After coagulating the bleeding from the bile duct wall, careful inspection is again necessary to avoid overlooking tiny branches of the bile ducts such as those arising from the caudate lobe, segment 4, or segment 5, which joins the hilar bile duct Fig. With the appearance of smaller branches into which 5-French stent tubes cannot be inserted, anastomosis should be abandoned and the orifice closed with sufficient sutures.
In patients with poor hepatic reserves, even small branches ought to be reconstructed by utilizing smaller tubes such as a part of disposable intravenous catheters.
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Intraoperative view following resection of the extrahepatic bile duct with hilar plate. During the resection of the hilar bile duct, the ductal wall can be recognized within fibrous connective tissue after mobilizing the portal vein and hepatic arteries in the Glissonean pedicle. Two neighboring duct orifices can be joined by two interrupted stitches to prepare them for anastomosis as a common channel [ 14 , 15 ]. It might be better to use stay sutures during anastomosis Fig. In another reconstruction technique for plural neighboring ducts, the Glissonean sheath, including plural orifices, could be treated as a single duct by regarding the septa as a thick wall of the duct.
When more than one duct orifice appears separately, plural orifices in the jejunum should be created according to the distance between the ducts. In the synchronous reconstruction of multiple individual anastomoses, entire rows of bile duct posterior walls should be accompanied first, followed by the anterior rows, because attempts to complete one anastomosis and then another may be difficult or sometimes impossible. Plasty of neighboring ducts. Two neighboring duct orifices can be joined by two interrupted stitches to prepare them for anastomosis as a common channel.
It might be better to use stay sutures during anastomosis. The limb is brought up in a retrocolic fashion to perform side-to-side anastomosis by means of a sufficiently large orifice made in the bottom of the mesocolon following the mobilization of the 2nd and 3rd portions of the duodenum. Alternatively, a retrogastric route can be used in patients who are morbid obese [ 16 ]. An anastomotic orifice in the jejunal limb should be created in a site that avoids tension at the anastomotic site by taking the length into concern that the stump of the jejunal limb would be attached to the peritoneum, because the transanastomotic tubes used for external biliary drainage should be brought out through the jejunal limb.
As the jejunal incision becomes enlarged during the anastomosis, it should initially be smaller than the width of the bile duct. The transanastomotic tubes we have used are 5-French polyvinyl chloride tubes pancreatic duct drainage tube; Sumitomo Bakelite Co.
The same number of tubes as bile ducts to be reconstructed are inserted through the jejunal incision and pulled out from the jejunal stump using blunt needles attached to the ends of the tubes Fig. The tip of each tube should be seized with mosquito forceps to prevent it from slipping out. Preparation of the transanastomotic stent tube. The same number of tubes as bile ducts to be reconstructed are inserted from the jejunal incision and pulled out from the jejunal stump using the blunt needle. Single-layer interrupted sutures with or absorbable monofilament material are used for the anastomosis.
Expert operators can use a limited number of continuous sutures in anastomosis of the extrahepatic duct. In the reconstruction of the intrahepatic duct, the wall of the bile duct appears as connective tissue after removing the portal vein and the hepatic artery from the Glissonean pedicle [ 13 ]. Thus, it is important to mobilize these vessels far enough away from the Glissonean pedicle to avert injuries caused by the suture needle during the anastomosis. The approximate center of each stitch is grasped by a rubber-shod clamp small rubber-tipped forceps so as to maintain distance between the jejunum and the bile duct by suspending them together, with the forceps clipping the bilateral ends of the stitch ropeway method Fig.
The needles are passed through the jejunum at an interval of 1—2.
In order to maintain a favorable view during the anastomoses of multiple ducts, the stitches are serially introduced starting from the most dorsal side toward the ventral side. For the purpose of subsequent identification and prevention of suture tangling, both ends of the stitches should be grasped by small forceps and hung them in order with a large forceps. During suturing, stitches placed previously should be tented and moved aside by hooking with a right-angle forceps to prevent each stitch from tangling.
