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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 4  |  Page : 162-166

Redo hepaticojejunostomy in the management of bilioenteric anastomotic strictures


1 Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi; Division of Surgical Gastroenterology, Kasturba Medical College, Manipal, India
2 Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India; Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
3 Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission26-May-2022
Date of Decision01-Aug-2022
Date of Acceptance08-Aug-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Dr. Bharath Kumar Bhat
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_43_22

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  Abstract 


Background: The Roux-en-Y hepaticojejunostomy (RYHJ) is the commonly done drainage procedure for strictures which occasionally follow operations on the gallbladder and bile ducts. However, 8%–40% of these anastomoses become narrowed again and the redo operation is technically challenging. There are only a few reports which have examined the results of these revision procedures and we therefore decided to analyse our experience of this unusual operation.
Aim: To study the role of redo-hepaticojejunostomy in the management of bilio-enteric anastomotic strictures.
Materials and Methods: Between January 2010 and January 2016, we performed 23 redo-hepaticojejunostomies for the strictures following an initial hepaticojejunostomy which was done for benign indications in our department and followed them for a minimum of 2 years with clinical, biochemical and radiological tests.
Results: There were 7 males and 16 were females who had a median age of 37 years (range 15–63 years). The median interval between the index operation and the stricture recurrence was 10 months. Thirteen (57%) patients underwent initial surgical revision and 10 had the procedure following unsuccessful percutaneous intervention. The median length of hospital stay was 10 days and 21 (91%) only had minor complications. There was no operative mortality. On follow-up of all 23 patients after 2–8 years, six (26%) patients developed stricture recurrence, of whom three were managed with percutaneous dilatation and three required a second revisional surgery. Seventeen patients are symptom-free.
Conclusion: Redo RYHJ is a feasible option for strictures following an initial biliary enteric anastomosis with no surgical mortality and three-quarters of the patients being rendered symptom-free.

Keywords: Anastomotic strictures, Redo hepaticojejunostomy, Roux-en-Y hepaticojejunostomy


How to cite this article:
Bhat BK, Ray S, Lalwani S, Mangla V, Mehta NN, Yadav A, Nundy S. Redo hepaticojejunostomy in the management of bilioenteric anastomotic strictures. Curr Med Res Pract 2022;12:162-6

How to cite this URL:
Bhat BK, Ray S, Lalwani S, Mangla V, Mehta NN, Yadav A, Nundy S. Redo hepaticojejunostomy in the management of bilioenteric anastomotic strictures. Curr Med Res Pract [serial online] 2022 [cited 2022 Sep 27];12:162-6. Available from: http://www.cmrpjournal.org/text.asp?2022/12/4/162/355202




  Introduction Top


A Roux-en-Y hepaticojejunostomy (RYHJ) is commonly performed for bile duct injuries which follow operations such as laparoscopic cholecystectomy or other procedures on the bile ducts.[1] However, the reported incidence of repeated anastomotic strictures following this procedure when it is done for benign biliary conditions ranges from 8% to 40%.[2],[3],[4],[5] These strictures can result in recurrent cholangitis, hepaticolithiasis, hepatic lobar atrophy, secondary biliary cirrhosis and portal hypertension.[6] There are several conservative approaches in the management of the RYHJ strictures like percutaneous balloon dilatation and endoscopic stent placement, which are not always successful. The surgical revision of the anastomosis has to be undertaken as a final resort when conservative approaches fail. The “redo” surgery in these situations is technically challenging due to the stricture being at a high level and the non-accessibility of healthy biliary mucosa. There are few reports which have looked into the operative revision of the RYHJ strictures.[7],[8],[9],[10],[11],[12],[13] Hence, we examined our results of this difficult procedure.


  Materials and Methods Top


We retrospectively analysed, from a prospectively maintained surgical database, the records of 23 patients who underwent redohepaticojejunostomy (methodology depicted in the [Flow Chart 1]) between January 2010 and January, 2016 for strictures of RYHJs done for benign indications in the Department of Surgical Gastroenterology at Sir Ganga Ram Hospital, New Delhi. Informed consent was taken from all the patients. It is a retrospective observational study with possible ethical issues involved is none.



