrificed, histological studies revealed cholecystitis, cholangitis, pericholangitis, and even focal hepatocyte necrosis. This unveiled the clinical "illusion" in Madden's study, suggesting that such pathological inflammation could become clinically significant if the experiment were prolonged or if immune resistance were lowered.

However, Qian Li himself later stated in 1980 that "reflux is not a concern as long as the anastomotic opening is large enough to allow bidirectional flow; symptoms will not occur" [2]. He attributed this mainly to the bipedal nature of humans, contrasting them with the quadrupedal dogs used in the experiments. Although the potential for cholangitis exists, actual occurrences are minimal [3]. This is supported by data from eight different case groups, both within China and internationally.

In this cohort of 441 secondary biliary surgeries, 81 cases involved Biliary-Intestinal Drainage (Bid), making up 18% of the cases [4]. The procedures included:

• 56 choledochoduodenal side-to-side anastomoses, of which 21 were secondary surgeries, one was a tertiary surgery, and 5 were end-to-side anastomoses.
• 2 Roux-Y hepaticojejunostomies
• 15 sphincterotomies of the Oddi sphincter, with six of these being secondary surgeries and one being a tertiary surgery.
• 2 Brown's cholangiojejunostomies
• 1 U-tube choledocho-intestinal bridging surgery

In this group, there were no instances of severe ascending infections post-Bid. However, one case of choledochoduodenal side-to-side anastomosis required a subsequent surgery due to a "test tube phenomenon," which was confirmed to be due to intrahepatic calculi falling two years post-operation [4].

Extensive practice has shown that as long as the Bid (Biliary-Intestinal Drainage) anastomotic site is wide, concerns about reflux are generally not a deterrent for surgeons. However, unfortunate cases do arise where, 2-3 years post-surgery, symptoms develop due to anastomotic narrowing caused by inflammatory proliferation. This has led to a variety of surgical innovations aimed at preventing anastomotic constriction and eradicating reflux. These innovations include the elongation of drainage intestinal tubes—sometimes up to 60 cm [5]. For targeted drainage, two parallel artificial intussusceptions are created on an open intestinal loop. These intussusceptions, along with parallel segments of bile and intestinal input loops, are then sealed to form a true Y-shaped, rather than T-shaped, anastomosis [6-10].

In light of the specific pathology of hepatolithiasis, it's recommended to perform a significant dissection of the extrahepatic bile duct and potentially extend it to the left and right hepatic ducts. This facilitates stone removal and stenosis alleviation, followed by a large-caliber side-to-side gallbladder-intestinal anastomosis, known as the Longmire-type operation, effectively preventing long-term postoperative stenosis. To eliminate the "blind pouch," a posterior duodenal foramen low choledochoduodenostomy is performed [2]. For physiological conformity and to reduce the incidence of gastrointestinal ulcers, a jejunal interposition is done to restore natural bile flow. To further facilitate future stone removal and biliary tract clearance, a subcutaneous blind loop (SB-jicd) is added [9].

Factors Related to the Efficacy of Bid (Biliary-Intestinal Drainage)

1. Incomplete Cure of Primary Disease

Bid serves the purpose of clearing bile flow but does not act as a substitute for treating the underlying primary disease. The surgery aims to completely remove gallstones, Ascaris lumbricoides, and manage primary lesions or complications in the liver, gallbladder, and pancreas. Despite initial optimism that intrahepatic stones would naturally pass through internal drainage, clinical evidence proves otherwise. In instances where intrahepatic calculi "collapse," they may obstruct the anastomotic site, causing symptoms. When biliary constriction above the anastomotic site is not corrected or eliminated, bile-intestinal reflux becomes difficult to manage, leading to challenging infections. In cases of malignancy, the focus is either on curative or palliative surgical approaches. For congenital choledochal cysts, removal of the cyst followed by Bid is advisable to prevent the cyst wall from becoming inflamed or malignantly transformed.

In the early stages, due to the Finster procedure's ease of operation and good short-term outcomes, there was a tendency to overuse it, accounting for 70% of Bid cases in this study group. Diagnostic capabilities at the time, such as imaging and direct cholangiography, were not as advanced, leading to an incomplete understanding of the pathology. This often resulted in neglecting the treatment of intrahepatic lesions and bile duct stenosis, subsequently causing a high reoperation rate of 13.2%, and in some cases, three or four subsequent surgeries. However, with the advent of Percutaneous Transhepatic Cholangiography (PTC), the use of Bus Ultrasound (BUS), and an improved understanding of the disease, surgical techniques advanced, leading to better outcomes.

2. Choice of Timing for Surgery

It is generally advised against performing emergency primary drainage (Bid). This recommendation is based on multiple factors. First, emergency surgeries for acute or severe conditions should not be complicated due to the immediate need for treatment. Second, the short time frame makes it challenging to gain a comprehensive understanding of the condition, thus complicating the decision for the optimal surgical approach. Lastly, performing Bid during the stage of inflammatory edema could reduce its safety and increase the likelihood of long-term restenosis.

However, there's a school of thought advocating for completing Bid in a single stage, thanks to advancements in diagnostic technologies. With the use of Bus, PTC, ERCP, CT, and choledochoscopy, a more accurate understanding of the condition is possible, allowing for more informed surgical choices. This avoids complications related to anatomical disarray, adhesions, and accessory injuries in case of a second surgery, thus minimizing the patient's physical and financial burdens.

In summary, the choice of surgical approach should be made after comprehensive consideration of several factors: the local anatomical conditions, the patient's overall ability to endure surgery, and both the short-term and long-term needs dictated by the disease condition.

3. Issues with Technology Implementation

The approach to biliary-enteric anastomosis has evolved significantly. Initially, the focus was solely on ensuring free bile flow. However, with time and lessons learned from clinical experience—sometimes at a cost—there's now a shift towards understanding the postoperative physiological and pathological changes in the body. This is considered a valuable progress in the field.

Technical Precautions and Best Practices

1. Preventing Anastomotic Stenosis: It's crucial to create a spacious channel for bile flow and to avoid performing this surgery during periods of inflammation.

2. Understanding Blood Supply: Given that the blood supply to the extrahepatic bile ducts is axially distributed, excessive separation of the bile ducts should be avoided to prevent ischemic stenosis caused by surgical trauma.

3. Suture Techniques: Leakage of bile between different layers of bile duct tissues can hinder tissue healing. Therefore, suturing should be done in a tension-free manner to prevent this.

4. Optimizing Duct Length: The non-functioning segment of the bile duct should be kept as short as possible to minimize the formation of blind pouches.

5. After Bid: Post-Bid, the regulatory function of the sphincter of Oddi is lost, leading to decreased pressure in the bile ducts. In this condition, the gallbladder merely serves as a diverticulum. Given that the cystic duct is small and convoluted, ongoing gallbladder inflammation and stone formation are almost inevitable. Therefore, it's recommended to remove the gallbladder when performing Bid.

4. Selection of Surgical Procedures and Principles of Joint Observation

With the abundance of Bid surgical procedures, how do we choose among them? In addition to considering patient conditions, pathology, available equipment, technical conditions, and the physician's personal experience, several principles and requirements are emphasized:

1. Biliary flow should be physiological: The surgery should aim to avoid disrupting the natural physiology and pH of the digestive system to minimize the risk of gastrointestinal ulcers.
2. Shorten the non-functioning bile duct segment: The non-functioning parts of the bile duct should be minimized to avoid complications.
3. Fewer short-term symptoms: The surgical method should have fewer immediate complications.
4. Low risk of restenosis: The surgery should minimize the risk of the internal drainage becoming narrow again.
5. Minimal "ascending infection": The chosen method should minimize the risk of infection moving upward in the system.
6. Complexity and safety of the operation: The surgical method should balance complexity against safety.
7. Favorable for monitoring and re-examination: Post-operative follow-up should be facilitated by the surgical method chosen.

Based on the aforementioned principles, the best surgical approach is chosen depending on the patient's condition.

1. SB-jicd: This method is generally the first choice for cases with multiple intrahepatic and extrahepatic stones to avoid the need for multiple surgeries.
2. Jied: For non-stone-related benign obstructions in the biliary tract, the Jied procedure is advisable to restore physiological conditions.
3. Finster Surgery: For older patients with severe diseases, the Finster operation may be suitable.  If conditions allow, this can be an alternative approach.
4. Oddi Sphincterotomy or Plasty: For obstructions in the far end of the common bile duct or stenosis at the outlet, these procedures may be performed.
5. Roux-en-Y Biliary Bypass: This method reduces the neutralizing effect of bile on gastric acid within the duodenum. There are claims that this could lead to an ulcer rate as high as 52%, although clinical observations put it at around 10%. Pappa-Lardo recommends an additional procedure (possibly a specific type of cut or incision, as the term "迷切" is not entirely clear, 建议此术附加迷切) to be included in the surgery. This suggestion, however, hasn't garnered much attention in China, where the surgical method in question is still widely used. One speculation for this could be that gastric acid levels are generally lower in the Chinese population compared to Western countries.

6. Endoscopic Sphincterotomy (ES): This surgical technique avoids the need for open abdominal surgery and represents a recent advancement in foreign countries. However, it hasn't gained widespread adoption in China yet, possibly due to limited experience with the procedure.

Comments on Several Commonly Used Surgical Procedures

I. Sphincterotomy and plasty of Oddi

In the case of Oddi sphincterotomy and plasty, the surgical procedure theoretically aligns with the natural flow of bile and eliminates the presence of a 'blind bag,' making natural stone expulsion possible. In this particular study, 15 cases were performed, accounting for 20% of all biliary-intestinal diversion (Bid) procedures. Post-operative ascending infections were observed in two cases, which were controlled using antibiotics.

Due to advancements in endoscopic technology, especially abroad, there's a shift towards duodenal endoscopic sphincterotomy (ES). This method avoids the need for a laparotomy and has a high stone-removal rate of 85-90%. However, the complication rate is also noted to be 28%.

When an incision of 10mm is made in the Oddi sphincter, it relieves muscle spasms but doesn't entirely remove the functionality of the distal bile duct sphincter. This makes it prone to restenosis, making it difficult to achieve the desired long-term outcome.

In terms of the distal sphincter, a more extended cut could result in complete severing of the ampullary and most of the common bile duct sphincter. The consequences of such cuts need to be weighed carefully, particularly in terms of potential for bile reflux and ascending infections.

Considering that the function of the distal sphincter of the bile duct comprises three components—the Oddi muscle, the inner wall sphincter of the bile duct, and the partial function of the circular muscle in the duodenum—if an incision of 1.5 cm is made, it would sever the entire ampulla and a large portion of the common bile duct sphincter. If the incision extends to 2.5-3 cm, all three components would be severed, essentially resulting in a low-position choledochoduodenostomy. Any incision of these various lengths must be done cautiously to prevent damage to the pancreatic duct. Moreover, due to the pressure equilibrium between the bile and intestinal tracts, reflux from the intestine to the bile duct is almost inevitable. This could easily lead to ascending infections. Additionally, there's the issue that a dilated common bile duct greater than 20 cm can still form a funnel-shaped narrow segment post-surgery.

Choi, in 1982, proposed a re-operative extraperitoneal approach to avoid the difficulties of adhesions and collateral damage encountered when dissecting the original surgical area.

Plasty involves the removal of a wedge-shaped portion of the anterior lateral wall of the common bile duct outlet, followed by suturing. To prevent reflux, a valve was designed.

This operation, when used as an adjunct to other internal drainage procedures, has considerable value in eliminating the 'blind bag.' Four such cases were noted in this study, and in one case, liver stones were no longer present two years post-operation, possibly a supporting case for the long-term efficacy of the procedure.

II. Choledochoduodenostomy

This procedure involves two types of anastomosis: lateral-lateral and terminal-lateral. The operation is simple, straightforward, and safe, with good short-term recovery. Influenced by the "illusion" created by Madden's experiments, this procedure was widely performed in earlier years. Among our group of 81 cases, this technique was applied in 61 cases, making up 75%. However, recent consensus—built upon observations from reoperations, insights from animal experiments, and a deeper understanding of the pathophysiology of the biliary tract—indicates that the appropriateness of this surgery has significantly decreased.

Particularly problematic is the classic Finster's fissure technique, which has several downsides: the anastomosis is narrow, there's a latent risk of retrograde infection and blind-end syndrome, and prolonged exposure to digestive juices can induce chemical cholangitis that leads to mucosal atrophy. This results in goblet cell and fibrous tissue proliferation, making the duct wall thick and hard. Post-anastomotic biliary infections often involve a complex mix of aerobic and anaerobic bacteria, complicating treatment. Sometimes, extreme measures like a B-II partial gastrectomy are required to divert food, or the posterior wall of the blind end needs to be cut open, or a new biliary-intestinal anastomosis has to be constructed.

The procedure is generally not recommended for those with hepatogenic stones that haven't been completely removed or if there's uncorrected bile duct stenosis above the anastomotic site. For gallstones combined with lower common bile duct narrowing, often termed "Western-style gallstones," this procedure can be the best option. It's also a viable choice for elderly or frail patients who can't endure complex surgeries.

To overcome the limitations of this technique, various improved methods have been introduced recently, including post-duodenal choledochoduodenostomy and hollow-end biliary anastomosis. These improvements are theoretically more sound and have shown good results in practice.

III. Biliary-Jejunal Roux-en-y Anastomosis

One issue with this technique is that extending the jejunal loop used for bile drainage to even 60 cm doesn't necessarily eliminate the risk of reflux infection. Directly routing bile into the jejunum disrupts physiological norms. This not only hampers the digestion and absorption of fats but also reduces the suppression of gastric juice secretion in the upper jejunum. For those with high gastric acid levels, the absence of bile to neutralize stomach acid in the duodenum can increase the incidence of ulcer disease. Additionally, an overly long jejunal loop can twist and adhere, causing potential obstructions. Changes in the functionality of this intestinal segment make it difficult to maintain a normal microbiota, giving rise to a condition known as "jejunal blind loop syndrome."

