2017年 · 第32卷第08期

Iatrogenic bile duct injury (BDI) has become a common serious disease of biliary tract in clinic, and its incidence is increasing obviously. At present, all kinds of BDI classification in the world and in China have their limitations, and it is necessary to formulate new, comprehensive and universally acceptable classification to suit the practical clinical situation. The timing and surgical method of BDI operation need to be determined according to the site and degree of the injury, the general condition and local inflammation of the patient. It is emphasized that experienced biliary tract specialists to perform repair and strive to transfer patients to hospitals with mature professional conditions are the keys to successful repair. Whether the operation is successful or not needs a long follow-up to be determined. Repair surgery requires good surgical skills, accurate preoperative judgment, and attention to the details of surgical operation. Biliary enterostomy should be selected for high bile duct injury, combined with hepatectomy if necessary, and open surgery should be used as much as possible in order to obtain satisfactory long-term treatment results.

Iatrogenic bile duct injury is the most common serious complication of cholecystectomy. Because of the unique anatomical structure of bile duct and blood vessel adjacent to the hilar gallbladder triangle, patients with bile duct injury combined with vascular injury are also common in clinical practice. This paper systematically reviews the clinical problem of bile duct injury combined with vascular injury caused by laparoscopic cholecystectomy from the aspects of relevant anatomical basis, mechanism, clinical manifestation, management principle and mode, combining the author's own clinical experience and domestic and foreign literature.

The main problem of iatrogenic bile duct injury is that the integrity and continuity of bile duct system structure and bile-intestinal pathway are destroyed, which leads to biliary obstruction and/or bile overflow, and then a series of pathophysiological changes such as jaundice, infection, systemic inflammatory reaction and liver function damage. Although bile duct injury generally does not endanger patients' lives in a short time, if the damaged bile duct cannot be properly repaired or reconstructed in time, the pathophysiological changes caused by it are often difficult to heal themselves, and the condition is getting worse day by day, and even serious problems such as septic shock or biliary cirrhosis occur. In addition, every case of iatrogenic bile duct injury may become a case of potential dispute. I believe that attending physicians who have had similar experiences will never forget the psychological pressure and emotional ups and downs they have experienced. In fact, bile duct injury repair is not just a simple medical activity. The specific thoughts and behaviors of patients, family members and attending physicians, such as emotions, decision-making and coping, will actually affect or even interfere with the whole treatment process and its results. Timely, appropriate and satisfactory remedial measures often make this adverse event full of unpredictable risks easy to understand and accept. When choosing the timing of bile duct injury repair, the above common problems that doctors and patients may face should be fully considered.

High bile duct injury refers to bile duct injury above the common hepatic duct, including type Ⅱ ~ Ⅳ in the Bismuth classification. The bile duct surgery group of the surgical branch of Chinese medical association proposed that the stenosis site in the bile duct injury classification Ⅱ 1D is from the confluence of the left and right hepatic ducts<2 cm and Ⅱ 2 d ~ Ⅱ 4 d injuries, E2-E5 injuries in Strasberg classification^[1,2,3]。 The repair of high bile duct injury is a difficult point in biliary tract surgery, and the restenosis rate after repair is 10% ~20%^[4,5,6]Surgery is the only definitive treatment for restenosis, but it is difficult, risky, uncertain and has many complications.

High bile duct injury refers to the injury of the horizontal bile duct at the confluence of left and right hepatic ducts and above. If improperly treated, it can be secondary to bile duct stenosis, recurrent cholangitis and intrahepatic bile duct stones. In the late stage, it can cause cholestatic cirrhosis, portal hypertension and multiple organ failure, which seriously affects the quality of life of patients and even threatens their lives^[1]。 With the continuous popularization of laparoscopic technique in digestive surgery, the incidence of high bile duct injury has increased and the subjects are younger, which brings high socio-economic costs^[2]。

laparoscopic cholecystectomy (LC) has been widely used as a treatment for benign diseases of the gallbladder. Compared with traditional open cholecystectomy, it has obvious advantages of less injury and faster recovery, but bile duct injury during LC is still a hot topic that hepatobiliary surgeons often pay attention to^[1]。 There are various causes of bile duct injury, and subjective causes include insufficient cognition of anatomical variation, irregular technical operation, blind overconfidence, etc. Objective reasons include anatomical abnormalities, gallbladder inflammatory lesions leading to unclear anatomical structure, etc. Although LC bile duct injury is closely related to the lack of experience, technical skill and local anatomy of the surgeon, it can sometimes occur in surgeons with some experience^[2]。

