(1) Biliary stricture shaping and tissue patch repair. It is suitable for cases where the intrahepatic lesion and upstream hepatic duct stenosis have been removed, the stones have been removed and there is no possibility of recurrence, and only mild hilar bile duct stenosis exists. Fully incise the stricture segment and the bile duct at both ends. The scarred bile duct tissue is removed, and the hepatobiliary flap is sutured to form the posterior wall of the bile duct. The defect of the anterior wall of the bile duct is repaired with a vascularized hepatic round ligament flap, gallbladder flap, stomach flap, jejunal flap or other autologous tissue patch;
(2) Bile duct stricture shaping and Roux-en-Y jejunal anastomosis. The stricture of the bile duct at the porta hepatis is fully incised and reshaped in situ. The bile duct incision and the jejunal loop are anastomosed side-to-side or end-to-side with Roux-en-Y. Since reflux cholangitis and extrahepatic bile duct stones may occur after side-to-side bile duct anastomosis, the extrahepatic bile duct is transected as much as possible and anastomosed end-to-side with bile duct, especially for patients with extrahepatic bile duct dilatation, Oddi sphincter relaxation, and those who have undergone Oddi sphincteroplasty. For cases with residual stones or the possibility of recurrence, the stump of the jejunal loop can be buried in the subcutaneous part of the abdominal wall as a passage for postoperative stone removal. It is worth noting that if the upstream hepatic duct stenosis is not corrected and the intrahepatic stones are not completely removed, choledochojejunostomy may cause or aggravate serious complications such as biliary infection. Therefore, this procedure is suitable for cases of hilar bile duct stenosis in which the intrahepatic lesions and upstream hepatic duct stenosis have been removed.
4. Choice of surgical plan for patients with intrahepatic bile duct stones combined with portal hypertension
Patients with intrahepatic bile duct stones develop secondary biliary cirrhosis and even biliary portal hypertension due to long-term and recurrent bile duct inflammation and mechanical obstruction. At this time, the choice of surgical treatment is often very difficult. On the one hand, patients have extremely poor tolerance for major surgery, and the incidence and mortality of surgical complications are high; on the other hand, there are many dilated collateral circulation vessels in the portal area during portal hypertension, and surgery is often more difficult due to heavy bleeding. It is sometimes difficult to decide whether to solve portal hypertension first or to deal with bile duct obstruction first, whether to deal with both at the same time in one operation or in stages, which tests the comprehensive judgment and handling ability of hepatobiliary surgeons for complex cases. It is generally believed that if the bile duct stenosis and intrahepatic lesions are relatively simple, portal hypertension is obvious, and the liver compensatory function is still good, the problems of bile duct and portal hypertension can be dealt with simultaneously in one stage of surgery. If the lesions of the bile duct and liver are complex, portal hypertension is obvious, and liver function is severely impaired, staged surgery is appropriate. Patients with severe bile duct obstruction and liver function impairment, especially those with concurrent infection, The bile duct should be drained first, and definitive biliary surgery should be performed at a later date after liver function improves. If portal hypertension is significant and varicose vessels of the hepatoduodenal ligament hinder biliary surgery, a portalocaval shunt should be performed first, and definitive biliary surgery should be performed at a later date after portal hypertension is relieved. However, it is undeniable that when facing such specific patients in the clinic, we often fall into a dilemma. At this time, individualized analysis and treatment must be carried out. If necessary, a comprehensive consultation should be organized with interventional departments, gastroenterology departments, endoscopy centers, etc., to develop a practical treatment plan and then decide on the specific surgical method.
