The Hepp-Couinaud Approach to Strictures of the Bile Ducts

Abstract

The results of operative repair of benign strictures of the bile duct after cholecystectomy, right hemihepatectomy, vagotomy and antrectomy, choledochal cysts in adults, and chronic pancreatitis, with particular reference to the use of the Hepp technique for hilar strictures and without the use of transanastomotic tubal stenting, were analyzed in 44 patients. End-to-side bilio-enteric anastomoses have been reported to be associated with restricturing and reoperation in 12% to 25% of cases and operative morbidity and mortality rates of 10% and 5% to 8%, respectively. Long-term transanastomotic tubal stenting is widely practiced in an attempt to prevent or diminish anastomotic stricturing. The Hepp technique of wide, accurate, mucosa-to-mucosa anastomosis between the left hepatic duct and a jejunal Roux loop was used in 28 patients with hilar bile duct strictures. The same technical principle of wide side-to-side anastomosis was used in most of the lower strictures. Patients have been observed for 1 to 14 years (median, 7 years). The operative mortality rate was 7% (3 patients), but only 2.4% (1 patient) in 41 noncirrhotic patients. Two patients who had undergone standard end-to-side hepaticojejunostomy required reoperation (Hepp procedures) for recurrent strictures. No recurrent strictures occurred with the use of the Hepp technique for hilar strictures or wide side-to-side anastomosis for lower strictures. None of these patients experienced episodes of ascending cholangitis. The Hepp approach provides a safe, durable, and highly effective solution to the problem of strictures of the bile duct, including hilar strictures. Transanastomotic tube stenting is not necessary.