Roux-en-Y Hepaticojejunostomy Research Articles

Comparative analysis of the bile duct reconstruction methods in children with choledochal malformation

To compare various methods of bile duct reconstruction in children with choledochal malformation (CM). There were 99 children with CM over 10-year period. Mini-laparotomy (ML), laparoscopy (LS) and laparotomy (LT) were used. We performed radical CM resection and bile duct reconstruction using Roux-en-Y hepaticojejunostomy (RYHJ) and hepaticoduodenostomy (HD). Surgery time, short-term and long-term postoperative outcomes were evaluated. ML was performed in 39 patients, LS - 51 patients, LT - 9 patients. In case of LS, hospital-stay was significantly lower after intracorporeal RYHJ formation compared to extracorporeal technique (p=0.02, Mann-Whitney U-test). Intracorporeal RYHJ requires more time (p=0.0003). Intestinal passage recovered 3 times faster in the ML RYHJ group compared to the LS RYHJ group (p=0.016, Mann-Whitney U-test). ML RYHJ was followed by significantly less duration of postoperative narcotic anesthesia compared to LS HD (3 vs. 4 days, p=0.02, Mann-Whitney U-test). In our study, ML RYHJ has an advantage over LS RYHJ regarding long-term outcomes. HD resulted higher incidence of severe postoperative pancreatitis (p=0.033) that required surgical correction (LT, p=0.043). ML RYHJ has some advantages over other methods of bile duct reconstruction. Therefore, we can currently recommend this method as a preferable one.

Incidence and Impact of Concomitant Vascular Injuries in Post-Cholecystectomy Bile Duct Stricture: A Prospective Study with MR Angiography

Introduction: Impact of concomitant vascular biliary injury (VBI) on post- cholecystectomy benign biliary stricture (BBS) repair is still debatable with studies both in favor and against. In our study we look for incidence of VBI and impact on long-term outcomes. Methods: Consecutive patients with BBS during the period December 2010 to May 2012 were included. Magnetic resonance angiography (MRA) with MRCP was done prior to repair. Long-term outcomes were analyzed as per McDonald grading. Results: 36 patients were included in the study. Median age was 36 (15-70) years and 28 (78%) were females. 10 patients (28%) had prior failed repair. 23 (64%) patients had high strictures (Bismuth Type ≥3). VBI was present in 22 (61%) involving right hepatic artery (RHA). Of these, laparoscopic cholecystectomy was performed in 18 patients (82%). Additionally right portal vein injury was present in one patient. In patients with prior failed repair 5 (50%) had RHA injury. 34 patients underwent Roux en Y hepaticojejunostomy (RYHJ). Median blood loss was 300ml (range 50-950). Median duration of surgery was 5 hours (range 2-9). Complications were present in 13 (36%) patients. At median follow up of 48 months (24 - 60), there were 8 failures (Success= 76%) requiring re-intervention. Two patients required right hepatectomy. Failed previous repair and secondary biliary cirrhosis were significantly associated with failure. Conclusion: Concomitant VBI has significant impact on long-term outcomes of BBS repair. It will be prudent to do MRA with MRCP during workup of BBS patients for better management planning

Su1527 OUTCOME OF ENDOSCOPIC TREATMENT OF BILIARY COMPLICATIONS FOLLOWING ADULT RIGHT LOBE LIVING DONOR LIVER TRANSPLANTATION

