Conventional Anastomosis Research Articles

Mechanical-Stapled Versus Hand-Sutured Anastomoses in Billroth-I Reconstruction with Distal Gastrectomy

In June 2000, we started performing mechanical-stapled anastomosis (MSA) for Billroth-I reconstruction (B-I) in distal gastrectomy. Thus, we performed a retrospective study to compare the clinical outcome of MSA and conventional hand-sutured anastomosis (HA). We evaluated 103 patients who underwent a B-I reconstruction. The data we collected included operative time, operative blood loss, time until oral intake, postoperative hospital stay, and anastomotic and general complications. We also examined the remnant stomach by endoscopy and classified it according to the Residue, Gastritis, Bile (RGB) criteria. The operative time was significantly shorter with MSA than with HA, but there were no other significant differences between the two groups. The RGB classification showed that there was more residual stomach content after MSA than after HA. The incidence of gastritis and bile reflux was not significantly different between the two procedures. The operative time for B-I reconstruction with distal gastrectomy was significantly shorter with MSA than with HA. While there were no significant disadvantages in the incidence of complications associated with MSA compared with HA, MSA resulted in more residue in the remnant stomach. The findings of this study showed the advantages and disadvantages of MSA, and suggest that MSA and HA are equivalent as anastomotic procedures in B-I reconstruction.

Bile Duct Growing Factor: An Alternate Technique for Reconstruction of Thin Bile Ducts After Iatrogenic Injury

A variant of bilioenteric anastomosis, laterolateral hepatojejunostomy, is described in which the opened anterior aspect of the common hepatic duct and left hepatic duct is anastomosed to a Roux jejunal limb. This technique is specially designed for thin, injured bile ducts in which a conventional anastomosis is difficult due to the small diameter of the ducts. A wide anastomosis is obtained, leaving the posterior wall as a conduit for bile, ensuring an adequate anastomotic diameter.

Manometric study in ulcerative colitis patients with modified ileal pouch–anal anastomosis

Sphincter-saving operations and construction of intestinal reservoirs aim at additional improvement quality of life of patients with restorative proctocolectomy. The conventional ileoanal anastomosis affects the function of the anal sphincters. There is a need for operative techniques that provide sufficient intraluminal anal pressure and thus a better postoperative continence and quality of life. Ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy was carried out in 42 consecutive ulcerative colitis patients (age range: 19-55 years and mean age of 35.52 years). There were 17 males (40.48%) and 25 females (59.52%). IPAA was performed at dentate line, according to a standard method, in 20 patients (47.62% of the cases; mean age of 35.20 years), 19 of which were in 1986-1995 and one patient in 1998. In 1996-2002, however, IPAA was performed after plicating the demucosed segment of rectal residual in 22 patients (52.38% of the cases; mean age of 35.82 years). This modification consisted in strengthening the internal anal sphincter by creation of a smooth muscle cuff through plication of a mucosectomized segment of rectal residual. The basal anal-canal and squeeze pressures were recorded prior to the operation as well as 1 month afterwards and then every 6 months for 2 years. Kelly-Hohlschneider's continence scores after Herold's modification were applied in 14 consecutive patients. Thanks to strengthening the internal anal sphincter by this segment, the basal pressure increased from a preoperative value of 68+/-6 mmHg up to 80+/-6 mmHg at the end of the second postoperative year (P<0.001). This favourable effect could be explained with the additional contractile potential of the plicated rectal segment resulting from the interference of the contractile potential of the internal anal sphincter with that of the smooth muscle cuff. The modified IPAA creates a novel and probably functionally active anatomical substrate. The basal anal-canal pressure is maintained sufficiently high through the tone of the smooth muscle cuff and internal anal sphincter. Our preliminary results suggest that the presented technique for performing IPAA may contribute to better functional results.

