Balloon dilatation of biliary strictures through a choledochojejuno-cutaneous fistula

Therapeutic Role of Subcutaneous Access Loop Created Adjunct to Hepaticojejunostomy for Management of Bile Duct Injury

BACKGROUND

Roux-en-Y hepaticojejunostomy (RYHJ) is usually required for major bile duct injury (BDI) as a definitive treatment. Hepaticojejunostomy anastomotic stricture (HJAS) is the most feared long-term complication following RYHJ. The ideal management of HJAS remains undefined. The provision of permanent endoscopic access to the bilio-enteric anastomotic site can make endoscopic management of HJAS feasible and attractive option. In this cohort study, we aimed to evaluate short- and long-term outcomes of subcutaneous access loop created adjunct to RYHJ (RYHJ-SA) for management of BDI and its usefulness for endoscopic management of anastomotic stricture if occurred.

MATERIALS AND METHODS

This is a prospective study including patients who were diagnosed with iatrogenic BDI and underwent hepaticojejunostomy with subcutaneous access loop between September 2017 and September 2019.

RESULTS

This study included a total number of 21 patients whom ages ranged between 18 and 68 years. During follow-up, three cases had HJAS. One patient had the access loop in subcutaneous position. Endoscopy was done but failed to dilate the stricture. The other 2 patients had the access loop in subfascial position. Endoscopy of them failed to enter the access loop due to failure of fluoroscopy to identify the access loop. The three cases underwent redo-hepaticojejunostomy. Parajejunal (parastomal) hernia occurs in 2 patients in whom the access loop was fixed subcutaneous position.

CONCLUSION

In conclusion, modified RYHJ with subcutaneous access loop (RYHJ-SA) is associated with reduced quality of life and patient satisfaction. Moreover, its role in endoscopic management of HJAS after biliary reconstruction for major BDI is limited.

Hepaticojejunostomy with gastric access loop versus conventional hepaticojejunostomy: a randomized trial

Roux-en-Y hepaticojejunostomy (RYHJ) with the provision of "gastric access loop" was developed to shorten the distance traveled by the endoscope to reach hepaticojejunostomy (HJ) anastomotic site. The aim of our study was to assess modified RYHJ with gastric access loop (RYHJ-GA) and compare it with conventional RYHJ (RYHJ-C) regarding short- and long-term outcomes and, moreover, to evaluate the feasibility and results of future endoscopic access of the modified bilio-enteric anastomosis. Patients eligible for RYHJ between September 2017 and December 2019 were allocated randomly to receive either RYHJ-C or RYHJ-GA. Fifty-two patients were randomly assigned to RYHJ-C (n = 26) or RYHJ-GA (n = 26). Three cases in RYHJ-C and 4 cases in RYHJ- GA developed HJ anastomotic stricture (HJAS) (P=0.68). 3 cases of RYHJ-GA had successful endoscopic dilation and balloon sweeping of biliary mud (one case) or stones (2 cases). Revisional surgery was needed in 2 cases of RYHJ-C and 1 case in RYHJ-GA (P=0.68). Modified RYHJ with gastric access loop is comparable to the classic hepaticojejunostomy regarding complications. However, gastric access enables easy endoscopic access for the management of future HJAS. This modification should be considered in patients with a high risk of HJAS during long-term follow-up.The trial registration number (TRN) and date of registration:ClinicalTrials.gov (NCT03252379), August 17, 2017.

Role of Interventional Radiology in the Management of Acute Cholangitis

Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.

A case of a smooth transition to subsequent percutaneous transjejunal biliary intervention for hepatolithiasis after biliary reconstruction by adding jejunostomy during an emergency operation for perforation due to balloon-assisted endoscopy

Treatments for hepatolithiasis include peroral endoscopy, percutaneous cholangioscopy, and surgery. Balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) has been widely performed in recent years for patients with hepatolithiasis after biliary reconstruction. However, accidental bowel perforation caused by BAERCP may need emergency surgery. Here, we describe a 77-year-old Japanese woman diagnosed with acute cholangitis due to hepatolithiasis after biliary reconstruction (a biliary diversion operation for pancreaticobiliary maljunction). She underwent BAERCP for treatment of hepatolithiasis, however, a small-bowel perforation occurred. She underwent an emergency operation to suture the perforation and add a catheter jejunostomy. She had no postoperative complications after surgery and was discharged 11 days after surgery. One month later, she was readmitted and underwent percutaneous transjejunal cholangioscopy-guided lithotripsy with complete removal of the calculi. Although endoscopists should be careful to avoid small-bowel perforation during BAERCP, if perforation occurs, addition of a catheter jejunostomy during emergency surgery can be easily transitioned to subsequent treatment of the hepatolithiasis.

Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography, Endoscopy, and Biliary Interventions

PURPOSE

The purpose of this study was to present the institutional experience of performing endoscopy, cholangiography, and biliary interventions through the modified Hutson loop by interventional radiology.

