Uncommon Procedure Research Articles

Clitoroplasty

Clitoroplasty, especially in an adult, is a rare procedure. The goals of clitoroplasty are to achieve a normal genital appearance and to preserve sensation with a satisfactory sexual response. We present two cases of acquired clitoromegaly. Case 1 is a 46-year-old woman with clitoromegaly caused by an androgen-producing ovarian tumor. The second case is a 49-year-old woman with clitoromegaly resulting from a prolonged history of self-injected anabolic steroid use. Both women underwent a clitoral reduction procedure with preservation of the neurovascular supply to the glans clitoris. Clitoroplasty is an uncommon procedure that is useful in correcting acquired clitoromegaly. The results are cosmetically acceptable, and sexual function can be preserved.

Analysis of Clinical Data in Patients with Girdlestone Arthroplasty: A New Score

Girdlestone's arthroplasty is an uncommon surgical procedure; it is performed in patiens with recurrent infection of the hip, polymicrobic sepsis or after multiple revisions. The number of hip replacements all over the world is always increasing, so the total number of prosthesis infections also continues to rise, although the relative incidence is lower than in the past. For this reason Girdlestone's arthroplasty must be a well-known procedure to hip surgeons. Clinical assessment of such patients cannot be performed with common hip ratings (e.g. Harris Hip Score) since hip instability, low range of motion, limb shortening and severe muscle loss are common. The patient's independence in daily living activity and freedom from pain should be the surgeon's main goals. We propose a specific clinical score for the outcome of the procedure, which is not to be found in the current literature as far as the authors are aware. The score can be useful for comparative clinical trials, for legal medicine purposes, etc. To illustrate it, we present 20 cases of Girdlestone's arthroplasty out of 265 hip revisions performed in our hospital. The outcome of the procedure in our patients was clinically good in eight cases, intermediate in ten cases, and bad in two cases. We believe the performing of such an intervention is justified when indicated by clinical signs, as we analyse them in our work. Our clinical score has been shown to be adequate to assess the clinical presentation of such patients.

Invited commentary

The article by Nakanishi [1Nakanishi K. Video-assisted thoracic surgery lobectomy with bronchoplasty for lung cancer: initial experience and techniques.Ann Thorac Surg. 2007; 84: 191-196Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar] describes one center’s initial experience with the expansion of minimally invasive therapy into another complex thoracic operation (ie, bronchial sleeve resection). Slightly more than a decade ago, many considered thoracoscopic lobectomy a bit farfetched, much less video-assisted thoracic surgery bronchoplasty. Today some will ponder using the technique in this article for carefully selected patients with favorable anatomic characteristics. The combination of surgeon experience and improved instrumentation has made thoracoscopic lobectomy the preferred approach in several centers including more than 85% of such resections in this commenter’s institution. Endoscopic staplers and high-resolution thoracoscopes now permit the exposure and safety enjoyed by surgeons who prefer open thoracotomy. In fact, these same instruments facilitate operating through a large wound by enhancing lighting, enabling viewing (particularly for second assistants), and dividing tissue in tight spaces. Ultimately, some surgeons “cross the threshold” by choosing thoracoscopy as a routine exposure method in their practice (armed with a countermove for most exposure challenges). Afterward they attempt other complex, yet less frequent operations in due course. As cited in reference 12 of the accompanying article, another busy thoracoscopic dominant center performed three sleeve lobectomies, which now totals 11 such resections using an interrupted suturing technique (R. L. McKenna, personal communication, e-mail, April 2007). Despite good imaging, thoracoscopic expansion is hampered by instrument limitations, time needed for learning curve investment, and a concentration of suitable cases. Regarding the latter, if sleeve lobectomy was practiced as commonly as aortic valve replacement (AVR), then we probably would have seen these reports sooner. I use AVR as a comparison because it is a complex operation requiring highly reliable deep suture control. Although also performed using similar nearby access incisions, minimally invasive AVR was reported more than a decade ago. Given the pervasive, less invasive trends in medicine, questioning whether our specialty should condone another complex thoracoscopic operation now seems less interesting than sorting out when individual surgeons are ready for this transition. Unfortunately, uncommon procedures will not generate publications demonstrating safety or equivalent outcomes quickly enough to validate the forays of early adopters. Perhaps surgeons could be credentialed for such operations by demonstrating thoracoscopic mastery of related advanced procedures. We need to consider how to best compile, organize, and disseminate the technical maneuvers required for our profession’s future. Enabling technology like robotic instruments, expanded mentoring programs, and web-based troubleshooting forums are all potential mechanisms to achieve these ends. Video-Assisted Thoracic Surgery Lobectomy With Bronchoplasty for Lung Cancer: Initial Experience and TechniquesThe Annals of Thoracic SurgeryVol. 84Issue 1PreviewMany surgeons think video-assisted thoracic surgery is too complex to be applied to bronchoplasty; therefore, our institution tried to develop some safe and reliable techniques for video-assisted thoracic surgery bronchoplasty. Full-Text PDF