Biliary duct injury is one of the most serious complications in biliary tract surgery. At present, the epidemiological survey results show that its incidence is about 0.5%^{[1,2,3,4,5,6]}。 Once the bile duct injury is improperly managed, it will lead to serious consequences. Many patients suffer from repeated operations or lifelong disability (biliary cripple), or even lose their lives. A reasonable treatment plan should be formulated according to the time of discovery after the injury, the site, extent and degree of the injury, the patient's general condition, local tissue conditions and the degree of abdominal infection, etc. For the surgical treatment of bile duct injury, end-to-end bile duct anastomosis is the first choice, but it is often limited by the scope of bile duct injury, and it is often combined with obvious bile duct tissue defects, which makes it difficult to complete end-to-end anastomosis. At this time, biliary enterostomy is the most suitable surgical treatment.

Nowadays, laparoscopic Cholecystectomy (LC) has long been the first choice for Cholecystectomy. More than 750,000 cholecystectomies are performed in the United States every year, the vast majority of which are performed laparoscopically. LC has now become the largest number of operations performed in the United States every year. However, with the popularization of laparoscopic cholecystectomy, iatrogenic bile duct injury has become the most common and serious complication in LC^[1]。 Compared with the 0.1% probability of bile duct injury in traditional open surgery, LC is accompanied by higher risk and more complicated repair conditions. The abundant anatomical variation of hepatic hilum is an important cause of biliary tract injury during LC. Broad bile duct injury, including not only the rupture or continuity interruption of intrahepatic and extrahepatic bile ducts, but also blood vessel injury, especially hepatic artery^[2]。 The shape and confluence mode of intrahepatic and extrahepatic bile ducts, the opening position of accessory hepatic duct, the confluence mode of cystic duct, and the variation of hepatic artery may lead to bile duct injury during LC operation. This article will discuss the relationship between the anatomical variation of hepatic hilar and bile duct injury as follows.

The patient was a 73-year-old male. He was admitted to hospital due to "abdominal pain, abdominal distension with anal stopping defecation and exhaustion for 3 days". Physical examination: No pigment spots were found on the skin, eyes, oral mucosa and anus. Abdominal distension, visible intestinal type, periumbilical tenderness (+), rebound pain (-), hyperactivity of intestinal sound, and audible sound of gas passing through water. He had frequent periumbilical dull pain in the past, and was discharged from hospital 20 days ago due to "small intestinal obstruction" after conservative treatment. Abdominal CT examination: intestinal effusion and dilatation of the small intestine, showing the level of gas and liquid, thickening of some intestinal walls with abnormal soft tissue density shadows, seemingly concentric circles, and enhanced lesions showing enhancement. Laparotomy revealed repeated intussusception of proximal ileum (Figure 1), after intussusception reduction, segmental thickening of the ileum at about 50 cm from the ileocecal region was seen, and a 3.5 cm-sized mass could be palpable in the intestinal lumen, which did not penetrate the serous membrane, and the swollen lymph nodes were not palpable at the root of the mesenteric membrane. Partial resection of the small intestine was performed (including a regional mesangial block resection, with both ends 10 cm from the tumor). Postoperative pathological report: Malignant melanoma of small intestine, tumor size 3.5 cm ×2.0 cm ×1.0 cm, nodular type, infiltrating intestinal wall mucosa to deep muscle layer near serosa, no nerve invasion and intravascular tumor thrombus, periintestinal lymph nodes (0/14), no tumor metastasis, no tumor invasion at both ends of intestinal tube and peripheral margin (Figure 2)。 Immunohistochemical staining results: HMB45 (+ + +), S-100 (+ + +).