Despite these challenges, this remains one of the most frequently used surgical methods. It allows for tension-free anastomosis with bile ducts at all levels, including the Longmire procedure. This versatility addresses issues like intrahepatic bile duct stenosis and enables the reconstruction or palliative bypass of the biliary-intestinal pathway following substantial resection of malignant liver tumors. Ongoing technical improvements aim to minimize the risk of reflux infection as much as possible.

IV. Intermittent Jejuno-Biliary-Duodenal Anastomosis (Jicd)

This surgical technique evolved from the Roux-en-y procedure. It was first reported by Grassi in 1969 and subsequently introduced in China by Shiweijin in 1982. The method involves interposing a segment of the jejunum between the bile duct and the duodenum, aiming to restore the physiological state of bile flow. This addresses some of the limitations associated with the Roux-Y method. Regarding the length of the interposed segment, Grassi recommended 20 cm, while Huang Zhiqiang advised against excessive length. An artificial nipple is designed at the distal end of the interposed jejunum and is inserted into the wall of the duodenum during anastomosis.[9] Shi Weijin suggests that a 60 cm length could essentially prevent reflux. Technically, attention must be paid to the "peristaltic direction" when placing the interposed intestinal segment. End-to-side anastomosis between the bile duct and jejunum is preferable as it allows for more flexible design of the anastomotic site.

However, the procedure comes with three anastomotic connections, making it more invasive and complex compared to the Roux-Y method, which involves two anastomotic sites, and choledochoduodenostomy, which has just one. This complexity has hindered its widespread adoption. Despite these challenges, the technique is currently being promoted in China due to its advantages. As it has not been in use for a long period, its long-term efficacy and ultimate evaluation still require further clinical validation.

V. Subcutaneous Blind Loop Interposition of Jejuno-Choledochoduodenal Anastomosis (SB-JICD)

This technique evolved from the aforementioned JICD and is specifically designed for cases where multiple intrahepatic stones are difficult to remove completely or where hepatic stones are expected to regenerate. The subcutaneous blind loop is reserved for direct access when needed to remove stones, worms, or facilitate bile drainage. It can also serve as a route for medication administration and postoperative monitoring.

Built upon the foundation of Roux-Y and JICD procedures, this technique involves interposing a segment of jejunum, which is then subcutaneously buried and marked with a silver clip. Corresponding skin surface markings can also be made for easier monitoring and treatment access. A blind loop length of around 10 cm is recommended to minimize the risks associated with "blind loop syndrome."

However, this procedure has not yet gained widespread acceptance. It leaves another option for suitable candidates, but it comes with its own set of challenges. Not only is the surgery complex, but the risk of infection in the blind loop also exists. Furthermore, the procedure may not be as effective in practice as it is in theory, especially for deeper hepatic lesions. Even if a cholangioscope is inserted through this route, it may not necessarily solve the problem.

VI. Others

Other techniques like gallbladder-gastrointestinal anastomosis are generally discarded due to the circuitous and narrow nature of the gallbladder duct, which cannot ensure reliable drainage. These methods are no longer considered viable options, especially in the case of late-stage malignant tumors or critically ill elderly patients. In our early practice, we performed a few gallbladder-stomach and gallbladder-jejunum anastomoses. These techniques played an active role in alleviating symptoms for patients with distal biliary obstruction-induced jaundice, such as those with late-stage pancreatic head cancer.

References:

1. Qian Li: Analysis of the pathogenesis of secondary cholangitis after biliary-intestinal anastomosis and the efficacy of various biliary-intestinal internal drainage procedures. Anthology of Papers on Cholelithiasis, Wenzhou Medical College, 1982.

2. Qian Li: Treatment of Primary Pigment Stones in the Common Bile Duct. Journal of Practical Surgery, 1986; 1:19.

3. Zhang Shengdao: Evaluation of choledochoduodenostomy in the treatment of severe acute cholangitis. Journal of Practical Surgery, 1986; 6(1): 42.

4. Li Mingjie: Hepatectomy for treating intrahepatic gallstones. Domestic Medicine, 1980 #161; Wannan Medical Journal, 1980, 13:51-55.

5. Shi Weijin: Indications and evaluations of JICD and SB-JICD. Journal of Practical Surgery, 1986; 6(1): 44.

6. Tan Yuqian: Evaluation of Roux-Y type cholangiojejunostomy. Journal of Practical Surgery, 1986; 6(1): 44.

7. Zhang HD: An Exploration on the prevention of Reflux in "Y" Type Choledochojejunostomy. Abd 'surg, 1985; 27:34.

8. Kassi M: Improved technique of end-to-side anastomosis of the intestine. SGO, 1974; 138:87.

9. Huang Zhiqiang, et al.: Artificial nipple-type intermittent jejuno-biliary-duodenal anastomosis. Journal of Practical Surgery, 1986; 6(1): 48.

This article was originally published in Proceedings of the Second Annual Surgical Conference of the Third Session in Anhui Province,Sept. 1988；87
Changhang Hospital, Li Mingjie

from 胆肠内引流

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper VII

Hepatobiliary basin-type biliary-enteric drainage

 A Case Report 

A 46-year-old male seaman initially underwent cholecystectomy and common bile duct stone extraction in 1973 for cholecystitis and cholelithiasis. Three months post-discharge, he experienced recurrent episodes of biliary tract infection, characterized by abdominal colic, jaundice, fever, and fatigue, persisting for three years. In 1976, symptomatic relief was achieved through the expulsion of two biliary stones via Chinese herbal medicine. Subsequent B-scan ultrasonography in June and December of 1990 identified choledocholithiasis with a 1.9cm diameter stone. Further imaging in October 1991 confirmed extrahepatic choledocholithiasis accompanied by common bile duct dilatation (2.2cm) and left intrahepatic cholelithiasis with bile duct dilatation. No signs of infection or jaundice were observed, and liver function tests were within normal limits. No surgical contraindications were identified, and elective surgery involving a high-level biliary tract incision, basin-type biliary-intestinal drainage, and focal hepatectomy was planned.

Surgical Procedures

Under the guidance of continuous epidural anesthesia, an L-shaped incision was initiated below the right costal margin. The xiphoid process was subsequently excised, extending the incision toward the right axillary line. Upon abdominal entry, the common bile duct was isolated from the pre-existing surgical scar, revealing a multitude of cast stones and a "residual gallbladder" that was notably large and stone-filled.

The perihepatic ligaments, including the left and right triangular, falciform, and left coronary ligaments, were then dissected to facilitate the downward mobilization of the liver. Palpation of the left hepatic duct revealed a cluster of stones accompanied by fibrosis in segment III of the left lateral lobe. Additional stones were identified at the hepatic duct confluence.

Continuing the dissection, the extrahepatic bile ducts outside the hepatic hilum were isolated. Incisions were made in the porta hepatis and umbilical plates, with blunt dissection used to reach the left and right primary hepatic ducts. A high-level incision was performed on the common hepatic duct up to its bulging part to extract the gallstones. This was immediately followed by a hepatectomy of segment III of the left lateral lobe to eradicate the intrahepatic stones and cystic duct dilatation.

The extracted intrahepatic stones were completely removed via the interface between the left hepatic section and the common hepatic duct, followed by a hydrogen peroxide rinse. Hemostasis was achieved via suturing of the left hepatic section. The "small gallbladder" was then excised, and the common bile duct incision was enlarged to facilitate the removal of the lower segment stones. A No. 7 probe was introduced into the duodenum to repair the common bile duct incision.

Subsequently, the common hepatic duct and primary left and right hepatic ducts were exposed, revealing the openings of the secondary hepatic ducts and caudal lobe bile duct. Stone removal and rinsing were performed following ductal dilatation. The basin's rim was meticulously trimmed to maintain a 2mm edge for optimal anastomosis, with a basin diameter of 3.5cm. Finally, hemostatic suspension was applied.

A segment of the jejunum was transected 15cm distal to its origin. The distal jejuno-colonic segment was then elevated anteriorly and anastomosed to the hepatobiliary basin in an end-to-side fashion, employing a layer of mucosal eversion. Upon inspection, no leaks were identified. Subsequently, an anastomosis was performed between the proximal jejunum and the biliary-enteric loop, 40cm distal to the initial anastomosis.

For drainage, a dual cannula system was employed to establish negative pressure drainage beneath the porta hepatis and the hepatobiliary basin. The intraoperative blood loss was recorded at 300ml, and a blood transfusion of 600ml was administered to maintain hemodynamic stability.

Postoperative Course

Hemostatic triple therapy was administered for three days postoperatively, alongside a gold-standard antimicrobial regimen consisting of gentamicin, ampicillin, and metronidazole. The patient's postoperative body temperature plateaued around 38°C for a duration of two weeks. Bloody abdominal exudate was observed for three days but showed no signs of bile leakage. Drainage tubes were safely removed on the 9th postoperative day, with no ensuing abdominal or incisional infections or jaundice. The patient was declared fit and discharged after three weeks.

A 5-month follow-up indicated no episodes of biliary reflux infection or abdominal symptoms. Digestive functions were observed to be normal, and a subsequent B-scan ultrasonography revealed no residual intrahepatic or extrahepatic calculi.

Discussion

There is currently no standardized surgical approach for treating intrahepatic and extrahepatic bile duct stones. Conventional extrahepatic bile duct surgeries often fail to entirely remove stones, alleviate hepatobiliary strictures, or establish smooth drainage, leading to recurrent symptoms. This often necessitates multiple surgeries and may result in acute obstructive suppurative cholangitis (AOSC) and biliary sepsis, both associated with high mortality rates [1]. In recent years, however, many scholars have advocated for extending surgical interventions into the liver itself, enabling comprehensive stone removal and subsequently improving treatment outcomes [2]. Although these procedures are more invasive, when executed with meticulous surgical techniques and well-planned pre- and post-operative care, they yield satisfactory results.

Primary hepatic ducts (Grade I) can be safely dissected beyond the liver parenchyma, thus facilitating the treatment of secondary hepatic duct (Grade II) stones and strictures. If the quadrate lobe is hypertrophic, some surgeons recommend local resection to improve surgical field visibility and ensure precise choledocho-intestinal anastomosis, thereby enhancing the procedure's safety. However, with adept dissection techniques, the liver can be mobilized and manipulated without necessitating quadrate lobe resection. Our case demonstrated that anastomosis could be conveniently performed without resecting the quadrate lobe.

For diverse intrahepatic stone locations, specific treatments were applied in each case. Superficial liver stones were excised through liver parenchymal incisions followed by hepatic repair. Segmental resections were performed for stones confined to specific lobes accompanied by proximal bile duct dilation. For cast stones, direct incisions were made according to the liver entry route, followed by bile duct repair or T-tube and U-tube drainage. For localized liver stones, "sculptural" hepatectomy was executed to avoid resection of healthy liver tissue. It is crucial to preserve the liver's blood supply and bile drainage routes while employing a combination of surgical techniques.

References

1. Huang Zhiqiang. "10-Year Progress in Surgical Treatment of Hepatolithiasis." Journal of Practical Surgery, 1991; 8.9: 447.

2. Wu, J. et al. "Hepatobiliary Basin-Type Enterohepatic Drainage: An Analysis of 209 Cases." Chinese Journal of Surgery, 1989; 27: 130.

3. Wang Zhesheng, et al. "Treatment of Intrahepatic Biliary Stricture Accompanied by Calculi Using Tongue Resection at the Hepatic Hilus: A Report of 56 Cases." Journal of Practical Surgery, 1991; 8.9494

This article was originally published in Transportation Medicine 1993. 7:91
Changhang Hospital, Li Mingjie, Yang Zonghua Shi Lianghui

from 肝胆管盆式胆肠内引流术一例 

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper VI

Surgical treatment of short bowel syndrome

Study of 2 Cases  

Abstract

Short Bowel Syndrome (SBS) manifests as malnutrition, electrolyte imbalances, and various other complications due to the extensive resection of the small intestine. We present two cases where reverse peristaltic bowel loop anastomosis was performed in the distal small intestine to mitigate the risks of SBS.

Case Studies

Case 1: Male Farmer, 29 Years Old

The patient underwent extensive resection of the lower small intestine due to torsional necrosis, sparing only 3 cm above the ileocecal valve and leaving 80 cm of the jejunum intact. To restore intestinal continuity, the distal 7 cm of the jejunum, along with its mesentery, was inverted and an end-to-end anastomosis was performed. Postoperative observations showed effective reverse peristalsis in the interposed bowel segment. Although the patient experienced frequent bowel movements and mild indigestion, there were no significant nutritional or electrolyte imbalances, negating the need for specialized nutritional interventions. The patient returned to work six months post-surgery and has remained symptom-free for 18 years.

Case 2: Female Peasant, 24 Years Old

The patient presented with segmental enteritis featuring multiple necrotic perforations. A resection of the lower small intestine and a right hemicolectomy were performed, leaving 100 cm of the jejunum. The distal 7 cm of the jejunum was inverted, followed by a jejunum-to-jejunum-to-transverse colon end-to-end anastomosis. The patient successfully recovered from postoperative infection risks. However, she experienced loose stools for three months post-surgery. Nutritional absorption was satisfactory, and she resumed her normal life within a year. X-ray barium examination eight months post-surgery revealed reverse peristalsis at the anastomotic site, with slow barium propulsion. She has remained largely symptom-free for 20 years, except for two instances of abdominal pain.

Both cases highlight the potential of reverse peristaltic bowel loop anastomosis in preventing the onset of SBS. The technique appears to be particularly effective in preserving nutritional absorption and electrolyte balance. It also allows for a reasonable quality of life post-surgery, as evidenced by the patients' ability to return to work and maintain a normal lifestyle over an extended follow-up period.