MATERIALS AND METHODS

A total of 61 of 64 modified Hutson loop access procedures were successful. This single-center retrospective study included 61 successful procedures of biliary interventions using existing modified Hutson loops (surgically affixed subcutaneous jejunal limb adjacent to biliary anastomosis or anastomoses) for diagnostic or therapeutic purposes in 21 patients. Seventeen of 21 patients (81%) had undergone liver transplantation. Indications included biliary strictures (n = 18) and biliary leaks (n = 3). The clinical success and complications were evaluated.

RESULTS

There were 3 of 26 modified Hutson loop retrograde biliary intervention failures (12%) before introduction of endoscopy and no failures (0 of 38 [0%]) subsequently (P = .06). Endoscopy or cholangioscopy was performed in 19 procedures by interventional radiologists. Retrograde biliary interventions included diagnostic cholangiography (n = 26), cholangioplasty (n = 25), stent placement (n = 29), stent retrieval (n = 25), and biliary drainage catheter placement (n = 5). No procedure-related mortality occurred. There was 1 major complication (duodenal perforation) (1.6%) and 12 minor complications (19%). In the 9 patients undergoing therapeutic interventions for biliary strictures, there was a significant decrease in median alkaline phosphatase (288.5 to 174.5 U/L; P = .03). There was a trend toward decrease in median bilirubin levels (1.7 to 1 mg/dL; P = .06) at 1 month post-intervention.

CONCLUSIONS

The modified Hutson loop provided interventional radiologists a safe and effective alternative access to manage biliary complications in patients with biliary-enteric anastomoses. Introduction of the endoscope in interventional radiology has improved the success rate of these procedures.

Utilization of a Modified Roux-en-Y Anastomosis as an Access point for Percutaneous Transjejunal Cholangioplasty of Recurrent Biliary Strictures

INTRODUCTION

Biliary duct injuries pose a significant management challenge due to the propensity for recurrent biliary strictures. Development of a modified Roux-en-Y hepaticojejunostomy known as a Hutson-Russell Pouch (HRP) provides a point of entry for repetitive access to the biliary tree. We aim to highlight the effectiveness of using the HRP as an access point for the long-term management of anastomotic and distal biliary strictures, thereby showcasing the value in potential widespread adoption of this modification to a standard surgical procedure.

MATERIALS AND METHODS

IRB-approved retrospective study of 36 patients (10 M, 26 F; mean age 55.19 ± 13.94; 15-83) underwent a total of 110 transjejunal cholangiograms. Indications for cholangiogram included cholangitis (n = 38), surveillance (n = 36), and elevated liver enzymes (n = 36). Technical success was defined by the ability to access and intervene in the biliary tree via HRP access. In case of stenosis, the ability to successfully dilate (< 30%) residual stenosis was considered a technically successful procedure. Clinical success was defined by normalization of the liver function tests or resolution of cholangitis.

RESULTS

Technical success was achieved in 83/110 (75.45%) of the cases, and clinical success was achieved in 102/110 (98.2%). Transhepatic access was needed in 27/110 (24.5%) of the cases. Interventions performed included balloon cholangioplasty in 104/110 (94.5%), biliary stone removal in 2/110 (1.8%), biliary stent placement in 2/110 (1.8%), and biliary drain placement in 4/110 (3.6%). There were a total of 9/110 complications (8.2%).

CONCLUSION

The HRP was an effective access point in the management of recurrent benign biliary strictures in this cohort.

Percutaneous Transjejunal Biliary Access in 60 Patients with Bilioenteric Anastomoses

PURPOSE

To determine success and complication rates of percutaneous transjejunal biliary access (PTJBA) in patients with bilioenteric anastomoses.

MATERIALS AND METHODS

In a single-center, retrospective study, 169 PTJBA procedures were performed over a 13.8-y period in 60 subjects (47 male; mean age, 54.5 y). Indications for biliary interventions were cholangitis (137 cases, 45 subjects) or hyperbilirubinemia (32 cases, 18 subjects). All patients had antecolic bilioenteric anastomoses without surgical fixation to the peritoneum (liver transplantation with hepaticojejunostomy, n = 37; hepatectomy with hepaticojejunostomy, n = 8; hepaticojejunostomy only, n = 12; pancreaticoduodenectomy, n = 3).

RESULTS

Initial PTJBA was successful in 140 cases (82.8%) in 35 subjects (58.3%). Twenty-one additional PTJBAs (12.4%) in 18 subjects (30.0%) were performed secondarily following a conventional transhepatic approach. Radiographic markers on the Roux-en-Y limb (P = .14, odds ratio [OR] = 2.98) or preprocedural imaging (P = .13, OR = 10.00) did not increase the odds of successful PTJBA. There were 7 major complications (4.3%) in 6 patients (10.0%) requiring hospitalization longer than 5 d, and 37 minor complications (23.0%) in 19 patients (31.7%). No procedure-related mortality was observed. Minor and major complication rates were not affected by time between bilioenteric anastomosis creation and PTJBA (P = .70, OR = 1.00; P = .62, OR = 1.00), longer dwell time of a transjejunal drain (P = .68, OR = 1.02; P = .49, OR = 0.71), or access size (P = .40, OR = 0.85; P = .23, OR = 0.59).