Fenestrated and Branched Endografts: Assessment of Proximal Aortic Neck Fixation

To investigate proximal fixation characteristics of different aortic endograft designs: a suprarenally placed fenestrated endograft, a modular branched endograft, an infrarenal endograft with suprarenal bare stent fixation, and the gold standard, a conventional hand-sewn anastomosis. Ten human cadaveric aortas were obtained at autopsy and transected 20 mm below the renal arteries to mimic an infrarenal aneurysm neck. In random order, the infrarenal, fenestrated, and branched endografts were deployed into the aorta. Using a hydraulic material testing machine, longitudinal load was applied to the distal end of each endograft until migration occurred, thus defining the displacement force (DF). Subsequently, a hand-sewn infrarenal anastomosis was tested in a similar manner. The median DF was 4.67 N (3.82-6.37) for the infrarenal endograft, 9.17 N (8.03- 10.81) for the fenestrated endograft, and 16.95 N (14.78-19.67) for the branched endograft. The differences in DF between the infrarenal and fenestrated endografts and between the fenestrated and branched designs were statistically significant (both p=0.005). The median force to dislodge the graft from the conventional anastomosis was 89.16 N (71.24-105.23). Suprarenally placed endografts, especially with additional branch grafts, provide improved proximal fixation compared to an infrarenal endograft with suprarenal bare stent fixation. However, none of the tested endografts approached the optimal, time-proven fixation, the hand-sewn anastomosis.

Prospective Evaluation of the St. Jude Medical Aortic Connector for Aortic-to-Autologous Vessel Graft Anastomoses

: Evolving technologies of proximal anastomosis devices meet the endeavor of surgeons to minimize manipulation of the ascending aorta during surgical myocardial revascularization. The objective of this study was to compare the patency rate of the saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices to the suture technique. : From September 2002 through July 2003, 86 patients underwent coronary artery bypass grafting with at least 1 vein graft anastomosed to the ascending aorta with the Symmetry G2 connector. Six-month clinical and angiographic follow-up, including Core-Lab quantitative coronary angiography (QCA) and corrected TIMI frame count (CTFC), was performed. : Eighty patients had at least 1 connector successfully implanted. Freedom from MACE (cardiac mortality myocardial infarction and target vessel reintervention) was 72/80 (90%). Six patients underwent a target vessel reintervention on the connector grafts. Six-month (mean 193 ± 36 days) angiography patency rates for the connector grafts were 72/81 (88.89%), 37/40 (92.5%) in sutured grafts, and 60/62 (96.8%) in arterial grafts. By QCA, 64/65 (98.5%) patent connector-grafts were free from more than 50% stenosis (1 connector-graft with a 51% stenosis). CTFC showed 65/65 (100%) patent connector-grafts with nonrestrictive flow. : Saphenous vein grafts anastomosed to the aorta with the Symmetry G2 connector have early and midterm patency rates comparable to the conventional sutured anastomoses. These results support the efficiency of the second generation of symmetry aortic connectors.

Low Anterior Resection with Coloanal Anastomosis for Rectal Cancer

Conventional low anterior resection with stapled or hand-sewn coloanal anastomosis is an alternative to abdominoperineal resection in selected low rectal cancers. The technique of intersphincteric resection, which includes removal of the internal sphincter, extends the possibility of sphincter preservation to patients with very low rectal tumors. Neoadjuvant treatment facilitates ultralow conservative surgery for locally advanced disease by inducing downstaging. Oncological results of conventional coloanal anastomosis and intersphincteric resection are similar to those of abdominoperineal resection, in terms of local control and survival. The restrictions of conservative surgery appear to be functional rather than oncologic. Rectal reconstruction using a colonic pouch decreases functional gastrointestinal disorders following coloanal anastomosis. The J-pouch is the standard reservoir, whereas the transverse coloplasty and side-to-end anastomosis constitute an alternative. Through utilization of new concepts and optimal surgical techniques for sphincter preservation, abdominoperineal resection should prove necessary for only 10% of rectal cancers.

Long-term reendothelialization of excimer laser—assisted nonocclusive anastomoses compared with conventionally sutured anastomoses in pigs

In contrast to conventional anastomosis methods, the excimer laser-assisted nonocclusive anastomosis (ELANA) technique involves a platinum ring and intima-adventitia apposition with a rim of medial and adventitial layers exposed to the bloodstream. The authors assessed the reendothelialization of porcine carotid arteries through ELANA compared with conventional anastomosis by using scanning electron microscopy. In 28 pigs a bypass with one ELANA and one conventional anastomosis was made on the left common carotid artery. All patent anastomoses were evaluated intraoperatively with the aid of an ultrasonographic flowmeter and postoperatively by using scanning electron microscopy at 2 weeks, 2 months, 3 months, and 6 months thereafter. Twenty-four of 28 bypasses (48 of 56 end-to-side anastomoses) were fully patent at the time of evaluation. On scanning electron microscopic evaluation of the bypasses, all 48 patent anastomoses showed complete reendothelialization, including all 24 ELANAs in which the endothelium covered the rim and the laser-ablated edge completely. No endothelial difference was observed between conventional anastomoses and ELANAs, aside from the obvious anatomical differences like the platinum ring, which had been completely covered with endothelium. At 6 months postsurgery, remodeling of the ELANA was observed, leaving the ring covered with a layer of endothelium as the most narrow part of the anastomosis. In long-term experiments, ELANA allows reendothelialization comparable to that achieved with conventional anastomosis. Considering its nonocclusive and high-flow characteristics, the ELANA technique is preferable in cerebral revascularization procedures.