Operative details

Pre-operative percutaneous transhepatic biliary drainage was done in patients with active cholangitis not responding to parenteral antibiotics or in those with coexistent hepaticolithiasis where an intraoperative access 'U' tube was planned to retrieve retained stones, if any, after the operation. All patients underwent open redo surgery through a reverse L incision. Following the division of the perihepatic and visceral adhesions between the viscera we approached the hepatic hilum after moblising the hepatic flexure of the colon and  Kocherisation More Details of the duodenum till the left renal vein entering the inferior vena cava was exposed. The hilar plate was then incised and the region of the bile duct confluence brought down. After identifying and preserving the right hepatic artery, the site of anastomotic stricture site [Figure 1] was reached by following the previously placed jejunal loop going to the hepatic hilum. The bilioenteric anastomosis was then dismantled following confirmation of the position of the proximal bile duct by aspiration of bile through a needle and syringe. The fibrotic duct was excised till healthy proximal biliary mucosa was reached. Occasionally, additional procedures such as resection of segment 4 of the liver were done in case it was overhanging and making the creation of a healthy anastomosis difficult. In some patients with intrahepatic stones, we performed cholangioscopic stone extraction in others we resected the left lateral segment if it was atrophic and placed an access 'U' tube if we were unable to clear the biliary system completely of calculi [Figure 2]. We performed single or multiple anastomoses depending on the number of ducts opened usually over silastic stents [Figure 3]. These were removed 3–6 weeks later after a tube cholangiographic confirmation of biliary tree clearance and an absence of leakage.
Figure 1: Intra-operative photograph showing hepaticojejunostomy stricture laid open anteriorly with the pre-operatively placed multiple biliary stents seen in situ (thick white arrow)

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Figure 2: Intra-operative photograph showing right and left hepatic ducts being prepared for the bilio-enteric anastomosis. The guidewire (white arrow) seen in the left ductal system enables the placement of percutaneous access 'U' tube

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Figure 3: Intra-operative photograph showing completed posterior wall bilioenteric anastomosis with T-tube and percutaneous access 'U' tube (white arrow) in situ

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Intraoperative data such as the duration of the surgery and the need for the blood transfusion and post-operative outcomes such as complications (graded according to the Clavien-Dindo system) and length of hospital stay after the procedure were recorded. The patients were followed up for a minimum period of 2 years with regular clinical (cholangitis, jaundice and external biliary fistula), biochemical (total Bilirubin >2 mg% and raised alkaline phosphatase level) and imaging (ultrasound suggestive of intrahepatic biliary radicle dilatation and Magnetic resonance cholangiopancreatography (MRCP) suggestive of stricture) tests for the stricture recurrence. A failure of the redo RYHJ was defined as the recurrence of the stricture as evidenced by clinical, biochemical and radiological parameters.


  Results Top


There were seven males and 16 females who had a median age of 37 (range 15–63) years. The indication for the index RYHJ was post-cholecystectomy bile duct injury in 15 (65%) patients and choledochal cyst excision in 8 (35%). Eighteen patients (78%) had Bismuth type III-V stricture. The median interval between the index operation and the stricture recurrence was 10 (range 2–168) months and the median duration between the onset of the stricture and redo RYHJ was 36 (range 3–276) months.

Cholangitis was seen in 20 (87%) patients with RYHJ stricture. Jaundice without cholangitis and external biliary fistulae were seen in 3 (13%) and 2 (8.7%) patients, respectively. The pre-operative serum biochemistry results are shown in [Table 1]. Four patients had co-existent hepaticolithiasis with one of them having lobar atrophy of the left lateral segment. Surgical revision [Flow Chart 1] was considered to be the first line of management in 13 (57%) patients. The percutaneous intervention was attempted in 10 (44%) with 5 (50%) requiring more than 1 attempt. Five patients underwent pre-operative biliary drainage. None of our patients received endoscopic management.
Table 1: Demographic, clinical and biochemical parameters

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The mean duration of the surgery was 223 min with 2 (8.7%) patients requiring intraoperative blood transfusions. Additional procedures such as segment 4 resection and the left lateral segment resection were done in two patients and cholangioscopic stone extraction and percutaneous access 'U' tube placement done in three patients each.