The 11-year-old child was admitted to the hospital for "10 h of hemolysis, accompanied by dry mouth, palpitations, and cold sweat all over the body". Physical examination: heart rate 130-140 beats/min, blood pressure 70/35 mmHg, acute blood loss. The abdomen was flat and soft, without tenderness, rebound pain and muscle tension in the whole abdomen, and no mass was palpable. Routine blood test: WBC 6.7×10⁹/L, RBC 1.22×10¹²/L, Hb 36 g/L, PLT 126×10⁹/L. Immediately after admission, anti-shock treatment such as blood transfusion and volume expansion was given. Emergency gastroscopy and colonoscopy excluded bleeding from gastric and colon lesions. Angiography was performed, showing active hemorrhage in the distal jejunal branch of the superior mesenteric artery (Figure 1)。 Hemocoagulase perfusion and jejunal branch embolization were performed through the opening of the superior mesenteric artery. Postoperative angiography showed that there was still contrast leakage, and the hemostatic effect was not good. An exploratory laparotomy was performed in the emergency department. During the operation, a mass of about 1.2 cm ×1.0 cm was found in the jejunal wall at a distance of about 80 cm from the ligament of Frederick (Figure 2), massive blood accumulation in the distal intestine. The middle part of the small intestine was opened and a colonoscope was placed. Intraoperative colonoscopy confirmed that there was active bleeding at the jejunal mass, and no abnormalities were found in the rest of the small intestine. A local resection of the jejunal mass was performed. After operation, the child recovered well after blood transfusion and other treatments, and was discharged from hospital 2 weeks after operation. Hb 96 g/L was re-examined before discharge. Postoperative pathological diagnosis: capillary hemangioma of the jejunum, submucosal thrombosis, with organized and papillary vascular endothelial hyperplasia.

A 51-year-old male was admitted to hospital due to "lower abdominal pain for more than 10 days, accompanied by frequent urination, urgency and incomplete urination". Physical examination: No positive signs in the abdomen. CT examination showed that a soft tissue mass was visible on the right side of the pelvic cavity, about 12 cm ×7 cm in size, with clear and smooth boundaries and uneven density, considering lipoma or fibrous tumor (Figure 1)。 Exploratory laparotomy was performed, and the mass was located in the anterior wall of bladder and behind the pubic symphysis, with tough texture and smooth capsule. Complete tumor resection was performed, and gray-white parenchyma was seen in the incised specimens after operation. Pathological examination: Enveloped nodular tissue, 13 cm ×9 cm ×9 cm in size, gray-white, tough in texture, gray-yellow and translucent in some areas (Figure 2)。 Under the light microscope, the tumor cells were spindle-shaped and separated by coarse collagen, with loose tissue, slender and oval nuclei, without nuclear division and necrosis (Figure 3)。 Immunohistochemical staining revealed: CK (−), VIM (3+), Bcl-2 (+), CD99 (+), Ki-67 (1% +), NF (−), CFAP (−), ALK (−), CD56 (−), DES (−), SMA (−), S100 (−), CD117 (−), Actin (−); Specific staining revealed: VG (red), Masson (blue), oil red O (−), immunohistochemical marker CD34 (+) (Figure 4)。 solitary fibrous tumors (SFTs) were diagnosed.