A Novel Minimally Occlusive Microvascular Anastomosis Technique Using a Temporary Intraluminal Shunt: A Prospective Technique to Minimize Brain Ischemia Time during Superficial Temporal Artery-to-Middle Cerebral Artery Bypass

To describe a new technique of suturing microvessels with persistent perfusion via a temporary intraluminal microshunt. Experiments were conducted in Wistar rats. Abdominal aorta grafts were explanted from donor rats. A soft silicon microcatheter was introduced into the lumen of this graft. The abdominal aorta of a recipient rat was prepared for end-to-side microvascular anastomosis. Acland clamps (S&T AG, Neuhausen, Switzerland) were applied, and a linear arteriotomy was made. One end of the graft-clad microcatheter was introduced into the lumen and occluded with a fenestrated Acland clamp. At a more distal part, a similar arteriotomy was performed, and the other end of the microcatheter was introduced into the lumen and clamped with a fenestrated Acland clip. This created a temporary shunt through the graft-clad microcatheter. Then, the graft was anastomosed to the arteriotomies at both ends, over the microcatheter, in an end-to-side manner. The microcatheter was explanted from the vessel lumen through an arteriotomy in the middle of the graft. The graft was clipped short to close this arteriotomy. The mean total occlusion time before perfusion was reestablished amounted to 3.7 minutes. This experiment was repeated in 12 animals (6 with and 6 without heparin) without technical complications. As controls, conventional anastomoses were made in 2 animals. Suturing microvessels mandates their occlusion during the period of anastomosis. Although ischemia is well tolerated by other tissue types, the brain is quite sensitive to even short windows of ischemia. Nonocclusive anastomotic techniques have been developed recently. These are confined to vessels with luminal diameters greater than 3 mm. We have evolved a novel technique that can be used with microvessels, as pertinent to superficial temporal artery-to-middle cerebral artery bypass. We have described a new technique for performing microvascular anastomoses over a temporary intraluminal microcatheter shunt.

Numerical simulation of steady flows in designed sleeve models at distal anastomoses

Flow characteristics in cuff-like sleeve models were studied using numerical methods. In steady flow, fluid motion in a baseline model resembled flow patterns in conventional distal anastomoses with the exception of a distinct vortex below the heel region at high flow rates. Two other models (with height and diameter increment) were also investigated and it was concluded that a model with height increment was a preferred alternative to the baseline model in improving hemodynamics for the sleeve design.

Anastomose coledocoduodenal término-lateral em plano único com eversão da parede do colédoco em suínos

This article aims to study the one layer end to side choledochusduodenal anastomosis creating a "neopapila" which, because of the mucosa recovering it, would prevent stenosis. Thirty male pigs were distributed within 3 equal groups = Group I (control)--conventional choledochusduodenal anastomosis. Group II (experiment)--one layer end to side anastomosis with evertion of the choledochus wall (neopapila). Group III (sham)--isolation and mobilization of the biliar tract with no choledocotomy. We got the biliar flow and pressure (pre and postoperative) monitorized on the 15 PO day the animals went trough an endoscopy and on the 30 PO day they were operated and the tissues were analysed under macro and microscopic view. Regarding to biliar flow and manometry there were differences between all groups but the III. Animals in groups I and II showed intestinal metaplasia and diminished elastic fibers in the choledochus. All animals showed choledoco dilation. The proposed technique allowed the same results as the standard technique.

