Roux-en-Y Hepaticojejunostomy Research Articles

Totally laparoscopic surgery for choledochal cysts with hand‑sewn Roux‑en‑Y reconstruction in a pediatric population.

Cyst excision and Roux-en-Y hepaticojejunostomy (RYHJ) is the standard treatment for choledochal cysts (CCs). In the present study, the results of totally laparoscopic surgery for CCs (TLCCs) in a pediatric population were evaluated. The clinical data of 28 children with CCs between June 2020 and June 2023 were retrospectively reviewed. All patients underwent TLCCs involving cyst excision and RYHJ. The jejunojejunal anastomosis was completed laparoscopically using manual sutures. Age at operation, operative time, postoperative recovery and complications were evaluated. The 28 patients comprised 8 boys and 20 girls who underwent TLCCs at a mean age of 4.2 years (range, 1 month-12.3 years) with a mean weight of 15.9 kg (range, 4.6-43 kg). All patients received ultrasound and magnetic resonance cholangiopancreatography examinations, which revealed a mean cyst diameter and length of 1.74±0.76 cm and 3.85±1.25 cm, respectively. The mean operative time was 214±43.8 min. The mean time until starting an oral diet after surgery was 2.89±1.23 days. Apart from bile leakage and wound infection, no other complications occurred during a median follow-up period of 18 months (range, 4-42 months). TLCCs can be performed safely by skilled surgeons in pediatric patients. TLCCs may be more physiologically compatible and accelerate recovery of intestinal function with reduced trauma and better esthetic outcomes than conventional laparoscopic surgery for CCs. Therefore, TLCCs with manual sutures may be considered as an option for minimally invasive surgery in pediatric patients with CCs.

Bile Duct Injury in Laparoscopic Cholecystectomy; A Multi Centre Experience

Background: Laparoscopic cholecystectomy (LC), a minimally invasive gallbladder removal surgery, has revolutionized the field with benefits like quicker recovery. However, it is not without risks, and bile duct injury (BDI) is a severe but rare complication. BDI incidence during LC varies (0.4%-0.9%), with potentially life-threatening consequences. Surgeon experience, intraoperative cholangiography, and careful handling are crucial in preventing and managing BDIs. Aim of the study: This study aims to present and analyze a Multi centre experience regarding the management of these bile duct injuries in LC. Methods: This retrospective study, conducted at UAE medical institutions from 2014 to 2024, analyzed 2400 Laparoscopic Cholecystectomy surgeries over ten years. Out of 18 patients, thirteen patients were treated with ERCP, while five required additional surgery. Inclusion criteria involved patients aged 30 to 70+, of both genders, with BDIs. Exclusion criteria included minor BDIs and comorbidities. Two diagnostic techniques, including intraoperative cholangiography and postoperative assessments, identified BDIs. Treatment varied based on Strasberg classification, involving suturing, ERCP, stent placement, and Roux-en-Y hepaticojejunostomy. Data analysis employed SPSS, presenting results through tables and graphs with statistical parameters. Result: The study focused on Laparoscopic Cholecystectomy-related Bile Duct Injuries (BDI), with a cohort primarily aged 51-70 (66.67%). This age group showed higher susceptibility to BDI. The average participant age was 55.21±12.54 years, with a male majority (55.56%). Among 18 Endoscopic Retrograde Cholangiopancreatography (ERCP) cases, five had BDI, diagnosed intra/postoperatively. Two patients with clinical symptoms had postoperative diagnosis through Percutaneous Transhepatic Cholangiography (PTC). Strasberg classification revealed 60% Type A injuries; Types E1 and E2 each constituted 20%. Treatment modalities varied, with ERCP for Type A injuries (60%) and Roux-en-Y Hepaticojejunostomy (RYHJ) for Types E1 and E2. Conclusion: ERCP is a valuable method for diagnosing and managing Bile Duct Injuries (BDIs). The predominant type of BDIs, specifically Type A, is typically diagnosed after surgery. ERCP demonstrates its efficacy in addressing the majority of Strasberg Type A BDIs. In substantial and intricate BDIs, the Roux-en-Y Hepaticojejunostomy is a secure and efficient approach.

Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program.

Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level. We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux-en-Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression. Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25years, p=0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p=0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI [0.12, 0.79], p=0.02). In children with choledochal cysts, most short-term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision-making should be driven by long-term and biliary-specific outcomes.

Laparoscopic repair of bile duct injuries: Feasibility and outcomes

IntroductionBile duct injuries (BDI) following laparoscopic cholecystectomy occurs in approximately 0.6% of the cases, often being more severe and complex. Roux-en-Y hepaticojejunostomy (RYHJ) is considered the optimal therapeutic option, with success rates ranging from 75% to 98%. Several series have demonstrated the advancements of the laparoscopic approach for resolving this condition. The objective of this study is to describe our experience in the laparoscopic repair of BDI. MethodsA retrospective, descriptive study was conducted, including patients who underwent laparoscopic repair after BDI. Demographic, clinical, surgical, and postoperative variables were analysed using descriptive statistical analyses. ResultsEight patients with BDI underwent laparoscopic repair (out of 81 surgically repaired patients). Women comprised 75% of the sample. A complete laparoscopic repair was achieved in 75% (6) of cases. The mean age was 40.8 ± 16.61 years (range 19−65). Injuries at or above the confluence (Strasberg-Bismuth ≥ E3) occurred in 25% of cases (2). Primary repair was performed in two cases. Half of the cases underwent a Hepp-Couinaud laterolateral RYHJ, while three patients received a terminolateral RYHJ, and one underwent a bi-terminolateral RYH. The mean operative time was 260 min (range 120−360). Overall morbidity was 37.5% (3 cases): two minor complications (bile leak grade A and drainage-related bleeding) and one major complication (bile leak grade C). No mortality was recorded. The maximum follow-up period reached 26 months (range 6–26). ConclusionsOur study demonstrates the feasibility of laparoscopic RYHJ in a selected group of patients, offering the benefits of a minimally invasive approach.

Hepaticojejunostomy with gastric access loop versus conventional hepaticojejunostomy: a randomized trial

Roux-en-Y hepaticojejunostomy (RYHJ) with the provision of “gastric access loop” was developed to shorten the distance traveled by the endoscope to reach hepaticojejunostomy (HJ) anastomotic site. The aim of our study was to assess modified RYHJ with gastric access loop (RYHJ-GA) and compare it with conventional RYHJ (RYHJ-C) regarding short- and long-term outcomes and, moreover, to evaluate the feasibility and results of future endoscopic access of the modified bilio-enteric anastomosis. Patients eligible for RYHJ between September 2017 and December 2019 were allocated randomly to receive either RYHJ-C or RYHJ-GA. Fifty-two patients were randomly assigned to RYHJ-C (n = 26) or RYHJ-GA (n = 26). Three cases in RYHJ-C and 4 cases in RYHJ- GA developed HJ anastomotic stricture (HJAS) (P=0.68). 3 cases of RYHJ-GA had successful endoscopic dilation and balloon sweeping of biliary mud (one case) or stones (2 cases). Revisional surgery was needed in 2 cases of RYHJ-C and 1 case in RYHJ-GA (P=0.68). Modified RYHJ with gastric access loop is comparable to the classic hepaticojejunostomy regarding complications. However, gastric access enables easy endoscopic access for the management of future HJAS. This modification should be considered in patients with a high risk of HJAS during long-term follow-up.The trial registration number (TRN) and date of registration:ClinicalTrials.gov (NCT03252379), August 17, 2017.

Billiary Tract Obstruction due to Gallbladder Carcinoma at Prof. Dr. R. D. Kandou General Hospital: Two Case Reports