Biliary complications are reported in 11-40% of adult right lobe living donor liver transplants (ARLLDLT), incidence being higher with multiple graft ducts. We reviewed the technique and outcomes of biliary reconstruction in ARLLDLT’s with ≥2 graft ducts. The aim of this study was to evaluate the success of endoscopic and percutaneous treatment in such patients with biliary complications. ABO incompatible, re-transplants, and primary sclerosing cholangitis recipients were excluded. Multiple ducts were present in 810 (53%) amongst 1536 ARLLDLTs from 2011-17. Single anastomosis (2D-1A or3D-1A) was performed in 436(54%), of which 405 had 2 graft ducts, and 31 had ≥3. Recipient common bile duct (r-CBD) was used in 413(95%) and roux -en Y hepaticojejunostomy (RYHJ) in 23(5%). Multiple anastomoses (≥2) were performed in 374 (46.2%). The type of anastomoses were: 2 graft ducts, 2 anastomoses(2D-2A); 285(76%); 3D-2A;70(19%), 3D-3A;15(4%), and 4D-2A;4(1%). For multiple anastomoses, recipient right hepatic duct (r-RHD) and recipient left hepatic duct (r-LHD) were used in 283, r-CBD and r-cystic duct in 64, r-CBD +RYHJ in 10, and only RYHJ in 17. At a median follow up of 36 months, biliary complication rate was 16.9%, higher than overall series (13.5%; p=0.03). Of 28 leaks (3.45%), 20 were re-explored, 9 converted to RYHJ. Of 109 strictures (13.45%), 87% were managed by endoscopic retrograde cholangiography and stenting (ERCP), 13 with ERCP+ percutaneous transhepatic biliary drainage (PTBD) using rendezvous technique. At last follow up, 93% were stent free, with remodelled strictures. The 5-yr OS in this group with multiple ducts was similar to overall cohort (90.4% vs.89%, p=0.293). Biliary strictures are the most commonly seen biliary complication after ARLLDLT. However, endoscopic and percutaneous treatment is successful in the majority of these patients and the overall outcome is comparable.

Biliary stricture after Roux-en-Y hepaticojejunostomy for bile duct injury–surgical challenge: a single-center expertise

Background Laparoscopic cholecystectomy has been considered the gold standard since the 1990. Yet the incidence of bile duct injury (BDI) has increased from 0.06 to 0.3% for open cholecystectomy to 0.5 to 1.4% when done laparoscopically. Roux-en-Y hepaticojejunostomy (RYHJ) is the most widely approved management for most post-cholecystectomy BDIs, yet some patients experience incapacitating biliary complications, such as jaundice or recurrent attacks of cholangitis, in addition to anastomotic stricture. Aim The aim of this study was to assess the short-term outcomes of a multidisciplinary approach regarding failed RYHJ after post-cholecystectomy BDI. Materials and methods A total of 15 patients were enrolled in the descriptive study after failure of RYHJ performed because of post-cholecystectomy BDI. Patients comprised six males and nine females. All patients after definitive treatment underwent follow-up by abdominal ultrasound and liver function tests for at least 11 months. Results One (6.7%) patient had liver transplantation because of liver cirrhosis. Four (26.7%) other cases were managed by revisionary surgery for the hepaticojejunostomy as the stricture was so tight. The reminder 10 cases underwent trial of percutaneous trans-hepatic cholangiography (PTC), but unfortunately six of them (40% of the whole group) failed to be dilated adequately, and they indeed underwent surgery, and the other four (26.7%) were dilated successful. During the follow-up, three (20%) patients had biliary leakage and two patients developed re-stricture, with one mortality because of pulmonary embolism. Conclusion Good long-term results can be achieved in patients with RYHJ stricture through a case-by-case analysis and an immediate multidisciplinary approach in expert hepatobiliary center.

Endoscopic retrograde cholangiopancreatography by double-balloon enteroscopy in patients with surgically altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) allows a diagnostic and therapeutic evaluation of pancreatobiliary diseases. However, the procedure in patients with surgically altered gastrointestinal anatomy represents a technical challenge. to report the diagnostic and therapeutic outcome of device-assisted enteroscopy (DAE) ERCP in patients with a surgically altered gastrointestinal anatomy. a prospective cohort of patients with a history of surgically altered gastrointestinal anatomy undergoing DAE-ERCP in a referral center was used. A double-balloon enteroscope was used to reach the papillary area or the bilio-enteric anastomosis. The clinical and endoscopic characteristics, and technical, diagnostic and therapeutic success were described. Clinical and endoscopic differences were evaluated according to diagnostic success, as well as the biochemical response in those patients with therapeutic success. ninety-six procedures were included in the study in 75 patients. Roux-en-Y hepaticojejunostomy (RYHJ) was the main surgical anatomy (82.3%) and cholangitis was the main indication for ERCP (49%). Diagnostic success was obtained in 69.8% of the participants. Of these, therapeutic success was obtained in 83.6% (overall success 58.3%). Cases with a diagnostic success had a higher frequency of cholangiography compared to those without diagnostic success (94% vs 0%, p < 0.001), as well as a lower probability of a failed cannulation (1.5% vs 100%, p < 0.001). A significant improvement was observed in patients with a therapeutic success in bilirubin, transaminases and alkaline phosphatase levels (p < 0.05). ERCP by means of double-balloon enteroscopy is a useful technique in patients with a surgically altered gastrointestinal anatomy, in whom access to the bile duct is required. However, these procedures are very challenging and diagnostic and therapeutic success where achieved in up to 60% of cases.

