After biliary tract injury, biliary-enteric drainage is one of the commonly used repair procedures, but some patients have anastomotic stenosis after the operation, which needs to be operated again, and it is tricky to deal with, and it is one of the difficulties in biliary surgery. From January 1990 to October 2010, 54 patients with anastomotic stenosis were admitted to our department after biliary and enteric internal drainage due to biliary tract injury, and all of them underwent hepato-biliary pelvic biliary and enteric Roux-en-Y internal drainage with biliary jejunostomy end-to-end anastomosis, and achieved better therapeutic effect. This paper analyzes the reasons for the occurrence of anastomotic stenosis and treatment methods. 1, Data and Methods 1.1 General data: of the 54 patients in this group, 18 were male and 36 were female; their ages ranged from 5 to 68 years old, with an average of 45.8±16.2 years old. Causes of biliary tract injury: 48 cases of medical origin, accounting for 88.9%; 6 cases of traumatic, accounting for 11.1%. After the occurrence of biliary tract injury, all the patients in this group had experienced one or more biliary tract repair surgeries, of which 22 cases were one time, 18 cases were two times, 14 cases were three times or more, and the most case had undergone eight surgeries. Before this admission, patients presented with recurrent abdominal pain, chills and fever, jaundice, combined with biliary cirrhosis, splenomegaly or hypersplenism, and portal hypertension in 20 cases. The main reasons for anastomotic stenosis after previous surgery were: inappropriate timing of surgery in 28 cases; defective surgical techniques in 20 cases; and improper surgical methods in 6 cases. 1.2 Preoperative preparation: patients were admitted to the hospital for routine examination, focusing on liver, kidney and other important organs function and biliary tract imaging examination. Through ultrasound, CT, magnetic resonance cholangiohydroscopy (MRCP), percutaneous transluminal cholangiography (PTC) and other methods, a clearer image of the biliary tract was obtained. Liver protection, nutritional support and other treatments were given to improve the patient’s systemic condition, small amount of multiple blood transfusion to correct anemia, protein infusion to correct hypoproteinemia, and anti-infective treatment was given to those with cholangitis. 1.3 Surgical treatment: general anesthesia was used for all patients in this group, and according to the patients’ previous surgical incisions, “reverse L-shaped” or “roof-type” or “Mercedes-Benz-type” incision was selected for the upper abdomen to fully reveal the surgical field. The surgical field was fully exposed. Thoroughly free the subhepatic hiatus, search for the biliary anastomosis through the original bridging jejunum or biliary drain, incise the jejunum side of the anastomosis, search for the openings of the left and right hepatic ducts, incise the left and right hepatic ducts, put them together, and shape them to form a relatively wide “hepatic and biliary tubes basin”, check that the bridge-collared jejunum has good blood flow, so that there is no twisting of the anastomosis, and that there is appropriate tension, and then use 5-0 high-quality non-invasive vascular needles to make the anastomosis. The 5-0 high quality non-invasive vascular needle and thread was used as the suture material to make a layer of lateral, interrupted and external suture of the biliary end, and the drainage tube was left in the anastomosis as appropriate. 2,Results The 54 patients in this group had good early recovery after biliary and intestinal anastomosis reconstruction without serious complications such as bile leakage, subdiaphragmatic abscess, hemorrhage, etc, and the liver function gradually recovered after operation.3 patients had fatty liquefaction of the incision after operation, which was healed after dressing change and other treatments.22 patients had a T-tube after operation with a smooth bile drainage, averagely about 450 ml/day, which started to be clamped off gradually about 10 days after operation, and then removed after T-tube imaging in about 3 months. The T-tube was removed after T-tube imaging. The evaluation criteria of long-term efficacy: excellent means that the patients have no symptoms such as abdominal pain, chills and fever, jaundice, etc., and return to normal work and life; good means that the patients occasionally have the above manifestations, which can be relieved by general anti-inflammatory and other treatments, and basically can maintain their work and life; poor means that the patients still have recurrent abdominal pain, chills and fever, jaundice, etc., and the liver function damage is aggravated, and they can’t maintain their normal work and life [3]. In this group, there are 45 patients obtained follow-up 1~12 years, average 4.5 years, according to the above efficacy evaluation criteria, 31 cases are excellent, 14 cases are good, the effect is more satisfactory. 