Elsevier

Surgery

Volume 153, Issue 1, January 2013, Pages 95-102
Surgery

Original Communication
Treatment of failed Roux-en-Y hepaticojejunostomy after post-cholecystectomy bile ducts injuries

https://doi.org/10.1016/j.surg.2012.06.028Get rights and content

Background

Roux-en-Y hepaticojejunostomy (RYHJ) is the most well-accepted treatment for most post-cholecystectomy bile duct injuries (BDI). RYHJ failure is a complex situation that requires expert planning and the possibility of using a combination of operative, radiologic, and endoscopic techniques. The aim of this study was to report our experience with a multidisciplinary approach to failed RYHJ after post-cholecystectomy BDI.

Methods

Between January 1996 and March 2008, 44 consecutive patients were managed for RYHJ failure in our department. They presented with recurrent cholangitis in 40 patients (91%) and/or jaundice in 9 (20%). First-line treatment consisted of primary revisionary surgery in 26 cases (59%; repeat RYHJ in 22 and hepatectomy in 4) and a percutaneous approach in 18 cases (41%; biliary interventions in 16 and portal vein embolization in 2).

Results

Postoperative mortality was nil. Postoperative morbidity was 11% after repeat RYHJ without hepatectomy, 80% (bile leaks) after hepatectomy, and 10% (mild cholangitis and hemobilia) after a percutaneous approach. Delayed revisionary surgery with the intent to wait for bile duct dilation failed in all 5 patients. With a mean follow-up of 49 ± 40 months, second- or third-line treatment was attempted in 7 patients (16%). One patient (2%) died because of suicide. Overall clinical success defined by the absence of incapacitating biliary symptoms after treatment was achieved in 39 patients (89%).

Conclusion

An immediate, multidisciplinary approach including repeat biliary surgery and/or a percutaneous approach in a tertiary hepatobiliary center is required to obtain good, long-term results when treating the failure of RYHJ post-cholecystectomy BDI.

Section snippets

Patients and methods

Between January 1996 and March 2008, 44 consecutive patients were treated in our department (Centre Hépato-Biliaire, Paul Brousse Hospital, Assistance Publique des Hopitaux de Paris, Villejuif, France) for the failure of RYHJ performed because of post-cholecystectomy BDI. Our group of patients comprised 13 males (30%) and 31 females (70%) with a mean (± SD) age of 51 ± 14 years (range, 17–78). All BDI were sustained during cholecystectomy performed for cholecystolithiasis. The approach for the

Results

The mean (± SD) follow-up period was 49 ± 40 months (range, 2–153). One patient (2%) died as a result of suicide 44 months after the initial hepatectomy. In 7 patients (16%), ≥2 treatments were required, with a mean follow-up of 33 ± 36 months (range, 2–85). At the time of last follow-up, clinical success had been achieved in 39 patients (89%): 34 patients (77%) were asymptomatic (Terblanche I–II), and 5 patients (11%) had experienced an improvement in their symptoms (Terblanche III). The

Discussion

This study shows that with an experienced multidisciplinary approach (according to the strategy summarized in Fig 3), patients with a failed RYHJ after post-cholecystectomy BDI can achieve good long-term clinical success in 89%. These results required more than the first-line revision in 16% of patients. Although we showed that waiting for bile duct dilation before revisionary surgery was not successful; moreover, we were unable to identify any prognostic predictive factor at referral in our

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