Fascioliasis-An Uncommon Cause of Recurrent Cholangitis

We report a case of Fascioliasis presented with recurrent cholangitis in a female necessitating multiple consultations and hospitalizations over a period of two years. Investigative profile failed to confirm any definite diagnosis prior to her admission in Hepato-Biliary-Pancreatic Surgery Division of the Department of Surgery of Bangabandhu Sheikh Mujib Medical University where she was provisionally diagnosed as a case suffering from extrahepatic cholagiocarcinoma. With the intent of extrahepatic excision with Rouxen-Y hepaticojejunostomy abdomen was explored and surprisingly 28 mature liver flukes (fasciola hepatica) were found lodged in the extra and intrahepatic biliary tree. Although fasciola hepatica infestation is more common in far East Asia, this case may represent the tip of an iceberg of endemic infestation of this trematode in Bangladesh which warrants further investigations.&#x0D; Journal of Surgical Sciences (2015) Vol. 19 (1) : 35-38

Individualized biliary reconstruction techniques in autotransplantation for end-stage hepatic alveolar echinococcosis

BackgroundBiliary reconstruction in ex vivo liver resection followed by autotransplantation (ERAT) for end-stage hepatic alveolar echinococcosis (HAE) remains the most challenging step, we present our experience with this complex procedure. MethodsA retrospective data analysis of 55 patients with end-stage HAE underwent ERAT, the biliary reconstruction techniques and short- and long-term outcomes were discussed. ResultsAll autografts were derived from the left lateral section after extensive ex vivo liver resection, multiple bile ducts were observed in 52 (94.5%) patients, and forty-four (80.0%) cases required ductoplasty. Biliary reconstruction was achieved with duct-to-duct anastomosis in 32 (58.2%) patients, Roux-en-Y hepaticojejunostomy (RYHJ) in 14 (25.5%) patients, and a combination of the two methods in 9 (16.4%) patients. Twenty (36.4%) patients had multiple anastomoses. Biliary leakage occurred in 8 (14.5%) patients postoperatively. Three (5.5%) patients died of liver failure, cerebral hemorrhage and intraabdominal bleeding. During a median of 31 months followed-up time, 3 (5.5%) patients developed anastomotic stricture, 1 of whom was treated by repeat RYHJ, while the others were managed with stenting. ConclusionsWith a well-designed plan and precise anastomosis, complex biliary reconstruction in ERAT can be performed with few biliary complications by a professional team.

No need for surgery: endoscopic management of posttransplant biliary strictures in the modern era

