BILIO-ENTERIC ANASTOMOSIS

STRICTURES
DIAGNOSIS AND MANAGEMENT
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INTRODUCTION
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• A precise hepaticojejunostmy (HJ) have following features.

– Tension-free
– Widely patent
– Mucosa-to-Mucosa anastomosis
– Well vascularized bile ducts
– Draining all parts of liver
• Even when a state of the art procedure is done, lack of even
one of these features changes the outcome dramatically and
puts the patient at risk of stricture development.
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• Roux-en-Y Hepaticojejunostomy (HJ) is the procedure of choice

for patients needing bilioenteric anastomsis.
• Several complications can occur.
– Anastomotic stricture (50%)
– Intra-hepatic stone formation
– Bile sump syndrome
– Obstruction of the Roux-en-Y anastomosis
– De novo or recurrent malignant disease
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RISK FACTORS
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• Absence of dilated bile ducts considered the most prominent

risk factor for development of HJ stricture.
• This lead some surgeons to delay the procedure until bile duct
dilatation obtained.
• However a few studies reported similar results in early repair
provided the procedure done by expert hepatobiliary surgeon.
• Presence of biliary peritonitis and post procedure biliary leak
both increase the risks.
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DIAGNOSIS
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CLINICAL AND BIOLOGICAL PRESENTATION

• HJ stricture progressively leads to retention of contaminated
bile.
• Any mild elevation of g-GT and/or transitionary fever should
highlight the possibility of an anastomotic stricture.
• Presenting symptoms are:
– Cholangitis (80%)
– Isolated jaundice (15%)
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RADIOLOGICAL IMAGING
• Ultrasound (US) Not for direct visualization of stricture
Evaluation of assessment of differential
• Computed Tomography (CT) diagnosis

• PTC
• MRCP (90%)
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Percutaneous Cholangiography Magnetic Cholangiography

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MANAGEMENT
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Therapeutic Options
• Multimodal and gradual management
• Repeated treatment sessions
• Combination of several approaches
• Conservative
– Percutaneous transhepatic
– Endoscopic
• Surgical
– Revisionary HJ
– Liver Transplant
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CONSERVATIVE
MANAGEMENT
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PERCUTANEOUS TRANSHEPATIC BILIARY DILATATION

• Therapeutic success of 90-100%

• Firstly, transhepatic cholangiography and external drainage

catheter placement;
– Percutaneous transhepatic tracts are made to ensure complete drainage of
all excluded territories.
– Insertion of external catheter, drains the entire biliary tree above the
stricture.
– If present, small biliary tract stones can be pushed forward with saline
irrigation into the bilioenteric anastomosis.
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• Secondly, stenting is done, 3 to 7 days after the initial procedure;

– Angioplasty balloon catheter is inserted beyond the stenosis and
gradually inflated.
– Followed with stenting with internal-external biliary drainage or wall-
stent placement.
• Control cholangiography with catheter exchange and
complimentary dilatation done every 6 weeks.
• If no residual stenosis is observed on at least two consecutive
sessions, catheter is removed.
• Patient followed regularly to detect any recurrent stricture.
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Other options
• Endoscopic retrograde balloon dilatation;
– Success rate of 70% using single balloon enteroscope.
– May facilitate both multiple stent placement and use of lithotripsy.
– Endoscopy maybe facilitated with the use of short-limb Roux-en-Y
reconstruction.
• Percutaneous transjejunal approach; is a valuable alternative with
satisfactory results when compared to endoscopy.
“Both these procedure are restricted to very few experienced centers”
• Rendez-vous technique
– Combination of both endoscopic and percutaneous approach
– Limited reported experience
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• Metallic Wall-Stent;
– Rationale is to limit the number of procedures and decrease hospital
stays.
– Initial promising results with high primary technical success rates.
– Long term results for benign stricture treatment with metallic stents
reported high rates of late re-occlusion.
• Retrievable Covered Stents;
– Good alternative to shorten the treatment duration when compared
to internal-external catheter.
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SURGICAL
MANAGEMENT
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REVISION HEPATICOJEJUNOSTOMY
• If well-conducted conservative management has failed or
associated Roux loop malfunction.
• Biliary strictures during revision surgery are often found at a
higher level than first surgery.
• It is a real therapeutic challenge to perform a redo-HJ, it needs
expertise in both liver and biliary surgery.
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ACCESS
• Use of intra-operative cholangiography for operative
identification of anatomy and/or any abnormality.
• Leaving the transhepatic biliary drainage in place before
surgery useful in localizing the bile duct after removal of HJ and
dissection of hilar plate to expose the primary confluence.
• If the confluence is not identifiable, hepatotomy between
segments 5 and 4 through the bed of gallbladder can be used
to access the secondary right biliary confluence.
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LIVER RESECTION
• Proposed in patients with HJ stricture with anticipated
complete biliary confluence destruction.
• Commonly needed in patients with initial high HJ and complex
biliary lesions with associated vascular injuries.
• Additional benefit is removal of atrophic liver parenchyma
secondary to long standing biliary obstruction.
a. Left and Right anterior hepatectomy
b. Right hepatectomy
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LIVER TRANSPLANT
• Indicated for irreversible liver parenchymal damage due to
– Secondary biliary cirrhosis
– Chronic liver failure
• Only if failure of all therapeutic strategies.
• High risk procedure in context of chronic sepsis in such
patients that is generally a contraindication for LT.
• In such condition, it is advised bile sterilization and sepsis
control in pre-transplant phase.
• But a certain degree of sepsis could probably be acceptable.
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KEY POINTS: DIAGNOSIS & MANAGEMENT

• About 50 % of late-HJ-related complications are NOT anastomotic
strictures and should be meticulously ruled out.
• Percutaneous transhepatic biliary dilatation with or without stent
placement is currently the approach of choice in the management
of HJ strictures with high success rates.
• The existence of a Roux-en-Y loop does not represent an absolute
contraindication to the endoscopic approach.
• Surgery should remain a second-line treatment since the vast
majority of strictures can be managed conservatively with
percutaneous or endoscopic dilatation.
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