Discussion

Importance of Intestinal Segmentation in SBS

The onset of Short Bowel Syndrome (SBS) is not solely determined by the length of the intestinal segment removed but also by its specific location. The small intestine demonstrates selective nutrient absorption at different segments—iron and calcium are primarily absorbed in the proximal jejunum, whereas bile salts and vitamin B are absorbed in the distal ileum. The duodenum, proximal jejunum, and distal ileum are considered pivotal for intestinal digestion and absorption. Thus, preserving these key segments and the ileocecal valve during resection can often prevent the development of SBS, even if up to 50% of the middle small intestine is removed.

Physiological Adaptations and Complications

The small intestine has a significant functional reserve, making it relatively tolerant to partial resection. However, extensive resection, particularly of functionally crucial segments, can trigger SBS. Initial symptoms often involve substantial fecal fluid loss and electrolyte imbalances. In some cases, increased gastric secretions can lead to peptic ulcers. Over time, the remaining small intestine may undergo compensatory changes, like villi enlargement and mucosal cell proliferation, to enhance absorption. If these compensatory mechanisms are inadequate, SBS may still develop, necessitating surgical interventions like short bowel anastomosis.

Limitations of Non-Operative Measures

Non-surgical treatments are generally supportive and aim to assist patients through the adaptation and compensatory phases. Our study group had ten other cases without specific short bowel anastomosis; three patients died within two months from severe electrolyte and fluid imbalances, despite aggressive fluid and blood transfusion therapies. The remaining seven underwent a challenging recovery period lasting 1-2 years.

Efficiency of Reverse Peristaltic Bowel Loop Anastomosis

Various techniques for short bowel anastomosis exist, but the reverse peristaltic bowel loop anastomosis has proven to be straightforward, effective, and complication-free, even in emergency scenarios. The optimal length for the interposed loop is between 7-14 cm for adults and less than 8 cm (3 cm for neonates) to prevent physiological intestinal obstruction due to reverse peristalsis. The location of the loop should be carefully considered, aiming for the distal side of the remaining small intestine to maximize its functional efficiency.

Preventative Strategies for SBS

In adults, the length of the small intestine can reach up to 7 meters, but the actual in vivo length is often around 3 meters. During resection, it's generally advised to limit the removal to less than 50% of the intestine. Special attention should be paid to conditions like Peutz-Jegher's disease, which may require multiple surgeries due to recurrent polyps. In such cases, individual polyp excision should be prioritized over extensive resection. Care should also be taken to preserve the ileocecal valve function and avoid indiscriminate incisions.

In summary, a multifaceted approach, considering the anatomical, physiological, and surgical aspects, is essential in both the treatment and prevention of SBS.

This article was originally published in Transportation Medicine 1991. Vol.5, No.1: 41-40
Changhang Hospital, Li Mingjie

from 短肠综合征的外科治疗

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper V

Diagnosis and treatment of closed retroperitoneal duodenal injury  

A Case Report

A 29-year-old male was admitted to our hospital one hour after experiencing a traumatic impact to his right rib area when his bicycle collided with the handle of a parked scooter. He reported immediate severe pain, difficulty breathing, and palpitations.

Initial Examination and Admission

Upon admission, the patient's vitals were as follows: Blood Pressure 15/10 kPa, Temperature 36°C, Pulse 68 beats/min. He appeared alert but in acute pain. Physical examination revealed a shallow abrasion along the clavicular midline of the right costal margin, a slightly tense right upper abdominal muscle, and no obvious tenderness or rebound pain. Abdominal puncture was negative. Laboratory tests indicated Hemoglobin levels at 125 g/L, WBC count at 10.2 x 10^9/L, with 75% neutrophils and 25% lymphocytes. B-ultrasound showed no abnormalities in the liver, spleen, pancreas, or kidneys, and no abdominal fluid was detected. Chest fluoroscopy was also normal.

After 16 hours of hospitalization, the patient experienced increasing right-sided lumbar and testicular pain. Further imaging revealed indistinct fat lines and psoas major muscle shadows on the right side of the abdominal wall, although the right kidney appeared normal. Despite rehydration and anti-inflammatory treatments, the patient's abdominal pain worsened.

Clinical Observations and Diagnosis

Subsequent physical examination showed increased abdominal muscle tension, widespread tenderness, particularly in the lower right quadrant, and rebound pain. Percussion of the right kidney area was painful. Repeat abdominal puncture and lavage were negative. Serum amylase levels were within normal limits, and WBC count was 11.1 x 10^9/L with 84% neutrophils and 16% lymphocytes. Urinalysis was negative. The patient was diagnosed with a closed retroperitoneal duodenal injury and underwent exploratory laparotomy 28 hours post-injury.

Discussion

Diagnostic Challenges and Characteristics

Retroperitoneal duodenal injuries are rare and serious abdominal traumas that often present diagnostic challenges due to their initially subtle symptoms. Characteristic symptoms such as right lumbago and testicular pain may occur as a result of stimulation of the right psoas major muscle and retroperitoneal testicular nerve by duodenal fluid. Additionally, the accumulation of extraintestinal air in the retroperitoneal space can make the outline of the right kidney clearly visible in X-ray examinations. Elevated levels of serum amylase can also indicate the overflow of pancreatic juice. Diagnostic abdominal puncture is a valuable tool for early diagnosis, and some practitioners successfully use intraoperative injection of methylene blue via a stomach tube for diagnosis.

Case Specifics

In this particular case, the patient exhibited symptoms of right lumbago, testicular pain, and signs of peritoneal irritation. Radiological findings revealed indistinct fat lines and psoas major muscle shadows on the right abdominal wall, while the right kidney outline remained clear. These factors led us to suspect a retroperitoneal duodenal injury. Exploratory laparotomy confirmed a retroperitoneal hematoma and diffuse green staining, corroborating our diagnosis.

Surgical Management and Postoperative Care

Despite the delayed surgery occurring 28 hours post-injury and considerable local inflammation, the patient experienced no postoperative complications. The surgical approach included gastrojejunal bypass, common bile duct drainage, and duodenal stump fistulization, supplemented by abdominal double cannula negative-pressure drainage.

Adjuvant Treatments

Postoperatively, we implemented a range of adjuvant treatments aimed at patient recovery. These included continuous gastrointestinal decompression and duodenal fistula to lower duodenal internal pressure and minimize the retention of irritating and inflammatory fluids. We also administered a combination of broad-spectrum antibiotics and provided rehydration to maintain water, electrolyte, and acid-base balance. Active postoperative support was instrumental in the patient's successful recovery.

This article was originally published in Transportation Medicine 1995. Vol.9, No.3
Changhang Hospital, Zhang Qi, Director: Li Mingjie

from 闭合性腹膜后十二指肠损伤诊治体会 

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper IV

Surgical treatment of acute gastroduodenal perforation 

Abstract

This study examines 76 cases of acute gastroduodenal perforation, categorized into digestive ulcer perforations (60 cases), perforations due to gastric cancer (10 cases), and traumatic duodenal ruptures (6 cases). Of these, 37 underwent gastrectomy, while 39 received perforation repair. Clinical outcomes favored gastrectomy, which displayed fewer postoperative complications such as re-perforation and bleeding. The study recorded 5 mortalities. The findings suggest that gastrectomy is the preferred surgical intervention for both immediate relief and long-term cure. Even palliative gastrectomy for malignant conditions can alleviate symptoms and improve quality of life. Perforation repair, although life-saving in certain situations, has significant drawbacks. For traumatic duodenal ruptures, post-repair treatment should include Berne-style diverticulization.

1. Clinical Data

The study involved 76 patients, comprising 69 males and 7 females, ranging in age from 14 to 73 years with an average age of 42 years. Among these patients, 32 were diagnosed with duodenal ulcer perforation with an average age of 35 years; 28 had gastric ulcer perforation with an average age of 54 years; 9 had perforations due to gastric cancer with an average age of 58 years; one case was identified as gastric malignant lymphoma aged 73; and 6 cases involved duodenal rupture due to trauma with an average age of 34 years. Concurrent conditions in the cohort included 7 cases of bleeding, 15 cases of shock, and 3 instances of additional visceral injuries among the 6 trauma-induced perforations. Comorbidities included hypertension in 12 cases, coronary artery disease in 8, diabetes in 6, and pulmonary tuberculosis in 4. Among the 18 cases that underwent surgery within 12 hours of perforation, 13 underwent gastrectomy and 5 received perforation repair. Of the 30 cases operated on between 13 and 24 hours post-perforation, 12 had a gastrectomy and 18 had perforation repair. Finally, among the 28 cases (including 6 trauma cases) who were operated on after 24 hours from perforation, 12 underwent gastrectomy.

2. Results

Gastrectomy

A total of 37 patients underwent gastrectomy, all of which were performed using the Billroth-I technique, with no immediate postoperative fatalities. Of the 10 gastrectomies performed for malignant conditions, 7 were palliative resections with survival periods ranging from 6 to 14 months. Three were curative resections, with survival periods ranging from 2 to 5 years; notably, one 73-year-old patient with gastric malignant lymphoma remained alive and symptom-free five years post-curative resection. Among the 23 patients who underwent gastrectomy for perforated peptic ulcers, all but one patient with a pancreatic-origin ulcer—who required three surgeries culminating in a total gastrectomy—were successfully treated. During an 8 to 10-year follow-up, only two cases exhibited mild symptoms of alkaline reflux gastritis but were otherwise healthy.

Perforation Repair

Out of 39 cases that underwent perforation repair, two patients died due to re-perforation or leakage on the fourth postoperative day, while another two experienced postoperative bleeding on the second and fifth days, resulting in one fatality. In cases involving duodenal trauma, two patients underwent simple repair but did not survive. Among the 34 surviving patients, one experienced re-perforation due to active ulceration at 2 years post-surgery and another at 5 years post-surgery. Additionally, 7 patients underwent subsequent gastrectomies due to persistent symptoms.

3. Discussion

Acute perforation of the stomach and duodenum presents an urgent clinical challenge, irrespective of the underlying etiology or disease progression. The immediate concern is the spillage of luminal contents, leading to acute peritonitis and a cascade of pathophysiological changes that require prompt intervention.

3.1 Evaluation of Non-Surgical Treatments

For cases where the perforation is small and quickly sealed by adhesion, symptoms and signs are mild, systemic disturbances are minimal, or high-risk factors such as advanced age and comorbidities are present, non-surgical treatment may be considered. However, most surgeons are reluctant to take this risk for several reasons:

1. A passive and negative mindset is prevalent, demanding rigorous and continuous observation and monitoring. The criteria for transitioning to surgical intervention are difficult to gauge, and the risk of delayed surgery could come at a significant cost.

2. Precise diagnosis in terms of localization and quantification is challenging. It is generally believed that duodenal ulcer perforations may self-seal, while conservative treatment for gastric ulcer perforations tends to be less effective.

3. Perforations due to gastric cancer necessitate further surgical intervention.

4. The underlying condition requires systematic examination and treatment after the acute phase, with at least half of the cases eventually requiring surgery. Additionally, the rate of re-perforation stands at 8.5%.

5. Post-treatment complications such as intra-abdominal abscesses and adhesions are possible.

Given these considerations, the majority of surgeons opt for surgical intervention.

Certainly, opting for surgical intervention carries risks associated with perioperative anesthesia, surgical trauma, and hemodynamic changes. However, the advantages often outweigh these concerns. Open surgery allows for a more accurate assessment of the nature and extent of the pathological changes, the status of intra-abdominal infection, as well as the location and size of the perforation. This enables a more targeted and proactive choice of surgical procedures. Furthermore, advancements in surgical techniques, improved monitoring measures, and the progress in antibiotics contribute to increasingly encouraging surgical outcomes.

3.2 Subtotal or Radical Gastrectomy

Whenever feasible, this should be the treatment of choice, boasting excellent therapeutic outcomes of 90%-95% for perforated ulcer diseases and a surgical mortality rate of less than 1%. It serves both diagnostic and therapeutic purposes. This approach is also suitable for treating perforations caused by gastric cancer. In cases of duodenal trauma followed by diverticulization, gastroenterostomy along with gastric resection is required. Out of the 37 gastrectomies performed in our study group, both short-term and long-term outcomes were favorable, except for cases of advanced gastric cancer where curative resection was not possible. The time elapsed since perforation should not be the sole criterion for selecting the surgical approach; rather, factors like the extent of edema and inflammation at the lesion site, as well as intra-abdominal infection, should also guide the choice. During gastrectomy, the lesion is removed, allowing for anastomosis on healthy tissue. In our group, four cases underwent this procedure 48 hours post-perforation and had smooth postoperative recoveries.

Of course, suturing techniques and comprehensive perioperative management are also crucial factors.

3.3 Perforation Repair

Since its inception by Von Heusner in 1892 and Bennett in 1896, perforation repair remains clinically valuable for life-saving measures even today. The procedure is characterized by its simplicity, minimal invasiveness, and safety, making it indispensable for high-risk patients. However, the technique is not without its drawbacks. Apart from the risks of postoperative bleeding and leakage, 50%–70% of patients ultimately require further surgical intervention or experience symptom recurrence. Illingworth reported that 40% of patients experienced symptom recurrence within one year and 70% within five years following perforation repair. Shi Huang reported that, in a long-term follow-up of 141 cases, 20% experienced bleeding, 9.2% had pyloric stenosis, and 4.7% suffered re-perforation. All five fatalities in our study group underwent this procedure. Moreover, perforation repair for gastric cancer provides only temporary relief and does not alter the disease course, with most patients succumbing to cancer within a year post-surgery.

The authors believe that this procedure should be strictly limited to the following conditions:

1. Severe peritonitis accompanied by shock.
2. Extensive edema around the perforation site, which could hinder the healing of anastomosis following gastrectomy.
3. Lost opportunity for palliative resection of the tumor.
4. Presence of other severe comorbidities or frailty due to advanced age, where any increase in surgical trauma would elevate the mortality risk.

Three technical aspects warrant special attention during perforation repair:

1. Care must be taken to avoid excessive inverting sutures, particularly in the pylorus and duodenum, to prevent iatrogenic stenosis.

2. Effective repair to prevent re-leakage is crucial. The first layer of sutures should be loosely approximated, followed by a second layer of seromuscular sutures for coverage, and then supplemented by an omental patch with an adequate blood supply.