The patient, 53 years old, was admitted to the hospital on April 6, 2016 due to "distension and pain in the right upper abdomen for 1 month". Physical examination: clear consciousness, good spirit, non-yellow sclera, soft abdomen, no tenderness and rebound pain, no palpation of the liver under the costs, no palpation of obvious mass, no edema in both lower limbs, blood white blood cells 4.7×10⁹/L, red blood cells 4.78×10¹²/L, HB 145 g/L, PLT 210×10⁹/L, hepatitis B surface antigen was negative, and tumor markers (AFP, CEA, CA19-9), blood biochemistry, coagulation function, urine and fecal routine were not obviously abnormal. Enhanced CT showed that the right liver was massively cystic and solid, and the tumor was first considered (Figure 1,Figure 2,Figure 3)。 Then on April 11, 2016, laparoscopy was performed under general anesthesia. During the operation, the tumor was found to be huge and cystic, located in the 7.8 segment of the liver. After puncture and aspiration of the cyst fluid, part of the cyst wall was removed and sent to rapid freezing pathology showing fibrous cyst wall tissue. No obvious malignant tumor cells were found. Liver cyst was diagnosed during the operation, and laparoscopic hepatic cyst decapping and fenestration drainage was performed. He was successfully discharged 5 days after the operation, and pathology showed liver fibrous cyst wall tissue. The patient was readmitted to the hospital on August 23, 2016 due to "more than 4 months after liver cyst fenestration and drainage and nearly 1 month of distension and pain in the right upper abdomen". B-ultrasound showed mixed right liver occupation (tumor?), and further enhanced CT showed: mixed cystic-solid occupation in the right liver. The tumor was considered first, the tumor was larger than before, and the cystic fluid was significantly increased than before (Figure 4,Figure 5,Figure 6)。 Then, on August 26, 2016, liver tumor resection + cholecystectomy was performed. During the operation, a tumor of about 20 cm ×20 cm in size protruding from the liver surface in the right liver and left inner lobe of the liver was found. The tumor envelope was intact, and the gap with the surrounding liver tissue was clear. The postoperative anatomical specimens showed a cystic-solid tumor of the liver, the solid component was fish-like and contained about 1 500 ml of coffee-colored liquid. Postoperative pathology suggested that the spindle cell region of the liver differentiated into leiomyosarcoma, considering spindle cell malignancy, immunohistochemistry: AFP (-), CD117 (-), CD34 (-), Ki-67 (+), EMA (-), CK-Pan (+), S-100 (-), SMA (+), Caldesmon-H (+), Vim (+), CD68 (-), Desmin (+), postoperative pathology diagnosed primary leiomyosarcoma of the right liver. Six months after the second operation, CT examination in the outpatient clinic showed that the tumor recurred again. Due to financial difficulties, the patient did not receive further treatment, and currently survives with the tumor.

Total mesangial resection of rectal cancer has become a standard procedure^[1]While for locally advanced rectal cancer, combined peripheral organ resection is one of the important surgical methods^[2,3]Both total pelvic organ resection and posterior pelvic organ resection are important surgical methods for resectable stage T4b rectal cancer. However, postoperative pelvic empty ileum moves down and falls into the pelvic floor, which is prone to complications such as adhesive intestinal obstruction and even perforation. This study retrospectively analyzed the clinicopathological data of 92 patients with locally advanced rectal cancer who underwent combined pelvic organ resection, and explored the efficacy of ileal suspension technique in preventing postoperative complications.

The concept of enhanced recovery after surgery (ERAS) refers to the application of various methods during perioperative period to reduce postoperative stress response, reduce postoperative complications, shorten postoperative hospital stay, and speed up patient recovery^[1]It has been recognized by most surgeons in China. laparoscopic pancreaticoduodenectomy (LPD) has many organs removed and the reconstruction of digestive tract is complicated. There are still many controversies and doubts around its implementation and application. Based on the previous work, our team applied ERAS to the perioperative period of LPD, and its application experience is reported below.

The CT portal vein imaging technique (CTPV) was analyzed in 58 patients with portal hypertension who required surgical hemostasis^[1]To explore the classification characteristics of portal vein system.

In recent years, the stratification of risk factors based on the evaluation of lymph node status of thyroid cancer has been continuously improved, including age, sex, tumor size, number of lesions, local invasion, etc^[1]And new factors are constantly being incorporated into the risk stratification. It was found that the positive rate of region VI was significantly higher when tumors were located in the middle and lower poles than in the upper poles^[2,3]。 This study will analyze the lymph node metastasis of patients with papillary thyroid carcinoma by combining the factors such as gender, age, preoperative TSH level, whether or not Hashimoto's thyroiditis, tumor size, number of lesions, capsule invasion, tumor location, etc. At the same time, further distinguish the lymph nodes in the central region, and compare the lymph node metastasis confirmed by postoperative pathology with the tumor location, so as to analyze the metastasis rule of lymph nodes and guide the clinical surgical treatment.