CONCLUSIONS

PTJBA is a relatively safe technique with a high success rate in patients with bilioenteric loops that are not surgically fixed to the peritoneum.

Recurrent pyogenic cholangitis: a review of imaging findings and clinical management

Recurrent pyogenic cholangitis (RPC) is an infective process involving the biliary tree typified by pigmented intraductal calculi with dilatation of the intra- and extrahepatic biliary tree. Previously endemic to South-east Asia, RPC can now be seen in Western countries with the increasing access to international travel and immigration. Affected patients are often plagued by recurrent bouts of cholangitis, and commonly suffer from complications such as abscess formation and biliary strictures. In severe cases, cirrhosis with portal hypertension may develop. The disease is also a known risk factor for cholangiocarcinoma, and can be seen in up to 5% of affected patients. Its exact etiology is unknown, but parasitic infections such as Clonorchis sinensis and Ascaris lumbricoides, ascending bacterial infection with gut flora (Escherichia coli) and low socioeconomic status have been associated strongly with it. This paper reviews the imaging features of the disease, as well as the roles of interventional radiology and surgery with respect to management of the condition.

Transjejunal biliary interventions: going back to a road less traveled

Percutaneous transhepatic biliary interventions are not without risk and potential complications. In patients with bilioenteric anastomosis in whom repeat biliary interventions are expected, percutaneous transjejunal access is a very useful approach that is not frequently used nowadays. We provide a brief review of the history, indications, and current status of transjejunal biliary interventions. Transjejunal biliary access provides a relatively atraumatic pathway to the biliary system in patients that need repeat interventions. Multiple studies have provided convincing data that in appropriately chosen patients receiving a bilioenteric anastomosis, an antecolic limb of jejunum should be placed for subsequent access in biliary intervention.

Management of intrahepatic stones: the role of subcutaneous hepaticojejunal access loop. A prospective cohort study

BACKGROUND

Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed.

PURPOSE

The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones.

PATIENTS AND METHODS

Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure.

RESULTS

Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1-5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures.

CONCLUSION

The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or re-formed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access.

The Value of Cholangiography through Jackson-Pratt Drains in the Management of Postoperative Biliary Injuries

Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.

Biliary-colonic fistula caused by cholecystectomy bile duct injury

Biliary-colonic fistula is a rare complication after laparoscopic cholecystectomy. We present a case of post-cholecystectomy iatrogenic biliary injury that resulted in a fistula between the common hepatic duct and large bowel. Magnetic resonance cholangiopancreatography provided good visualization of injury even with concurrent normal level of alkaline phosphatase. Radiologic findings and surgical management of this condition are discussed in detail.

Jejunal access loop cholangiogram and intervention using image guided access

Jejunal access loop is fashioned in patients who undergo Roux en Y hepaticojejunostomy and biliary intervention is anticipated on follow up. Post-operative study of the biliary tree through the access loop is usually done under fluoroscopic guidance. We present a series of 20 access loop cholangiograms performed in our institution between August 2004 and November 2008. We aimed to evaluate the safety and efficacy of the procedure and to highlight the role of CT guidance in procuring access. Access loop was accessed using CT (n = 13), ultrasound (n = 3) or fluoroscopic guidance (n = 4). Fluoroscopy was used for performing cholangiograms and interventions. Twelve studies had balloon plasty of the stricture at anastomotic site or high up in the hepatic ducts. Seven studies showed normal cholangiogram. Plasty was unsuccessful in one study. Technical success in accessing the jejunal access loop was 100%; in cannulation of anastomotic site and balloon plasty it was 95%. One case required two attempts. Procedure-related complications were not seen. All patients who underwent balloon plasty of the stricture were doing well for variable lengths of time. Access loop cholangiogram and interventions are safe and effective. CT guidance in locating/procuring the access loop is a good technique.

Therapeutic value and outcome of gastric access loops created during hepaticojejunostomy for iatrogenic bile duct injuries

BACKGROUND AND PURPOSE

Hepaticojejunostomy is the reconstructive procedure performed for iatrogenic bile duct injuries. Anastomotic site stricture is the most significant complication of this operation. Revision surgery is associated with a significant morbidity and mortality. Creation of access to the anastomotic site facilitates the management of such strictures by minimal access techniques and reduces the need for revision surgery. This retrospective study aims to investigate the technical accessibility, usefulness, morbidity related to and the outcome of hepaticojejunostomy with gastric access loops performed as the treatment for iatrogenic bile duct injuries.