The median length of hospital stay was 10 days with the majority 21 (91%) having minor (Clavien Dindo Grade <III) complications. Twenty-three were followed up with clinical and liver function test for a minimum period of 2 (range 2–8) years. At follow-up, 6 (26%) patients developed stricture recurrence, of which three were managed with percutaneous dilatation and three required second revisional surgery [Table 2].
Table 2: Post-operative outcomes

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  Discussion Top


Although percutaneous interventions in the form of balloon dilatation are an attractive less invasive option for biliary strictures following a hepaticojejunostomy, previous studies [Table 3] have reported failure rates of 15%–45%. Most of these patients need multiple sessions of dilatation with the mean number ranging from 2 to 8. There is also the need for prolonged stenting for a mean duration of 8.5–11.5 months.[14],[15],[16],[17],[18] In a recent study by Czerwonko et al., percutaneous dilatation was considered the first choice in the management of anastomotic strictures. The study also highlighted the need for at least three consecutive sessions which were done at prefixed times for good or excellent results.[19] In a similar study by Kirkpatrick et al. percutaneous balloon dilatation by a stricture protocol was found to reduce the need for operative revision.[20] However, the technical failure due to undilated biliary system secondary to co-existent internal or external fistula requiring skilled interventional radiologist, non-availability of the facilities, expertise and the cost involved for multiple attempts also limit the applicability of repeated percutaneous procedures in the management of patients who live far away from major medical centres. The neglected, untreated cases of RYHJ strictures usually present with co-existent hepaticolithiasis, lobar atrophy with recurrent cholangitis which can rule out the possibility of percutaneous intervention as definitive option. This is the usual scenario in developing countries with poor access to tertiary medical care. In our study, four patients presented with hepaticolithiasis; one of them with lobar atrophy requiring additional surgical procedure along with redohepaticojejunostomy. Surgical revision of a previously performed bilioenteric anastomosis which has strictured is an alternative which, although technically demanding is a one-time procedure in patients who cannot visit hospitals repeatedly.[11],[12],[13]
Table 3: Various treatment modalities and its long-term success rates in the management of hepaticojejunostomy anastomotic strictures

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Endoscopic management [Table 3] with double-balloon enteroscopy is also a feasible option in the hands of expert has shown a clinical success rate of 53%–85% with plastic stents. However, recurrence was 10% in those who are deemed cured.[21] The recurrence with balloon dilatation alone is 40% as shown in some studies.[22] The application of fully covered self-expanding metal stents has improved the results with clinical success seen in 85% of patients.[23] There are several reports over the applicability of the endoscopic ultrasonography-guided approach in managing this difficult condition.[24],[25] Technical feasibility and wide availability are the limitation of this approach. None of our patients have received the endoscopic management before the surgery.

The stricture is usually diagnosed after recurrent cholangitis in 90%–100% occurs as demonstrated in other studies.[11],[12],[13],[26] Similarly, 86.5% of our patients had cholangitis at presentation.

The time interval between the index RYHJ and the development of anastomotic stricture has been found to have a wide range from 5 months to 8 years.[10],[12],[26],[27] In our study, the median interval of stricture recurrence from the index repair was found to be 10 months. None of the patients had secondary biliary cirrhosis or portal hypertension at surgery; however, this might have been because the median interval between the redo RYHJ and the onset of stricture was only 36 months.

Thirteen (57%) of the patients in our series received surgical revision as the first line of treatment. Among the remaining 10, a trial of percutaneous dilatation was first attempted and in these five required multiple sessions. Pottakkat et al. reported that early technical failure and the anatomy of the biliary tree showing clear delineation of the left hepatic duct should prompt early surgical revision. We offered an upfront surgical revision where there is the availability of good extrahepatic duct length in about five patients.[11]

The redo of RYHJ can be done with minor complications in the majority of the patients [Table 3] as suggested by some series.[11],[12],[13] In our study, most patients had only minor complications and none of them died. The challenges that we faced were in achieving a healthy proximal biliary duct due to the loss of tissue during surgical revision, which is the case in other reported series as well.[7],[9]

A number of surgical series have shown a similar success rate of about 50%, which is lower than the success rate following the index repair.[7],[8],[9],[10] However, two Indian series have shown good long-term surgical outcomes in the range of 89%–94%.[11],[12] In our study with a minimum follow-up of 2 years, clinical and biochemical success was seen in 74% of patients.

Our study has some limitations as it was a retrospective study of a small number of patients with recurrent strictures. The other limitation was the heterogeneous cohort in the study with patients of different indications for the index operation. We believe that considering the spectrum of the long-term sequelae of the prolonged biliary obstruction, there is a need to embark on the definitive procedure.


  Conclusion Top


Redo RYHJ is a feasible option for strictures following an initial biliary enteric anastomosis with no surgical mortality and three-quarters of the patients being rendered symptom-free. Although the procedure has inherent challenges; in the hands of an expert hepatobiliary surgeon, it is a feasible and useful option, especially in patients who live far away from sophisticated medical facilities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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