Hepaticoduodenostomy as Biliary Reconstruction in a Patient with Roux-En-Y Gastric Bypass

Abstract

Introduction: Roux-en-Y hepaticojejunostomy is a mainstay in biliary reconstruction. However, patients with prior Roux-en-Y gastric bypass (REYGB) are challenging given the altered anatomy. There are a number of reconstructive solutions. We report management of a Strasberg E4 bile duct injury repaired with hepaticoduodenostomy. Methods: 55-year-old female with prior REYGB for morbid obesity presented with right upper quadrant abdominal pain and underwent a laparoscopic converted to open cholecystectomy for acute cholecystitis, complicated by a bile duct injury. She was transferred to OHSU for further surgical management. As she was clinically nontoxic, she was managed with continued percutaneous peritoneal drainage with subsequent conversion to transhepatic biliary drainage (PTBD). Two months after her index operation, she underwent definitive repair after confirmation of no vasculobiliary injury. Results: The patient underwent a wide Kocher maneuver to completely mobilize the duodenum for a side-to-side Hepp-Couinaud hepaticoduodenostomy reconstruction. The duodenal conduit easily reached the confluence of the hepatic bile ducts after lowering the hilar plate and extending the ductotomy. She was discharged post-operative day five. Intra- and postoperative cholangiograms showed no bile leak and patent hepaticoduodenostomy. At one month follow-up, she was doing well and the PTBD was removed. Conclusions: Multiple approaches have been described for biliary reconstruction after REYGB. Given the proximity of the duodenum to the hilum, it can be a useful option because it may allow for future endoscopic access to the biliary tree. Familiarity with various options for biliary reconstruction will become more relevant to hepaticopancreaticobiliary surgeons as the prevalence of REYGB increases.