"Remove the lesion, remove all the stones, correct the stenosis, unobstructed drainage, and prevent recurrence" is the treatment principle of intrahepatic bile duct stones. For intrahepatic biliary calculi, it is often necessary to remove the lobe or segment of the liver including the lesion. If there is a variation in the intrahepatic bile duct, and no fine anatomy is done during the operation, but large clamps and large ligations are used, it is easy to accidentally injury the adjacent hepatic bile duct. Shanghai Biliary Diseases Consultation Center discussed a case of "hepatectomy of V segment for intrahepatic bile duct stones, resulting in right posterior lobe hepatic duct injury combined with biliary fistula" put forward by Wang Jian's team of biliary and pancreatic surgery of Shanghai Renji Hospital, focusing on how to avoid accidental injury of adjacent hepatic lobe or segment hepatic duct during hepatectomy, how to accurately and quickly find the fistula during operation, the repair method of hepatic lobe or segment hepatic bile duct fistula, and the technique of hepatic segment bile duct jejunostomy. The opinions discussed by experts are summarized as follows.

The split right posterior hepatic duct is a relatively rare hilar bile duct variation, with an incidence of about 4%. If the cystic duct opens into the right posterior hepatic duct, it is easy to accidentally injury the right posterior hepatic duct during cholecystectomy. Most of the right posterior hepatic ducts are slender and difficult to repair. If improperly handled, it is easy to cause stenosis at the repair site after operation, resulting in stones and cholangitis at the proximal end of the stenosis. Shanghai Biliary Diseases Consultation Center discussed a case of "treatment of restenosis after repair of split right posterior hepatic duct injury" in the Department of Biliary and Pancreatic Surgery, Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine, focusing on how to avoid accidental bile duct injury during laparoscopic cholecystectomy, whether endoscopic papillary Sphincterotomy (EST) is reasonable for treating intrahepatic bile duct stones with hepatobiliary duct stenosis, the repair method of stenosis after bile duct injury, and the method of bile duct jejunostomy. The opinions discussed by experts are summarized as follows.

In recent decades, the incidence of thyroid cancer has increased at the fastest rate among endocrine malignancies worldwide^[1]。 Among the pathological types of thyroid cancer, papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC) are differentiated thyroid cancer (DTC), the most common; Medullary thyroid carcinoma originating from thyroid parafollicular cells (C cells) is relatively rare; However, undifferentiated carcinoma with high malignancy and poor prognosis is even rarer. Among them, the proportion of DTC exceeds 90%, and its prognosis is better than other types, and most of them are curable, but its recurrence rate is also higher, about 20% ~30%, and may be higher in some subgroups^[2]。 According to statistics, the incidence of thyroid cancer is 9.1/100,000 in women and 2.9/100,000 in men^[3]。 Due to the development of ultrasound, the detection rate of thyroid nodules is increasing. In addition to ultrasound, the development of thyroid fine-needle aspiration biopsy (FNAB) and its cytological evaluation has been a milestone in the diagnosis of thyroid nodules, greatly reducing the proportion of diagnostic surgeries for benign nodules. In 2007, the National Cancer Center developed the Bethesda system for reporting thyroid needle aspiration cytology^[4]There are some benign and malignant cytological types that cannot be determined in this system. Because the diagnosis cannot be confirmed, many patients have undergone unnecessary diagnostic surgery, which is very costly. Therefore, more accurate detection means are needed to improve the diagnostic accuracy of this part of patients. In recent years, with the development of molecular biology technology, great progress has been made in the study of the molecular mechanisms related to the occurrence, development, metastasis and prognosis of thyroid cancer^[5]At the same time, many related molecular markers have been found, which can be well used in the diagnosis of thyroid cancer; Some of these molecular markers are closely related to the prognosis of thyroid cancer, and the detection of these molecular markers has high guiding value in formulating initial treatment strategies for thyroid cancer.