Extrapancreatic bile duct injury

　　Extracorporeal bile duct injury is actually more common due to iatrogenic injury, with an incidence rate of about 0.3-0.5%, that is, about 1 occurrence in every 200-300 cholecystectomies. Some bile duct injuries are discovered and properly handled during surgery, unfortunately, some are discovered only after surgery, causing serious complications, making it difficult to handle, and affecting the therapeutic effect. Most extracorporeal bile duct injuries occur during cholecystectomy, a few occur when cutting and closing the duodenum during the performance of complex subtotal gastrectomy, and can also occur when cutting and exploring the common bile duct or resecting the duodenal diverticulum around the ampulla of Vater, causing accidental injury to the common bile duct. Analyze the causes of bile duct injury during cholecystectomy:

　　① Operation errors, such as blind clamping and hemostasis or large suture ligation during sudden massive hemorrhage during surgery; excessive traction of the gallbladder when cutting the cystic duct, mistakenly cutting and ligating the common bile duct or common hepatic duct instead of the cystic duct, etc.

　　② Anatomical malformation of the biliary tract system, such as an extremely short cystic duct, absence, or its opening in the right hepatic duct, etc., if not identified during surgery, it may cause injury.

　　③ Severe inflammation, close local adhesions, unclear anatomy, and accidental injury during surgery if not careful; it is worth noting that sometimes there are no such objective factors, and bile duct injury also occurs during routine cholecystectomy, which requires the surgeon to investigate the cause. Most bile duct injuries caused by abdominal trauma are accompanied by injury to large blood vessels and adjacent organs.

　　Extracorporeal bile duct injury often occurs concurrently with pleurisy, shock, and injury to other organs, so it should be highly vigilant.

　　1. Pleurisy: Mild cases may have no symptoms. The main clinical manifestations are chest pain, cough, chest tightness, shortness of breath, and even respiratory distress. When infectious pleurisy or pleural effusion is secondary to infection, there may be chills and fever. Pleurisy caused by different etiologies may be accompanied by clinical manifestations of the corresponding diseases, and the most common symptom of pleurisy is chest pain.

　　2. Shock: Due to severe injury, acute effective blood volume deficiency caused by various pathogenic factors, leading to a clinical syndrome characterized by neuro-humoral factor disorder and acute circulatory disorder. These pathogenic factors include massive hemorrhage, trauma, poisoning, burns, asphyxia, infection, allergy, and heart pump function failure, etc.

　　3. Injury to other organs.

　　The clinical manifestations of extrahepatic bile duct injury depend on the degree of injury, the severity of stricture, and whether there is bile leakage. The main manifestations are bile fistula and/or obstructive jaundice. Patients may have a large amount of bile exuding from the wound after the injury or after surgery. After the bile excretion decreases, symptoms such as upper abdominal pain, fever, and jaundice appear. Some patients may also develop gradually deepening jaundice, accompanied by persistent pain in the upper right abdomen and fever shortly after surgery.

　　The consequences of extrahepatic bile duct injury are very serious, so it is especially important to prevent its occurrence. In fact, most iatrogenic bile duct injuries are preventable. The surgeon should concentrate attention, operate carefully and meticulously, and follow certain operational routine steps, such as when performing cholecystectomy, first expose the common bile duct, hepatic duct, and cystic duct, identify the relationship among the three after distinguishing them, and tie the cystic duct with silk thread without cutting it off immediately. Then, perform a retrograde cystic dissection from the bottom of the gallbladder to the point where the cystic duct joins the common bile duct. It is only at this time that the cystic duct is tied and cut. If the above three duct relationships cannot be distinguished during the dissection of the cystic duct, consider performing a common bile duct incision, inserting a probe, and helping to determine the position of each bile duct. Cholangiography can also be performed intraoperatively to help locate. In addition, when separating the gallbladder, it should be as close to the gallbladder wall as possible, and bleeding should be stopped carefully. It is forbidden to use large suture ligation for hemostasis, and one should always be vigilant about the existence of bile duct anomalies.

　　The diagnosis of extrahepatic bile duct injury is generally not difficult. For patients with obvious biliary obstruction, percutaneous liver puncture cholangiography (PTC) is most helpful for diagnosis, which can determine the diagnosis and clarify the location of the obstruction, and is conducive to formulating surgical plans before surgery. If there is an external fistula, contrast imaging can be performed through the fistula, but it is often unable to show the full picture of the bile duct. The diagnostic value of ERCP is not as great as that of PTC, and it generally cannot show the condition of the bile ducts near the obstruction well. Diagnostic abdominal puncture or lavage can also be performed, and positive results can be obtained. B-ultrasound, X-ray chest and abdominal flat film, and MRI can assist in diagnosis.

