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

Abstract

INTRODUCTIONAbout 80% of BDI occur after cholecystectomy constituting a catastrophe for both the patient and the surgeon as they are associated with significant morbidity and mortality, reducing long-term survival and quality of life, and are associated with high rates of subsequent litigation.1,2 Laparoscopic cholecystectomy (LC) has largely replaced open cholecystectomy (OC) but its potential disadvantage is a 2-fold increase in BDI. Moreover, injuries after LC are more proximal, are revealed earlier, are presented by leaks more than by strictures, are repaired more frequently by nonspecialists, and more associated with lost segment and ischemia due to combined vascular injury.3 Most of BDI present as biliary stricture, external or internal fistula, and biliary peritonitis. 4 If left untreated BDI may be complicated with biliary strictures, hepatic atrophy, cholangitis and intra-hepatic lithiasis. Later, fibrosis or even secondary biliary cirrhosis and portal hypertension can develop, enhanced by prolonged biliary obstruction associated with recurrent cholangitis.5 Also there is ABSTRACT 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.

Perpendicular duodenum jejunum anastomosis for conventional postoperative endoscopic access in biliodigestive diversions in Roux in Y

“…A wide variety of surgical procedures with biliary access handles have been performed in order to facilitate endoscopic approaches, and for this reason many authors have attempted to design a series of procedures. Barker and Winkler 20 published an additional procedure to hepaticojejunostomy, taking the end of the proximal handle of the Roux-in-Y to the abdominal wall, building a jejunum stoma in the right subcostal area of the abdominal wallHelmy, et al 9,21 report the use of a pedicle gastric tube lodged between the proximal and distal segments of the injured biliary ducts, in a first clinical case, with positive results at the time of the 5-month follow up, and a series of 18 cases with injuries and loss of segment after 2 years without complications. They concluded that it has advantages over other procedures because the functional sphincter of Oddi is preserved, facilitating diagnostics and therapeutic procedures, such as the endoscopic retrograde choliopancreatography, which has been proven to be extremely difficult after a Rouxin-Y hepaticojejuno anastomosis.…”

Isolated vascularized gastric tube biliary enteric drainage: a paediatric case series experience

“…Helmy et al had a cohort of 18 adult patients who mainly had IVGT grafts for bile duct injuries [9]. It is important to note that they used a trans-anastomotic stent within the graft, and one stent was blocked postoperatively and had to be removed.…”

“…Helmy et al published a study using an isolated vascularized gastric tube (IVGT) graft as a biliary conduit in 2011 [8]. The IVGT graft was later successfully adapted for adult patients with common bile duct injuries [9]. Given the concerns regarding RYBD, children's long life expectancy and the lack of interventional radiological services, we have adopted IVGT graft as a primary reconstructive procedure for our paediatric patients at our institution and review our experience.…”

Anastomosis perpendicular duodeno-yeyunal para un acceso endoscópico convencional posoperatorio en las derivaciones biliodigestivas en Y de Roux

“…Barker y Winkler 20 publicaron un procedimiento adicional a la hepático-yeyunostomía, llevando la parte terminal del asa proximal de la Y de Roux a la pared abdominal, construyendo un estoma de yeyuno en el área subcostal derecha de la pared abdominal. Helmy, et al 9,21 reportan el uso de un tubo gástrico pediculado interpuesto entre los segmentos proximal y distal de la vía biliar lesionada, en un primer caso clínico, con buenos resultados en un seguimiento de 5 meses, y una serie de 18 casos con lesiones y pérdida de segmento con un seguimiento a 2 años sin complicaciones. Consideran que tiene ventajas sobre otros métodos porque se preserva el esfínter de Oddi funcional, facilitando procedimientos diagnósticos y terapéuticos como la colangiopancreatografía retrógrada endoscópica, la cual ha probado ser sumamente difícil después de una anastomosis hepático-yeyuno en Y de Roux.…”