Abstract: Gallbladder cancer is the fifth most common gastrointestinal malignancy with a high mortality rate. Detection of gallbladder carcinoma in early stages can be difficult, despite improvements in ultrasound and CT-Scan imaging. It is possible to cure gallbladder cancer surgically at an early stage. We reported two cases of gall bladder carcinoma, 65-year-old and 52-year-old females, with the chief complaints of abdominal pain in the right upper quadrant (RUQ) and obstructive jaundice in both cases. The abdominal CT-scans showed circumferentially irregular focal thickening of gallbladder wall, and severe intra and extrahepatic cholestasis. Endoscopic preoperative biliary drainage using biliary stent was performed in one case. Open cholecystectomy with in toto common bile duct resection and portal lymphadenectomy followed by roux en-y hepaticojejunostomy reconstruction were performed for both cases. Both patients are still well with no cancer recurrences over two-year follow-up. The symptoms of gall bladder cancer were non-specific, and commonly included RUQ abdominal pain, weight loss, anorexia, nausea or vomiting, jaundice, and pruritus. Imaging with ultrasound and CT-Scan had improved preoperative diagnosis of gallbladder cancer. Outcomes of patient with incidental finding of gallbladder cancer had better prognosis since it provided the patient to be staged and managed appropriately with resection. In conclusion, early detection of gallbladder cancer results in better surgical outcome and less patient morbidity and mortality which shows its importance. Keywords: gallbladder carcinoma; early-stage detection; common bile duct resection

The role of Roux-en-Y hepaticojejunostomy for the management of biliary complications after living donor liver transplantation

IntroductionPost living donor liver transplantation (LDLT) biliary complications can be troublesome over the post-operative course of patients, especially those with recurrent cholangitis or choledocholithiasis. Thus, in this study, we aimed to evaluate the risks and benefits of Roux-en-Y hepaticojejunostomy (RYHJ) performed after LDLT as a last option to deal with post-LDLT biliary complications.MethodsRetrospectively, of the 594 adult LDLTs performed in a single medical center in Changhua, Taiwan from July 2005 to September 2021, 22 patients underwent post-LDLT RYHJ. Indications for RYHJ included choledocholithiasis formation with bile duct stricture, previous intervention failure, and other factors. Restenosis was defined if further intervention was needed to treat biliary complications after RYHJ was performed. Thereafter, patients were categorized into success group (n = 15) and restenosis group (n = 4).ResultsThe overall success rate of RYHJ in the management of post-LDLT biliary complications was 78.9% (15/19). Mean follow-up time was 33.4 months. As per our findings, four patients experienced recurrence after RYHJ (21.2%), and mean recurrence time was 12.5 months. Three cases were recorded as hospital mortality (13.6%). Outcome and risk analysis presented no significant differences between the two groups. A higher risk of recurrence tended to be related to patients with ABO incompatible (ABOi).ConclusionRYHJ served well as either a rescue but definite procedure for recurrent biliary complications or a safe and effective solution to biliary complications after LDLT. A higher risk of recurrence tended to be related to patients with ABOi; however, further research would be needed.

Therapeutic Role of Subcutaneous Access Loop Created Adjunct to Hepaticojejunostomy for Management of Bile Duct Injury.

Roux-en-Y hepaticojejunostomy (RYHJ) is usually required for major bile duct injury (BDI) as a definitive treatment. Hepaticojejunostomy anastomotic stricture (HJAS) is the most feared long-term complication following RYHJ. The ideal management of HJAS remains undefined. The provision of permanent endoscopic access to the bilio-enteric anastomotic site can make endoscopic management of HJAS feasible and attractive option. In this cohort study, we aimed to evaluate short- and long-term outcomes of subcutaneous access loop created adjunct to RYHJ (RYHJ-SA) for management of BDI and its usefulness for endoscopic management of anastomotic stricture if occurred. This is a prospective study including patients who were diagnosed with iatrogenic BDI and underwent hepaticojejunostomy with subcutaneous access loop between September 2017 and September 2019. This study included a total number of 21 patients whom ages ranged between 18 and 68years. During follow-up, three cases had HJAS. One patient had the access loop in subcutaneous position. Endoscopy was done but failed to dilate the stricture. The other 2 patients had the access loop in subfascial position. Endoscopy of them failed to enter the access loop due to failure of fluoroscopy to identify the access loop. The three cases underwent redo-hepaticojejunostomy. Parajejunal (parastomal) hernia occurs in 2 patients in whom the access loop was fixed subcutaneous position. In conclusion, modified RYHJ with subcutaneous access loop (RYHJ-SA) is associated with reduced quality of life and patient satisfaction. Moreover, its role in endoscopic management of HJAS after biliary reconstruction for major BDI is limited.