3. In cases of traumatic duodenal rupture, if repair proves challenging, nearby organs such as the stomach, intestine, or gallbladder can be used, or a vascularized patch may be applied for suturing and sealing. However, this must be accompanied by thorough diverticulization to ensure proper drainage [5].  

References

[1] Shen Hongxun. Current Status and Progress in Surgical Treatment of Peptic Ulcers: Transportation Medicine 1991, 5(1): 26~

[2] Berne CT. Duodenal Diverticularization for Duodenal and Pancreatic Injury. Am J Surg. 1974, 127:503~

[3] Rodney Maingot. Abdominal Surgery. Shanghai: Science and Technology Press, 1965, pp. 244-247.

[4] Shi Huang. Simple Repair for Acute Gastric and Duodenal Ulcer Perforation. Chinese Journal of Surgery, 1964, 12:646.

[5] Jiang Kai, Pan Youlan, Li Mingjie.  Diagnosis and Treatment of Closed Retroperitoneal Injury of the Duodenum. Wuhu Medicine, 1997, 3(2): 9~

Li Mingjie
Changhang Hospital, Wuhu, Anhui Province, China
Surgical Department, Zip Code: 241000
Received: June 5, 1995; Revised: October 21, 1997
Originally published in the Chinese Journal of General Surgery, Supplement to Volume 6, December 6, 1997, pp. 22-23.

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】

Surgical paper III

Surgical management study of hepatic injury

Abstract

The incidences of the hepatorrhexis in trauma have markedly increased lately.  In its treatment, there are still some difficulties due to acute massive hemorrhage.  The clinical experiences are presented by the author.  The Pringle technique, hepatorrhaphy, resectional debridement hepatotomy, hepatic artery selected libation and double catheter drainage have been employed.  Postoperative treatment of re-hepatorrhagia, bile leakage or infection is emphatically recommended in emergency cases.

Key Words:
1. Traumatic Hepatorrnexis
2. Resectional Debridement Hepatotomy
3. Double catheter Drinage

May 11, 1990

As technological advancements in production and transportation continue to rise, so too does the incidence of hepatic trauma. These injuries often present as life-threatening conditions with a general mortality rate ranging from 20% to 25%. In a study conducted by McEarrall in 1962, 55% of 200 accidental deaths that occurred while walking were attributed to liver injuries. While modern medicine has made strides in reducing mortality rates through improved rescue technologies and blood transfusion methods, the liver's inherent fragility and thin capsule continue to pose challenges. Complications such as bile leakage and infection can arise in addition to hemorrhaging. The liver's unique anatomy, particularly the complexity surrounding the second porta hepatis, further complicates emergency surgical interventions. Given that the liver is not a paired organ, only partial excision is possible, adding another layer of complexity to its treatment. Despite the high risks associated with hepatic injuries, there remains a lack of uniform treatment standards. This paper reviews 35 clinical cases encountered over the past three decades, alongside a comprehensive literature review, to discuss various aspects of this challenging issue.

Non-Surgical Management of Superficial Hepatic Injuries

Clinical Experience

In our clinical practice, we have encountered three cases of superficial hepatic injuries. Upon surgical exploration, the lacerations were found to be superficial, and active bleeding had ceased. Consequently, suturing was deemed unnecessary; instead, the abdominal cavity was either cleaned or drained. All patients exhibited a stable postoperative course and made full recoveries.

Literature Review and Case Study

Superficial liver injuries that neither affect circulatory dynamics nor present with peritonitis or other complications can often be managed conservatively. Such injuries frequently self-terminate bleeding during the surgical intervention. Minor amounts of hemoptysis and bile leakage in the abdominal cavity are typically reabsorbed spontaneously.

Oldham's study reported 53 pediatric liver trauma cases, with 49 being managed conservatively. One illustrative case involved an 8-year-old boy who fell from a height of one meter. He experienced localized pain in his right hypochondriac region and mild discomfort in the lower right abdomen. Despite these symptoms, he displayed no muscle guarding, maintained normal blood pressure, and had a hemoglobin level of 120 g/L. A diagnostic aspiration of 2 ml of yellow, non-coagulated fluid from his abdomen confirmed liver injury. Hospitalized for three days without significant changes, he was discharged and observed for one month without complications. While the exact grade of liver injury was not surgically confirmed, it was presumed to be mild, and the patient exhibited a natural recovery.

Complications and Lessons Learned from Surgical Repair of Hepatic Injuries

Clinical Experience

During liver repair, the common practice of using mattress sutures may offer temporary hemostasis and wound closure. However, this technique often leads to complications such as necrotic infection and secondary hemorrhage. These adverse outcomes are primarily due to inadequate drainage, wound bed inactivation, autolysis of liver tissue, and bile accumulation.

Case Study

A 13-year-old male fell off the back of a cow, sustaining a transverse rupture in the center of his right liver upon impact with a cliffside. The surgical intervention employed mattress sutures for hemostasis and closed the liver wound, neglecting to perform common bile duct decompression and drainage. Although the patient initially recovered well postoperatively and was discharged after 14 days, he later developed hemobilia, recurrent right upper abdominal colic, hypotension, and anemia. Multiple rounds of blood transfusion and anti-infection measures proved ineffective over a week of conservative treatment. Subsequent surgery involved ligation of the hepatic artery and common bile duct drainage, leading to full recovery. A 10-year follow-up showed favorable growth and no residual sequelae.

Lessons and Recommendations

The key takeaway from this case is the critical need for debridement hepatectomy during the initial operation. This procedure removes necrotic liver tissue, followed by individual vessel ligations. Open drainage techniques, such as double-cannula negative pressure drainage, should be utilized. Alternatively, pedicled omentum can be loosely packed and affixed to the wound, in conjunction with common bile duct decompression and drainage. Implementing these measures can prevent the complications described above. Stone's research corroborates this approach, demonstrating successful hemostasis in 37 cases through the use of pedicled omentum packing in liver injuries.

Management of Large Vessel Injuries in the Second Porta Hepatis Region

Clinical Considerations

For injuries involving large vessels in the second porta hepatis area, it is crucial to provide ample exposure for manual pressure or non-injurious vascular clamping to temporarily halt bleeding. In situ repair of ruptured vessels can also yield successful outcomes. However, the use of Schrock catheter shunts is not universally applicable.

Case Study

A 42-year-old male, employed as a car driver, sustained injuries to the right retrohepatic bare area and a laceration of the inferior vena cava due to a vehicle rollover. A right thoracoabdominal incision was made to mobilize the liver. During wound exploration, profuse bleeding was encountered and temporarily controlled through emergency hand compression. Upon clearing the surgical field, a 0.5 cm tear in the inferior vena cava was discovered. Hemostasis was achieved through vessel repair using Satinsky forceps and continuous everting sutures with fine threads. Subsequently, liver laceration debridement and suturing were performed, leading to a successful outcome.

Clinical Implications

In cases like this, flipping the liver to expose the wound for hemostasis could exacerbate the tearing of already damaged vessels, thereby intensifying bleeding. Rapid blood transfusion would be futile in such situations and could precipitate intraoperative mortality.

Manual Techniques for Hemostasis in Liver Surgery

Practical Approaches

During surgeries involving the left outer lobe of the liver or its surrounding areas, manual pressure or hand kneading can effectively control intraoperative bleeding. Additionally, irregular resections can be safely and conveniently performed.

Abdominal Hematocrit and Transfusion as an Emergency Measure in Liver Rupture

Criteria and Rationale

In the absence of concomitant hollow organ injuries, abdominal hematocrit and transfusion can serve as a feasible and effective emergency measure for managing liver ruptures. This approach is particularly beneficial when immediate external blood sources are unavailable.

Multifaceted Concerns in Liver Injury Management

Beyond Hemorrhage

Liver injuries pose challenges that extend beyond bleeding issues. Given the liver's intricate bile duct system, bile overflow can exacerbate peritonitis through chemical irritation. Furthermore, the liver's portal venous system, which collects blood from the digestive tract, presents a heightened risk for anaerobic infections.

Importance of Intraoperative Measures

Intraoperative drainage and perioperative prophylaxis against anaerobic infections are critical components in minimizing intra-abdominal infections. Earlier, we underestimated and inadequately managed these aspects, leading to secondary infections—a lesson that has since guided our approach.

Discussion

Ease of Diagnosis in Typical Cases

Diagnosing liver injuries is generally straightforward. For closed injuries, the presence of trauma to the right hypochondriac region, or an associated fracture of the right lower rib, coupled with right upper abdominal pain and internal bleeding, usually confirms the diagnosis through positive abdominal puncture tests.

Challenges in Less Obvious Cases

However, diagnostic difficulties arise when intra-abdominal hematoma is less than 200 ml, as abdominal puncture tests often return negative results. Moreover, such low volumes of intra-abdominal bleeding do not typically affect hemodynamics, complicating the diagnosis further. In these instances, abdominal lavage or repeated peritoneal punctures can yield positive results, thereby proving decisive for diagnosis.

Diagnostic Tools and Their Limitations

While visceral angiography and isotope-based liver scans using Selenium-76 and Isotope-198 offer valuable insights, they are not universally applicable. Non-invasive ultrasound and dynamic CT observations are beneficial alternatives. However, the dynamic observation of the hemogram proves to be of the utmost importance in these cases.

(1) Management of Hemorrhagic Shock

In the event of hemorrhagic shock, immediate measures should be taken to establish effective venous access, preferably in the upper limb. Additionally, a central venous pressure catheter should be inserted to ensure accurate monitoring and rapid volume expansion of the effective circulating blood volume. Concurrently, blood supplies should be actively prepared.

If the shock state persists and hemoglobin levels continue to decline, intraperitoneal liver blood transfusion may be performed under stringent conditions. This approach is particularly crucial in cases of massive acute hemorrhage, with increasing numbers of successful interventions reported in recent literature [4, 5].

When surgical intervention becomes necessary, it should be executed promptly alongside blood transfusion and preparation. This strategy aims to maximize the rescue opportunities for patients experiencing hemorrhage at rates exceeding the speed of blood transfusion.

(2) Mortality Rates and Surgical Approaches

(2) Research by Jaejackdavis indicates a 29% mortality rate for liver injuries treated with surgical resection. This rate can surge to 50% when conventional hepatectomies are performed. Consequently, debridement hepatectomies are the preferred surgical approach for liver contusions and lacerations to minimize further trauma.

Best Practices for Liver Surgery

During hepatic suture cutting, it is crucial to ensure adequate blood supply and bile drainage for the preserved liver segments. Failing to do so increases the risk of complications such as necrotic infections and bile leakage. Therefore, the guiding principles for liver trauma surgery include comprehensive debridement, effective hemostasis, prevention of bile leakage, and unobstructed drainage.

(3) Hepatic Artery Ligation: A Risk-Benefit Analysis

In severe liver injuries that are not amenable to hepatectomy or complications involving intra-hepatic vascular and biliary fistulas, selective hepatic artery ligation can offer a reliable hemostatic solution. The rationale behind this is that the portal vein provides 75% of the liver's blood supply and 50% of its oxygen. After ligation of a high-pressure hepatic artery, blood flow from the portal vein is enhanced. Collateral circulation can be established within 10 hours, typically eliminating the risk of liver necrosis. According to the Walt system, this approach can be effective in up to 31% of cases [6].

Postoperative Considerations

Post-ligation, transient spikes in serum markers like lactate dehydrogenase, transaminase, cholelithiasis, and alkaline phosphatase have been observed, but these levels normalize within 7–14 days. However, careful postoperative management is essential, including blood volume and oxygen supplementation, infection prevention, and dietary restrictions to mitigate the liver’s metabolic load. This technique should be used cautiously in patients with liver cirrhosis and liver diseases.

Operational Guidelines

During the procedure, excessive dissection in the porta hepatis region should be avoided to facilitate collateral circulation. Also, the ligation should be as close to the lesion as possible for targeted efficacy, avoiding the ligation of the liver's intrinsic arteries which could compromise the entire liver's blood supply.

(4) The Role of Common Bile Duct Decompression and Drainage

Aside from treating superficial injuries, common bile duct decompression and drainage should be considered a standard adjunctive procedure for managing this condition. This method facilitates bile drainage, mitigates intrahepatic cholestasis and bile leakage, and aids in infection control.

Monitoring and Diagnostic Benefits

The procedure serves as an essential monitoring tool for assessing postoperative liver function recovery and hemobilia (biliary tract bleeding). During the operation, methylene blue can be introduced to inspect for potential leaks in the intrahepatic bile ducts. Postoperatively, this technique can also be employed for angiographic studies.

(5) Hepatic Blood Transfusion in the Context of Massive Blood Loss

The liver has a rich blood supply, making severe injuries prone to extensive bleeding. The complications arising from massive blood transfusions cannot be overlooked. For instance, when transfusion volumes reach up to 4000ml, coagulation mechanisms can be disrupted, leading to uncontrolled bleeding.

Clinical Relevance

To mitigate this, hepatic blood transfusion becomes critically important. Ye [5] reported successful rescue in a case involving the transfusion of 6000ml of hepatic blood.

Theoretical Foundation

The theoretical underpinning is that the liver processes 1500ml of blood per minute and less than 1ml of bile. About 91% of bile is made up of water and inorganic salts, and the rest are trace amounts of substances like cholesterol and cholic acid. Therefore, mixing this with hepatic blood for transfusion poses no harm.

Practical Applications

Animal studies have confirmed the non-toxic nature of bile. Both anaerobic and regular cultures of liver blood from the portal vein have shown negative results, confirming its safety for transfusion.

Implementation Guidelines

For implementation, an abdominal puncture can be performed preoperatively to draw blood. A sterile suction device is then used for filtering and transfusion. If fresh blood is collected instead of pooled blood, anticoagulant measures are necessary. Otherwise, anticoagulants can be omitted, simplifying the process.