On Reducing Abnormal Hemodynamics in the Femoral End-to-Side Anastomosis: The Influence of Mechanical Factors

This study was concerned with investigating the influence of mechanical factors on the hemodynamics of the end-to-side anastomosis in an attempt to identify critical factors and establish if it is possible to re-engineer existing, patient-specific, by-pass grafts with a view to increasing their patency. The study chose the femoral artery as the principal subject of interest. Wall shear stresses (WSS) and wall shear stress gradients (WSSG) were taken as the primary quantities of interest. Angle, graft calibre, interposition cuffs, proximal outflow and inlet waveform were studied. The study found that the use of cuffs and patches can significantly reduce abnormal WSS and WSSG by up to 70% when compared to a benchmark 45 degrees conventional anastomosis. The Taylor patch was found to be more robust in reducing peak WSS magnitudes and gradients than the Miller cuff, where design variables proved to be more critical. On the addition of a Taylor patch to a realistic end-to-side femoral anastomosis, the peak WSS and WSSG were found to be reduced by 27% and 57%, respectively. In conclusion, it is possible to use idealised models to identify critical disease influencing factors and to use these findings to reduce the effects of abnormal hemodynamics in realistic, patient-dependant models.

Die Technik der laparoskopisch-thorakoskopischen Ösophagusresektion beim Ösophaguskarzinom - Erste Erfahrungen

Esophageal resection for carcinoma is still associated with high mortality and morbidity. Minimally invasive techniques are regarded to reduce operative trauma. However, to date only few studies on minimally invasive esophageal resection have been published. We describe in detail the technique of combined laparoscopic and thoracoscopic esophageal resection with gastric-pull-up and conventional open cervical anastomosis for esophageal squamous carcinoma. Prone positioning of the patient with bilateral lung ventilation was used during the thoracoscopic part of the operation. Our first experiences in 5 patients confirm the feasibility of the technique. We did not observe any surgical related adverse incidences and found the typically advantages of minimally invasive surgery, such as early mobility, less pain and a comfortable cosmetic result in our patients. Although the number of procedures is to low to decide the value of minimally invasive surgery for esophageal cancer, we think it could be a promising technology to reduce mortality and morbidity for esophageal resection.

Flow dynamics of the St Jude Medical Symmetry aortic connector vein graft anastomosis do not contribute to the risk of acute thrombosis

BackgroundThe efficacy of the St Jude Medical Symmetry aortic connector (St Jude Medical, Inc, St Paul, Minn) for coronary artery bypass is currently debated. Potential drawbacks are the biocompatibility of the endoluminal device, the need for graft manipulation during the procedure, and the 90° offset of the vein graft from the ascending aorta, which may induce graft kinking and abnormal fluid dynamics. In this article, a computational approach was designed to investigate the fluid dynamics pattern at the proximal graft. MethodsFour models of hand-sewn anastomoses and two models of automated anastomoses were constructed; a finite volume technique was used to simulate realistic graft fluid dynamics, including aortic compliance and proper aortic and graft flow rates. The anastomosis geometry performance was analyzed by calculating time-averaged wall shear stress and the oscillating shear index at the toe and heel regions of the proximal graft. ResultsTime-averaged wall shear stress was significantly lower in the hand-sewn anastomosis models than in the two models that simulated the use of the aortic connector (0.38 ± 0.07 Pa vs 1.32 ± 0.4 Pa). Higher oscillating shear index values were calculated in the hand-sewn anastomosis models (0.15 ± 0.02 Pa vs 0.06 ± 0.02 Pa). ConclusionsAutomated anastomosis geometry is associated with less critical fluid dynamics than with conventional hand-sewn anastomosis: the shape of the proximal graft induces more physiological wall shear stresses and less oscillating flow, suggesting a lower risk of atherosclerotic plaque and intimal hyperplasia as compared with conventional anastomosis geometry. Therefore, the reported early thrombosis and late failure of the St Jude Medical aortic connector anastomoses are not related to unfavorable fluid dynamics.

Radiations ionisantes délivrées par voie externe sur l'anastomose prothéto-artérielle pour limiter l’hyperplasie intimale et étude de la résistance biomécanique. Expérimentations et résultats