Outcomes of laparoscopic versus open resection of pediatric choledochal cyst

BackgroundUntreated pediatric choledochal cyst (CC) is associated with complications including cholangitis, pancreatitis, and risk of malignancy. Therefore, CC is typically treated by surgical excision with biliary reconstruction. Both open and laparoscopic (lap) surgical approaches are regularly used, but outcomes have not been compared on a national level. MethodsThe Nationwide Readmissions Database was used to identify pediatric patients (age 0–21 years, excluding newborns) with choledochal cyst from 2016 to 2018 based on ICD-10 codes. Patients were stratified by operative approach (open vs. lap). Demographics, operative management, and complications were compared using standard statistical tests. Results were weighted for national estimates. ResultsCholedochal cyst excision was performed in 577 children (75% female) via lap (28%) and open (72%) surgical approaches. Patients undergoing an open resection experienced longer index hospital length of stay (LOS), higher total cost, and more complications. Anastomotic technique differed by approach, with Roux-en-Y hepaticojejunostomy (RYHJ) more often utilized with open cases (86% vs. 29%) and hepaticoduodenostomy (HD) more common with laparoscopic procedures (71% vs. 15%), both p < 0.001. There was no significant difference in post-operative cholangitis or mortality. ConclusionsAlthough utilized less frequently than an open approach, laparoscopic choledochal cyst resection is safe in pediatric patients and is associated with shorter LOS, lower costs, and fewer complications. HD anastomosis is more commonly performed during laparoscopic procedures, whereas RYHJ more commonly used with the open approach. While HD is associated with more short-term gastrointestinal dysfunction than RYHJ, the latter is more commonly associated with sepsis, wound infection, and respiratory dysfunction. Level of evidenceLevel III: Retrospective Comparative Study.

S2829 ERCP via EUS Guided Duodenojejunostomy for a Biliary Stricture After Roux-en-Y Hepaticojejunostomy

Introduction: Patients with a Roux-en-Y hepaticojejunostomy (RYHJ) present a unique challenge when endoscopic retrograde cholangiography (ERC) is required. Standard approaches range from a surgical approach involving laparoscopic assistance to device assisted enteroscopy, with transoral approaches generally being variably successful, due to anatomy, length of intestinal limbs after surgery, and limitations in available accessories for use in device assisted enteroscopy. Here, we report the endoscopic use of a LAMS to create a duodenojejunostomy (DJ), thereby enabling ERC in a patient with RYHJ. Case Description/Methods: A 46-year-old woman status post cholecystectomy complicated by common bile duct injury necessitating RHYJ and prior anastamotic strictures, presented with recurrent self-limited cholangitis. She presented to clinic with intermittent episodes right upper quadrant pain, and fever which were treated conservatively with antibiotics. MRCP demonstrated stricture of the hepatic duct near the anastomosis [1]. Device assisted endoscopy was performed, but the anastomosis was unable to be reached. After discussing endoscopic, IR, and surigcal options we proceeded with EUS guided interventions given the anticipated need for recurrent interventions for a biliary stricture. EUS demonstrated mild intrahepatic dilation with limited access points for hepaticogastrostomy. The bile duct and hepaticojejunostomy were visualized from the bulb with small bowel adjacent to the anastomosis [2]. The jejunum was accessed using a 19 G FNA needle, and bile was aspirated to confirm intraluminal location. The jejunum was filled with 200 mL of sterile water and contrast [3]. A 15 mm x 10 mm AXIOS was then deployed in good position, creating a DJ, which was confirmed fluoroscopically and endoscopically [4]. Contrast was then injected through the stent to exclude a leak. 4 weeks later, ERCP was performed via the DJ [5]. Cholangioscopy was performed which showed some edematous bile duct mucosa without findings concerning for malignancy [6]. Biopsies and brushings were performed and three plastic stents were placed. The patient tolerated the procedure well, the tissue was benign and the patient has had resolution of her cholangitis symptoms. Discussion: In conclusion, we report a novel use of LAMS enabling ERC in patient’s status post RHYJ which allows easy access for repeat interventions and avoids the difficulties and limitations of device assisted enteroscopy ERCP.Figure 1.: Image 1. MRCP showing hepatic duct stricture near the anastomosis Image 2. EUS with bile duct adjacent to fluid filled jejunum Image 3. EUS with FNA needle accessing hepaticojejunostomy Image 4. EUS with LAMS deployed from duodenum to jejunum Image 5. Matured duodenojejunostomy Image 6. Cholangioscopy demonstrating edematous mucosa.

