A hepaticojejunostomy: technical errors with 'twists and turns'

Reoperation After Cyst Excision with Hepaticojejunostomy for Choledochal Cysts: Our Experience in 18 Cases

Background

Complete cyst excision with biliary reconstruction is the treatment of choice for choledochal cyst (CC). The aim of this article is to review our experience in patients who underwent reoperation between January 1995 and December 2014.

Material/Methods

The records of 18 patients (female/male, 15/3) were retrospectively analyzed including age, sex, cyst type, initial procedure, lab and imaging findings, indications for reoperation, intraoperative findings, and results of reoperation. The median follow-up period was 6 years.

Results

The rate of reoperation in this study was about 6.8%. Eighteen patients (7 type Ia, 2Ic, 9 IV-A) developed severe postoperative complications and required surgical intervention. The median time interval from primary surgery to reoperation was 19.5 months (range, 3 days to 8 years). Two early complications required surgery due to anastomotic bile leakage and intussusception. Sixteen late complications occurred, including 3 intrahepatic bile duct stenosis with calculi, 5 anastomotic strictures with/without stones, 4 intrapancreatic cyst remnants, 3 adhesive bowel obstructions, and 1 internal hernia. For patients with persistent dilatation of the intrahepatic bile duct or anastomotic stricture, removal of stones and revision of hepaticojejunostomy were performed, with additional hepatic ductoplasty when necessary. Radical excision of the dilated cystic remnant in the head of pancreas was performed in 4 patients, with 1 needing additional pancreaticojejunostomy procedure. No deaths occurred. Sixteen patients recovered uneventfully after reoperation, and 2 wound infections developed.

Conclusions

A wide hepaticojejunostomy with/without ductoplasty is essential to prevent cholangitis, anastomotic stricture, and calculi formation. Complete cyst excision, including the intrapancreatic portion, should be meticulously pursued.

'O' configuration of biliary-enteric drainage: a preventable surgical error

Surgical errors in Roux limb reconstruction are not reported widely. A young male who underwent hepaticojejunostomy after biliary injury developed acute obstruction of the proximal jejunum. Barium study revealed the O configuration of alimentary limb-'O' sign. At laparotomy, he was found to have the alimentary limb joining on to itself and without any connection with the biliary limb. The O loop complex was resected, and Roux-en-Y construction was refashioned. He made an uneventful recovery and is well at one year follow-up. We have reviewed the literature and propose a classification system for such type of errors. Every effort should be made to prevent this complication.

The outcome of laparoscopic portoenterostomy for biliary atresia in children

AIM

There were only a few reports on laparoscopic portoenterostomy for biliary atresia in children. We report our experience on laparoscopic Kasai operation for biliary atresia.

MATERIAL AND METHODS

A retrospective review of all children who had biliary atresia underwent laparoscopic portoenterostomy from January 2002 to September 2006 were included and analyzed.

RESULTS

Sixteen children (five boys and eleven girls) with a mean age of 66 days (range 47-106 days) at operation were included in this study. All patients had type III biliary atresia. There was no conversion to open procedure. The operative time ranged from 193 to 435 min (mean 292 min). At a median follow-up of 72 months (range 33-89 months), eight patients were free of jaundice with bilirubin level <20 μmol/L and did not require liver transplantation. Seven patients underwent liver transplantation. One patient who had persistent elevated bilirubin defaulted follow-up. One patient complicated with volvulus of intestine post-operatively. All patients survived except one patient who had combined liver and intestine transplantation.

CONCLUSION

Laparoscopic portoenterostomy in children with biliary atresia is technically feasible. 50% of children who had type III biliary atresia were free of jaundice and did not require liver transplantation. A longer follow-up is required to assess the long-term outcome.