　　After surgery for extrahepatic bile duct injury, dietary adjustment is needed, and symptoms can be relieved through liver-nourishing food therapy.

　　1) Liver-nourishing and Cold-preventing Vegetable

　　Tomato sauce green fish slices: Green fish nourishes the liver and improves eyesight, and nourishes the stomach and strengthens the spleen. Suitable for people with chronic illness, neurasthenia, chronic hepatitis, and chronic nephritis.

　　Vegetable braised flat beans: Flat beans are known as the best vegetarian food for strengthening the spleen and stomach in spring, especially suitable for the elderly, pregnant women, lactating mothers, and patients with hypertension, coronary heart disease, and cerebrovascular disease.

　　2) Liver-nourishing and Cold-resistant Soup

　　Leek and pork liver soup: Leek is warm and pungent, and eating it in spring is most beneficial for Yang Qi. When it is paired with pork liver, it can nourish the liver blood. Suitable for patients with liver disease, night blindness, constipation, and other conditions.

　　3) Liver-nourishing and Cold-removing Congee

　　Black glutinous rice congee: Black glutinous rice has a neutral taste and is sweet, containing 15 amino acids and various vitamins. It can benefit the liver, nourish the spleen, and nourish the kidneys, making it an excellent food for replenishing the body in spring. This congee is suitable for people with liver and kidney deficiencies and women who are physically weak after childbirth.

　　Jujube congee: Jujube nourishes Qi and blood, benefits the liver, strengthens the spleen and regulates the stomach, and warms and replenishes Yang Qi. This congee is suitable for symptoms caused by weak spleen and stomach, such as poor appetite, loose stools, insufficient Qi and blood, thrombocytopenia, anemia, chronic hepatitis, malnutrition, and others.

　　4) Liver-protecting and cold-resisting tea

　　Honey and red tea: Put 5 grams of red tea leaves in a thermos cup, pour boiling water over it, cover it and steep for a moment; add an appropriate amount of honey and brown sugar. Drink one cup before each meal, which can warm the middle and nourish the stomach. This tea is suitable for spring when the liver qi is strong and the spleen and stomach function is poor.

　　Scallion and ginger tea: Take one scallion, crush and chop it, put it in a pot, add one bowl of boiling water, boil it with high heat, add a large pinch of red tea leaves, add one spoon of ginger juice, and drink the strong tea while hot. Then cover the quilt and go to sleep. It can increase heat and resist cold, prevent early spring wind-cold colds.

　　The above information is for reference only. For detailed information, please consult a doctor.

　　The treatment of extrahepatic bile duct injury caused by abdominal trauma depends on the condition of the injury, such as combined organ injury, blood loss, abdominal contamination, and medical conditions and technical strength. For patients with severe injury and significant blood loss, active anti-shock treatment should be carried out while rapidly controlling active bleeding and repairing or removing the injured organs. Complex bile duct injuries can be treated first by placing a 'T' tube for drainage, and then scheduled for bile duct repair surgery after the condition is stable. If the condition and conditions allow, as well as iatrogenic bile duct injury, the following principles can be followed for treatment:

　　The laceration of the common bile duct should first carefully remove the necrotic tissue at the edge of the laceration, make another incision near the proximal or distal end of the laceration, place an appropriately sized 'T' tube, one arm of which passes through the laceration as an internal support, and then suture the laceration with fine thread.

　　If the laceration exceeds half of the circumference or the bile duct is completely ruptured, it should be trimmed and anastomosed at the distal end with 5-0 nylon thread or fine thread under tension-free conditions, and the 'T' tube should be placed in the same manner as above to serve as support.

　　The retention time of the 'T' tube is generally not less than half a year.

　　If there is tension at the anastomosis, it is forbidden to pull it together forcibly. Low-positioned lacerations can be anastomosed with the duodenum, and high-positioned lacerations even located at the right and left hepatic ducts can undergo choledochojejunostomy or hepatic duct jejuno-Y anastomosis.

　　The success of bile duct reconstruction depends on skilled operation techniques, meticulous debridement surgery, the operation technique of the anastomotic mucosa, accurate alignment of the anastomotic mucosa, and tension-free anastomosis.

　　The simple and reliable treatment for gallbladder laceration or gallbladder duct rupture is cholecystectomy. Proper drainage after surgery is an important measure to prevent abdominal infection.