(6) Prevention of Postoperative Complications

(6) Loose suturing of the liver trauma is beneficial for drainage. The procedure should ensure that all areas around the liver, particularly the porta hepatis, are adequately drained.

Practical Recommendations

• Drainage Systems: The use of double sets of silicon tube negative pressure suction systems is preferred in the porta hepatis region. This is to prevent complications like infections and bile leakage.

• Pharmacological Measures: Antibiotics should be administered to minimize the risk of postoperative infections.

• Blood Volume: Replenishing blood volume is essential for stabilizing the patient’s condition.

• Liver Protection: Additional measures should be taken to protect the liver post-surgery.

• Oxygen Supply: Oxygen should be administered as part of the postoperative care to ensure optimal recovery.

(7) Treatment of Combined Injuries

(7) When dealing with patients who have sustained multiple injuries, prioritization is key. Special attention must be paid to cerebral and thoracic trauma, as these can be life-threatening.

Practical Recommendations

• Prioritization: Determine the most urgent injuries that need immediate treatment. Usually, head injuries and thoracic injuries take precedence due to their potential severity.

• Simultaneous Treatment: Whenever possible, manage cerebral and thoracic traumas concurrently to maximize the chances of a successful outcome.

• Exploration Post-Laparotomy: After opening the abdominal cavity, careful exploration of other internal organs is crucial. This is to identify and treat any other possible injuries and to prevent any complications like leakage.

• Holistic Approach: By addressing all injuries in a coordinated manner, the success rate of the treatment is likely to improve.

(8) Conservative Treatment of Liver Trauma

The data presented by old ham [1] from Mott Children's Hospital in the U.S. shows that a conservative approach to liver trauma can often be effective. Out of 188 cases of closed abdominal trauma, 53 involved liver injuries. Only four required emergency surgery due to acute hemorrhage. The rest were managed non-operatively, with only three later requiring delayed surgical intervention due to complications from biliary peritonitis. This results in a relatively low surgical intervention rate of 13.2% (7/53).

Key Points to Consider

• CT and Liver Enzyme Monitoring: Any conservative treatment must involve rigorous monitoring, including CT scans and liver enzyme tests (GOT, GPT).

• Hematocrit Levels: It's crucial to maintain hematocrit levels above 30% to ensure effective treatment.

• Medical Support: Excellent medical services and the availability of surgical intervention at any time are necessary.

• Risks: Such a conservative approach does carry risks, including post-transfusion hepatitis and the potential for acquired immunodeficiency syndrome (AIDS).

• Long-term Effects: The impact of abdominal blood on long-term adhesive intestinal obstruction remains inconclusive.

• Clinical Judgement: Based on clinical experience, liver trauma that does not cause hemodynamic changes can be managed conservatively with thorough monitoring and responsible clinical observation.

References

[1] Oidham KT et al. "Blunt liver injure in childhood: Evolution of therapy and current perspective." J Current Surg. 1988;45(1):41

[2] Stone HH et al. "Use of pedicle omentum as an autogenous pack for control of hemorrhage in major injuries of the liver." S.G.O. 1975;141:92

[3] Li, Mingjie. "Left Lateral Hepatectomy for Intrahepatic Gallstones" 国内医学外科分册 1980; 161; 皖南医学 1980;13:51

[4] Lu, Xianding. "Report of 4 Cases of Intra-abdominal Hematocrit and Transfusion Due to Traumatic Liver Rupture" 中华外科杂志 1980; 18(3):211

[5] Ye, Shengdan. "A Case Report of Massive Liver Blood Transfusion for Traumatic Liver Rupture" 实用外科杂志 1986: 6(3):425

[6] Walt HJ. "Discussion of hepatic artery ligation." Surg 1979; 86:536

Contributors

Wuhu Changhang Hospital

• • Li, Mingjie
  • Wang, Yueqin

This article was originally published in "交通医学 (Transportation Medicine)" 1996; 10(1): 60-62. (A paper presented at the Transportation Ministry's 1990 Surgical Academic Symposium).

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】

Surgical paper II

PEUTZ syndrome

A 14-Year Case Study of Three Surgical Interventions Due to Complications

Surgical paper I

Regular resection of left lateral lobe of liver for intrahepatic calculi

Introduction

Intrahepatic calculi, otherwise known as stones within the bile ducts situated above the left and right hepatic ducts, are an often underdiagnosed but significant clinical entity. Over the past five years, our hospital has recorded 368 cases of primary bile duct stones, which constitute 83.4% of the 441 cases of cholelithiasis surgeries performed during the same time frame. Of these, 112 cases were identified as intrahepatic stones, accounting for 30.4% of primary bile duct stone cases. These statistics align closely with domestic literature on the subject [4, 5]. However, it should be noted that the actual incidence is likely higher, given the limitations in diagnostic capabilities. The distribution of intrahepatic stones within the liver is further detailed in Table 1.

Table 1        Distribution of 112 Cases of Intrahepatic Stones

Intrahepatic calculi present a unique challenge in diagnosis and treatment, often leading to misdiagnosis and unsuccessful interventions. Until recently, the condition has been marked by a cycle of recurrent episodes, multiple surgeries, and repeated failures in treatment.

In a concerted effort to enhance the treatment outcomes for intrahepatic calculi, our hospital initiated a new surgical approach. Between 1975 and 1976, we performed resections of the left lateral lobe of the liver in five patients. Following a period of 3 to 4 years of postoperative surveillance, the long-term therapeutic outcomes have been promising. This innovative approach has not only yielded good long-term curative effects but also provided valuable insights that have significantly improved our treatment protocols for intrahepatic calculi.

Clinical Data

The study sample comprised a total of five patients: two males and three females, ranging in age from 21 to 40 years. Among them, two patients presented with residual stones. Intraoperatively, all cases were complicated by choledocholithiasis—stones in the common bile duct. The primary location for the intrahepatic calculi was identified as the left lateral lobe of the liver, where varying degrees of fibrous atrophy were also noted.

Surgical Procedure

All surgeries were performed under general anesthesia with abdominal incisions. Resection of the left lateral lobe was the principal surgical intervention. A "T"-shaped tube was employed for external drainage of the common bile duct, or additional intrahepatic calculi were extracted using a "joining forces" technique.

Postoperative Outcomes

Two cases experienced complications, specifically delayed hemorrhage and abdominal infection. The hospitalization duration for these patients varied between 14 and 72 days. However, all patients recovered fully and were discharged. Postoperative recurrence of choledocholithiasis was noted in two cases, necessitating further surgical intervention supplemented by a choledocho-duodenal lateral anastomosis. Subsequent examinations revealed no presence of intrahepatic bile duct stones.

Long-term Follow-up

All patients were followed for a period of 3 to 4 years postoperatively and showed no signs of recurrence. Overall health status was reported as good. (For a detailed summary of the original medical records, please refer to Table 2). 

Diagnosis of Intrahepatic Calculi

The majority of surgeries for intrahepatic stones are performed to address biliary obstruction. Among the 112 cases in this group, 95 were complicated by common bile duct stones (84.9%). Previously, the removal of extrahepatic stones and restoration of biliary tract patency were considered sufficient for a "cure," supplemented by general treatment. However, this approach failed to account for potential adverse reactions arising from persistent intrahepatic infections. This oversight often resulted in repeated episodes and surgeries.

Diagnostic Methods

1. Intraoperative Indicators: If the common bile duct is expanded by pigment stones or filled with sediment and the gallbladder is clear of stones, this suggests hepatogenic stones, warranting further examination of intrahepatic lesions.

2. Visual and Tactile Examination: The liver's surface may exhibit localized hardness, paleness, and dome-shaped prominence, along with localized atrophy. In contrast, healthy liver tissue may show compensatory hypertrophy.

3. Liver Abscesses: Multiple bile duct-derived liver abscesses often indicate intrahepatic calculi.

4. Angiographic Evidence: "T" angiography may reveal negative shadows, such as a bean-and-pod pattern, suggesting intrahepatic stones.

5. Postoperative "T" Tube Drainage: The presence of sediment-like stone deposition in the drainage bottle indicates a reduction in postoperative intrahepatic stones.

The Role of Left Extrahepatic Lobectomy in Treatment

1. Minimal Surgical Trauma: This procedure inflicts moderate damage on liver function and minor disturbance on the body overall. When executed correctly, it solves most treatment challenges related to intrahepatic stones, ensuring short-term recovery and long-term satisfaction.

2. Complete Elimination: It eradicates lesions and prevents ongoing infections and stone reformation due to poor drainage and bile retention.

3. Alternate Exploration: The surgery allows for the exploration and removal of stones from other hepatic lobes, offering a different vantage point for tackling intrahepatic lesions.

4. Convenience: Compared to intrahepatic cholangiojejunostomy, left lateral lobe hepatectomy is technically easier to perform.

However, it's crucial to note that simpler surgical interventions are more suitable for patients with toxic shock, severe systemic infections, or extremely compromised liver function. Relief of obstruction is better achieved with "T" external drainage.

Surgical Indications

The following cases are considered appropriate candidates for the surgical resection of the left lateral lobe of the liver for treating intrahepatic calculi:

1. Multiple Intrahepatic Stones in the Left Lateral Lobe: Particularly when accompanied by fibrous atrophy, and when other hepatic lobes either have no stones or have stones that can be completely removed by other methods.

2. Calculus in the Outer Lobe with Poor Drainage: Cases where the outer lobe has calculus, along with bile duct stenosis and poor drainage, making it likely that stone regeneration will occur if only the liver parenchyma is cut open for stone removal.

3. Inaccessible Calculus at the Junction: Cases where there is calculus at the junction of the left inner lobe hepatic duct that cannot be removed through other means.

4. Left Lateral Lobe Calculus with Abscess: Cases where an abscess is present along with the calculus in the left lateral lobe.

5. Necessity for Roux-Y Longmire Surgery: Cases where the extrahepatic bile duct cannot be located due to inflammation or adhesion, or is too narrow to be shaped, thereby necessitating a Roux-Y Longmire procedure (anastomosis between the intrahepatic bile duct and jejunum) for drainage.

   Implementation Technique of Regular Left Lateral Lobectomy

   Preoperative Preparations

   • Anesthesia: Continuous epidural anesthesia is recommended.
   • Positioning: Patients should lie on their back with their right side elevated.
   • Incision: A right rectus abdominis longitudinal incision is advised. The xiphoid process is sufficient, and if necessary, the seventh costal arch can also be cut off and exposed through extrapleural enlargement.

   Hemostatic Techniques

   1. Local Blocking Method: After freeing the left lateral lobe, an assistant holds it or presses it against the costal arch, and the surgeon performs resection with minimal blood loss. This was the method used in all 5 cases.
   2. Hepatic Portal Block Method: The hepatoduodenal ligament is freed, and the hepatic artery and portal vein are blocked for 15 minutes, then relaxed for 5 minutes. This can be done safely and repeatedly.
   3. Other Techniques: Liver forceps, rubber bands, and the mattress suture method were not used.

   Surgical Procedures

   1. Ligament Resection: Cut several ligaments like the ligamentum cirrhosae, falciform ligament, left triangular ligament, left coronary ligament, and hepatogastric ligament.
   2. Vein Ligation: Place a needle 1 cm to the left of the second hepatic portal and ligate the left hepatic vein. Be careful not to damage the middle hepatic vein.
   3. Liver Capsule and Parenchyma: Cut the liver capsule 1 cm along the left side of the suspensory ligament and sever the liver parenchyma with a knife handle. The cut should be flat, not in a "V" shape, to avoid damaging the left inner vein.
   4. Vessel Ligation: Each vessel should be ligated individually.
   5. Stone Removal: The hepatic duct and common bile duct are jointly opened to remove the stones, followed by internal and external suturing or drainage.
   6. Final Steps: The mattress suture is limited to not crossing the suspensory ligament. Turn over the suspensory ligament to cover the liver section and fix it. Use subhepatic siphon drainage or negative pressure drainage.

Discussion

Stone Distribution and Diagnosis

The distribution of intrahepatic stones is not random but follows patterns influenced by anatomical and dynamic factors, particularly favoring the left lobe. Direct imaging techniques are ideal but may not always be practical, making clinical judgment during surgery crucial.

Left Lobe Calculus

Calculus in the left lobe often undergoes significant fibrous atrophy, losing much of its function. However, the anatomical boundary of this lobe is well-defined, facilitating a safer and more convenient hepatectomy.

Treatment Efficacy

Left lateral hepatectomy is effective in treating most hepatolithiasis issues. Chinese reports show a success rate of around 90%. There were recurrence cases, but these were not related to the liver, suggesting that more comprehensive internal drainage strategies might prevent such outcomes.

Treatment Goals

The key to treating intrahepatic calculi is to remove the focus, ensure drainage, and prevent new stone formation. Surgery alone may not be sufficient, and a multi-pronged approach involving other treatments may be needed to prevent recurrence.

Infections

Hepatolithiasis often comes with serious infections, which can lead to abdominal infections. Aseptic techniques should be strengthened to mitigate this risk. The use of intraoperative bile duct irrigation should be carefully considered as it can spread infections.

Blood Transfusion

The necessity of blood transfusion is not emphasized; for generally healthy patients, it can often be avoided.

Etiology

The high frequency of intrahepatic stones, particularly bile pigment sediment-like stones, is not yet fully understood. However, it appears to be linked to biliary ascariasis and subsequent infections by Gram-negative bacteria. These factors contribute to the formation of stones with various cores, like parasite cadavers, making it an important subject for preventive medicine.

Summary

The paper summarizes the treatment and follow-up of 5 patients who underwent left lateral lobectomy to address intrahepatic stones. It delves into the surgical indications, the benefits of this particular surgical approach, the techniques employed, and the precautions that should be taken. One of the key takeaways is the recommendation to combine left lateral lobectomy with other methods like "reunion" for stone removal or incisions in the liver parenchyma. Coupled with the establishment of "valveless" internal drainage, this multifaceted approach aims to eliminate infection and prevent the recurrence of stones. The paper concludes that this strategy offers a viable treatment alternative for the complex issue of intrahepatic stones.