Background: Biliary strictures are a common source of morbidity following orthotopic liver transplantation (OLT). While traditional management has been biliary reconstruction with Roux-en-Y hepaticojejunostomy (RYHJ), advances in endoscopic and percutaneous therapies have made these non-operative interventions commonplace in the management of both early and late posttransplant strictures. We set out to evaluate our center’s experience with the management of biliary stricture following OLT. Methods: All OLTs from January 2013 to June 2018 at a single institution were reviewed from a prospectively-maintained database. Patients with biliary bypass prior to or at time of transplantation were excluded. All biliary anastomoses were performed as a choledochocholedochostomy without the use of stents or T-tubes. Patients with biliary strictures were identified, and patient demographics, donor and operative details, and postoperative outcomes were collected. Descriptive statistics are reported as medians and interquartile range (IQR). Groups were compared using Wilcoxon rank-sum test, and p-values <0.05 were considered statistically significant. Results: A total of 462 grafts were transplanted into 449 patients during the study period. Among the 462 transplants that occurred, the biliary stricture rate was 15.6% (n = 72), with 95.8% (n = 69) being anastomotic strictures and 22.2% (n = 16) associated with a concurrent biliary leak. All patients underwent initial attempt at endoscopic treatment. 57 patients (79.2%) achieved stricture resolution with endoscopy alone. Among this group, the median time to first endoscopic retrograde cholangiopancreatography (ERCP) was 28 days (13–80 days) and treatment included a median of 3 (2–4) ERCP interventions over a median 186 days (142–273 days). The interventions utilized during ERCP included sphincterotomy, balloon dilation, and stent placement (TABLE). Patients who underwent balloon dilation at the time of first ERCP were further out from transplantation compared to those who had balloon dilation deferred until subsequent ERCP (40 vs 16 days, p < 0.01), reflecting our practice of avoiding dilation on a new ductal anastomosis. However, balloon dilation at initial ERCP was not associated with quicker stricture resolution (186 days vs 174 days, p = 0.58). Overall, only 3 patients (4.2%) required additional “step up” intervention beyond ERCP – two patients were managed with percutaneous transhepatic cholangiography (PTC) catheter placement and only one patient underwent RYHJ over the entire experience for a refractory biliary stricture. Conclusion: In our experience with liver transplantation over 5.5 years, endoscopic management of posttransplant biliary strictures resulted in successful stricture resolution. While repeat endoscopies are required for treatment, a strategy of watchful waiting in collaboration with an experienced endoscopist may avert the need for surgical reconstruction.

Management of nonvascular postlaparoscopic bile duct injury

Background and Aim of the Work: Early management of postlaparoscopic nonvascular biliary injuries by an expert team is essential to achieve a good outcome. In this article, we would evaluate the results of this prospective multicentric study in the management of postlaparoscopic nonvascular biliary injuries. Patients and Methods: This prospective multicentric study enrolled 168 patients with iatrogenic nonvascular bile duct injury (BDI). In all cases, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and further management was done according to Strasberg type of injury. Results: Intra-abdominal biliary collection was managed by ultrasound-guided drainage. Type A (19%) was diagnosed and treated by ERCP. Types B and C (20.2%) were treated by duct reconstruction of the isolated segment and Roux-en-Y hepaticojejunostomy (RYHJ), respectively. Strasberg type D nondevascularized partial injury (7.1%) was treated by primary repair around stent. In complete type D patients and E (10.7% and 43%, respectively), Roux en-Y hepaticojejunostomy with lowering the hilar plate was performed. After ERCP, 78% of patients developed hyperamylasemia and only 4.8% developed pancreatitis. After HJ, 9.7% of patients developed stricture and were treated by percutaneous transhepatic cholangial dilatation. Conclusion: This study proved the safety and efficacy of the management of iatrogenic BDI by an expert team implementing different diagnostic and treatment modalities such as ultrasound, computed tomography scan, and ERCP in addition to different surgical options, particularly the use of right end-to-side and left side-to-side RYHJ, with lowering the hilar plate and anterior anastomosis.

Long-Term Follow-Up of Patients with Primary Sclerosing Cholangitis Undergoing Liver Transplantation with Duct-to-Duct Biliary