Management Strategies for Choledochal Cysts in Infants and Children Our Experience at Department of Pediatric Surgery ,L.R.H, Peshawar

Objective: This study aims to understand more about choledochal cysts and how they are managed in children under 12 years old. Setting and Design: A Descriptive Study at Department of Pediatric surgery L.R.H. Hospital Peshawar. Method and Material: The most common kind of malformation of the biliary tree in Pakistan is choledochal cyst malformation (C.C.M.). Congenital choledochal anomalies range from asymptomatic to life-threatening cholangitis or pancreatitis. Surgeons now recommend total cyst ectomy and bilioentenric anastomosis. This five-year research examines. Clinical presentation, blood and laboratory testing, imaging, surgery, and predictive data were evaluated from case records. Twenty-three children with choledochal cysts were treated between January 2019 and December 2021, and their clinical presentation, diagnostic tests, and treatments were recorded. ERCP or a cholangiogram confirmed choledochal cysts after ultrasound diagnosis (P.O.C.). Before surgery, children with cholangitis received antibiotics and percutaneous transhepatic biliary drainage (excision of the cyst and jejunal loop interposition hepaticoduodenostomy) Results: Twenty-three patients were analyzed; eight presented with chronic abdominal pain, five with a history of cholangitis, two with acute cholangitis, four with biliary peritonitis, and one with a history of pancreatitis. Following cyst excision, Roux-en-Y hepaticojejunostomy (RYHJ) was performed in 13 patients, and hepaticoduodenostomy (H.D.) was performed in 4 patients. One example of congenital choledochal malformation type II was treated with cyst excision and drainage because cholangitis and jaundice threatened the patient's life. The median age was 3, and the gender distribution was about even. Of the patients who sought care, 18 presented with jaundice, 15 with abdominal discomfort, 12 with fever, and 9 with a mass in their stomach. Only four people had all three symptoms of characteristic jaundice, pain, and lump. Overall, the results of both ERCP in 7 patients and P.O.C. in 14 cases were favorable. There were two distinct clinical presentations: I infantile form (less than a year), which included nine infants with jaundice in all, acholic stool in 7, lump abdomen in 4, but only one with classical triad; and (ii) childhood form (more than a year), which included twelve patients with abdominal pain, jaundice, and cholangitis. Twenty patients had a type I cyst, and three had a type Iva cyst. Only two kids said no to surgery, while the rest went through with it. Only three newborns were lost during surgery, but the other 18 did well following their follow-up visits (median 25 months). Six had extrahepatic biliary atresia, two had congenital hepatic fibrosis, and one had congenital biliary cirrhosis. Practical implication: Our study will provide a new data to the health care providers about choledochal cysts and how they are managed in children under 12 years old Conclusions: However, total cyst removal and Roux en Y hepaticojejunostomy (RYHJ) anastomosis is the definitive treatment of Congenital Choledochal Malformation. However, several other temporary therapies are also necessary at various phases of the illness. Their criticality—evolutionary stages may differentiate two types of choledochal cysts from infancy through adulthood. The prognosis is favorable following surgery, but early identification and referral are critical for reducing the risk of complications and mortality. Keywords: Choledochal cyst, ERPC, H.D., RYHJ, and C.C.M. (Endoscopic retrograde cholangiopancreatography)

Outcome assessment of biliary stricture repair following cholecystectomy in a tertiary care centre.

