Postoperative Surveillance of Bile Duct Cysts through Modified "Roux en Y" Hepaticojejunostomy by Transgastric Endoscopic Access

Abstract

Background: Choledochal cyst is a congenital dilatation of extra or intrahepatic bile ducts and is usually associated with pancreaticobiliary malformation, risk of choledocholithiasis, and biliary tract cancer. The standard treatment consists of complete cystic resection with biliodigestive anastomosis; the hepaticojejunostomy is the preferred type of reconstruction. Methods: A survey of all choledochal cyst cases operated by the Pancreas Group of our service was carried out from July 1984 to March 2020, and 27 patients who underwent surgical treatment were identified. Based on the need for subsequent access to biliodigestive anastomosis for intrahepatic lithiasis treatment, biliary stricture, and further cancer surveillance on remnant intrahepatic cysts, a modified "Roux-en-Y" hepaticojejunostomy was proposed providing surveillance of remnant choledochal cyst and treatment for postoperative anastomotic or intra-hepatic complications by less invasive strategy. Results: A surveillance strategy must be considered. All the current procedures depend on advanced radiology, generate discomfort to the patient in ostomy cases, or rely on more invasive and repeated biliary surgical procedures. The new technique proposes a jejunal segment of approximately 10,0 to 15,0 cm kept far from the anastomosis allowing its placement, without tension, in the anterior gastric wall below the small curvature between the body the stomach antrum, which enables access to the bile ducts through Endoscopy (ERCP), guided by Endoscopic Ultrasound (EUS). Conclusion: The modified "Roux en Y" hepaticojejunostomy is a new and straightforward technique that allows surveillance of patients submitted to the biliodigestive anastomosis of any kind and are useful in patients submitted to choledochal cyst resection.