METHODOLOGY

Twenty-seven consecutive patients who have undergone hepaticojejunostomy (including three revision surgeries and a re-revision surgery) with gastric access loops from July 2005 to October 2009 were followed up for clinical, biochemical, radiological and endoscopic evidence of anastomotic site occlusion and the need for intervention. Morbidity related to gastric access loops was assessed by dyspepsia disability score.

RESULTS

Mean follow up was 35.4 (range 6-61) months. Three patients developed anastomotic strictures at 4, 22 and 5 months after hepaticojejunostomy and had successful endotherapy via the gastric access loop. They remain well at 33rd, 31st and 3rd months, respectively, following intervention. Based on the dyspepsia disability score none of the patients had symptomatic dyspepsia affecting daily activities.

CONCLUSIONS

Gastric access loop is accessible and useful for stricture dilation and other endotherapeutic procedures. In the absence of significant symptoms related to bile reflux, gastric access loop could be considered as a useful and safe adjunct in the management of hepaticojejunostomy by surgeons especially in settings with limited facilities and expertise for radiological manipulations.

Intrahepatic biliary strictures without hepatic artery thrombosis after liver transplantation: an analysis of 1,113 liver transplantations at a single center

BACKGROUND

Intrahepatic biliary strictures (IHBS) without hepatic artery thrombosis (HAT) is a serious complication and known to increase the risk of graft failure after liver transplantation. This manuscript describes the incidence, risk factors, clinical pictures, management, and outcomes.

METHODS

Between 1994 and 2002, 1,113 liver transplantations were performed in 974 adult patients. Data was retrospectively analyzed in terms of incidence, risk factors, clinical pictures (type of strictures), management (radiologic, surgical management), and outcomes.

RESULTS

Sixteen (1.4%) grafts had IHBS without HAT. Specific risk factors were not identified from donors or recipients. However, ischemic factors from the donors were suspected from non-heart-beating donors (n=1) and cardiac-arrest donors (n=2). Three types of IHBS were identified: (1) diffuse type (n=7), (2) bilateral proximal type (n=7), and (3) unilateral type (n=2). Overall success rate of radiologic interventions was 31.3% (5/16). Of the 11 patients who did not improve, 6 died: diffuse type (3/7, 42.9%), bilateral type (3/7, 42.9%), and unilateral (0/2, 0%). Three patients had retransplantation, and two patients are waiting retransplantation. The majority of the IHBS were diffuse or bilateral (14/16, 87.5%), and rate of the graft failure was high (10/14, 71.4 %). Overall graft survival of IHBS was lower than that without IHBS (P=0.025).

CONCLUSIONS

The majority of the IHBS without HAT were of a diffuse or bilateral proximal type. Patients with diffuse or bilateral proximal type have a low success rate from radiologic intervention and may benefit from early retransplantation.

Long-term outcome of hepaticojejunostomy with routine access loop formation following iatrogenic bile duct injury

BACKGROUND

Hepaticojejunostomy is the 'gold standard' procedure for repairing iatrogenic bile duct injuries. The aim of this study was to examine the long-term outcome following hepaticojejunostomy for iatrogenic bile duct injury and the utility of routine construction of an access loop.

METHODS

Patients with iatrogenic biliary injuries were treated with hepaticojejunostomy and access loop by a single surgeon. Injuries were classified according to the Bismuth level. An 'excellent' outcome was achieved if the patient never experienced jaundice or cholangitis in the follow-up period, and the outcome was 'good' if the patient developed symptoms but was asymptomatic for more than 12 months.

RESULTS

Forty-eight patients underwent such operation. There was one operative death. Thirty-three patients were followed for 3 years or more (mean follow-up 80.4 (range 46-118) months). Thirteen of the 33 injuries were Bismuth level II, 13 were Bismuth level III and seven were Bismuth level IV. Outcome was dependent on the Bismuth level (P < 0.001). It was excellent in all 13 patients with Bismuth level II injuries, excellent in seven and good in six of the 13 patients with Bismuth level III injuries, and excellent in one and good in six of the seven patients with Bismuth level IV injuries. Moreover, the need for access loop intervention was dependent on the Bismuth level (P < 0.001). No patient with Bismuth level II injury required intervention, compared with five of 13 with Bismuth level III and six of seven with Bismuth level IV injuries.

CONCLUSION

Biliary reconstruction affords satisfactory long-term outcome. The likelihood of needing the access loop for radiological intervention is dependent on the Bismuth level. The authors recommend that an access loop be constructed in all patients with Bismuth level III and IV injuries.

Using MR cholangiopancreatography to evaluate iatrogenic bile duct injury

OBJECTIVE

The purpose of this study was to assess the role of MR cholangiopancreatography (MRCP) in the evaluation of iatrogenic bile duct injuries.