Bile duct injuries (BDIs) are the potential grievous complications of cholecystectomy that result in substantial morbidity and mortality. Outcomes of BDI management depend on multiple factors such as the type and extent of injury, timing of repair, and surgical expertise. The present retrospective study was conducted to analyse the risk factors associated with the BDI repair outcomes. The data of patients having primary or recurrent bile duct stricture following BDI from 1985 to 2018 were retrospectively evaluated. A total of 268 patients underwent hepaticojejunostomy (HJ). Of the total, 218 patients had primary bile duct stricture, and 50 patients had HJ stricture. The most commonly performed procedure for primary BDI was Roux-en-Y HJ (RYHJ), followed by right hepatectomy, right posterior sectionectomy, and left hepatectomy. All patients with strictured HJ underwent RYHJ, except one who underwent a right hepatectomy. Outcome assessment using the McDonald grading system showed that 62%, 27%, 5%, and 6% of patients with primary bile duct stricture had grade A, grade B, grade C, and grade D complications, respectively, with a mortality rate of 3.21%, whereas 46%, 34%, and 18% patients with strictured HJ had grade A, grade B, and grade C complications, respectively, with a mortality rate of 2%. High-up biliary strictures, early repair, and blood loss > 350mL are the surrogate markers for failure of repair. Management of BDI needs a multidisciplinary approach. The outcomes of both primary biliary stricture and strictured HJ can be improved with management of patients in a tertiary care centre. However, attempts to repair within 2weeks of injury, Strasberg E4 and E5, and blood loss of > 350mL may have an adverse effect on the outcome of HJ.

Redo hepaticojejunostomy in the management of bilioenteric anastomotic strictures

Background: The Roux-en-Y hepaticojejunostomy (RYHJ) is the commonly done drainage procedure for strictures which occasionally follow operations on the gallbladder and bile ducts. However, 8%–40% of these anastomoses become narrowed again and the redo operation is technically challenging. There are only a few reports which have examined the results of these revision procedures and we therefore decided to analyse our experience of this unusual operation. Aim: To study the role of redo-hepaticojejunostomy in the management of bilio-enteric anastomotic strictures. Materials and Methods: Between January 2010 and January 2016, we performed 23 redo-hepaticojejunostomies for the strictures following an initial hepaticojejunostomy which was done for benign indications in our department and followed them for a minimum of 2 years with clinical, biochemical and radiological tests. Results: There were 7 males and 16 were females who had a median age of 37 years (range 15–63 years). The median interval between the index operation and the stricture recurrence was 10 months. Thirteen (57%) patients underwent initial surgical revision and 10 had the procedure following unsuccessful percutaneous intervention. The median length of hospital stay was 10 days and 21 (91%) only had minor complications. There was no operative mortality. On follow-up of all 23 patients after 2–8 years, six (26%) patients developed stricture recurrence, of whom three were managed with percutaneous dilatation and three required a second revisional surgery. Seventeen patients are symptom-free. Conclusion: Redo RYHJ is a feasible option for strictures following an initial biliary enteric anastomosis with no surgical mortality and three-quarters of the patients being rendered symptom-free.

Total robotic choledochal cyst excision with Roux-en-Y hepaticojejunostomy in adults

Choledochal cyst (CDC) excision with bilio-enteric anastomosis has been reported by a laparoscopic approach. With the advent of robotic surgery, it is likely to simplify the performance of such complex procedures. Herein, we present our technique of total robotic CDC excision with intra-corporeal Roux-en-Y hepaticojejunostomy (RYHJ). The patient was placed in a reverse Trendelenburg position. The robotic ports were placed in a "C"-shaped manner, with the camera port placed ~2 cm below the umbilicus. A 12-mm assistant port was placed in between the camera and the left-sided robotic port. Robotic dissection and excision of extrahepatic part CDC were performed, and subsequently, intra-corporeal robotic RYHJ with jejunojejunostomy was completed. Intra-operatively, indocyanine green dye was used to delineate the biliary anatomy and to check the anastomotic integrity. All three patients were female with a median age of 21 (18-34) years. Two patients had type IVa, and one had a mixed variant of type I(C) with type VI. The median operative time was 420 min, whereas docking and console time was 22 (20-25) min and 400 (360-450) min, respectively. The median blood loss and length of hospital stay were 50 (50-100) ml and 6 (5-6) days, respectively. One patient has mild acute pancreatitis in the post-operative period, which was managed conservatively. Robotic CDC excision and reconstruction seem to be a safe, feasible, and effective surgical option that provides the benefits of minimal access surgery but also greatly aids in complex dissection and reconstruction.