Laparoscopic transhiatal resection of giant epiphrenic esophageal diverticulum

Epiphrenic diverticula are rare. Their true incidence is unknown. Thoracotomy or thoracoscopy with resection and myotomy is the most common reported approach for the surgical treatment of epiphrenic esophageal diverticula. In patients with large epiphrenic diverticula, the laparoscopic approach is an uncommon procedure. In this case, the laparoscopic transhiatal approach was shown to be safe and effective over with short-term follow-up. However, long-term follow-up of this procedure is needed.

Trans-Aortic Counterpulsation: A Viable Alternative?

Transthoracic intra-aortic balloon pump (IABP) insertion has been a relatively rare and uncommon procedure. However, it is an established beneficial option in patients with severe peripheral vascular disease (PVD) accompanied with bi-lateral femoral arterial occlusion. There are several viable alternatives to trans-aortic IABP insertion, including trans-axillary or in abdominal aorta (requiring a laparotomy). Cardiac surgery has the advantage of an open sternum, facilitating effortless direct intraaortic balloon (IAB) insertion into the aorta. The IAB can be inserted either through a 9-mm graft or directly into the ascending aorta. During cardiac surgery, direct insertion into the ascending aorta with the balloon tip lying distally in the abdominal aorta is facilitated with an open sternum. The base of the balloon lies ∼2 cm below the left subclavian and can be confirmed through a trans-esophageal echocardiogram (TEE). Elimination of a graft insertion saves the team from time-consuming maneuvers and additional hemorrhagic complications. In our experience, postoperative vasoplegic syndrome coupled with myocardial edema contributed to patent instability and was treated with vasopressin and transthoracic IAB insertion. The CS 100 (Datascope Corp., Mahwah, NJ) console allowed the ability to time the balloon accurately. This case report details our experience with one such patient and establishes trans-aortic counter-pulsation as a safe and viable option in patients with severe PVD, where percutaneous insertion is precluded or has failed.

Robotic assistance in urological microsurgery: initial report of a successful in-vivo robot-assisted vasovasostomy.

During recent years many urologists have been convinced of the advantages of robot-assisted, minimally invasive urological procedures. Because microscope-assisted vasovasostomy is a rather uncommon procedure, most urologists lack microsurgical experience. Use of the da Vinci robotic system (Intuitive Surgical, Mountain View, CA, USA) virtually eliminates the microsurgical challenge of tremor, limited dexterity, and miniaturized instrumentation. Different centres have investigated the use of robotic assistance in vasovasal anastomosis in animal and human ex-vivo models. According to the current literature we are the first European centre to report a successful in-vivo robot-assisted vasovasostomy using the da Vinci robotic system.

Examination of failed ex vivo metal-on-metal metatarsophalangeal prosthesis and comparison with theoretically determined lubrication regimes

Replacement of the first metatarsophalangeal (MTP) joint is a relatively uncommon procedure compared with hip and knee arthroplasty. A cobalt chrome-on-cobalt chrome MTP prosthesis, which had a diamond-like carbon (DLC) coating applied to its articulating faces, was obtained for ex vivo analysis. By modelling the ball and socket implant as an equivalent ball-on-plane model and employing elastohydrodynamic theory, the predicted lubrication regimes applicable to this implant design were determined. These calculations were undertaken for a 10–1500 N range of loading values and a 0–30 mm/s range of entraining velocities, for both worn and unworn situations. Calculations showed that the implant would almost always operate in the boundary lubrication regime. The presence of scratches on the articulating faces of the ex vivo sample further implied boundary lubrication. The DLC coating had been removed from the entire face of the phalangeal component and from most of the face of the metatarsal component. From the latter it appeared as if the coating had been scratched and then flaked away parallel to the scratches. In turn this suggested a corrosion based failure of the interface between the DLC coating and the cobalt chrome subsurface.