SUBJECTS AND METHODS

In this prospective study, MRCP was performed in 10 postoperative patients (nine female and one male, ranging in age from 17 to 79 years) suspected of having bile duct injury as a result of surgery. Presence or absence of biliary dilatation, excision injury, stricture, fluid collection, and free fluid was noted. Excision injury was diagnosed if a segment of bile duct was not visible on any of the MRCP sequences. Positive cases were classified according to anatomic location and extent of injury. Results were compared with endoscopic retrograde cholangiopancreatography in five patients, percutaneous transhepatic cholangiography in one, surgery in four, and clinical follow-up in three.

RESULTS

Three patients had normal findings on MRCP and remained asymptomatic on clinical follow-up. Four patients had bile duct excision injury on MRCP that was surgically proven, and one had stricture, confirmed by percutaneous transhepatic cholangiography. Of these five patients, one had Bismuth type I injury, two had type II, one had type III, and one had type IV. Two patients had findings suggestive of cystic duct leak on MRCP that were confirmed on cholangiography.

CONCLUSION

MRCP can accurately diagnose postoperative biliary strictures and excision injuries and can characterize and anatomically classify these injuries for planning reparative surgery. It can also suggest the presence of cystic duct leaks in patients who have undergone cholecystectomy.

Ultrasound guidance in accessing the afferent limb of a modified Roux-en-Y choledochojejunostomy for percutaneous dilation of biliary strictures

Percutaneous retrograde biliary dilation via the afferent limb of a modified Roux-en-Y choledochojejunostomy is used in the management of chronic biliary strictures. Access to the afferent loop may be challenging in the absence of surgically placed radiopaque markers. Ultrasound (US) guidance was used to access the loop in 10 patients with subcutaneous afferent loops and three patients with subfascial afferent loops. Successful puncture was made in all 10 patients with subcutaneous loops and in one patient with a subfascial loop. Initial fluoroscopically guided attempts failed in five loops, which were then successfully accessed with use of US guidance. US is useful in accessing subcutaneous afferent loops.

A subcutaneous or subfascial jejunostomy is beneficial in the surgical management of extrahepatic bile duct cancers

BACKGROUND

Extrahepatic bile duct cancers are rare tumors with a dismal prognosis. Even after a resection, obstructive cholestasis and other biliary complications are the rule. To facilitate retrograde access to the biliary tree for treatment of such biliary complications, a modified Roux-en-Y hepaticojejunostomy is constructed such that the afferent limb is brought up as a subcutaneous or subfascial jejunostomy (SJ). The safety and utility of construction of an SJ was evaluated in patients with extrahepatic cholangiocarcinoma.

METHODS

From 1985 to 1997, 24 patients with extrahepatic bile duct cancers received an SJ as part of their management. Demographic data, operative data, tumor characteristics, and postoperative courses were retrospectively reviewed. All but 3 patients were followed to the time of death.

RESULTS

The average age of the patients was 62 +/- 9 years. The tumor was resected in 17 patients. Major complications occurred in 5 patients (21%). There was 1 operative death (4%). None of the complications could be attributed to construction of the SJ, although 1 patient had a soft tissue infection at the site of the percutaneous access of the SJ. Frequent dilatations of biliary strictures were required in 5 patients, and 1 patient eventually required insertion of an internal biliary stent. These procedures could all be accomplished through the SJ.

CONCLUSIONS

The SJ is a technically simple and safe addition to the management of resectable and unresectable extrahepatic bile duct cancers, particularly proximal lesions. The procedure facilitates brachytherapy if indicated, and it allows convenient management of postoperative biliary complications, including recurrent strictures.

Current Management of Recurrent Pyogenic Cholangitis

Recurrent pyogenic cholangitis (RPC) is a chronic disease with multiple exacerbations requiring repeated biliary dilatation and stone removal. Even after adequate biliary drainage, most patients will have progression of intrahepatic disease. Management of patients with RPC is a multidisciplinary challenge for endoscopists, interventional radiologists, and surgeons because of the frequency and inaccessibility of strictures and stones. Complete stone clearance at any one operation is difficult. Hepaticojejunostomy with a subcutaneous afferent limb is a safe and effective way to provide access to the biliary tree for the management of patients with RPC. In our experience, trans-stomal cholangioscopic stricture dilatation followed by stone removal remains the basis of therapy in patients with RPC. By diligent surveillance, we should be able to eliminate or decrease the number of stones and prevent cholangitis and its sequelae.

Subparietal hepaticojejunal access loop for the long-term management of intrahepatic stones

BACKGROUND

The subparietal hepaticojejunal biliary access loop is a recognized technique for the long-term management of primary intrahepatic stone disease. This paper assesses the results of this approach in a series of South African patients.

METHODS

Between 1985 and 1997, 21 patients, of mean age 34 (range 24-66) years, underwent surgical extraction of intrahepatic stones and formation of an hepaticojejunal access loop. The access loop was subsequently used for further stone removal and stricture dilatation. Patients were followed prospectively (median 47 months) and details of the number and type of procedures performed, stone clearance rates, morbidity and subsequent outcome were recorded.