When creating a large anastomosis, a stay suture placed in the center of the orifice can help surgeons to plan the suture interval. One of the sutures used for fixation of a transanastomotic stent might be clipped with a different type of forceps for easy recognition. Using a rapid-absorbing suture material for fixing the stent may enable it to be withdrawn without difficulty on the 14th postoperative day. The sutures except those at each corner are tied serially on the inside of the lumen. Surgeons should pay attention not to tear the bile duct by using improper ligation technique.
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Tied sutures of the posterior row are then cut, except the ones involved in stent fixation. Ropeway method for the anastomosis of the posterior row. The approximate center of the each stitch is clipped by a rubber-shod clamp small rubber-tipped forceps so as to maintain distance between the jejunum and the bile duct by suspending them together with forceps clipping the bilateral ends of the stitch.
The fixation is usually performed on the proximal side of the bulge of the tube to prevent the tube from slipping out. Insertion and fixation of the transanastomotic stent tube s. As with the posterior row, suturing should start at the most dorsal side and progress ventrally. The needles are passed through the jejunum from the outside inwards, and through the bile duct from the inside outwards to be tied on the outside.
After the suturing of the entire anterior row of the anastomosis is complete, all sutures including those at both corners are tied serially on the outside of the anastomosis. The mucosal layer of the jejunum should be buried intraluminally during the tying. In cases requiring reconstruction of tiny branches where the intraluminal mucosal layer cannot be recognized, needles should be inserted along with the stent tube in order to securely stitch the mucosa of the duct.
The jejunal wall where the stent tubes have been pulled out is buried with interrupted sutures of seromuscular layer of the jejunum. After that, the tubes are fixed to the jejunal serosal layer with absorbable suture. Use of rapid-absorbing material is preferable in order to permit removal of the tube within a few weeks. The stump of the proximal jejunum is anastomosed with the side wall of the Roux-en-Y limb in end-to-side or side-to-side fashion. In reconstructing the intrahepatic ducts, the portal side of the duct wall should be treated as the posterior wall of the anastomosis and sutured first, since this side is relatively thick and tough compared with the opposite side because of the existence of rich fibrous tissue.
Of course, it is rather important to practice precise ligation technique, placing one of the fingers pulling the suture string beyond the tying point when making knots. If a wall is torn while tying the sutures, indwelling a perianastomotic sump tube with a continuous drainage system could be the best treatment instead of adding sutures over the torn duct.
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If a transanastomotic tube is adequately placed and the duct orifice is covered with the jejunum, the bile leakage could disappear within a few postoperative days as a result of the preemptive perianastomotic continuous drainage. Especially in patients who undergo reconstruction of the relatively small intrahepatic branches, an external biliary drainage tube may not work at all or may stop aspirating suddenly during the early postoperative days. An obstruction of the stent tube may occur in these cases; however, no special treatment is necessary because bile juice can flow into the jejunum through the space between the luminal surface and the stent tube.
Cholangiography via the stent tube should be strictly limited except in cases of severe and persistent bile leakage, because the procedure frequently causes severe cholangitis during the acute phase after the hepatectomy. In surgery for hepatobiliary malignancy, reconstruction of the biliary system with hepaticojejunostomy has become a standard procedure [ 1 — 4 , 7 , 8 , 15 ]. The mucosa-to-mucosa anastomosis using a Roux-en-Y jejunal limb has proved to be safe and feasible even in the reconstruction of multiple subsegmental ducts, with postoperative bile leakage frequency rates of 2.
Choledochoduodenostomy or hepaticoduodenostomy are accepted alternative approaches to bilioenteric reconstruction. The procedure seems to be preferable from an anatomical point of view when it is used only for the reconstruction of the middle bile duct, excluding the hilar or intrahepatic ducts. The long-term outcome of hepaticoduodenostomy has been reported to be comparable with that of hepaticojejunostomy as regards biliary function [ 11 ]. However, bilious gastritis due to duodenogastric reflux has occurred significantly more frequently following hepaticoduodenostomy than after hepaticojejunostomy in the treatment of benign disease [ 17 ].
