Postoperative surveillance of bile duct cysts through modified “Roux en Y” hepaticojejunostomy by transgastric endoscopic access

Abstract

Presenter: André de Moricz MD | Irmandade Santa Casa de Misericórdia de São Paulo Background: Choledochal cyst (CC) 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 for CC consists of complete cystic resection with biliodigestive anastomosis; the hepaticojejunostomy is the preferred type of reconstruction due to lower complication rates. 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 22 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” was proposed hepaticojejunostomy providing surveillance of remnant choledochal cyst and treatment for postoperative hepaticojejunostomy complications by less invasive strategy. Results: Considering the possibility of late complications such as stenosis or incomplete resection of the cyst, 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 Endoscopic Retrograde Cholangiopancreatography (ERCP) guided by Endoscopic Ultrasound (EUS) and therefore less invasive access than the ones described in the literature. 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 once it enables vigilance of the remnant bile duct and makes interventions possible when needed.