Biliary atresia benign stricture

　　The most common cause of bile duct benign stricture is direct or indirect bile duct injury during cholecystectomy, accounting for 90% of bile duct stenosis caused by surgery. The incidence of bile duct injury during open cholecystectomy is about 0.5%, while laparoscopic cholecystectomy (LC) does not seem to reduce the incidence of bile duct complications and may even show a rising trend.

　　Surgical bile duct stenosis is mostly fibrotic stenosis at the site of bile duct injury, and occasionally stenosis caused by other reasons. Nagafuchi reported a case of a patient who underwent laparoscopic cholecystectomy (LC), and postoperative trauma neuritis occurred in the common bile duct, leading to bile duct stenosis. Traumatic neuritis is not a true tumor but an overgrowth of damaged nerve fibers that innervate the bile duct after bile duct injury. Such bile duct stenosis has a poor response to dilation and stent treatment.

　　Liver transplantation surgery is also a main cause of postoperative bile duct stenosis. Bile duct reconstruction is required after liver transplantation surgery, and stenosis often occurs at the anastomosis of the bile ducts. Chronic pancreatitis is one of the causes of benign bile duct stenosis. Due to the special anatomy of the distal bile and pancreatic ducts, diseases of the bile and pancreas can affect each other. Chronic pancreatitis, especially chronic inflammation of the pancreatic head, often affects the distal bile duct, causing fibrosis and stenosis of the bile duct wall. It can also cause bile duct stenosis by direct compression of the dilated pancreatic head on the common bile duct. 30% of chronic pancreatitis can be complicated by bile duct stenosis.

　　Some vascular diseases such as atherosclerosis,结节性多动脉炎(nodular polyarteritis) and other diseases that involve the hepatic artery or thrombosis of the hepatic artery after liver transplantation can lead to biliary ischemia, causing stenosis of the ischemic area of the bile duct. In addition, upper abdominal trauma, sclerosing cholangitis, Mirriz syndrome, and other conditions can also lead to bile duct stenosis.

　　Biliary atresia benign stricture, in addition to general symptoms, can also cause other diseases. The disease is serious, with rapid progression and rapid deterioration, leading to acute severe cholangitis (ACST), sepsis, and other conditions. Therefore, once detected, active treatment is required, and preventive measures should also be taken in daily life.

　　Patients with ductal benign stricture have a history of biliary or upper abdominal surgery (trauma) or recurrent cholangitis, and their symptoms are detailed as follows:

　　(一)Symptoms

　　1. Obstructive jaundice or excessive bile leakage from the drainage port may occur within 24 hours after surgery (injury), or there may be no early symptoms after surgery (injury), with intermittent dull pain in the upper abdomen, chills, fever, jaundice, grayish stools, etc. for several weeks to several years.

　　2. During an acute attack, Schick (Charcot) triad may occur.

　　3. Chronic cases may have long-term jaundice, irregular fever patterns, deepening jaundice after fever, and cholestatic liver cirrhosis. Or there may be cholangitis without jaundice. Severe cases have a rapid progression of the disease, rapidly deteriorating, and may appear ACST, sepsis, etc.

　　(二)Signs

　　1. Abdominal pain in the upper abdomen during the attack.

　　2. Jaundice.

　　3. Liver enlargement and tenderness.

　　4. There may be signs of portal hypertension.

　　With the accumulation of treatment experience and lessons, the concept of 'prevention first' is being advocated by more and more surgeons. In upper abdominal surgery, carelessness is the first link in causing ductal benign stricture.

　　1. In medical work, medical staff should strictly follow operational routines to reduce the occurrence of iatrogenic injury.

　　2. Develop good living habits and avoid abdominal trauma.

　　3. Aggressively treat primary diseases such as bile duct stones and infection.

　　4. The consequences of bile duct injury are serious, so it is very important to prevent its occurrence. In fact, the vast majority of iatrogenic bile duct injuries can be prevented. The surgeon should concentrate his attention during the operation, operate carefully and meticulously, and follow certain operational routine steps.

　　Ductal benign stricture refers to the scar contracture of the bile duct lumen caused by bile duct injury and recurrent cholangitis. It can be caused by iatrogenic injury, abdominal trauma, and bile duct stones, infection. The examinations that ductal benign stricture patients need to do include:

　　1. Increased white blood cells and neutrophils; laboratory tests show obstructive jaundice; severe liver function impairment, with an inverted white and globulin ratio. Blood culture may be positive.

　　2. Retrograde cholangiography, percutaneous liver puncture cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP) can show the location, shape, and extent of the stricture. If the bile duct is not visualized, it does not exclude bile duct stricture. Sometimes, intravenous cholangiography can also show the lesion bile duct.

　　3. B-ultrasound can show the sonogram of bile duct dilation at the proximal part and (or) calculi. Intraductal ultrasound (IDUS) has special value in the diagnosis of the etiology of bile duct stricture, as it can differentiate between benign and malignant bile duct lesions through the characteristics of the sonogram of different lesions in the bile duct stricture.

　　4. MRCP can correctly diagnose biliary stricture after liver transplantation, but compared with ERCP, due to lower resolution, the details of the lesion are not clear enough, and the degree of stricture is often exaggerated.

　　Dynamic observation of alkaline phosphatase and gamma-glutamyltransferase, and MRCP can make an early diagnosis.

　　Benign bile duct stricture is mostly caused by iatrogenic factors or bile duct inflammation, and patients should pay more attention to their dietary habits in their daily life.

　　1, Minimize the intake of fats, especially animal fats, and do not eat fatty meat or fried foods. As much as possible, replace animal fats with vegetable oils.