Background Reconstruction of biliary drainage after liver transplantation (LTx) in patients with primary sclerosing cholangitis (PSC) has been a matter of controversy. Over the recent years, the traditional method of Roux-en-Y hepaticojejunostomy (RY) has been challenged by duct-to-duct (DD) biliary reconstruction. The argument against DD reconstruction has been for potential increased risk of development of cholangiocarcinoma (CCA) in the bile duct remnant. Methods This is a retrospective review of biliary complications, graft and patient survival after LTx in PSC patients based on type of biliary reconstruction DD vs. RY. Results A total of 120 LTx for PSC were performed between 2005 and 2016. Twenty two patients were excluded because they received partial grafts. DD was done in 39 patients and 59 patients were reconstructed with RY. One-, 5-, and 10-year survival was similar between the two groups. Bile leak and biliary stricture was not significantly different between the 2 groups. Nine patients in DD group (23%), and 13 patients in RY group developed biliary strictures and all managed endoscopically or percutaneously. There was one case of anastomotic leak in each group. There was no case of CCA observed in these patients over the long period of follow-up. Conclusion DD biliary reconstruction at the time of LTx in selected PSC patients is both effective and safe, with comparable outcomes with those with RY reconstruction and NO increased risk for development of CCA in the bile duct remnant.

Congenital choledochal malformations in children: management strategies

Background: A Congenital Choledochal Malformations (CCM) is common congenital defect of biliary tree in Asian subcontinent. Presentations of CCM are vague from asymptomatic to life threatening cholangitis or pancreatitis. Complete cyst excision and bilioenteric anastomosis is now accepted surgical treatment.Methods: This is a retrospective study of five years duration. In this study the clinical presentation, haematological, biochemical and radiological findings, operative procedure and outcome were studied from case records.Results: Total of 20 patients were studied, with clinical presentation of recurrent abdominal pain in eight cases, previous history of cholangitis in five cases, acute cholangitis two cases, biliary peritonitis in four cases and previous history of pancreatitis in one case. In 13 cases Roux-en-Y hepaticojejunostomy (RYHJ) and in 4 cases hepaticoduodenostomy (HD) done after cyst excision. One case of type II CCM managed with only cyst excision, in two cases Lilly’s procedure, one case requires temporary external drainage and in two cases temporary internal drainage done in view on cholangitis and jaundice.Conclusions: However, the definitive treatment of CCM is complete cyst excision and bilioenteric anastomosis, though lot of other temporary majors are also required at different stages of disease.

Endoscopic Gastrojejunostomy: A Novel Approach to Roux Obstruction Following Roux-en-Y Hepaticojejunostomy: 2017 Presidential Poster Award

Roux-en-Y hepaticojejunostomy (RYHJ) is a procedure generating a direct connection between the hepatic bile ducts and the jejunum. Major indications include biliary strictures and iatrogenic injuries while studies have also indicated a role in biliary cancer. We present a novel endoscopic treatment of a Roux limb obstruction following RYHJ for a cholangiocarcinoma. A 75-year-old female with a history significant for cholangiocarcinoma involving the extra-hepatic biliary tract underwent a RYHJ following complete biliary duct resection. Two months following surgery, she presented with abdominal pain with labs suggestive of cholestatic disease. Abdominal CT revealed a very large distended Roux limb (Figure 1), thus a percutaneous biliary drain (PBD) was subsequently placed. One month later, trial of internal biliary drainage was unsuccessful. Cholangiogram noted a patent PBD and hepaticojejunal anastomosis, however again indicated obstruction. To avoid open repair, endoscopic therapy was performed. Following a normal EGD, EUS revealed a dilated Roux limb abutting the gastric antrum (Figure 2). This was confirmed by visualization of both guide wire advancement and contrast injection into the PBD. Initial fistulizing was attempted using a Hot AXIOSTM stent system; however, device deployment failed. Under EUS, a 19g FNA needle was introduced into the limb with advancement of a guide wire. The FNA needle was exchanged for needle-knife instrumentation and multiple cutting passes were performed. The fistula was dilated with an 8mm balloon and two double-pigtail stents were deployed with excellent biliary return (Figure 3). Directional flow was verified under fluoroscopy with contrast injection through her PBD. Lastly, a cholangioscopy performed through the PBD, further confirmed the pigtail catheter placement within the Roux limb. Follow-up cholangiogram 2 weeks later noted patent stents, and the PBD was removed. Multiple EUS-guided techniques have been described in the literature for biliary obstructions. In 2014, a “modified RYHJ” reported fixing the distal Roux limb to the anterior gastric wall for secured endoscopic access should the need arise. However, this has not been universally implemented. Thus, with the recent paradigm shift to minimally invasive endoscopic interventions in an effort to circumvent invasive surgical repair, we have described a safe alternative for the treatment of Roux limb obstructions following a “traditional” RHYJ.Figure: CT abdomen and pelvis noting a distended Roux limb adjacent to the liver.Figure: EUS noting a distended Roux limb abutting the gastric antrum.Figure: Direct visualization with EGD of two double-pigtail stents within the gastric antrum.