Purpose. – To evaluate the use of external ionizing radiation for the prevention of intimal hyperplasia in anastomosis between PTFE and artery. Methods. – Bypass using a 6 mm PTFE was performed on a swine subrenal aorta with a distal conventional anastomosis ( N = 35) associated (test group; N = 17) or not (control group; N = 18) with post-operative external radiation (20 Gy) on this anastomosis. At 45 days, histological studies and morphometric studies were performed on the aorta receiving the anastomosis. Two protocols were performed, the first protocol with standard analysis and the animals were randomly assigned to either group (test group; N = 11 and control group; N = 13) and the second protocol with test of extraction comparing the biomechanical resistance between the irradiated group ( N = 6) and the control group ( N = 5). Results. – Twenty-one animals survived the procedure in the first protocol, 11 in the second. The endothelium was restored in either group. Histological recasting was observed in the media after radiation with fibrosis and areas of necrosis. Intimal thickness was significantly lower after irradiation in the heel ( P < 0.01), the head ( P < 0.01) and the suture line ( P < 0.001) of the artery in the first protocol. The intimal thickness was also significantly lower in the second protocol after radiation in the heel ( P < 0.05) and the head of the artery ( P < 0.05). There was no difference between the two groups comparing the resistance. Conclusion. – After external irradiation, the thickness parameter of the intima decreased significantly in comparison with the control group with similar resistance. Media fibrosis and necrosis need to be confirmed by further investigation.

Particle-hemodynamics modeling of the distal end-to-side femoral bypass: effects of graft caliber and graft-end cut

Late-stage occlusions of peripheral synthetic bypass grafts are frequently due to intimal hyperplasia and/or thrombosis at the distal anastomosis, resulting in unacceptably high failure rates. It has been widely established that hemodynamic and blood particle interactions with the vascular surface as well as surgical injury and compliance mismatch are inciting mechanisms capable of eliciting various cellular level responses associated with distal anastomotic intimal hyperplasia (IH) formation. Primary geometric factors influencing anastomotic hemodynamics include the graft-to-artery diameter ratio and graft-hood shape, which are determined by the graft caliber and initial graft-end cut selected by the vascular surgeon. In this study, the particle-hemodynamic effects of graft-end cuts (straight, curved, and S-shaped) and graft-to-artery diameter ratios (2:1 vs. 1.5:1) have been numerically assessed in four common unexpanded anastomotic configurations with respect to vortical flow patterns, wall shear stress based parameters, and platelet interactions with the vascular surface. Sites of significant platelet–wall interactions have been identified by a novel near-wall residence time (NWRT) model, which includes shear stress based factors for platelet activation and endothelial cell expression of anti-thrombogenic compounds. Of the configurations evaluated, straight and curved graft-end cuts with a graft-to-artery diameter ratio of 1.5:1 were found to reduce the particle-hemodynamic potential for IH development at locations critical to flow delivery. Nevertheless, the potential for significant IH occurrence via platelet and/or endothelial response pathways was highly evident in all conventional anastomoses considered, such that a decisively superior configuration was not determined. These results illustrate the need for alternative anastomotic designs with the intent of reducing critical hemodynamic wall parameters and mitigating regions of significant particle–wall interactions.

Delayed blind-pouch apposition, guide wire placement, and nonoperative establishment of luminal continuity in a child with long gap esophageal atresia

Delayed primary esophago-esophagostomy is the most physiologically attractive approach to establish luminal continuity in children with pure esophageal atresia. However, excessive tension on the mobilized esophageal ends can lead to anastomotic separation and severe leakage. To circumvent these complications, the blind pouches of a 2 1 2 -month-old child were approximated unopened when, during the extrapleural thoracotomy, a conventional anastomosis was not feasible. A suture was passed through the tip of the 2 ends and made to exit through the mouth and the gastrostomy. After healing occurred, the suture was replaced under fluoroscopic control by a Seldinger-type wire. A vein dilator then was passed over the wire, establishing the continuity between the esophageal segments. Subsequent dilatations increased the anastomosis to the desired diameter. Leakage and an additional thoracotomy were avoided, and the hospital stay was shortened. The child, now 6 years old, is well and swallows normally.

Keyhole procedure: A new technique for intestinal anastomosis with a large opening and less tissue trauma, using both circular and linear staplers

Background. We designed a new technique, termed the keyhole procedure, that uses a linear stapler to enlarge the anastomotic opening made with a circular stapler. The present study was performed to evaluate this technique in terms of maximum bursting pressure and area of anastomotic opening and compare it with conventional anastomosis using a circular stapler in an animal model. Methods. Anastomoses were created by the new technique or by the conventional method in swine small intestine. Anastomosis integrity was assessed by the air leakage test. Anastomotic openings were photographed and measured with an image analyzer. Results. It was found that the area of the anastomotic opening obtained with the new technique was more than 3 times that of the control (P <.001). There was no significant difference between the methods in maximum bursting pressure. Conclusions. The keyhole procedure provides a larger anastomotic opening than conventional anastomosis with a circular stapler, without impairing the integrity of anastomosis. (Surgery 2003;133:345-8.)