　　2, A considerable number of gallbladder inflammation and cholelithiasis are indeed related to high cholesterol levels and metabolic disorders in the body, so it is necessary to limit foods high in cholesterol such as fish roe, yolks of various eggs, and the livers, kidneys, hearts, and brains of various meat-eating animals.

　　3, It is best to cook food by steaming, boiling, stewing, and braising, and avoid eating a large amount of fried, baked, grilled, smoked, or preserved foods.

　　4, Increase the intake of foods rich in high-quality protein and carbohydrates such as fish, lean meat, dairy products, fresh vegetables, and fruits to ensure heat supply, thereby promoting the formation of glycogen in the liver and protecting the liver.

　　5, Eat more foods rich in vitamin A such as tomatoes, corn, and carrots to maintain the integrity of the gallbladder epithelial cells, prevent the shedding of epithelial cells to form the core of stones, and thus trigger stones or cause stones to increase in size and quantity.

　　6, If conditions permit, drink fresh vegetable or melon juice such as watermelon juice, orange juice, and carrot juice more often, and increase the frequency and quantity of drinking water and eating, to increase the secretion and excretion of bile, and alleviate inflammation and bile stasis.

　　7, Eat less of foods rich in fiber such as radish and celery to avoid increased gastrointestinal motility due to difficulty in digestion, which may trigger biliary colic.

　　8, Quit smoking and drinking, and reduce the intake of spicy and刺激性 foods, such as wasabi oil, to avoid stimulating the gastrointestinal tract and exacerbating the condition.

　　It is advisable to consume light, easy-to-digest, low-fiber, temperature-appropriate, non-irritating, and low-fat liquid or semi-liquid foods, and should not be indulged in for a moment's pleasure by eating and drinking excessively, as this may cause unnecessary trouble and even trigger bile duct bleeding, which may be life-threatening.

　　For most cases of bile duct stricture, biliary-enteric anastomosis is the most definitive method of biliary reconstruction. However, due to the lack of long-term follow-up results from a large number of cases, the exact therapeutic value of this repair technique is yet to be further evaluated, and its surgical indications should be strictly controlled.

　　For cases of bile duct injury in difficult-to-reconstruct liver segments or lobes, and secondary segmental liver necrosis, liver abscess, or bile duct stones, the diseased bile duct and the involved segment of the liver can be resected together. For patients with end-stage biliary disease caused by secondary biliary cirrhosis after complex bile duct injury, liver transplantation may be the only effective means.

　　The application of endoscopic and interventional techniques in the diagnosis and treatment of iatrogenic bile duct injuries is increasing, but balloon dilation of the narrowed segment of the bile duct or stent support after surgery cannot achieve satisfactory long-term efficacy for cases of bile duct stricture or anastomotic stricture of the bile-enteric anastomosis. Only for a few minor bile duct injuries without tissue defects, endoscopic papillotomy and stent placement can be used as definitive treatment. The most important value of endoscopic and interventional techniques in the treatment of bile duct stricture is as an adjuvant treatment method for controlling bile leakage and infection before definitive surgery and for the management of recurrent bile duct stricture after surgery.

　　Firstly, all patients should undergo surgical treatment. For a few patients with poor general condition, it is advisable to first actively undergo non-surgical treatment to prepare for preoperative care.

　　1. For early fresh bile duct injuries, where the stenotic segment is not long, an end-to-end anastomosis can be performed, supported and drained for more than 1 year, but the long-term effect is often unsatisfactory. For those who cannot be end-to-end anastomosed, if conditions permit, various types of bile-enteric anastomoses can be performed, but the Roux-Y anastomosis between the bile duct and jejunum is most commonly used.

　　2. For late-stage patients with traumatic stenosis or primary bile duct stenosis caused by bile duct inflammation, bile-enteric anastomosis should also be performed to relieve bile duct obstruction (see Bile Duct Stones and Bile Duct Inflammation).

　　3. For stenosis at the hilum, especially when both hepatic duct orifices are stenotic, the hilum should be dissected to expose the bile duct 2 cm above the stenosis, or a partial resection of the liver quadrilateral lobe can be performed to expose it. The incision should cross the upper and lower ends of the stenosis, and整形 may be necessary if necessary, to enlarge the bile duct lumen, and even it may be necessary to incise the common bile duct, left (and/or) right hepatic ducts, and anastomose them with the Y-shaped jejunal side-to-side or end-to-side, with the requirement to remove as much of the stones in the proximal bile duct as possible to improve the surgical outcome.

　　4. For extrahepatic bile duct stenosis, a vascularized free ileum or gastric flap can be used for repair.

　　5. For primary bile duct stenosis, localized liver lesions, and severe cases, partial hepatectomy can be performed, often involving the left lateral segment of the liver.

　　6. If multiple lesions are present, accompanied by stones, and severe liver parenchymal damage, and if simple bile-enteric anastomosis cannot achieve the purpose, the aforementioned combined surgery needs to be used.

　　7. In a few cases where definitive repair is impossible, the stenotic segment can be long-term supported and fixed with an U-shaped tube, or various types of balloon catheters can be used to dilate the stenotic bile ducts.

　　Secondly, the selection of the timing for surgery.

　　1. Injuries found during surgery should be handled promptly and properly;

　　2. If jaundice or peritonitis occurs in the near postoperative period, an immediate reoperation should be performed. If the local inflammation is not severe, repair surgery should be performed according to the situation. If the local inflammation is severe, and it is estimated that repair is unlikely to be successful, proximal bile duct drainage for 3 to 6 weeks can be performed first, and then surgery can be performed after the inflammation subsides;

　　3. For late-stage stenosis, especially restenosis after repair, necessary diagnostic examinations such as ultrasound, CT, and ERCP should be performed to clarify the degree and extent of the lesion, and a definitive operation should be scheduled.