Advanced Roux-en-Y hepaticojejunostomy with magnetic compressive anastomats in obstructive jaundice dog models

BackgroundAlthough commonly used procedure, Roux-en-Y hepaticojejunostomy (RYHJ) remains to be complicated, time consuming, and has a relatively poor prognosis. We designed the magnetic compressive anastomats (MCAs) to perform RYHJ more efficiently and safely.Materials and methods36 dogs were divided into two groups randomly. After obstructive jaundice model construction, RYHJ was performed with MCAs in study group or by hand-sewn in control group. Both groups were followed for 1, 3, and 6 months after RYHJ. The liver function and postoperative complications were recorded throughout the follow-up. At the end of each time point, dogs were sent for magnetic resonance imaging (MRI) and sacrificed. Anastomotic samples were taken for anastomotic narrowing rate calculation, histological analyses, tensile strength testing, and hydroxyproline content testing.ResultsThe anastomotic construction times were 44.20 ± 23.02 min in study group, compared of 60.53 ± 11.89 min in control group (p < 0.05). The liver function recovered gradually after RYHJ in both groups (p > 0.05). All anastomats were expelled out of the body in 8.81 ± 2.01 days. The gross incidence of morbidity and mortality was 33.3% (6/18) and 16.7% (3/18) in study group compared with 38.9% (7/18) and 22.2% (4/18) in control group (p > 0.05), and there is no single case of anastomotic-specific complications happened in study group. The narrowing rates of anastomosis were 14.6, 18.5, and 18.7% in study group compared with 35.4, 36.9, and 34% in control group at 1st, 3rd, and 6th month after RYHJ (p < 0.05). In study group, preciser alignment of tissue layers and milder inflammatory reaction contributed to the fast and better wound healing process.ConclusionPerform RYHJ with MCAs is safer, more efficient than by hand-sewn method in obstructive jaundice dog models.

Iatrogenic bile duct injury repair using isolated vascularized gastric tube: early experience in two tertiary centers

Background: Bile duct injuries (BDI) constitute a disaster for both the patient and the surgeon without satisfactory results with the classic use of roux-en-Y hepaticojejunostomy (RYHJ). The purpose of this study was to evaluate our newly introduced technique utilizing isolated vascularized gastric tube (IVGT) as an alternative for RYHJ in reconstruction of the bile duct after iatrogenic BDI with lost segment.Methods: This is a prospective study included 18 consecutive patients suffered from iatrogenic BDI with lost segment admitted to Assiut and Sohag University Hospitals, during the period from September 2013 to June 2016. Patients were subjected to operative treatment with the interposition of IVGT to bridge the lost bile duct segment. Patients were evaluated regarding demographic criteria, clinical picture, different investigations, efficacy of the use of IVGT and evaluation of post-operative complications after a mean follow-up of 2 years.Results: Eighteen patients underwent repair of BDI utilizing IVGT during the study period. Three patients (17%) suffered immediate repairs, 10 patients (55%) experienced intermediate repairs and late repairs were performed for the last 5 patients (28%). Bile leak as a specific early morbidity was present in 3 patients (17%) with upper biliary tract injury without any operative mortality. Also, there was one patient with stent obstruction relieved by stent extraction. With long-term follow-up there was not any patient of biliary stricture.Conclusions: IVGT proved to be feasible and safe for bile duct replacement and is a good alternative for biliary reconstruction being more anatomical and physiological than RYHJ.

Roux limb volvulus and perforation as a rare complication of Roux-en-Y hepaticojejunostomy

Roux-en-Y hepaticojejunostomy (RYHJ) is a versatile surgical procedure for various hepatobiliary disorders with success rate as high as 90 %. Complications such as cholangitis, biliary calculi, pancreatitis, liver failure, reflux induced peptic ulcer disease have been described in the literature. We describe a rare complication of RYHJ which we recently encountered which to our knowledge has not been reported previously.