Biliary Complications Following Donation after Brainstem Death Liver Transplantation

Introduction: Biliary complications are increasingly seen after liver transplantation. Different modalities are used to overcome these complications. In this study, we investigated the occurrence of biliary complications following donation after brainstem death (DBD) liver transplant and their management. Methods: A retrospective review of patients who underwent DBD orthotopic liver transplant (OLT) from October 2014 to October 2020. The primary outcome was biliary stricture and the secondary outcome was return to theatre. Results: A total of 366 patients underwent DBD whole OLT during the study period. There were 229 (62.6%) males and 137 (37.4%) females. Recipients median age was 55 years (range 16-73) and donors median age was 50.5 years (range 11-89). Mean cold ischaemic time was 581 ± 218.7 minutes. Duct to duct anastomosis was performed in 240 (65.6%) patients, and 126 (34.4%) patients underwent Roux-en-Y hepaticojejunostomy (RYHJ). Eighteen (4.9%) patients experienced bile leak, 39 (10.7%) patients experienced anastomotic biliary stricture (ABS) and 18 (4.9%) patients had ischaemic cholangiopathy. Hepatic artery thrombosis occurred in 27 (7.4%) patients, 29 (7.9%) patients had early allograft dysfunction and six (1.6%) patients experienced primary non function. ABS was treated with RYHJ in 23 (6.3%) patients, Endoscopic Retrograde Cholangiopancreatography (ERCP) in nine (2.5%) patients, conservative management in eight (2.2%) patients and retransplant in one (0.3%) patient. Overall, 84 (22.9%) patients returned to theatre and 27 (7.4%) patients underwent retransplant. Conclusion: Biliary complications following DBD liver transplant is a frequent occurrence and careful monitoring and planning is required to improve patients’ outcomes.

Laparoscopic hepaticojejunostomy for the treatment of bile duct injuries in difficult scenarios (with video)

Open Roux-en-Y hepaticojejunostomy (RYHJ) is the treatment of choice for bile duct injuries (BDI) sustained during laparoscopic cholecystectomy. Although in recent years the mini-invasive approach has been explored at expert centers, laparoscopic RYHJ for challenging surgical scenarios has rarely been attempted. We herein report two cases of RYHJ for BDI in highly complex surgical scenarios, such as right posterior BDI or failure of previous repairs, with special emphasis on the technical aspects through the embedded videos. The first was an intraoperative repair in a 55-year-old female who suffered a Strasberg type C (transection of the aberrant right hepatic duct) thermal lesion. The second was an iterative repair in a 54-year-old female with a history of a Strasberg type E1 lesion (injury of the main hepatic duct more than 2 cm from the confluence) that had been repaired intraoperatively with an end-to-end anastomosis over a T-tube nine months before referral. Both patients had an uneventful recovery and were discharged four and five days after surgery. After 2.5 and 4 years of follow-up, both patients are asymptomatic and have normal imaging and laboratory tests. To our knowledge, there is no other report in the literature regarding intraoperative laparoscopic right posterior RYHJ for BDI. Laparoscopic RYHJ for BDI repair in the hands of expert laparoscopic biliary surgeons is feasible and safe, even in very challenging surgical scenarios, as herein reported, offering the benefits of mini-invasive surgery. Future high-quality and long-term comparative studies are necessary to elucidate its potential superiority against the standard open approach.

Outcome of Roux-en-Y Hepaticojejunostomy for Iatrogenic Major Bile Duct Injuries Sustained during Cholecystectomy

Introduction: Iatrogenic bile duct injuries (BDI) complicate about 0.3% open and 0.85% laparoscopic cholecystectomies. Many of these can be managed with endobiliary stenting. However, major BDI (involving transection or laceration of more than 25% of CHD or CBD and causing subsequent biliary strictures) usually requires surgical intervention. Our objective was to evaluate the outcome of Roux-en-Y hepatico-jejunostomy (RYHJ) in major BDI with respect to McDonald grading.