References  

1. Qian, Wenzhi.  Preliminary experience in treating hepatolithiasis by intrahepatic cholangiojejunostomy. Chinese Journal of Surgery 18221- 1965
2. Meng, Xianmin. Hepatectomy. Shanghai Science and Technology Press, Shanghai 1965
3. Han, Yongjian. Liver Surgical Anatomy.  Shanghai Science and Technology Press, Shanghai 1963
4. Huang, Zhiqiang. Hepatolithiasis and its treatment. Chinese Journal of Surgery. 91716-1961
5. Ran, Ruitu. Surgical treatment of intrahepatic bile duct stones. Chinese Journal of Surgery, 9:216-1961
6. Zhou, Hongquan.  Discussion on etiology and treatment of hepatolithiasis. Chinese Journal of Surgery 50(8):501-1964

Li Mingjie, Department of Surgery, Nanling County Hospital

This article was published in Journal of Wannan Medical College, Wannan Medicine, 1980, 13:51  and Domestic Medicine Surgery Volume (Part 1), 1981, 39

from 肝左外叶规则性切除治疗肝内结石

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】

In support of Application for Chief Surgeon

Since the resumption of professional journals and academic activities after the Cultural Revolution in 1979, I have published dozens of papers in journals such as Southern Anhui Medicine, Journal of Bengbu Medical College, Lectures of Provincial Medicine, Domestic Medicine (Surgery) and Jiaotong Medicine.  In 1979 and 1980, I participated in the preparation and re-founding of Anhui Orthopedic Society and Surgical Society respectively, and attended the annual meetings (1-6 sessions) of the two societies.  I also participated in many academic activities of surgery in China and the Ministry of Transportation.  

In 1994, I was involved in the planning and organization of a symposium on orthopedics in the Yangtze River Basin area, helping to compile a special issue of Orthopedic Clinic for Journal of Southern Anhui Medical College, Vol-13 supplement, 1994) under the guidance of Professor Jingbin Xu, editor of Chinese Journal of Orthopedics, carrying over 100 published papers, with participants and contributions from all over the country.

In September, 1995, I published two papers at the National Academic Conference on Acute and Severe Surgery (Guilin, 1995), among which "Problems in the Treatment of Liver Trauma" (0190) won the certificate of excellent papers.  I have also published papers in the First International Academic Conference of Chinese Naturopathy (Chengdu, 1991) and Naturopathy (published in Taiwan Province).

1 Professional path and deputy chief physician performance

 (On evolution of several theoretical problems in surgery)

1.1 In the early 1960s, a large number of patients suffered from acute volvulus, ascaris lumbricoides intestinal obstruction and cholelithiasis.  Carrying out a large number of related operations for these cases consolidated my mastering  the basic surgical skills.  In addition, for the treatment of toxic shock in late cases, we practitioners underwent an arduous zigzag path from vasoconstriction and pressure increase to volume expansion and improvement of microcirculation, which proves to be an epoch-making change and progress both theoretically and clinically. 

1.2  In Southern Anhui, there used to be a large number of patients with portal hypertension, hypersplenism and upper gastrointestinal bleeding in the early years of late-stage schistosomiasis and late hepatitis cirrhosis. techniques. The medicine community has also gone through a process of repeated debate and re-evaluation of the choice between shunt and devascularization techniques.  In this regard, as far back as in 1975, I performed splenectomy, splenorenal vein anastomosis and other types of shunt surgeries. Due to the high rate of postoperative embolism, the blood supply to the liver was reduced and hepatic encephalopathy was easily induced.  Later on, I switched to various types of portal-azygous devascularization, and obtained many lessons and various experiences for improvements from the treatment of this difficult problem. 

1.3 Biliary lithiasis still bothers the surgical community. With the development of hepatobiliary surgery and improvement of monitoring methods, surgical procedures for this challenging problem of intrahepatic calculi are constantly updated and improved.  I started the surgery of regular resection of the left lateral lobe of the liver for this disease in 1980 (the paper on five early cases was published in the Annual Meeting of the Provincial Surgery in 1980 and in Journal of Southern Anhui Medicine (80, 13; 51, “Regular resection of the left outer lobe of the liver for the treatment of intrahepatic stones”).  Also starting in 1980, various types of choledocho-intestinal drainage (Finster, Longmire, Roux-en-Y, etc.) were successively performed.  In 1992 and 1995, three cases were treated with intrahepatic bile duct incision, stone removal and plasty, and "basin" biliary and intestinal drainage (The first case was reported in “Communication Medicine”,  93,7; 91, “A case of hepatobiliary basin type biliary enteric drainage”). This work advanced the operation to the treatment of intrahepatic lesions, leading to improved  clinical efficacy. 

1.4 In recent years, the incidence rate of acute pancreatitis has increased. All severe pancreatitis patients in my department were cured by measures such as focus removal, pancreatic bed drainage, intraperitoneal lavage, 5-Fu, somatostatin and other measures to inhibit exocrine, anti-shock and anti-infection. In recent years, one patient was rescued in my department despite the complicated stress ulcer bleeding after operation was performed in another external hospital.  

1.5 On the basis of treatment and operation for various thyroid diseases, hyperthyroidism operation was performed after 1980, and two cases of radical thyroidectomy (neck-mimicking surgery) were performed in 1994. One case was re-operated due to recurrence 3 years after the initial surgery was performed in an external hospital.  No further recurrence was observed during follow-up.  

1.6 In addition, there are surgeries such as excision and anastomosis of cervical aneurysm, thymopharyngeal duct cyst, thyroglossal duct cyst and cystic hygroma resection, etc. 

1.7 Over the past 30 years, more than 1,000 cases of breast cancer, gastric cancer, colon cancer and rectal cancer have been treated, and many of them have survived for a long time.   

1.8  The prevention and treatment of short bowel syndrome after large intestinal resection as a surgical method of interposition of distal reverse peristaltic bowel loops, the observation shows no diarrhea and malnutrition for 21 years. This paper was published in the Journal of Bengbu Medical College (82; 7: 214, PEUTZ Syndrome) and Traffic Medicine (91; 1: 41, “Surgical treatment of short bowel syndrome”).   

1.9 The management of duodenal injury has its particularity and complexity, and its retroperitoneal injury is especially prone to missed diagnosis and misdiagnosis.  The prognosis of patients who underwent surgery more than 24 hours after injury is grim.  In a case report from 1994, following the principle of "rest transformation" of duodenum, I performed a Berne-like operation 28 hours after injury, and the recovery was smooth. My paper was published in Communication Medicine (“Experience in Diagnosis and Treatment of Closed Retroperitoneal Duodenal Injury”, by Mingjie Li). 

1.10  Subdiaphragmatic total gastrectomy, jejunostomy, supradiaphragmatic esophagectomy, thoracic esophagogastrostomy, lobectomy, mediastinal thymoma removal, diaphragmatic hernia repair, etc. which started years ago.

2. Work involving various medicine disciplines 

The two hospitals I have served are both base-level primary hospitals. The "major surgery" department covers general surgery, orthopedics, urology, chest surgery, obstetrics and gynecology, ophthalmology and otorhinolaryngology,  anesthesia, radiation, laboratory test and other related work.  As professional subject leader, I have long been engaged in the work of all of the above areas, outlined below. 

2.1 Orthopedics is one of my key areas, only second to general surgery.  I have performed all major surgeries in this area, and participated in academic activities at all levels, including publication of numerous papers, professional talks and compilation of a special issue on Orthopedics.  My representative operations treating bone injury and bone disease include closed nailing of femoral neck (for the paper, see Orthopedics Clinical 1994, 13:37, Closed nailing treatment of femoral neck fracture in 45 cases), surgical paraplegia (paper in Anhui Province Medical Lectures 1982;, 4:21, Surgical paraplegia analysis of 14 cases), spinal tuberculosis surgery (paper Spinal tuberculosis a surgical therapy in Proceedings of First Provincial Orthopedic Annual Conference, 1979), lumbar disc surgery, spinal cord tumor enucleation, bone tumor removal and orthopedic surgery, etc.    

2.2 Urological surgery: nephrectomy, stripping of renal pedicle lymph nodes, removal of various segments of ureteral calculi and Urethral trauma realignment repair, ureteral transplantation, vasovasostomy, spermatic vein–inferior epigastric vein anastomosis, hypospadias repair, radical resection of bladder cancer and penile cancer, etc. 

2.3 Gynaecology and obstetrics: I founded the department of obstetrics and gynecology of our hospital, having operated Cesarean section (lower segment and extraperitoneal operation), hysterectomy (abdominal type and vaginal type), oophorectomy, repair of vesicovaginal fistula and cervical cancer resection, etc. 

2.4 Ophthalmology and otorhinolaryngolog: parotid gland, tonsil, maxillary sinus, mastoid, cataract, artificial pupil, enucleation, nasolacrimal duct anastomosis, strabismus correction, etc.   

2.5 Anesthesiology: various segments of epidural block, cervical plexus block, brachial plexus block, intubation general anesthesia and intravenous compound anesthesia, etc.    

2.6 Radiology: I founded the department of radiology in 1960, and concurrently served as the head of the department for 2 years (1960-1962).  Very familiar with its routine work and related angiography. 

Environment trains people.  A wide range of issues encountered in the long-term work of grass-roots hospitals enabled me to dabble in many subjects.  The knowledge and skills of these relevant areas complement each other, contributing to and deepening the improvement of my surgical expertise.  Various Level-4 and Level-5 surgeries have been performed to keep placing me at the forefront of contemporary surgery.

3  Continuous innovations and some experience to share 

Over the past 40 years, with high technological development, diagnosis and monitoring methods are constantly updated.  With the change of social life, diseases are also changing. In an aging society, geriatrics takes a prominent position.  Many factors make the clinical work evolve too.  This requires physicians to constantly hunt for scientific and technological information, learn from the experience of others, study hard and embrace the courage for innovation, in order to improve the service quality for our patients. 

3.1 Improvement and innovation 

3.1.1 The key to the control of traumatic infection is complete debridement at the first diagnosis, rather than relying on drainage and antibiotics.  Techniques involve a large quantity of water washing, elimination of foreign objects and inactivating tissues, disinfection, and no suture.  When postoperative inflammatory reaction occurs, apply local wet compress with alcohol, supplemented with with or without antibiotics.  Following this strategy, surgery within 6 hours of trauma is almost completely free from infection. 

3.1.2 Over the past 30 years, based on the experience of over 1,000 cases of gastrectomy I have performed, the preset gastric tube has basically been abandoned except for special needs, and there were no cases of failure.  This requires excellent anastomosis, perfect hemostasis, intraoperative emptying of the residual stomach, and attentive postoperative monitoring. 

3.1.3 For extensive peritonitis, after the nidus and infectious substances are removed, abdominal cavity drainage can be abandoned to reduce postoperative adhesion.  The key for this to work is to wash it thoroughly during the operation.  As the drainage is quickly blocked by fibrin glue in the abdominal cavity and soon stops working, it only increases the pain of the patient. To be sure, however, in cases such as pancreatitis, abdominal abscess, etc., if continuous overflow is expected, double-cannula negative pressure drainage is still required.   

3.1.4  For any surgery, regardless of scale, its success or failure makes a big difference to the health and safety of patients.  As a surgery practitioner, I attach importance to the technical improvement of each and every "small" surgery.  Some of my technical innovations and experience are outlined below. 

For inguinal hernia repair, the focus is the transverse abdominal fascia, the traditional Bassini method should be replaced by the modified Madden procedure, which greatly reduces the pain of postoperative tension suture for patients, and is also conducive to healing, with the recurrence rate  greatly reduced. 

For circumcision, the conventional routine procedure has plagued both doctors and patients with the poor alignment of the inner and outer plates, hematoma, edema, as well as difficulty in stitches removal.  I modified the procedure, using local venous anesthesia to support neat cutting under a tourniquet, with perfect hemostasis, accompanied by careful sutures with human hair or absorbable thread.  The benefits include no pains during the operation, good alignment, fast healing and avoiding stitches. (see my paper published in Jiaotong Medicine 90; 4（3)：66,  Several improvements of circumcision） 

Anal fistula seton therapy or open resection can cause patients to suffer from postoperative pain and a prolonged recovery period post-surgery. I used long-acting anesthesia (with local injection of diluted methylene blue) to ensure the primary resection and suture. Most cases receiving this treatment result in primary healing, with the course of treatment greatly shortened.

3.2 Some General Experiences 

Based on what I have learned from my 40 years of hands-on surgical practice, I feel that in order to be a qualified surgeon, we need not only consolidate the basic knowledge with continuous updating, but also exercise meticulous working methods with a high sense of responsibility, supported by logical thinking and practical orderly working style.  It is very difficult to just follow a unified norm or standard procedure when the real-world surgery scenario involves so many moving parts to be weighed and considered, factors like the ever-changing condition, physical differences, positive and negative effects of drugs, advantages and disadvantages of the techniques in consideration, the reserve function of body organs, the length of the course of the disease, and even the natural environment, mental and material conditions, and so on.  One must be equipped with high adaptation wisdom.  It is not an exaggeration to say that the adaptation ability determines a surgeon’s diagnosis and treatment level and the clinical effects.   

3.2.1 The entire process on the operating table involves struggles between personal fame and the interests of patients.  The so-called following "safety first, and draw the line accordingly” principle is often not a feasible practice.  A competent physician must have the courage to take risks for his patients. It is often the case to be placed in the position in fighting for patients' good chances of rescue that can be missed because of a small mistake in one's thinking.  I have countless memories of such incidents in the past, one of which is as follows.  In the fifth operation of biliary tract, cavernous blood vessels caused by portal hypertension due to biliary cirrhosis were distributed all over the hepatic hilus, and in addition, the inflammation was thickened.  After struggling for 8 full hours of operation, I finally managed to open the biliary duct and save the life of the patient.  This was a victory of perseverance. 

