Risk Factors of Postoperative Anastomotic Stricture After Excision of Choledochal Cysts with Hepaticojejunostomy

Abstract

The aim of this study was to investigate the risk factors of postoperative anastomotic stricture after excision of choledochal cysts and hepaticojejunostomy. Among 65 patients who underwent surgery for choledochal cyst between March 1995 and June 2005, we selected 34 adult patients who were diagnosed as having choledochal cyst. We divided patients into two groups, depending on postoperative anastomotic stricture developed or not. Medical records and radiological findings of each patient were reviewed retrospectively. H&E stain and Masson-Trichrome stain of each specimen of the resected cyst were performed, and thickness of cyst wall, the grade of fibrosis, loss of smooth muscle layer, loss of mucosa, and infiltration of inflammatory cells were measured. Of the 34 patients, excision of choledochal cyst and hepaticojejunostomy were done in 33 patients, and 1 patient with chronic pancreatitis underwent pylorus-preserving pancreaticoduodenectomy. Anastomotic stricture and intrahepatic duct stones postoperatively developed in eight patients; one patient of 19 type I cyst and seven patients of 15 type IVa, developing significantly more in the type IVa choledochal cyst (P<0.05). The size of choledochal cyst in the stricture group was 7.0 cm, and that of the non-stricture group, 4.2 cm, showing significant difference between the two groups (P<0.05). The stricture group presented shorter duration of symptoms (27.63±61.72 days; ranged, 1∼180 days) than the non-stricture group (483.33±916.41 days; ranged, 1∼3,560 days), and it was statistically significant (P<0.05). Pathologically, significant difference was found between anastomotic stricture and infiltration of inflammatory cells (P<0.05). The results indicate that anastomotic stricture is influenced by the type IVa choledochal cyst, size of cyst, duration of symptoms, and the grade of infiltration of inflammatory cells. Therefore, closed careful follow-up is important in patients who underwent cyst excision with hepaticojejunostomy for type IVa choledochal cyst. If the anastomotic stricture develops, nonoperative management should be recommended, rather than operation, as much as possible.

Management of Congenital Bile Duct Cysts

“…Late postoperative complications include cholangitis, intrahepatic strictures and/or lithiasis, occurring in most cases from anastomotic stricture or biliary stasis in the intrahepatic biliary tree but also in patients with patent anastomotic stoma [6,14]. Kim et al [28] recently emphasized that anastomotic stricture tended to increase with increasing cyst size, short symptom duration and the grade of infiltration of inflammatory cells, and was closely related to the type of BDC. They reported a late occurrence of anastomotic stricture and intrahepatic duct stones in 23.5%, which was significantly more frequent in IV-A cysts justifying the need for careful long-term follow-up.…”

Choledochal Cyst: A Report of 3 Cases and a Review of its Treatment and Outcome

“…When reconstructing a hepaticoenterostomy is it pertinent to create a wide stoma at the hepatic end for the anastomosis; this is to allow free for drainage and reduce the risk of anastomotic stricture [59]. An end-to-end anastomosis minimises the risk of blind loop syndrome, reflux, stone formation, and recurrent cholangitis from bile stasis.…”

Hepaticojejunostomy Anastomotic Strictures

“…Indeed, the rates of HJ strictures range from virtually 0 to 6 % in children [37,38] when the anastomosis is performed on the hepatic hilum, while it may reach up to 24 % in adults [39]. This finding is probably related to the fact that inflammation of the cyst wall is mild in children under 10 years of age and more severe in older children and adults, likely resulting from severe histological damage to the common hepatic duct used for a bilioenteric anastomosis [40].…”

“…This finding is probably related to the fact that inflammation of the cyst wall is mild in children under 10 years of age and more severe in older children and adults, likely resulting from severe histological damage to the common hepatic duct used for a bilioenteric anastomosis [40]. Other risk factors for the development of HJ after choledochal cyst excision include shorter duration of symptoms [39], increased size of the cyst [39], and type IVa cysts [40] where inflammation is associated with histological damage of the common hepatic duct after HJ and may lead to severe scaring at the bilioenteric anastomosis [40]. Altogether, these results suggest that the balance between the risks of malignant transformation and the risks of invalidating symptoms following HJ stricture, especially in adults with type IVa cysts, should lead to cautious consideration of surgery on a case-by-case basis rather than on a systematic operative approach basis.…”