The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis.

Roux-en-Y hepaticojejunostomy (RYHJ) is currently considered as the definitive treatment for iatrogenic bile duct injuries and the principal representative of biliary diversion procedures. This technique has met many milestones of extensive evolution, particularly the last years of concomitant technological evolution (laparoscopic/robotic approach). Anastomotic strictures and leaks, which may have deleterious effects on the survival and quality of life of a patient with biliary obstruction of any cause, made the need of the development of a safe and efficient RYHJ compulsory. The aim of this technical analysis and the juxtaposed discussions is to elucidate with the most important milestones and technical tips and tricks all aspects of a feasible and reliable RYHJ technique that is performed in our center for the last 25 years in around 400 patients.

Long-Term Outcome of Percutaneous Biliary Interventions for Biliary Anastomotic Stricture in Pediatric Patients after Living Donor Liver Transplantation with Roux-en-Y Hepaticojejunostomy

PurposeTo retrospectively evaluate long-term outcomes of percutaneous transhepatic biliary drainage (PTBD) followed by balloon dilation and placement of an internal drainage tube for anastomotic stricture in pediatric patients who underwent living donor liver transplantation (LDLT) with Roux-en-Y hepaticojejunostomy (RYHJ). Materials and MethodsFifty-two patients (23 male, 29 female; median age, 5 y) with anastomotic biliary stricture were treated with PTBD followed by balloon catheter dilation and long-term placement of an internal drainage tube, which was removed upon cholangiographic confirmation of free flow of bile into the small bowel. Clinical success, tube independence rate, risk factors of recurrent biliary stricture, and patency rates were evaluated. ResultsThirty-nine patients (75%) had no stricture recurrence. Of 13 patients (25%) with recurrence, six were treated again with the same percutaneous biliary interventions and showed no further recurrence. Clinical success was noted in 43 of 52 patients (83%). Drainage tubes were removed from 49 patients (94%). Multivariate logistic regression analysis indicated that serum alanine aminotransferase level > 53 IU/L at discharge after the initial series of percutaneous biliary interventions was a significant risk factor for recurrent biliary stricture (P = .002). Kaplan–Meier analysis showed 1-, 3-, 5-, and 10-year primary and primary assisted patency rates of 75%, 70%, 70%, and 68%, and 94%, 92%, 88%, and 88%, respectively. ConclusionsPTBD followed by balloon dilation and internal drainage may be an effective treatment for anastomotic biliary stricture after pediatric LDLT with RYHJ.

Duct-to-Duct Biliary Anastomosis Yields Similar Outcomes to Roux-en-Y Hepaticojejunostomy in Liver Transplantation for Primary Sclerosing Cholangitis.

Background:While Roux-en-Y hepaticojejunostomy (RYH) is the common anastomotic technique for liver transplantation (LT) in patients with primary sclerosing cholangitis (PSC), duct-to-duct (DD) reconstruction may be used if the recipient common bile duct is normal. There are conflicting observational data on the rate of success of DD reconstruction versus RYH, in PSC.Objectives:The aim of this study was to assess the safety and efficacy of DD anastomosis, compared to RYH reconstruction, among adults transplanted for PSC.Patients and Methods:All adult patients, who underwent primary LT for PSC between 1990 and 2012, were evaluated, according to type of biliary reconstruction. Recipient and graft survival, postoperative medical and surgical complications, and postoperative resource utilization rates were compared between the two groups.Results:Totally, 73 patients fulfilled the inclusion criteria. Of them, 58 had RYH and 15 had DD reconstruction. A total of 53 subjects (73%) were male, with the mean age ± standard deviation at LT of 43.3 ± 14.4 years. Rates of recipient mortality, graft failure, biliary complications, acute cellular rejection, and reoperation were similar in both groups. Postoperative cholangiography was used more frequently in patients with DD reconstruction (33.3% vs. 8.6%, P = 0.026).Conclusions:In selected recipients with PSC, DD reconstruction is a safe and efficacious technique, with long-term clinical outcomes comparable to RYH.