3, Discussion 3.1 Causes of anastomotic stenosis after biliary tract injury with biliary and intestinal endodrainage 3.1.1 Timing of surgery: after the occurrence of biliary tract injury, the first repair surgery is crucial, and if it is unsuccessful, it will surely increase the difficulty of reoperation. At the time of biliary tract injury, the bile duct is often not dilated, the diameter of the bile duct is about 4-6mm, and the wall of the bile duct is also very thin, about 1mm, if this time to perform biliary and intestinal internal drainage, the difficulty of surgical operation is greater, easy to anastomotic leakage after the operation, the possibility of anastomotic stenosis in the long term is also greater. In our group, there are 18 patients who had undergone biliary and intestinal drainage in the past when the surgical conditions were not available, and abdominal pain, chills, fever, jaundice and other obstructive cholangitis manifestations appeared about 3 months after the operation, and biliary and intestinal anastomotic stenosis was confirmed by the imaging examination. Therefore, when the diameter of the bile duct is small and the wall is thin, the choice of bilioenteric internal drainage should be very careful. According to the situation of the bile duct defect, less than 2cm, the bile duct end – end anastomosis or other types of repair surgery; greater than 2cm can be used with the appropriate caliber of the silicone tube into the proximal end of the bile duct, properly fixed, and then lead it out of the abdominal wall, the bile will be externally drained. When the sinus tract of the drainage tube is formed, the drainage tube is gradually clamped, so that the bile duct is passively expanded, creating conditions for the later bile duct repair surgery. After the occurrence of biliary tract injury, bile leakage is prone to occur, and a large amount of bile accumulates in the abdominal cavity, which is prone to the formation of cholestatic peritonitis. In our group, 10 patients underwent internal biliary and intestinal drainage in this situation, and anastomotic stenosis occurred without exception. Gao Zhiqing et al. reported a case in which internal biliary-intestinal drainage was performed in the presence of cholestatic peritonitis, and the patient died postoperatively due to uncontrollable infection [5]. The aim of surgical intervention at this time is to remove bile, smooth drainage and control infection, and then consider definitive biliary repair surgery when the intra-abdominal infection has been controlled in about 3 months, there are no residual abscesses in the subhepatic space, and the patient’s general condition has improved. 3.1.2 Surgical technique: using bilioenteric endodrainage as a way to repair biliary tract injury is a complex and major surgery with high technical requirements for the operator. Common technical errors are: ① Improper choice of suture material: 8 cases in this group were previously sutured with No. 4 or No. 7 ordinary silk thread [7], and when reopened, it was found that the scar proliferation around the thread knot was more obvious, which led to the narrowing of the anastomosis. ② Suture is too dense or too loose: too dense makes the tissue ischemic necrosis, too loose will leak bile, both can aggravate the local inflammatory reaction and lead to anastomotic stenosis. ③ Wrong suture method: In the past, 4 cases of this group had bile-intestinal inversion suture, all of which had stenosis, and in the reoperation, it was seen that there was a circle of thread knot located in the anastomosis, and in 2 cases, there were many stones with a diameter of about 0.5cm centered on the thread knot, i.e., the “curtain of the anastomosis”. Bile duct or intestinal blood flow obstruction: after thermal injury of bile duct, the tissue is easy to be necrotic due to blood flow obstruction, and sometimes it is difficult to recognize; improper ligation of jejunal artery of bridge collaterals can cause intestinal ischemia; excessive anastomotic tension leads to poor healing. The anastomotic ischemia caused by the above