Clinical features and treatment of sump syndrome following hepaticojejunostomy

Abstract

Cholangitis after Roux-en-Y hepaticojejunostomy is usually caused by anastomotic stricture. A small number of cases present without evidence of obstruction and are ascribed to reflux of gastro-intestinal content into the biliary tree above the anastomosis (sump syndrome). Despite prophylactic rotating antibiotic therapy, the cholangitic episode may be severe and life-threatening. From 2001 to 2006, six patients who had undergone an end-to-side hepaticojejunostomy presented to our institution with recurrent episodes of biliary sepsis. Anastomotic stricture was excluded by liver MRI/MRCP and percutaneous transhepatic cholangiogram (PTC). Barium meal showed reflux of contrast into the biliary tree in all patients. Three patients had a short jejunal Roux limb (less than 50 cm) on pre-operative imaging. Five patients underwent surgery and two of them had two operations. One patient had a Tsuchida antireflux valve and subsequently underwent lengthening of the Roux loop. Three patients had lengthening of the Roux loop; one underwent re-do hepaticojejunostomy and one had concomitant revision of the hepaticojejunostomy and lengthening of the Roux loop. The latter underwent further lengthening of the Roux loop. Three patients are cholangitis-free 6, 36 and 60 months after surgery; two still experience mild episodes of cholangitis. An adequate length of the Roux loop is important to prevent reflux. However, Roux loop lengthening to 70 cm or more does not always resolve the problem and cholangitis, although generally less frequent and severe, may recur despite appropriate reconstructive or antireflux surgery. In these cases, life-long rotating antibiotics is the only available measure.