Roux-En-Y Hepaticojejunostomy: An Evaluation Of Its Indications and Results in Benign and Malignant Biliary Tree Disease

Background: Roux-en-Y Hepaticojejunostomy (RYHJ) is the most common form of reconstruction of the biliary pathway. It is a time honoured, durable, less resource intensive and a definitive procedure. Objectives: The aim of this study was to evaluate the indications of Hepaticojejunostomy and to assess the outcome of surgery following change in surgical technique of Hepaticojejunostomy. Methods: All patients who underwent RYHJ from Magh 2067 (January 2011) till Ashad 2071 (July 2014) in a single surgical unit at the Department of Surgery, Kathmandu Medical College Teaching Hospital were included. Demographics of the patient, indications for surgery, type of surgery, hospital stay and duration of drain placement were evaluated. Since, this is a prospective descriptive study, only mean value was calculated for age, hospital stay and duration of drain placement using SPSS Statistics 17.0 for statistical analysis. Results: Twenty patients underwent RYHJ during the study period. Fifteen percent (n=3) were done for malignant diseases. The most common indication was choledocholithiasis (n=8, 40%) followed by choledochal cyst (n=3, 15%) and bile duct injury (n=3, 15%). The morbidity was minimal. The mean duration of drain in situ was four days (range one to 14 days) and the mean hospital stay was six days (range two to 15 days). Prolonged drain placement and hospital stay was noted in two patients with malignant diseases. However, they were non bilious in nature. We encountered no mortality. Conclusion: Roux-en-Y Hepaticojejunostomy (RYHJ) is a common and safe method of biliary reconstruction. The indication of the procedure is varied and wide.DOI: http://dx.doi.org/10.3126/jkmc.v3i3.12247Journal of Kathmandu Medical CollegeVol. 3, No. 3, Issue 9, Jul.-Sep., 2014, page

Biliary reconstruction and Roux-en-Y hepaticojejunostomy for the management of complicated biliary strictures after bile duct injury

Background: There are controversies over the optimal surgical strategy for the management of complicated biliary strictures after Bile Duct Injury (BDI). The purpose of this study is to investigate the efficacy of biliary reconstruction and Roux-en-Y hepaticojejunostomy (RYHJ) for this condition. Methods: Included in this single-center retrospective clinical study were 10 patients with the diagnosis of BDI-associated biliary strictures between July 2010 and July 2013. Results: The 10 patients included 6 women (60%) ranging in age from 26 to 64 years with a mean of 48.6 years. They were patients who failed in repeated conservative, interventional, endoscopic therapies in other hospitals. The interval between the initial operation causing BDI and this operation in our hospital was less than 3 months in 2 patients, less than 6 months in 2 patients, and more than a year in 3 patients. According to the Strasberg classification of BDI, there were 3 cases of type E2, 1 case of type E3, 6 cases of type E4, one patient with type E2 also had right hepatic duct injury besides common bile duct injury. All the 10 patients received biliary reconstruction and RYHJ based on their bile duct conditions. The non-traumatic technique was used in all cases, knowing that the diameter of the bile duct reconstructed was about 1.5 to 3cm. Two patients received segment I hepatectomy; 3 patients received biliary supporting tube placement during operation, which was removed 6 months after operation; and 3 patients received reconstruction of the hepaticojejunostomy anastomosis. All patients recovered well after a mean length of postoperative hospital stay of 9.2 days (range 7 to 13 days). By July 2013, the patients has been followed up for a mean of 19.9 months (range 4 to 36 months), during which no incisional complication, hemorrhage, bile leak, biliary re-stricture, acute pancreatitis, acute cholangitis, or cystic artery pseudoaneurysm occurred in any patients. The level of serum total bilirubin and conjugated bilirubin remained within the normal range. Conclusions: According to the Strasberg classification and the bile duct condition, appropriate biliary reconstruction and RYHJ for BDI-related biliary strictures can bring good outcomes.