Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

Abstract

Aim: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury.

Methods: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively.

Results: Bile duct injury was caused by cholecystectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini-incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively.

Conclusion: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.

Figures

Figure 1

Strasberg classification of bile duct injury. E1: Transected main bile duct with a stricture more than 2 cm from the hilus; E2: Transected main bile duct with a stricture less than 2 cm from the hilus; E3: Stricture of the hilus with right and left ducts in communication; E4: Stricture of the hilus with separation of right and left ducts; E5: Stricture of the main bile duct and the right posterior sectoral duct.

Figure 2

Computed Tomography angiography (CTA) of one type E4 injury patient displayed the lesion of the proper hepatic artery (arrow), although some compensatory collateral arterial blood supply from the left gastric artery could be identified. This patient received liver transplantation.

Figure 3

MRCP appearance of one type E3 injury patient showing dilation of intrahepatic bile ducts (arrows).

Figure 4

Plastic reconstruction in one type E3 patient merging several bile duct openings into one at the hilum after removal of the scarred ducts (the same patient in Figure 3).