The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis

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Abstract

Roux-en-Y hepaticojejunostomy (RYHJ) is currently considered as the definitive treatment for iatrogenic bile duct injuries and the principal representative of biliary diversion procedures. This technique has met many milestones of extensive evolution, particularly the last years of concomitant technological evolution (laparoscopic/robotic approach). Anastomotic strictures and leaks, which may have deleterious effects on the survival and quality of life of a patient with biliary obstruction of any cause, made the need of the development of a safe and efficient RYHJ compulsory. The aim of this technical analysis and the juxtaposed discussions is to elucidate with the most important milestones and technical tips and tricks all aspects of a feasible and reliable RYHJ technique that is performed in our center for the last 25 years in around 400 patients.

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Most cited references 53

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Postoperative bile duct strictures: management and outcome in the 1990s.

James Coleman, Kristin A. Sauter, K. Campbell … (2000)

To describe the management and outcome after surgical reconstruction of 156 patients with postoperative bile duct strictures managed in the 1990s. The management of postoperative bile duct strictures and major bile duct injuries remains a challenge for even the most skilled biliary tract surgeon. The 1990s saw a dramatic increase in the incidence of bile duct strictures and injuries from the introduction and widespread use of laparoscopic cholecystectomy. Although the management of these injuries and short-term outcome have been reported, long-term follow-up is limited. Data were collected prospectively on 156 patients treated at the Johns Hopkins Hospital with major bile duct injuries or postoperative bile duct strictures between January 1990 and December 1999. With the exception of bile duct injuries discovered and repaired during surgery, all patients underwent preoperative percutaneous transhepatic cholangiography and placement of transhepatic biliary catheters before surgical repair. Follow-up was conducted by medical record review or telephone interview during January 2000. Of the 156 patients undergoing surgical reconstruction, 142 had completed treatment with a mean follow-up of 57.5 months. Two patients died of reasons unrelated to biliary tract disease before the completion of treatment. Twelve patients (7.9%) had not completed treatment and still had biliary stents in place at the time of this report. Of patients who had completed treatment, 90. 8% were considered to have a successful outcome without the need for follow-up invasive, diagnos tic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture after laparoscopic cholecystectomy had a better overall outcome than patients whose postoperative stricture developed after other types of surgery. Presenting symptoms, number of stents, interval to referral, prior repair, and length of postoperative stenting were not significant predictors of outcome. Overall, a successful outcome, without the need for biliary stents, was obtained in 98% of patients, including those requiring a secondary procedure for recurrent stricture. Major bile duct injuries and postoperative bile duct strictures remain a considerable surgical challenge. Management with preoperative cholangiography to delineate the anatomy and placement of percutaneous biliary catheters, followed by surgical reconstruction with a Roux-en-Y hepaticojejunostomy, is associated with a successful outcome in up to 98% of patients.

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Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment.

L. Stewart, L W Way (1995)

To analyze the treatment of bile duct injuries during laparoscopic cholecystectomy to discern the factors affecting outcome. An analysis of the treatment of 88 patients with laparoscopic bile duct injuries. A university hospital. Eighty-eight patients with major bile duct injuries following laparoscopic cholecystectomy. Success of treatment, morbidity rate, mortality rate, and length of illness. Operations to repair bile duct injuries were unsuccessful in 27 (96%) of 28 procedures when cholangiograms were not obtained preoperatively, and they were unsuccessful in 69% when cholangiographic data were incomplete. In some cases, lack of complete cholangiographic information led to an inappropriate and harmful operation. When cholangiographic data were complete, the first repair was successful in 16 (84%) of 19 patients. A primary end-to-end repair over a T tube (13 patients) was unsuccessful in every case in which the duct had been divided. Direct closure of a partial defect in the duct was successful in four of seven patients. Fifty-four (63%) of 84 Roux-en-Y hepaticojejunostomies were successful. Factors responsible for the unsuccessful outcomes were the following: incomplete excision of the scarred duct, use of nonabsorbable suture material, use of two-layer anastomosis, and failure to eradicate subhepatic infection before the attempted repair. Dilatation and stenting was uniformly unsuccessful as primary treatment (three patients) and was unsuccessful in only seven of 26 patients following a previous operative repair. Patients first treated by the primary surgeon had an average length of illness of 222 days (P < .01). Only 17% of primary repair attempts and no secondary repair attempts performed by the laparoscopic surgeon were successful. Patients whose first repair was performed by tertiary care biliary surgeons had a length of illness of 78 days (P < .01), and 45 (94%) of 48 repairs by tertiary care biliary surgeons were successful. Surgeons who specialize in the repair of bile duct injuries achieve much better results than those with less experience. The worse results of other surgeons could be attributed in many instances to specific correctable errors. Nonsurgical treatment was usually unsuccessful and substantially increased the duration of disability.

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Benign biliary strictures. Surgery or endoscopy?

G Tytgat, Mieke van Driel, E. A. Rauws … (1993)

This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions. Surgery is considered the treatment of choice, offering more than 80% long-term success. Endoscopic stenting has been reported to yield similar results and might be a useful alternative. In this nonrandomized retrospective study, 101 patients with benign biliary strictures were included. Thirty-five patients were treated surgically and 66 by endoscopic stenting. Patient characteristics, initial trauma, previous repairs, and level of obstruction were comparable in both groups. Surgical therapy consisted of constructing a biliary-digestive anastomosis in normal ductal tissue. Endoscopic therapy consisted of placement of endoprostheses, with trimonthly elective exchange for a 1-year period. Mean length of follow-up was 50 +/- 3.8 and 42 +/- 4.2 months for surgery and endoscopy, respectively. Early complications occurred more frequently in the surgically treated group (p < 0.03). Late complications during therapy, occurred only in the endoscopically treated group. In 46 patients, the endoprostheses were eventually removed. Recurrent stricturing occurred in 17% in both surgical and endoscopic patients. Surgery and endoscopy for benign biliary strictures have similar long-term success rates. Indications for surgery are complete transections, failed previous repairs, and failures of endoscopic therapy. All other patients are candidates for endoscopic stenting as the initial treatment.

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Author and article information

Journal

Journal ID (nlm-ta): Gastroenterol Res Pract

Journal ID (iso-abbrev): Gastroenterol Res Pract

Journal ID (publisher-id): GRP

Title: Gastroenterology Research and Practice

Publisher: Hindawi Publishing Corporation

ISSN (Print): 1687-6121

ISSN (Electronic): 1687-630X

Publication date (Print): 2016

Publication date (Electronic): 13 April 2016

Volume: 2016

Electronic Location Identifier: 3692096

Affiliations

1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17, 11527 Athens, Greece

Author notes

*Demetrios Moris: dimmoris@ 123456yahoo.com

Academic Editor: Alessandro Zerbi

Article

DOI: 10.1155/2016/3692096

PMC ID: 4846744

PubMed ID: 27190504

SO-VID: 7170ab8e-a6bc-4e23-830e-63866f37db13

License:

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 21 January 2016

Date accepted : 28 March 2016

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The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis

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Karger: Gastroenterology

Most cited references 53

Postoperative bile duct strictures: management and outcome in the 1990s.

Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment.

Benign biliary strictures. Surgery or endoscopy?

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