RESULTS

The distribution of intrahepatic stones was left lobe in 13 of 21 patients, right lobe in one and bilateral in seven. Six patients underwent additional left lobectomy at the initial operation because of associated atrophy of the left lobe. Following operation, stone removal and/or stricture dilatation was performed on 97 occasions (median 4 (range 0-24) procedures per patient). Complete stone clearance was achieved in 17 of 21 patients with partial clearance in the remaining four. There were no major complications and no deaths associated with the procedures.

CONCLUSION

The subparietal access loop permits long-term access to the intrahepatic ducts allowing removal of stones and dilatation of strictures with minimal patient discomfort and low morbidity.

Percutaneous dilatation of biliary strictures through the afferent limb of a modified Roux-en-Y choledochojejunostomy or hepaticojejunostomy

BACKGROUND

This report is a 13-year prospective evaluation of percutaneous balloon dilatation of benign biliary strictures through the subcutaneous or subfascially positioned afferent limb of a choledocho or hepaticojejunostomy in 30 patients.

DATA SOURCE

Twenty-seven strictures developed after a common duct injury sustained at the time of cholecystectomy, two after hepatectomy reconstruction for trauma and one following a gastrectomy. Twelve injuries (40%) were recognized at operation. Of the 18 patients where the injury was unrecognized at the time of operation, 8 had not been reoperated at the time of referral, 7 had late repairs by the referring physician, and 3 had late repairs at our institution. The follow-up is 1 to 13 years.

RESULTS

There has been 1 late death and 6 patients are lost alive. The jejunal-limb was accessed 50 times with two minor and no major complications. There have been two parajejunal hernia repairs, but there have not been any reoperations for recurrent biliary strictures.

CONCLUSIONS

Benign biliary strictures can be effectively managed by repeat balloon dilatations thru the afferent limb of a choledocho or hepaticojejunostomy, thus eliminating the need for repeat surgical interventions.

Atraumatic method of intraoperative retrograde transhepatic biliary stent insertion

A significant risk of hepatic injury remains using reported methods of intraoperative retrograde transhepatic stenting (IRTS). Our hypothesis was that we could minimize this risk by: (1) using a pliable sheath to create a stent tract that follows the curve of the biliary tree, (2) decreasing the stent diameter, and (3) avoiding the hepatic hilum. We evaluated the safety of a novel technique of intraoperative stenting employing these three concepts. Twenty-four patients underwent IRTS between 1992 and 1995 at our institution after potentially curative resection (one bypass). Malignant disease was present in 22 of 24 patients. Bile ducts were normal caliber in all patients. There was no operative mortality and 38% operative morbidity, all readily treated. All complications were due to stent dislodgment. There were no deaths. This novel atraumatic method of IRTS has acceptable morbidity and mortality. Complications due to stent insertion are minimal. The technique compares favorably with previous methods of IRTS and offers a viable alternative to the surgeon when a transhepatic stent is required. Anchoring the stent securely to the skin is essential to prevent catheter dislodgement.

Operative enteroscopy. A useful tool in the evaluation and intervention of bilioenteric anastomoses

Roux-en-Y hepaticojejunostomy is the procedure of choice in the management of patients with major bile duct injuries. In instances of anastomotic stricture, this anastomosis is inaccessible to conventional endoscopy. A technique is described for assessment and intervention of bilioenteric anastomoses that escape the reach of conventional endoscopy. Three cases are presented illustrating the feasibility of open and laparoscopic-assisted small-bowel endoscopy. All patients presented with recurrent cholangitis and had multiple interventions in their biliary tree prior to referral. At operation, the limb of jejunum going to the bilioenteric anastomosis was identified, an enterotomy was made, and a flexible endoscope was passed to evaluate the anastomosis. In two cases the anastomosis was revised by endoscopically excising scar tissue. In the third case the anastomosis was patent and unnecessary intervention was avoided. There was no morbidity or mortality and the patients had complete resolution of their symptoms. Operative endoscopy appears to be useful in the evaluation and intervention of bilioenteric anastomoses that cannot be evaluated by conventional endoscopy.

The Hutson loop and prosthesis: clinical uses in hepato-biliary intervention

A number of method of making a Roux-en-Y hepaticojejunostomy have been advocated to help the radiologist gain access to the biliary system. We have found markers and rings unsatisfactory and therefore designed and tested our own prosthesis. Reliable rapid access is easily achieved using this device with a much reduced radiation dose to both patient and radiologist. The prosthesis has been used for the past 3 years, and the last 23 patients are reviewed. Seven patients have required repeated interventions via the loop and we present the findings and our results.