TS20P LAPAROSCOPIC REPAIR OF TRAUMATIC DIAPHRAGMATIC HERNIAE: A CASE PRESENTATION AND SYNTHESIS OF THE LITERATURE EXPERIENCE

Purpose Traumatic diaphragmatic herniae are an uncommon sequelae of abdominal trauma which present a significant diagnostic challenge, especially when unaccompanied by other intraabdominal injuries necessitating exploratory laparotomy. Laparoscopic repair is a relatively new and uncommon procedure, with the literature consisting almost entirely of isolated case reports and small case series. We present one of our own cases, and perform a quantitative analysis of the combined literature experience to date.Methodology Cases reports of laparoscopic repair of traumatic diaphragmatic herniae were identified by a Medline literature search. Clinical findings, technical decisions and outcomes were correlated via database.Results Data from 50 cases was available. There was no common standard method of repair although the majority (31/50) were accomplished without the use of mesh. The major complication rate was 4%, the overall complication rate was 16%. Defects greater than 10cm long were associated with a 41% rate of open conversion, versus 0% if less than 10cm. There were no recurrences described.Conclusion Laparoscopic repair of traumatic diaphragmatic herniae enjoys a low rate of major complications, whilst avoiding the morbidity of open repair. Several technical points remain open to operator preference, and we invite discussion regarding the merits of each.

Surgical Treatment of Chronic Thromboembolic Pulmonary Hypertension

Pulmonary hypertension as the result of chronic pulmonary thromboembolic disease is a serious condition with poor long-term prognosis. The condition is one of the more common cardiovascular diseases affecting Americans, yet it is severely underdiagnosed. Pulmonary thromboendarterectomy is the definitive treatment for chronic pulmonary hyper-tension as the result of thromboembolic disease; however. it is an uncommon procedure, primarily because of lack of recognition on the part of the clinicians. Patients affected by chronic thromboembolic pulmonary hypertension (CTEPH) may present with a variety of debilitating cardiopulmonary symptoms. However, once diagnosed, there is no curative role for medical management, and surgery remains the only option. Palliation therapy with medical management in order to delay surgery carries the risk of prolonging the disease and irreversibly damaging unaffected pulmonary vasculature.

Posterior bone block procedure for posterior shoulder instability

The posterior bone block procedure is an uncommon surgical procedure used in the treatment of posterior shoulder instability. The purpose of this study is to report the results of the posterior bone block procedure in the treatment of posterior shoulder instability. We retrospectively reviewed 21 shoulders that had undergone a posterior bone block procedure in the treatment of recurrent posterior shoulder instability between 1984 and 2001. Fifteen patients (16 shoulders) had a prior traumatic posterior glenohumeral dislocation and 5 patients (5 shoulders) had a prior traumatic posterior glenohumeral subluxation. The mean age at surgery was 24.8 years (range 17-40 years). Patients were evaluated with the Constant score, the Duplay score, a subjective result, and radiography. Preoperatively, ten shoulders had glenoid fractures, two shoulders had loss of the normal contour of the posterior osseous glenoid, and ten shoulders had humeral head impaction fractures (reverse Hill-Sachs lesion). Seventeen shoulders underwent preoperative computed tomography and had average glenoid retroversion of 9.6 degrees (range 0-21 degrees ). At an average follow-up of 6 years, all patients reported their subjective results as good or excellent. At follow-up the mean Constant score was 93.3 points (range 80-103 points), and the mean Duplay score was 85.6 points (range 40-100 points). Fifteen patients returned to sports at their pre-injury level. Three patients were considered clinical failures; one with a recurrent posterior dislocation and two with substantial posterior apprehension on follow-up examination. Two shoulders had glenohumeral arthritis on radiographs at the latest follow-up. The posterior bone block is a good treatment option for posterior dislocation. The risk of recurrent dislocation is low following this procedure.

Bilateral ciliary sulcus implantation of secondary piggyback multifocal intraocular lenses

Ciliary sulcus implantation of secondary multifocal intraocular lenses (IOLs) is an uncommon procedure. We describe a young pseudophakic patient with monofocal IOLs who achieved a high level of satisfaction following bilateral implantation of multifocal IOLs. They were used successfully to correct a residual refractive error for distance vision and to provide spectacle-independence for near vision. Postoperative symptoms such as glare were not problematic.