conditions is an important cause of stenosis. ⑤ Improper placement of the drainage tube in the biliary anastomosis: the drainage tube was not placed in the bile duct above the anastomosis, which could not play the role of support and drainage; the drainage tube was not properly fixed, and it was easy to fall off in the early postoperative period and form bile leakage. In our group, there were 6 cases in which the biliary drainage tube, which played a supporting role, was dislodged or removed in less than one month after the operation, resulting in anastomotic stenosis in the long term. (6) Omission of important bile ducts: after the occurrence of high biliary tract injury, two to four bile duct breaks may be formed in the hepatoportal area, and the neighboring bile duct breaks need to be put together and shaped before anastomosis with the jejunum is performed in reoperation. In our group, there were two cases in which the bile duct of the right posterior lobe of the liver was omitted in the previous surgery and was not anastomosed with the jejunum, which resulted in bile leakage, intra-abdominal infection, and finally anastomotic stenosis after surgery. 3.1.3 Surgical modalities: Biliary endodrainage includes choledocho-jejunal Roux-en-Y anastomosis, choledocho-jejunal Warren anastomosis, and intercalated jejunal choledochoduodenal anastomosis, etc. [8], of which the choledocho-jejunal Roux-en-Y anastomosis is the most commonly used modality. Bile duct jejunoileal anastomosis can be performed in two ways, end-to-end and end-to-side, and Wang Yi et al. concluded that if the diameter of the bile duct severed end is greater than 2 cm, continuous end-to-end anastomosis with non-invasive sutures should be selected; if the diameter of the bile duct severed end is less than 2 cm, end-to-side anastomosis of the bile duct jejunoileum should be selected [9]. However, in our group of patients, anastomotic stenosis was seen after bile duct jejunum end-to-end anastomosis in 6 cases in the past, so we think this idea is worth exploring. Due to the presence of the jejunal circular muscle, there is a tendency for the anastomosis to contract after biliojejunal end-to-end anastomosis, which predisposes to stenosis over time. Therefore, we believe that biliary end – side anastomosis may be more appropriate. 3.2 Management of anastomotic stenosis after biliary tract injury with bilioenteric internal drainage Experiencing an unsuccessful repair procedure after a biliary tract injury is doubly painful for the patient and more challenging for the physician. Therefore, such re-operation for biliary repair is best performed by an experienced physician in a biliary surgical specialty in an effort to improve the success rate of the procedure. 3.2.1 Timing of surgery: After the occurrence of biliary tract injuries (especially medical biliary tract injuries), the attending physician, patient and family members are in a state of anxiety, and all of them hope that the repair surgery can be performed as soon as possible. However, if biliary intestinal drainage is performed hastily when the surgical conditions are not available, it may bring more difficult situation due to surgical failure. Therefore, the timing and mode of surgery should be selected according to the specific conditions of the patient, and if necessary, the surgery can be staged. According to the experience of our hospital in dealing with biliary tract injuries, we believe that the more appropriate timing for biliary enteral drainage is: ① liver function has not been irreversibly impaired; ② there is no abscess formation around the hepatic hilar bile ducts; ③ bile ducts are dilated above the plane of the injury, with a diameter of 0.8cm or more. 3.2.2 Surgical approach: repair and reconstruction of bile-intestinal anastomotic stenosis is the surgical approach for these patients. In this group of cases, we used the bile duct jejunum end – side anastomosis of the hepatic bile duct pelvic bile-intestinal Roux-en-Y endodrainage, and the efficacy is more satisfactory. 3.2.3 Key points of preoperative preparation: ① Obtaining a complete and clear image of the patient’s biliary tract before surgery is the basis for successful surgery, and high-quality MRCP is preferred. If PTC examination is performed, special attention should be paid to the fact that only part of the bile ducts may be visualized, and multi-point puncture should be performed if necessary, and the success rate of puncture can be improved under the guidance of ultrasound. ②Control the infection and improve the general condition of the patient. For patients with long-term biliary drainage or evidence of anaerobic infection, preoperative hyperbaric oxygen therapy is feasible to reduce the incidence of postoperative anaerobic infection. ③ Most patients have a history of multiple biliary operations and severe intra-abdominal adhesions, and preoperative blood preparation and bowel preparation are required. ④ Prepare fine suture materials and intraoperative ultrasound, cholangiography and other equipment. 