Incidence, timing, and management of biliary tract complications after orthotopic liver transplantation

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A review of the management of iatrogenic bile duct injuries

Injuries to the extrahepatic biliary tree occurring during cholecystectomy or other upper gastrointestinal surgical procedures are not uncommon. The consequences are often catastrophic. We report the results of a personal series of bile duct repairs from a tertiary referral centre over a twenty-one year period. A total of 33 patients were referred. Percutaneous transhepatic cholangiography was the radiological investigation of choice to outline the biliary system. Percutaneous transhepatic dilatation was performed in six patients and 22 patients had either primary surgical repair, or reconstruction of their biliary tree performed by hepaticojejunostomy with an 80 cm Roux-en-Y limb. Of these only two have required revision surgery. We recommend early referral of patients with recognised iatrogenic injuries to specialist hepatobiliary units with no attempt at repair prior to referral.

Intrahepatic stones. The transhepatic team approach

OBJECTIVE

The authors reviewed the combined interventional radiologic and surgical management of 54 patients with intrahepatic stones at the Johns Hopkins Hospital. The team approach used large-bore transhepatic stents to access the intrahepatic ducts until they were stone free.

SUMMARY BACKGROUND DATA

Intrahepatic stones are uncommon in western countries. As a result, few American institutions have had much experience, and multiple management algorithms have been suggested. Nonoperative, operative, and combination surgical and nonoperative approaches have been advocated. At Johns Hopkins, combined surgical and percutaneous management has been used for 18 years.

METHODS

This team approach includes (1) percutaneous placement of transhepatic access catheters, (2) surgery for underlying biliary disease and stone removal, and, when necessary (3) postoperative percutaneous choledochoscopy and stone removal through the transhepatic stents.

RESULTS

The median age of the 54 patients was 50 years, and 32 were men. Biliary disease included 27 benign strictures, 7 sclerosing cholangitis, 5 choledochal cysts, 5 parasitic infections, 5 choledocholithiasis, and 5 biliary tumors. Fourteen patients (26%) were treated exclusively with percutaneous techniques. Forty patients (74%) had surgery, including 36 Roux-en-Y hepatico- or choledochojejunostomies with large-bore transhepatic stents. Eighteen of these 40 patients (45%) with multiple intrahepatic stones, strictures, or both required additional procedures after operation. No hospital deaths occurred after any of the percutaneous or surgical procedures. With a mean follow-up of 60 months, 94% of patients were stone free, 87% of patients were symptom free, and 73% have had their transhepatic stents removed.

CONCLUSIONS

A combined radiologic and surgical approach with transhepatic stents is a safe and effective method for managing intrahepatic stones.

Aggressive surgical therapy for Klatskin tumors

Thirty-one patients underwent limited hepatic resection with Roux-en-Y biliary-enteric anastomosis and placement of biliary stents for cholangiocarcinoma of the hepatic duct bifurcation (Klatskin tumor). Resection included wide tumor excision and bile duct resection at the liver hilum without major hepatic resection and was undertaken in all patients unless precluded by intraoperative evidence of vascular invasion. All patients were operated on by a single surgeon during the 10 years between 1981 and 1991. Similar procedures were performed for both curative (n = 17) and palliative (n = 14) treatment of this disease entity. In this series, the overall mean postoperative survival of these patients was 17 months. The mean postoperative survival of patients undergoing surgery with curative intent was 21 months in contrast to 12 months for those undergoing planned palliation. One patient in this series has been alive for more than 6 years with no evidence of disease. Five patients experienced major postoperative complications (16%), and there were two perioperative deaths (6%). This retrospective review supports an aggressive surgical approach in patients with Klatskin tumor.

Appraisal of hepaticocutaneous jejunostomy in the management of hepatolithiasis

Hepaticocutaneous jejunostomy offers the advantage of permanent percutaneous access to the biliary tract in patients with complex biliary problems. The long-term value, however, has not been assessed. In 41 patients who underwent this procedure for intrahepatic stones, there was no hospital mortality, and the postoperative morbidity rate was 10%. The presence of the cutaneous stoma facilitated postoperative flexible choledochoscopy for dilatation of biliary strictures and extraction of residual stones. On follow-up, symptoms recurred in 12 patients (29%) at a median time of 27 months (range: 1 to 97 months). Reconstruction of the cutaneous stoma and flexible choledochoscopy via the jejunal loop helped to resolve the acute cholangitis (n = 4) and to eradicate recurrent stones in all cases. Hepaticocutaneous jejunostomy was also beneficial in the management of three patients who experienced further recurrence of symptoms. There was no major difficulty in reconstructing the cutaneous stoma and in performing choledochoscopy via the jejunal loop. The overall complication rate related to the cutaneous stoma was 15%. Repeat laparotomy for recurrent disease was required in only one patient who underwent a second bilio-enteric anastomosis for a nondilatable left duct stricture. We conclude that hepaticocutaneous jejunostomy is a valuable procedure in the management of hepatolithiasis.

Roux-en-Y hepaticojejunostomy with subcutaneous access and the use of Gianturco stents for the management of biliary tract strictures

The need to control recurrent biliary strictures implies the practice of repeated major surgical procedures. The hepaticojejunostomy with subcutaneous jejunal access (Chen's procedure) allows the permanent option of a non-operative management of recurrent biliary tract anastomosis complications. Through the subcutaneous jejunal access, the application of a Gianturco metallic prosthesis is permitted and the correction of biliary-intestinal anastomosis strictures with non-operative methods is possible. This report is a review of a series of 20 patients treated with the Chen procedure, of whom 3 patients also had implantation of Gianturco stents via hepaticojejunostomy with subcutaneous access.