Analysis of clinical data in patients with Girdlestone arthroplasty: a new score

Girdlestone's arthroplasty is an uncommon surgical procedure; it is performed in patiens with recurrent infection of the hip, polymicrobic sepsis or after multiple revisions. The number of hip replacements all over the world is always increasing, so the total number of prosthesis infections also continues to rise, although the relative incidence is lower than in the past. For this reason Girdlestone's arthroplasty must be a well-known procedure to hip surgeons. Clinical assessment of such patients cannot be performed with common hip ratings (e.g. Harris Hip Score) since hip instability, low range of motion, limb shortening and severe muscle loss are common. The patient's independence in daily living activity and freedom from pain should be the surgeon's main goals. We propose a specific clinical score for the outcome of the procedure, which is not to be found in the current literature as far as the authors are aware. The score can be useful for comparative clinical trials, for legal medicine purposes, etc. To illustrate it, we present 20 cases of Girdlestone's arthroplasty out of 265 hip revisions performed in our hospital. The outcome of the procedure in our patients was clinically good in eight cases, intermediate in ten cases, and bad in two cases. We believe the performing of such an intervention is justified when indicated by clinical signs, as we analyse them in our work. Our clinical score has been shown to be adequate to assess the clinical presentation of such patients.

Reduction Otoplasty: Correction of the Large or Asymmetric Ear

Reduction otoplasty is an uncommon procedure performed for macrotia and ear asymmetry. Techniques described in the literature for this procedure are few. The authors present their ear reduction approach that not only achieves the desired reduction effectively and accurately, but also addresses and creates the natural anatomic proportions of the ear, leaving a scar well hidden within the fold of the helix.

Aesthetic Labia Minora Reduction with Inferior Wedge Resection and Superior Pedicle Flap Reconstruction

Aesthetic surgery of female genitalia is an uncommon procedure, and of the techniques available, labia minora reduction can achieve excellent results. Recently, more conservative labia minora reduction techniques have been developed, because the simple isolated strategy of straight amputation does not ensure a favorable outcome. This study was designed to review a series of labia minora reductions using inferior wedge resection and superior pedicle flap reconstruction. Twenty-one patients underwent inferior wedge resection and superior pedicle flap reconstruction. The mean follow-up was 46 months. Aesthetic results and postoperative outcomes were collected retrospectively and evaluated. Twenty patients (95.2 percent) underwent bilateral procedures, and 90.4 percent of patients had a congenital labia minora hypertrophy. Five complications occurred in 21 patients (23.8 percent). Wound-healing problems were observed more frequently. The cosmetic result was considered to be good or very good in 85.7 percent of patients, and 95.2 percent were very satisfied with the procedure. All complications except one were observed immediately after the procedure. The results of this study demonstrate that inferior wedge resection and superior pedicle flap reconstruction is a simple and consistent technique and deserves a place among the main procedures available. The complications observed were not unexpected and did not extend hospital stay or interfere with the normal postoperative period. The success of the procedure depends on patient selection, careful preoperative planning, and adequate intraoperative management.

Technical Advances of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Pulmonary endarterectomy is the definitive treatment for chronic pulmonary hypertension as the result of thromboembolic disease. Although significant progress has been made over the last decade in recognition, diagnostic modalities, and treatment of this disease, chronic thromboembolic pulmonary hypertension (CTEPH) continues to be severely underdiagnosed and as a consequence pulmonary endarterectomy remains an uncommon procedure. Patients with CTEPH may present with a variety of debilitating cardiopulmonary symptoms. However, once diagnosed, there is no curative role for medical management, and surgery remains the only option. Medical management in these patients is only palliative, and surgery by means of transplantation for this type of pulmonary hypertension is an inappropriate use of resources with less than satisfactory results. In this article we describe the technical advances of pulmonary endarterectomy and the current procedure as it is performed at University of California-San Diego Medical Center.

Percutaneous removal of two intracardiac and pulmonary trunkal catheter fragment by using a snare-loop catheter

Endoluminal retrieval of foreign bodies in the cardiac laboratory is an uncommon and challenging procedure for the endovascular specialist, and its only alternative is an open exploration. The availability of smaller catheter systems allows retrieval with minimally invasive techniques. We report retrieval of two catheter fragments using a snare-loop catheter through the femoral vein.