Thus, reconstruction using the duodenum would not be the first choice for reconstructing the intestine. Despite recent advancements in endoscopic and interventional treatments, the majority of patients with major bile duct injuries finally undergo Roux-en-Y hepaticojejunostomy after long-term non-surgical treatment [ 19 , 20 ]. To maximize postoperative quality of life, the choice of hepaticojejunostomy instead of duct-to-duct anastomosis for patients with iatrogenic major bile duct injury should be more aggressively considered.
The use of transanastomotic stents seems to be nonessential for anastomosis between the jejunum and distal bile ducts such as the common hepatic duct or bilateral hepatic duct [ 10 , 21 ]. However, in biliary reconstruction following hepatobiliary resection, which usually requires stitches on the subsegmental small branches, we believe the transanastomotic stent is indispensable for recognizing the small duct orifices buried in the connective tissue of the Glissonean sheath.
Especially in patients whose bile ducts were torn during the anastomosis, or who suffered from bile leakage postoperatively, stent tubes can play an important role in achieving complete healing of the anastomosis by maintaining continuity between the duct and jejunum, preserving the luminal space, and reducing the volume of bile leakage. Most cases of postoperative bile leakage after bilioenteric anastomosis can be treated conservatively by maintaining a prophylactically placed drain and a transanastomotic stent [ 2 , 8 , 22 ]. Persistent and intractable bile leakage is caused by one or more overlooked and isolated bile ducts that have not been anastomosed.
Ethanol injection therapy may be necessary to eradicate the bile duct [ 23 ]. It is rather important not to miss small bile ducts during anastomosis, especially in the reconstruction of intrahepatic or hilar bile ducts. The most frequent late complication after bilioenteric anastomosis is cholangitis, which is sometimes associated with intrahepatic lithiasis [ 7 ].
Although this condition is usually attributed to retrograde bacterial infection, it is important to use imaging studies to clarify whether an anastomotic stricture exists. Furthermore, once such a stricture is definitively demonstrated, its dilatation can be performed by percutaneous transhepatic cholangioscopic PTCS drainage [ 24 ] or an endoscopic approach [ 25 ], but only once recurrence of the malignancy has been ruled out. After biliary system resection, reconstruction using the Roux-en-Y jejunal limb has been well-established with safe and secured results, even when that is performed with the small intrahepatic branches.
In contrast with the lower extrahepatic bile duct, the wall of the hilar or intrahepatic bile ducts can be recognized within the fibrous connective tissue in the Glissonean pedicle. Regardless of the level of the bile duct, precise mucosa-to-mucosa single-layer interrupted sutures and placement of transanastomotic stent tubes achieve sufficient anastomosis with infrequent bile leakage or stricture.
Meticulous inspection to avoid overlooking small bile ducts can decrease the chance of postoperative intractable bile leakage after the reconstruction of the hilar or intrahepatic ducts. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author s and source are credited. National Center for Biotechnology Information , U. Journal of Hepato-Biliary-Pancreatic Sciences.
The catastrophe caused the meltdown of three nuclear reactors at the facility, leading to the worst nuclear disaster since Chernobyl. The water used to cool the reactors has been leaking into the soil and contaminating the ground water on the premises of the nuclear facility, with some escaping into the Pacific Ocean. The 48 year old Japanese man said that workers were sent to various places in Fukushima, including an area called H3 with high radiation levels. When he climbed to the top of the meter-high tank Uechi found white adhesive tape covering an opening of about 30 centimeters.
After using a blade to remove the tape he applied a sealing agent on the opening and fit a steel lid fastening it with bolts. According to instructions he was to use four bolts, though the lid had eight bolt holes. According to the employee, his colleagues later told him that the use of adhesive tape was a usual practice to deal with the problem of sealing in radioactive water. Among other makeshift cost-cutting measures was the use of second-hand materials. Uechi also said that wire nets were used instead of reinforcing bars during the placement of concrete for storage tank foundations.
In addition, waterproof sheets were applied along the joints inside flange-type cylindrical tanks to save on the sealing agent used to join metal sheets of the storage tanks. Rain and snow had washed away the anti-corrosive agent applied around clamping bolts, reducing the sealing effect, Uechi added.