Novel proximal and distal anastomotic devices for coronary artery bypass surgery

THE CURRENT LITERATURE describes many varied experimental and clinical applications of minimally invasive techniques to enhance outcomes after coronary artery bypass grafting (CABG). Many techniques facilitating anastomotic procedures are described, but long-term data supporting improved patency rates, efficiency of surgical technique, and outcomes are limited. The growing need for minimally invasive procedures and means of reducing the complexity of endoscopic suturing will be the impetus that drives the development and implementation of such anastomotic devices. Applications of simultaneous suturing, stapling, clipping, stenting, and sealing devices have provided insight toward the development of clinically acceptable procedures to facilitate positive outcomes in minimally invasive CABG surgery. Proximal anastomotic devices not only decrease operative time but also allow the surgeon to avoid using a partial occlusion clamp on the ascending aorta during CABG.1 Successful reports of an aortic anastomotic device (AAD) for sutureless anastomosis to the proximal aorta of saphenous vein grafts without aortic manipulation2,3 may provide the technologic basis to pursue distal anastomotic devices in coronary surgery. However, applying such techniques to create distal anastomoses may prove more difficult and require development of unique technologies; robotic assistance toward totally endoscopic CABG makes these goals more challenging. The ideal distal anastomotic device would have applicability to all potential conduits with interchangeable proximal/distal order and a safe bailout in the case of device malfunction.4 The ability to decrease operative time, create superb anastomoses without technical imperfection, and improve long-term patency rates lends excitement to the developing frontier of distal anastomotic devices in minimally invasive CABG surgery. The objective of this review is to compare the existing devices and provide a basis for continued development of novel anastomotic devices. The anesthetic implications will be considered.

A flow visualization study of an anatomic coronary artery anastomosis model with an implant

Flow Streamlining Devices is a new tool in Coronary Artery Bypass Grafting (CABG). They aim in: a) Performing a sutureless anastomosis to reduce thrombosis at the veno-arterial junction, and b) Providing a hemodynamically efficient scaffolding to reduce secondary flow disturbances. Thrombosis and flow disturbances are factors that have been reported as contributing factors to the development of intimal hyperplasia (IH) and failure of the graft. By reducing thrombosis and flow disturbances, it is expected that IH will be inhibited and the lifetime of the graft extended. To evaluate the hemodynamic benefits of such an implant, two models were designed and fabricated. One simulated the geometry of the conventional anastomosis without an implant, and the other simulated an anastomosis with a flow streamlining implant. Identical flow conditions relevant to a coronary anastomosis were imposed on both models and flow visualization was performed with dye injection and a digital camera. Results showed reduction of disturbances in the presence of the implant. This reduction seems to be favorable to hemodynamic streamlining which may create conditions that may inhibit the initialization of IH. However, the compliance and geometric mismatch between the anastomosis and the implant created a disturbance at the rigid compliant wall interface, which should be eliminated prior to clinical applications.

Co-existing biliary anomalies and anatomical variants in choledochal cyst.

Excision is the treatment of choice for choledochal cyst, and free bile drainage is essential to avoid ascending cholangitis. However, anastomosis between the relatively narrow common hepatic duct and bowel (conventional anastomosis) in case of type IV-A cyst, co-existing biliary anomalies and anatomical variations may cause ascending cholangitis resulting from insufficient biliary decompression. One hundred and four patients with choledochal cyst were treated by cyst excision. Conventional anastomosis was performed in 22 patients and hilar anastomosis in 82. An anastomotic stricture developed in nine of the 22 conventional anastomosis cases and all required reoperation. Of the 82 hilar anastomosis cases, only one required reoperation for a primary stricture. Co-existing biliary anomalies and anatomical variants were seen in 26 patients: (1) primary stricture in 18; (2) aberrant posterior duct in two; (3) low confluence of the hepatic ducts in two; (4) aberrant hepatic artery in two; and (5) very small bile duct in two. All 26 patients underwent widening of the ductal lumen (ductoplasty) or additional procedures. Complete removal of the extrahepatic bile duct and a wide hilar anastomosis is essential to prevent ascending cholangitis. Ductoplasty or additional procedure can be performed only at the hilum.