Anesthetic Management of Combined Heart-Liver Transplantation

COMBINED HEART AND LIVER transplantation (CHLT), initially reported by Starzl et al 1 Starzl T. Hakala T.R. Shaw B.W. et al. Heart-liver transplantation in a patient with familial hypercholesterolemia. Lancet. 1984; 3: 1382-1383 Abstract Scopus (211) Google Scholar in 1984, has been successfully performed in adults and children. 2 Figuera D. Ardaiz J. Martin-Judez V. et al. Combined transplantation of heart and liver from two different donors in a patient with familial type IIa hypercholesterolemia. J Heart Transplant. 1986; 5: 327-329 PubMed Google Scholar , 3 Wallwork J. Williams R. Calne R. Transplantation of liver, heart, and lungs for primary biliary cirrhosis and primary pulmonary hypertension. Lancet. 1987; 2: 182-184 Abstract PubMed Scopus (79) Google Scholar , 4 Olivieri N. Liu P.P. Sher G.D. et al. Brief report: Combined liver and heart transplantation for end-stage iron-induced organ failure in an adult with homozygous beta-thalassemia. N Engl J Med. 1994; 330: 1125-1127 Crossref PubMed Scopus (66) Google Scholar , 5 Couetil J. Soubrane O. Houssin D.P. et al. Combined heart-lung-liver, double lung-liver, and isolated liver transplantation for cystic fibrosis in children. Transplant International. 1996; 10: 33-39 Crossref Google Scholar , 6 Dennis C.M. McNeil K.D. Dunning J. et al. Heart-lung-liver transplantation. J Heart Lung Transplant. 1996; 15: 536-538 PubMed Google Scholar , 7 Detry O. Honore P. Meurisse M. et al. Advantages of inferior vena cava flow preservation in combined transplantation of the liver and heart. Transpl Int. 1997; 10: 150-151 Crossref PubMed Google Scholar , 8 Surakomol S. Olson L.J. Rastogi A. et al. Combined orthotopic heart and liver transplantation for genetic hemochromatosis. J Heart Lung Transplant. 1997; 16: 573-575 PubMed Google Scholar , 9 Offstad J. Schrumpf E. Geiran O. et al. Plasma exchange and heart-liver transplantation in a patient with homozygous familial hypercholesterolemia. Clin Transpl. 2001; 15: 432-436 Crossref Scopus (30) Google Scholar , 10 Eckhoff D. Frenette L. Sellers M.T. et al. Combined cardiac surgery and liver transplantation. Liver Transpl. 2001; 7: 60-61 Crossref PubMed Scopus (46) Google Scholar , 11 Ruygrok P. Gane E.J. McCall J.L. et al. Combined heart and liver transplantation for familial amyloidosis. Intern Med J. 2001; 31: 66-67 Crossref PubMed Scopus (22) Google Scholar , 12 Praseedom R. McNeil K.D. Watson C.J. et al. Combined transplantation of the heart, lung, and liver. Lancet. 2001; 358: 812-813 Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar , 13 Pirenne J. Verleden G. Nevens F. et al. Combined liver and (heart-) lung transplantation in liver transplant candidates with refractory portopulmonary hypertension. Transplantation. 2002; 73: 140-156 Crossref PubMed Scopus (45) Google Scholar , 14 Gandhi S. Reyes J. Webber S.A. et al. Case report of combined pediatric heart-lung-liver transplantation. Transplantation. 2002; 73: 1968-1969 Crossref PubMed Scopus (18) Google Scholar , 15 Grazi G. Cescon M. Salvi F. et al. Combined heart and liver transplantation for familial amyloidotic neuropathy: Considerations from the hepatic point of view. Liver Transpl. 2003; 9: 986-992 Crossref PubMed Scopus (40) Google Scholar CHLT is an uncommon procedure, with only 37 procedures reported in the United States by the United Network for Organ Sharing Scientific Registry of Transplant Recipients (SRTR) database. 16 UNOS, United Network for Organ Sharing. Available at: http://www.UNOS.org. Accessed February 1, 2006 Google Scholar Historically, there are few indications for CHLT and definitive dual-organ candidacy criteria have not been established. Previous case reports and small series have detailed the surgical procedure and outcomes; however, no reports have detailed intraoperative management strategies to optimize the physiologic support and function of each organ. This manuscript highlights unique anesthetic considerations for the intraoperative management of the CHLT recipient.