3.2.2  Adjust measures to real world conditions, and keep an open mind to break the routine to save a patient.  The key to life-saving in case of liver and spleen trauma and massive hemorrhage of ectopic pregnancy in the countryside lies in rigorous transfusion of the abdominal blood.  To wait for the blood supply in these scenarios means to wait for death.  I remember a case of liver trauma in which 1700ml of liver blood was transfused locally to support the successful operation.  (See paper Related issues in the treatment of liver trauma (review), in Proceedings of the National Academic Conference on Acute and Major Surgery, 95; 190） 

3.2.3 For difficult surgery and new surgery, one must accumulate the relevant knowledge and operation skills, by reviewing literature, consulting experienced experts for guidance, and visiting and studying surgery scenes, before embarking on the operation, to minimize potential misses or accidents.  In my first case of hepatobiliary-pelvic internal drainage operation, I asked for direct guidance from a professor of surgery. The subsequent two cases were successfully completed all by myself.   

Looking back on my 40 years of career in surgery, I deeply feel that clinical surgery is a combination of science, perseverance, determination, and a sense of responsibility.  It is like a small boat that ups and downs in the forefront of the waves.  Walking on thin ice, one can hit hidden rocks at any time.  The hardships and risks of our career are among the highest in all trades.  Fortunately, I have not failed the society.   Along the journey, there have been countless joys of success, together with many sleepless nights and panic moments.  For the rest of my career years, I am determined to maintain the service spirit of "healing the wounded and rescuing the dying", to complete the journey to the end.   

Appendix 1, Publications
Appendix 2, Relevant Materials and Records of Level III and Level IV surgeries

《李家大院》6: 业务自传和工作报告

【李名杰从医66年论文专辑（英语电子版）】

汉阳一江水 立委  汇编

按：老爸李名杰行医一甲子余，悬壶‎济世，妙手仁心。特汇编专辑作为纪念。《论文发表》，是医疗实践的心得和理论升华，其成绩被业界认可，并且具备一定的传承价值，文风严谨，格式规范。除主场外科、骨科、妇产科外，亦涉及中西医结合，挖掘祖国医学遗产，抛砖引玉。附录中出具典型病例《手术记录》，详述其手术程序及术中的应变措施，使术式规范并且具有一定的个性化。 《教育园地》摘取了具有经典意义的临床课题及其实践经验，以及笔者汇编的医学培训教材，为后学者开辟入门之路，是学院教科书难以囊括的补充！

目     录

壹  论文篇

外科

一、李名杰：肝左外叶规则性切除治疗肝内结石
二、李名杰：PEUTZ氏症候群
三、李名杰 王月琴：肝外伤救治中的几个问题
四、李名杰 黄厚宝: 胃十二指肠急性穿孔的手术治疗
五、江凯 李名杰：闭合性十二指肠腹膜后损伤诊治分析
六、李名杰：短肠综合征的外科治疗
七、李名杰 仰宗华 史良会：肝胆管盆式胆肠内引流术一例
八、李名杰：胆肠内引流
九、李名杰：胆道手术中几个特殊问题的诊治体会
十、江凯 李名杰：闭合性十二指肠腹膜后损伤诊治分析
       张琪 李名杰：闭合性腹膜后十二指肠损伤诊治体会 
十一、李名杰：胃恶性淋巴瘤亚急性穿孔腹膜炎误诊一例
十二、李名杰：成人腹膜后畸胎瘤感染并发慢性脓瘘1例
十三、李名杰 王益生：胃内打火机异物一例
十四、李名杰：先天性脐膨出一期修补成功一例
十五、李名杰：以缝线为核心的总胆管复发结石6例报告
十六、李名杰 史良会：膀胱内塑料管异物一例
十七、李名杰：腹部创伤 (综述)
十八、李名杰 何进贤：腹壁皮下异位胰腺一例报告
十九、李名杰译：全胰切除的临床经验
二十、李名杰：包皮环切术的几点改进
二十一、李扬缜 李名杰 商建忠 汪桐: 一种全新微创包皮环切术的临床观察

骨科

一、李名杰：脊椎结核的一次手术治疗
二、李名杰：椎弓结核并发截瘫手术一例报告
三、李名杰：外科截瘫14例手术分析
四、李名杰: 软脊膜下脂肪瘤并发高位截瘫
五、李名杰：闭式穿钉治疗股骨颈骨折45例
六、李名杰：足内翻扭伤致第五跖骨基底部骨折30例
七、丁明秀 许竞斌 李名杰: 在基层公社卫生院开展椎间盘摘除手术的体会 

外一篇：骨科导师许竞斌先生从医50周年纪念增刊资料 

妇产科

一、潘耀桂 李名杰：宫内妊娠流产合并输卵管妊娠破裂一例报告
二、李名杰 潘耀桂：利凡诺 (Rivanol) 羊膜腔注射引产术

外二篇：
潘耀桂：腹膜外剖腹产术
潘耀桂：阴道内滴虫和霉菌感染的防治

外三篇：
李扬缜 蔡圣朝：桑榆虽晚，终存报国之情 --周楣声对针灸事业的贡献
李扬镇：从马王堆古墓出土医学著作看预防医学的科学造诣
李杨缜：灸药并治类风湿性关节炎临床体会

贰 教育篇

一、手术例案

一、四级手术例案（6例）
二、直肠癌手术记录单

二、学术主持

后记 老爸，一生行医，妙手仁心，拯救无数生命，解除患者伤痛，受益者众，为之称颂和感恩！本书记录了他风釆的人生，虽挂一漏万，还是留下了许多珍贵的从医经验和理论总结，是为不朽的丰碑！更可贵的是医徳医风，以及追求无限，孜孜不倦的精神。如今，老爸年近九十，仍然勤耕细作，尽职尽责，从不言止，为我们树立了不可超越的人生榜样。敬祝老爸身体健康，安享晚年！

《李家大院》电子版

【李名杰医学论文目录（科学网）】

【李名杰从医60年纪念专辑（立委频道电子版）】

(文献复习及临床分析)

芜湖长航医院  李名杰

通过60年代以来的临床实践，各种检察手段的进展，尤其 Bus、 PTC、ERCP、CT 等进入临床动物实验以及胆道病理生理研究的深化，对胆肠内引流 (Bid) 有一个再认识的过程。虽然争论问题尚多，然却走出一条深化和逐渐成熟的道路。

自1884年首次提出十二指肠乳头切开，100年来是在不断探索中前进。术式繁多，径路各异，至今仍无规范术式。实际上对其手术指征和技术细节，都要根据实际病情、个人经验及设备条件而选择。

现就随机挑选一组南陵地区1974-1980年间441例胆系手术病例资料，结合手头文献，对 Bid 试行评述。

胆肠内引流用途

1、 因肿瘤或损伤使胆肠通道中断或狭窄，为恢复正常胆流，另作人工通道者。

2、肝内、外胆管结石或胆管狭窄手术矫正后，防止胆流淤滞、感染复发和结石再生而作旨在使胆流通畅的内引流术。

关于“返流性感染”和“盲袋综合征”问题

一切 Bid，均破坏了 Oddi 氏括约肌能生理功能，而使胆肠之间的“阀门”消失。虽然通过重力、压力、蠕动方向等因素，胆肠顺流是基本的，然而在某些特定情况下，如食物的充盈、肠道的逆蠕动及体位改变等，肠胆返流总是可以发生的；以致随之发生的感染，还有短路吻合以下旷置的胆管就成为“盲袋”或“污水池” (Dump Pool)，由此而产生的胆管炎症状及其病理改变，历来为人们所关注。

著名的 Madden 的动物实验 (1970): 作无肠道准备的狗胆囊结肠吻合。钡剂放射学检查监察，131例中，除1只狗吻合口狭窄出现胆管炎症状外，余均无症状。他结论: 吻合口宽大通畅，返流也不会引发胆管炎。他甚至将“上行性感染”改称为“下行性感染”。然而，他未作病解和切片检查!

12年后，我国钱礼于1982年作了类似的实验（1）。术后34 - 105天予以病解和切片。他的10只实验狗虽然处死前皆无症状，然肝胆病理切片上都显示胆囊炎、胆管炎及胆管周围炎，甚至肝细胞灶性坏死。这就说明了 Madden 氏的临床“假象”，若实验延长或抵抗力下降时，这种病理上的炎症就会在临床上表现出来。

不过，就钱礼本人于1980年又称“返流不要紧，只要吻合口够大，可进又可出，就不会产生症状”（2）。其主要原因是，人是站立动物，与上述狗的实验两样。虽然发生胆管炎的基础是存在的，但实际发生胆管炎极少（3）。下表国内外8组病例足以说明此一事实。

本组441例次胆系手术中，作 Bid 81例。占18%（4）。胆总管十二指肠侧侧吻合56次，其中二次手术21例，三次手术1例，端侧吻合5例。肝管空肠 Roux-Y 术式2例，Oddis 括约肌切开15例。其中二次手术6例，三次1例，Brown 氏胆管空肠吻合2例，U形管胆肠架桥1例。本组 Bid 未发生严重上行感染，但有1例胆总管十二指肠侧侧吻合术于术后2年由于肝内结石塌方下降发生“试管现象”而为再次手术所证实。（4）

大量实践证明，只要 Bid 吻合口宽畅，返流问题在大多数场合下是不致使外科医师望而却步的。不幸的是往往在术后2-3年由于炎症增生而发生吻合口狭窄而产生症状。这就使众多的改良应运而生，旨在防止吻合口狭窄和消除返流的术式，有加长引流肠管，甚至长达60cm（5），为定向引流而设置旷置肠袢上作2个顺向人工套迭，合拢胆、肠输入段肠袢之并行一段，而成真正Y而非T形（6-10）。针对肝胆管结石的病理特点，主张将肝外胆管大段剖开，还可延及左右肝管，以便取石和解除狭窄，再作胆肠大口径侧侧吻合，即 Longmire 类术式，有效地防止术后远期狭窄。十二指肠后孔洞式低位胆总管十二指肠吻合术（2），以消除“盲袋”。为符合生理，减少胃肠溃疡的发生而产生了空肠间置术而恢复生理性胆流。为便于再次取石和疏通胆道，在此基础上，又增设了皮下盲袢 (SB-jicd)（9）。

Bid 疗效相关因素

一、原发病未能根治

Bid 只是疏通胆流，并不能代替原发病的治疗。而实施这类手术的前提，恰需尽可能彻底清除胆石、蛔虫及处理肝、胆、胰的原发病灶或其合并症。完企寄望于肝内结石通过内引流自然排出的设想，临床上却作出反证。肝内结石一旦“塌方”将堵塞吻合口导致症状，吻合口以上的胆管狭窄未能矫正或消除，肠胆返流一旦进入狭窄处以上就难以排出，即易进而不易出，而发生更难处理的感染。恶性疾病要看能否根治抑或姑息手术。先天性总胆管囊肿以切除囊肿再作 Bid 为妥，否则囊壁易炎症硬化或恶变。

我们早期因 Finster 术式操作简易，近期疗效好，有滥用现象，占本组 Bid 70%。加之当时影象学和直接胆管造影等诊断手段尚未普及，对病理全貌无法精确了解，而忽视了肝内病灶的清除和肝内胆管狭窄的处理，从而造成再手术率高，达13.2%，甚至三、四次手术的。后来随着 PTC 的开展和 BUS 的使用以及认识的提高，术式增多，手术技术的进步，疗效才有所提高。

二、手术时期的选择

一般主张不作急症一期内引流。除了急症病重手术不宜复杂之外，主要涉及到短时间内难以全面了解病情，而使最佳术式选择困难，还由于炎症水肿期加作 Bid 安全度降低和远期再狭窄易于发生等。

但也有主张一期完成 Bid 的，是由于检察技术的进步。包括 Bus、PTC、ERCP、CT 及胆道镜的使用，有可能对病情了解而作出正确选择，从而避免了再次手术的解剖紊乱、粘连、副损伤等困难，以减少病人体质上和经济上的损失。

总之，要看局部解剖条件和全身手术负载能力以及病情的近、远期需要而综合考虑抉择。

三、技术实施问题

胆肠吻合术已从单纯考虑胆流通畅，发展到重视术后对机体的生理病理改变，这是从临床经验教训中付出代价而得来的可贵进步。

防止吻合口狭窄，作一个宽敞的通道，避免炎症时期进行手术。由于肝外胆管血供呈轴性分布，为避免手术创伤致缺血性胆管狭窄，分离胆管不宜过大过广。胆管各层组织之间渗胆有碍组织愈合应予防止，缝合应无张力。尽量缩短失功能段胆管长度以减少盲袋。Bid 后 Oddi 括约肌调节功能丧失，胆管内压力下降，胆囊只不过是一个憩室而已。加上胆囊管细小迂曲，胆囊的续发炎症和产生结石实属难免，所以胆囊不管如何，作 Bid 必予切除。

四、术式选择和共守原则

Bid 术式众多，如何选择? 除根据病情、病理、设备和技术条件以及医师个人的习惯经验之外，还必须符合下列原则和要求:

1、胆流符合生理。避免破坏消化道的生理及 PH，以减少胃肠溃疡的发生。
2、胆管失功能段盲端尽量缩短。
3、近期近发症少。
4、内引流口再狭窄可能性小。
5、“上行感染”少。
6、手术的复杂性及安全性
7、利于监测复查。

基于上述原则，以病情为基点作出最佳选择。一般讲肝内外多发结石，应首选 SB-jicd，避免多次手术。胆道非结石良性梗阻宜作  Jied，恢复生理状态，然年迈病笃者可作 Finster 手术。条件许可时可改作低位空洞式胆总管十二指肠吻合术。胆总管远端结石嵌顿和出口部狭窄行 Oddi 括约肌切开或成形术，而 Roux-en-y 胆流转道，减少了十二指肠内胆汁对胃酸的中和作用。术后胃酸增加，有说导致溃疡病达 52%，而临床观察为10%，Pappa-Lardo 氏建议此术附加迷切，然国内尚未引起重视，还在广泛地使用本术式，可能因国人较欧美人胃酸低的缘故。内窥镜括约肌切开术 (ES) 可避免剖腹，是国外的新进展。国内经验不多，尚未普及。