3.2.4 The main points of surgical techniques: according to the operating habits of our hospital, the following aspects need to be paid attention to: ① use general anesthesia to ensure good analgesia and muscle relaxation; ② choose a wide incision, with the whole abdominal automatic retractor, to achieve good exposure; ③ sufficiently free the liver, reveal the subhepatic space; ④ follow the bridge collaterals of the jejunum or biliary drainage to find a narrow bile-intestinal anastomosis, and flexibly use the “With the help of intraoperative ultrasound, cholangiography and other equipments, the narrow anastomosis was gradually cut in the direction of bile ducts, and the stones, threads, titanium clips and other foreign objects in the bile ducts were removed, and the direction of each bile duct was confirmed, and corresponded to the biliary image before the operation to ensure that no important bile ducts were missed and the special bile ducts were identified. The direction of each bile duct was confirmed, and corresponded with the preoperative bile duct image to ensure that no important bile ducts were missed, especially the bile ducts of the posterior lobe of the right liver; ⑤ Because the use of an electric knife produces scabs that may lead to ischemia of the bile duct tissues, it is preferable to use sharp instruments, such as sharp knives or scissors, to incise the bile ducts; ⑥ In the event of multiple bile duct breaks, the neighboring breaks of bile ducts may be assembled to form the “hepatic and biliary duct basin”. When suturing, 5-0 non-invasive vascular suture was used, and the knot was tied outside the lumen of the bile duct according to the principle of “outside in, outside out” to ensure that the inner wall of the bile duct was smooth. The distance between the needle and the edge is 2~3mm, and the knot is tightened and loosened appropriately to ensure that the bile ducts have good blood flow; (7) If the broken ends of the bile ducts are far apart and cannot be put together, each bile duct must be anastomosed with the jejunum; (8) The anastomosis of the hepatic biliary pelvis and the jejunum is done by the end-to-side anastomosis with 5-0 high-quality, nondestructive vascular sutures as the suture material for the “one-layer, intermittent,” and “one-layer, intermittent, and one-layer” anastomosis. “A layer, interrupted, external” suture, the knot in the anastomosis outside, to keep the inner wall of the anastomosis is smooth, the needle distance and side distance are about 3 ~ 4mm; ⑨ to ensure that the bridge tab jejunum blood flow is good, bile-intestinal anastomosis is not twisted, tension is appropriate, the bridge tab jejunum and the proximal jejunum anastomosis is in line with the proximal jejunum anastomosis, there is no “anti-connections “; ⑩ if the anastomosis is wide, the diameter of 2cm or more, the anastomosis technology is excellent, the anastomosis may not leave a drain. Smaller bile-intestinal anastomosis should be placed in the drain with good material, and one side of the horizontal arm should be placed above the anastomotic plane to achieve better support and drainage. The straight arm is drawn from the bridge tab jejunum about 10cm from the anastomosis, and is properly fixed with double purse-strings sutures, and drained from the abdominal wall in the same position. 3.2.5 Key points of postoperative treatment: ① Reasonable use of antibiotics to prevent postoperative infection; ② Strengthening supportive therapy; ③ Careful observation of the patient’s abdominal signs and drainage, and timely detection and treatment of bile leakage, bleeding and other complications; ④ Do a good job of educating the patient, and instruct the patient to protect the bile duct drainage tube, to prevent accidental dislodgement of the drainage tube. Inform the patients in detail about the specific time to carry the tube, how to carry out biliary flushing and imaging, how to safely pull out the tube and other precautions, and the time to carry the tube is 3-6 months; ⑤ Carry out long-term follow-up for the patients.