Osteotomy for Malunited Forearm Shaft Fractures in Children

Osteotomy to correct malunion after forearm fracture in children is an uncommon procedure. The uncommon nature of this procedure and the complex nature of forearm anatomy contribute to the difficulty of restoring proper alignment. The purpose of this paper is to report nine cases and describe a simplified method for deformity correction. This is a retrospective review of the authors' experience with recommendations for surgical technique. Average maximum deformity prior to osteotomy was 31 degrees. All patients united with satisfactory postoperative alignment. There was one superficial wound infection. Average improvement in forearm rotation was 102 degrees. Based on these satisfactory results and a review of the literature, the authors recommend correction of forearm malunion when functional range of motion does not return by 6 months after the initial injury.

Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system

There is uncertainty around the types of interventions that are provided by emergency medical services (EMS) to children during prehospital transport. We describe the patient characteristics, events, interventions provided and outcomes of a cohort of children transported by EMS. This prospective cohort study was conducted in a city of 750 000 people with a 2-tiered EMS system. All children <16 years of age who were attended by EMS during a 6-month period were enrolled. Data were extracted from ambulance call reports and hospital charts, and analyzed using descriptive statistics. During the study period there were 1377 pediatric EMS calls. Mean age was 8.2 years (standard deviation 5.4), and the most Common diagnoses were trauma (44.9%), seizure (11.8%) and respiratory distress (8.8%). The ambulance return code was Urgent in 7%, Prompt in 57%, Deferrable in 8% and Not Transported in 28%. Fifty-six percent received either an Advanced Life Support or Basic Life Support prehospital intervention. Common procedures included cardiac monitoring (20.0%), oxygen administration (19.8%), blood glucose monitoring (16.3%), spine board (12.2%), limb immobilization (11.1%) and cervical collar (10.0%). Uncommon procedures included administering medications intravenously (IV) (1.4%), bag-valve-mask ventilation (0.3%) and endotracheal intubation (0.1%). Seventy-eight percent of attempted IV lines were successful. Only 9.0% of EMS-transported children were admitted to hospital, and 2.2% were admitted to the intensive care unit. This first study of Canadian pediatric prehospital interventions shows a high rate of non-transport, and a low rate of Urgent transports and hospital admissions for children. Very few children receive prehospital airway management, ventilation or IV medications; consequently EMS personnel have little opportunity to maintain these pediatric skills in the field.

The Value of Reoperative Procedures After Unusual Reconstructions in the Gastrointestinal Tract Associated With Substantial Morbidity

Reconstructive procedures of the gastrointestinal tract after resection or for bypass surgery are well established and almost completely standardized but still may cause significant morbidity. Deviations from standard reconstructive procedures have pitfalls, especially when complex reconstructions are required, and may lead to substantial morbidity. Scientific evidence for the indication to reoperate as well as the best methods to be applied is lacking and surgical experience indispensable. We report on 10 reoperative cases between 1999 and 2003 after uncommon reconstructive procedures in the gastrointestinal tract associated with substantial morbidity. In five cases (five of seven), operative correction of uncommon reconstructions in the upper gastrointestinal tract after gastrectomy, completion gastrectomy, or distal gastric resection could completely alleviate the complaints including reflux esophagitis, whereas incomplete relief of symptoms was achieved in the remaining two cases (two of seven). Corrective procedures used end-to-side esophagojejunostomy or end-to-side gastrojejunostomy with a retrocolic isoperistaltic jejunal Roux-en-Y loop and end-to-side jejunojejunostomy approximately 40 cm distal to the proximal anastomosis for biliary and exocrine pancreatic drainage. After biliodigestive anastomosis, problematic cholangitis could be completely alleviated in three cases (three of three) using end-to-side hepaticojejunostomy with a retrocolic isoperistaltic jejunal Roux-en-Y loop and end-to-side jejunojejunostomy 40 cm distal to the hepaticojejunostomy for reconstruction of the continuity of the gastrointestinal tract. Compliance with well-established standard reconstructive procedures is of elementary importance in the gastrointestinal tract. Operative correction of uncommon reconstructions associated with morbidity is usually indicated.