Robotic revision surgery for type IV choledochal cyst

Complete excision of the cyst with Roux-en-Y hepaticojejunostomy (RYHJ) is the standard treatment for a choledochal cyst (CDC). Incomplete cyst excision and anastomotic stricture are the common causes of recurrent symptoms. The use of the robotic platform for re-operation after open surgical treatment of the CDC has not been previously reported. The technique of robotic revision surgery using the daVinci®XiTM robotic surgical system is described in this report. A 24-year-old female with a history of open CDC excision and choledochoduodenostomy at three months of age, presented with intermittent fever and abdominal pain for ten years duration. Preoperative evaluation with upper gastrointestinal endoscopy and magnetic resonance imaging revealed choledochoduodenostomy stricture with cystic dilatation of biliary radicals predominantly in the left lobe liver suggestive of type IVa choledochal cyst. The patient underwent robotic dismantling of strictured choledochoduodenostomy, left hepatectomy and Roux-en-Y right hepaticojejunostomy. The procedure was performed with four 8 mm robotic trocars placed at the umbilicus level and one infraumbilical assistant trocar. Key steps are intra-abdominal adhesiolysis, dismantling of the choledochoduodenostomy, inflow control to the left hemiliver, parenchymal transection to the left of the middle hepatic vein, division of left hepatic duct, intraparenchymal transection of the left hepatic vein and Roux-en-Y right hepaticojejunostomy. The operative time, blood loss, and postoperative hospital stay were 410 minutes, 200 mL, and four days, respectively. At seven months follow-up, the patient is asymptomatic with normal liver function test. Robotic revision surgery for CDC is safe and the feasibility reported in the present patient needs to be documented in a large case series.

Laparoscopic Choledochal Cyst Excision with Hepaticoduo-denostomy: An Experience

Background: Standard treatment for choledochal cyst (CDC) is excision of cyst with biloenteric reconstruction. Most common methods of reconstruction following CDC excision are Roux en y hepaticojejunostomy (RYHJ) and Hepaticoduodenostomy (HD). Although HD has been employed in paediatric population, its use in adult patients has been limited.Â

Role of laparoscopy in the treatment of internal biliary fistulas in a high-volume center and a review of the literature.

Biliary fistulas may result as a complication of gallstone disease. According to their tract, abdominal internal biliary fistulas may be classified into cholecystobiliary and bilioenteric fistulas. Surgical treatment is challenging and requires highly trained surgeons with high preoperative suspicion. Conventional surgery is still of choice by most of the authors. However, laparoscopy is emerging as a minimally invasive alternative. We investigated the surgical approach, conversion rate, and outcomes according to the type of biliary fistula. We retrospectively reviewed 11,130 laparoscopic cholecystectomies, 31 open cholecystectomies, and 31 surgeries for gallstone ileus at our institution from May 2007 to May 2020. We diagnosed internal biliary fistula in 73 patients and divided them into two groups according to their fistulous tract: cholecystobiliary fistula and bilioenteric fistula. We described demographic characteristics, preoperative imaging modalities, surgical approach, conversion rates, surgical procedures, and outcomes. We additionally revised the literature and compared our results with 13 studies from the past 10years. There were 22 and 51 patients in the cholecystobiliary and bilioenteric groups, respectively. Our preoperative suspicion of a fistula was 80%. We started 88% of procedures by laparoscopic approach. The effectiveness of laparoscopy in the resolution of internal biliary fistula was 40% for cholecystobiliary fistula and 55% for bilioenteric fistulas. The most frequent cause for conversion to laparotomy was the difficulty to identify anatomical features, in addition to the need to perform a Roux en-Y hepaticojejunostomy. Choledocholithiasis was not associated with an increase in conversion rates. Laparoscopic resolution of a biliary fistula is still a matter of controversy. Despite the high conversion rates, we believe that a great number of patients benefit from this minimally invasive technique. A high preoperative suspicion and trained surgeons are vital in the treatment of internal biliary fistulas.