Clinical Application Of Inferior Epigastric Jejunal Blind-loop In The Treatment Of Complex Hepatolithiasis After Choledochojejunostomy

Objective:After Roux-en-Y choledochojejunostomy,the occurrence of cholangitis and recurrent stones is still a difficult point in the current treatment.Therefore,how to safely,simply and effectively treat residual stones,anastomotic stricture and recurrent stones after choledochojejunostomy has become the focus of treatment.This is also in line with the current concept of minimally invasive surgical treatment.The aim of this paper was to analyze the safety and efficacy of the inferior epigastric jejunal blind-loop in the treatment of complex hepatolithiasis after choledochojejunostomy.Method:According to the inclusion and exclusion criteria,the clinical information of 31 patients with complex hepatolithiasis after choledochojejunostomy who visited the Department of Hepatobiliary and Pancreatic Surgery of the First Hospital of Jilin University from January 2018 to January 2021 was collected and analyzed.They were divided into two groups according to whether the blind jejunal loops of the abdominal wall was indwelled during surgery,and 17 patients underwent simple Roux-en-Y choledochojejunostomy,hereafter referred to as the control group.Fourteen patients underwent Roux-en-Y choledochojejunostomy combined with the inferior epigastric jejunal blind-loop,hereafter referred to as the blind loop group.The clinical data of patients in the two groups were statistically analyzed,including preoperative general data of age,weight,previous history of biliary tract surgery,presence or absence of cirrhosis,presence or absence of hypertension,presence or absence of choledochojejunostomy stricture and distribution of hepatolithiasis.Intraoperative data included duration of surgery,postoperative blood loss and whether T-tube was placed for intraoperative choledochojejunostomy.Postoperative data included postoperative hospital stay,postoperative anal ventilation time,total hospital costs and postoperative complications.Postoperative complications included anastomotic bleeding,wound infection,bile leakage,intestinal fistula,postoperative residual stones,postoperative cholangitis,pulmonary infection,pleural effusion,abdominal infection and gastric emptying disorder.Preoperative and postoperative laboratory tests included White blood cell count（WBC）,Aspartate transferase（AST）,Alanine aminotransferase（ALT）,Alkaline phosphatase（AKP）,γ-glutamyl transpeptidase（γ-GT）,and Total bilirubin（TBIL）.In the blind loop group,postoperative complications were treated with choledochoscopy through the blind loop sinus after surgery.SPSS 26.0 software was used for statistical analysis between data using c2 test,Kruskal-Wallis H test rank sum test and t-test.Results:Preoperative general data: There was no significant difference in gender,age,body weight,liver cirrhosis,hypertension and the times of previous biliary tract surgery between the blind loop group and the control group（P > 0.05）.There was no significant difference in preoperative laboratory tests（WBC,AST,ALT,AKP,γ-GT and TBIL）between the two groups（P > 0.05）.There was no significant difference in preoperative imaging data（distribution of hepatolithiasis location and number of cases with choledochojejunostomy stenosis）between the two groups（P > 0.05）.Intraoperative data: There was no significant statistical difference in duration of operation,intraoperative blood loss and the number of T-tubes of intraoperative choledochojejunostomy between the two groups（P > 0.05）.Postoperative data: There was no significant difference between the two groups in postoperative hospital stay,postoperative anal ventilation time and total hospital costs（P > 0.05）.There was no significant difference between the two groups in laboratory test results（WBC,AST,ALT,AKP,γ-GT and TBIL）on postoperative day one（P > 0.05）.There was no statistical significance in postoperative complications（anastomotic bleeding,wound infection,bile leakage,intestinal fistula,postoperative residual stones,postoperative cholangitis,pulmonary infection,pleural effusion,abdominal infection and gastric emptying disorder）between the two groups（P > 0.05）.The 31 patients included in the analysis were all patients who had previously undergone choledochojejunostomy,but no blind loop was indwelled,11 patients had anastomotic stricture,and the remaining 20 patients had no anastomotic stricture.Of the 17 patients in the control group,3 patients had residual stones,of which 1 had the T-tube to remove the stones and the other 2 patients did not undergo surgical treatment.Of the 14 patients in the blind loop group,7 patients had residual stones after surgery,and choledochoscopy was applied through the blind loop sinus to explore the choledochojejunostomy and biliary tract,and none of them had stenosis.Four of these patients underwent choledochoscopic stone extraction through blind loops,and the stones were successfully removed.Two patients visited our hospital again due to occasional symptoms such as fever,abdominal pain,and abdominal distension and underwent choledochoscopy through the blind loop for stone extraction;one patient underwent choledochoscopy through the blind loop four times within 1 year to remove the stones.Conclusions:Roux-en-Y choledochojejunostomy combined with inferior epigastric jejunal blind-loop can be performed for patients with disposable unremovable hepatolithiasis who need multiple times.The inferior epigastric jejunal blind-loop combined with Roux-en-Y choledochojejunostomy is a safe and effective surgical approach for patients with hepatolithiasis after choledochojejunostomy.The inferior epigastric jejunal blind-loop provides a permanent and reusable treatment channel into the biliary tract,which not only allows the removal of postoperative residual stones,but also allows minimally invasive treatment of complications such as recurrent stones,anastomotic stricture,and biliary stricture through this channel to avoid reoperation for patients.