几种常用术式的评述

一、Oddi 括约肌切开、成形术

本术式理论上胆流符合生理，且无盲袋，因消除了括约肌的作用可以自然排石。本组作此手术15例，占 Bid 20%，可作壶腹部取石，解除胆道出口狭窄。我们观察到2例，术后近期有上行感染，呈疟疾样寒战、发热，抗生素可以控制。

由于内窥镜技术日益发展，晚近国外逐渐改行十二指肠内窥镜括约约肌切开术 (ES)，可以避免剖腹，亦可经 T 管作胆道镜切开术，但目前尚未普及。也存在出血、穿孔、胰腺炎、胆管炎并发症，且远期易干狭窄失效，目前仅少数医疗中心报导，但相信这是发展方向。据称 ES，10mm结石可自行排出，15mm 结石在取石器械协助下取出，其总排石率达 85-90%，合并症发生率 28%。

该术切开10mm，解除该肌收缩痉挛而未完全消除胆管远端括约肌功能，易于再狭窄，终难达到预期目的。

鉴于胆管远端括约肌功能包括 Oddi 肌，胆管壁内括约肌及十二指肠环行肌部分作用三部分组成，若切开 1.5cm 则切断全部壶腹部及大部胆总管括约肌。切开 2.5-3cm，则切断上述三者，而实际上作了一个低位胆总管十二指肠吻合术。上述各种幅度的切开均需防止损伤胰管，又因胆肠压力平衡，肠胆返流在所难免。由此而产生的上行感染亦易发生。还有一个问题是 >20cm的扩张胆总管，手术后仍会形成一个漏斗状狭窄段。

1982年 Choi氏 提出再手术腹膜外途径，避开了解剖原手术区的粘连的困难和副损伤。

成形术，切除胆总管出口部前外侧壁一楔状部份，再予缝合，其长度等于胆总管横径为妥。为防止返流，冉瑞图设计了活瓣。

此术若作为其他内引流术的附加手术，可以消除盲袋，颇有价值。本组有4例胆总管十二指肠吻合术附加此术，其中1例肝内多发结石两年后因其他手术进腹，肝色泽正常，原肝内结石已不复存在，是否可说明其疗效。

二、胆总管十二指肠吻合术

有侧侧和端侧吻合两种。手术简便、易行，安全性大，近期恢复好，加之 Madden 实验的“假象”的影响，早年进行较多。本组81例施行此术达61例，占75%。通过再手术观察，动物实验的揭示（2），以及对胆道病理生理认识的深化，晚近一致认为其手术适应症明显地下降了。尤其是经典的裂隙式 Finster 氏术式，其吻合口狭窄，逆行感染和盲端综合征潜在危险，长期的消化液刺激，诱发化学性胆管炎导致胆管粘膜萎缩。杯状细胞及纤维组织增生，管壁增厚硬化。胆肠吻合后胆道感染的菌群复杂，常为需氧和厌氧菌混合感染，使处理更为辣手。对此，有时甚至要作 B-II 式胃部分切除，使食物改道，ES 盲端后壁切开、或重建胆肠吻合。

对肝源性结石而未能取净，吻合口上方尚有胆管狭窄而未予矫正者不宜作此手术。对胆源性结石合并胆总管下段狭窄者，即西方式胆石，此术可为最佳选择。对年迈体弱不堪复杂手术者亦可选用。

晚近为克服本术式弊端，种种改进术式应运而生，为十二指肠后胆总管十二指肠吻合术，胆管远端空洞式物合等。理论上趋于合理，实践上也收到良效。

三、胆管-空肠Roux-en-y吻合术

问题是引流胆汁的旷置肠袢即使延长到60cm，返流感染也难绝对消除。胆汁直接进入空肠，违反生理，除对脂肪消化吸收不利外，还因上部空肠肠相胃液分泌抑制的降低，对胃酸高者，十二指肠内无胆汁中和，溃疡病发病率易于增高。还有旷置过长的肠袢可发生扭曲，粘连而不？梗阻。此段肠管功能上改变，难以保持正常菌群，相反，肠内细菌种类和数量的增多，而产生“空肠盲袢综合征”。

然而它仍然是目前应用最多的术式，因为它可无张力地随意与各级胆管吻合，包括 Longmire 术式，解决了肝内胆管狭窄处理的径路，和肝部门恶性肿瘤大块切除后的胆肠通道的重建或姑息性肝内胆管转流。加上技术上的种种改进，可最大限度地解除返流感染问题。

四、间置空肠胆管十二指肠吻合术 (Jicd)

此术是在 Roux-en-y 基础上发展而来，1969年由 Grassi 首次报导，国内施维锦于1982年率先报导使用此术。将一段空肠间置在胆管和十二指肠之间，使胆流恢复生理状态，消除了Roux-Y 术式的弊端。至于间置长度，Grassi 氏用20cm，黄志强氏也不赞成过长，而在间位空肠远端设计一个人工乳头并于吻合时置入十二指肠壁内（9）。施维锦则用60cm称基本可以防止返流。技术上需注意安置间位肠管要“顺蠕动”。胆管空肠宜作端侧吻合，利于随意设计吻合口。

但该术式有三个吻合口。较之 Roux-Y 二个吻合口和胆总管十二指肠吻合一个吻合口，手术侵袭范围大，操作较多，其普及受到阻碍。由于其有优越之处，国内正在推广中。开展此术时间不长，其远期疗效和最后评价尚待临床实践验证。

五、皮下盲袢间置空肠胆总管十二指肠吻合(SB-JICD)

由上述 JICD 发展而来，为肝内多发结石难以取净或估计肝源性结石再生而设计的。皮下盲袢留待需要时径直打开取石、取虫或疏导胆流，也可作用药径路，还可作术后复查监护。

本术式是在 Roux-Y 和 JICD 基础上，加留一段空肠移入皮下埋藏，以银夹标记，相应皮表亦可作标记，以示监护和治疗时入路。盲袢长度以10cm为宜，以减少“盲袢综合征”。不过此术远未普及，但为适应者留下又一选择余地，因为不但手术繁琐、盲袢的感染存在，日后使用也并非推理上那么有效，深入肝内的病灶，即使由此置入胆道镜，也未必就能解决问题。

六、其他

诸如胆囊-胃肠吻合均因胆囊管迂曲、细小，不能保证引流除外，晚期恶性肿瘤或急重高龄病人，一般已予摒弃。我们早期作过少数胆囊-胃、胆囊-空肠吻合术，对解除胆管远端梗阻性黄疸 (如晚期胰头癌)，缓解病情，也起过积极作用。

一九八七年七月三十日

Internal Drainage of Biliary-interstinal (IDBI)

Li, Ming-jie

Worker's Hospital of Wuhu Changjiang Shipping Company, Wuhu

ABSTRACT

From 1974 to 1980, the clinical data of 441 biliary duct surgical procedures were reviewed. And meantime, 81 cases of the IDBI, including 61 choledochoduodenostomy, 15 Oddi's sphincterotomy，2 hepatocholangiojejunstomy in Roux-en-Y，2 choledochojejunstomy in Brown type and one case of biliary-interstinal bridging in U type, were performed (18%)。

This series of patients were in good health without symptoms and/or signs of reflux except for two patients that one died of infection of the U bridge and the other recurrent cholelithiasis  in Finster's technique for which re-operation had been performed.

IDBI technique was extensively used for biliary tract obstruction and cholelithiasis. But the reflux problem after surgery has been emphasized and discussed in this paper.

With the proper use of ultrasound, CT scans，endo-scopic, PTC and ERCP, there have been major advances in the diagnosis and therapy of biliary tract disorders lately.

Key words:

Internal drainage of biliary-interstinal, Sump pool syndrome,  Cholelithiasis.

1988.9.

参考资料:

1、钱礼：胆肠吻合后继发胆管炎的发病机制和各种胆肠内引流术疗效分析。胆石症论文汇编，温州医学院 1982
2、钱礼：胆总管原发性色素结石的治疗。实用外科杂志 1986； 1:19
3、张圣道：在重症急性胆管炎治疗中对胆总管十二指肠吻合的评价。实用外科杂志 1986; 6(1): 42
4、李名杰：肝切除治疗肝内结石。国内医学 1980 #161；皖南医学 1980，13:51-55
5、施维锦：JICD 和 SB-JICD 的指征及评价。实用外科杂志 1986; 6(1): 44
6、谭毓铨：Roux-Y 式胆管空肠吻合术的评价。实用外科杂志 1986; 6(1): 44
7、Zhang HD：An Exploration on prevention of Reflux in “y” Type Choledochojejunostomy, Abd 'surg  1985; 27:34
8、Kassi M：Improved technique of end-to-side  anastomosis of the intestine.  SGO, 1974; 138:87
9、黄志强等：人工乳头式间位空肠胆总管十二指肠吻合术。实用外科杂志 1986; 6(1): 48
10、王训颖：胆总管空肠定向引流术。中华外科杂志 1980; 18:320
11、Choi TK Ann: Snrg.  1982; 196: 26

原载 安徽省三届二次外科年会论文汇编 1988；87

【爸爸妈妈医学论文目录】

【立委按】老爸行医60多年，实践经验异常丰富，也曾发表20多篇专业论文，但那是前电子时代。现在统一整理，数字化留存，除了作为纪念，也为专业文献的知识积淀以及新人的经验搜索做一点贡献。老爸说，论文中报告的有些手术难度很高，至今还占外科前沿，具有借鉴价值。

肝胆管盆式胆肠内引流术一例

芜湖长航医院 李名杰 仰宗华 史良会

    患者男，46 岁，船员，于 1973 年因胆囊炎、胆石症，作胆囊切除，胆总管取石外引流，出院后三个月出现胆系感染症状，绞痛黄疸发热，累发，持续三年，1976年用中药活疗，排出结石二枚，症状消失。1990年6月及12月作B超检查发现胆总管结石，直径1.9cm，1991年10月B超及大剂量静脉胆道造影检查，证实肝外胆管结石伴胆总管扩张(2.2cm)及左肝内结石伴胆管扩张，但无感染及黄疸，肝功正常，无手术反指征，拟择期作高位胆管切开盆式胆肠内引流加病灶肝切除术。

    手术方法

    在持续硬膜外阻滞麻醉下，作右肋缘下 L形切口，切除剑突，右抵腋前线，进腹后从原手术疤痕中解剖出胆总管，扪及其中大量铸型结石，显露出“残余胆囊”，指尖大并内含结石。转而游离肝周韧带，包括左右三角、镰状及左冠状韧带，使肝脏松动下移，扪摸左肝管矢状部有结石集簇伴左外叶Ⅲ段纤维化，肝管汇合部结石，继续解剖肝门外肝外胆管，切开肝门板及脐板，钝性分离其纤维膜直抵左右级肝管，高位切开肝总管抵隆突部，取出胆色索性结石，旋即作左外叶Ⅲ段肝切除，消除左肝内结石及囊状扩张之胆管，从左肝断面与肝总管会合掏尽肝内结石，双氧水冲洗，左肝断面缝扎止血，再作“小胆囊”切除，并由此扩大胆总管切口，取出其下段结石，7号探子通入十二指肠，修补此胆总管切口。将肝总管及左右I级肝管敞开，分别显露各Ⅱ级肝管及尾叶胆管开口，分别予以扩张取石冲洗，并修整盆缘，使盆沿保持 2mm，以利吻合，盆径3.5cm，止血牵吊搁置。

    空肠起始部下 15cm 切断肠管，远端空肠结肠前上提与肝胆管盆作端侧一层粘膜外翻吻合，检查无泄漏，在输胆肠袢40cm处作与近端空肠侧端吻合。肝门盆下作双套管负压引流，术中失血 300ml经过平稳，术中补血600ml

    术后经过

    术后用止血三联三天，选用庆大霉素、氨卡青霉素及甲硝唑金三联(Gold Standard)抗感染，术后体温38℃左右达两周，腹腔血性渗液三天，无渗胆，术后9天撤除引流，无腹腔及切口感染，无黄疸，三周痊愈出院。

    随访5个月，无胆系返流感染及腹部症状，消化功能正常，B超复查未发现肝内外结石残留。

    讨论

    肝内外胆管结石，至今仍无规范术式，肝外胆管手术无法除净结石，解除肝胆管狭窄和通畅引流，常致症状复发，导致多次手术，甚至因此而出现AOSC及胆源性败血症，病死率甚高（1)，近年来多数学者已将手术延伸至肝内，方可一举取得胆石，使疗效提高(2)，其手术虽创伤较大，但对于一般选择性手术病例，准确的手术技术，合理的术前准备及术后处理，可获得满意效果，

    I级肝管在肝实质之外，可以安全解剖出来，以此可进一步处理Ⅱ级肝管之结石和狭窄，若方叶肥大，有人主张(可予局部切除，改善手术野显露，使胆肠吻合准确，提高安全系数，然解剖得法，肝脏下降并可向上翻转牵引，并非必需作方叶切除，本例未切方叶，亦感吻合方便。

    对肝内各处结石，则分别情况各作如下处理:表浅肝结石，可切开肝实质取石再作肝修补;局限于叶段的结石并近侧胆管扩张者，可作叶段切除;对某部的铸型结石，可按入肝径路直接将其切开取石，再作胆管修补或置T管、U管引流;对局限性肝结石，则可作"雕刻式"肝切除，以避免牺牲健肝的“规则性”切除，但需注意保留肝脏的血供及胆汁流路，还可各术式联合使用。

参考文献

1.黄志强.肝胆管结石外科治疗10年进展. 实用外科杂志 1991;8.9:447.

2.吴金术等.肝胆管盆式肝肠内引流术209例.中华外科杂志1989;27:130

3.王哲生，等.肝门部舌状切除治疗肝内胆管狭窄伴结石 56例报告. 实用外科杂志1991;8.9494.

          本文原载《交通医学》1993；7:91

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