Primary sclerosing cholangitis

Primary sclerosing cholangitis is a rare disease of unknown etiology. Sclerosis of the bile ducts may actually be the final result of multiple factors such as autoimmune, bacterial, congenital, drug, or viral injury. The most commonly associated diseases are ulcerative colitis and chronic pancreatitis. Except in the earliest stages of the disease, liver histologic findings are not specific. Most patients present with jaundice, pain, and pruritus, although an increasing number of asymptomatic patients with inflammatory bowel disease and abnormal liver function are being identified. Cholangiography is key to the diagnosis and is usually pathognomonic except in the unusual case where primary sclerosing cholangitis is confused with cholangiocarcinoma. Many forms of medical therapy have been tried, including antibiotics, azathioprine, cholestyramine, colchicine, cyclosporine, D-penicillamine, steroids, and ursodeoxycholic acid. To date, none of these medications has been proved to alter the course of this disease. Recent reports of ursodeoxycholic acid trials have been encouraging, but long-term results of ongoing randomized trials have yet to be published. In recent years, balloon dilatation of biliary strictures has been accomplished via endoscopic and percutaneous transhepatic approaches. However, in patients with primary sclerosing cholangitis, these nonoperative manipulations must be done repeatedly, may entail multiple general anesthetics, and are difficult to perform. We believe that a direct surgical approach to the biliary tree with long-term transhepatic stenting is indicated in selected patients with severe hilar or extrahepatic stricturing, persistent jaundice or recurrent cholangitis, and no evidence of cirrhosis. Hepatic transplantation should be reserved for patients with primary sclerosing cholangitis who have well-established cirrhosis and have not responded to other therapeutic measures.

Surgical management of bile duct stones

The biliary surgeon in the 1990s must be familiar with all of the available techniques for the treatment of bile duct stones. Experience and judgment are important in the successful management of the individual patient with intrahepatic or extrahepatic stones. Knowledge of the nonsurgical methods of stone removal is important in the decision-making process. However, the biliary surgeon must resist the temptation to do less than a thorough removal of all stones at the operation lest the patient be subjected to additional procedures, which carry their own risks of morbidity and death. The goal should be to clear the stones from the biliary system with the fewest procedures offering the lowest morbidity and mortality risks to the patient.

Dilatation of intrahepatic biliary strictures in patients with hepatolithiasis

To investigate the role of balloon dilatation in the management of complicated hepatolithiasis with intrahepatic biliary stricture, 57 consecutive patients who received 208 sessions of dilatation in addition to the usual treatment were analyzed. The strictures were located in the right intrahepatic ducts (84.2%), left intrahepatic ducts (12.3%), or both (3.5%). Dilatation began 3-4 weeks after surgery. The routes of dilatation included the matured T-tube tract (3 cases), percutaneous transhepatic biliary drainage tracts (42 cases), and both (12 cases). The immediate overall success rate of complete stone clearance increased significantly from 0% predilatation to 94.7% postdilatation. The main complications of dilatation therapy consisted of septicemia (10.5%), hemobilia (10.5%), and mild diarrhea (80%). Eight patients (14%) with long-segment strictures received 11 postdilatation biliary stentings. Complications were 1 patient with occlusion and 2 patients with "spontaneous" hemobilia. Severe multiple strictures and coexistent secondary biliary cirrhosis were the contributing factors to complications. During the follow-up of 3.4 +/- 1.2 years, recurrence of strictures was found in 4 patients. Two of them belonged to the stenting group. The cumulative probability of restricture was low: 4% at 2 years, 6% at 2.5 years, and 8% at 3 years. We conclude that in complicated cases of hepatolithiasis with intrahepatic biliary stricture, dilatation and stenting are good adjuvant therapies.

Percutaneous management of benign biliary strictures with balloon dilation and self-expanding metallic stents

Seventy patients with benign biliary strictures were treated by means of percutaneous balloon dilation and stenting. Patients with stenoses relapsing during catheter stenting (18/70) were treated with self-expanding metallic stents. Results were evaluated in 56 patients; in patients without sclerosing cholangitis (n = 47) the patency rate with both modalities of treatment was 96%, while in the patients with secondary sclerosing cholangitis (n = 9), it was 33%, for a total success rate of 86%. The average follow-up was 23 months (range 3-72 months). Major complications included one death for septic shock (1%), three severe hemorrhages (4%), two of which required arterial embolization, two pleural effusions (3%), and one liver abscess following arterial embolization. Moderate fever for 1-2 days was a common finding after percutaneous puncture and balloon dilation. Percutaneous management of benign biliary strictures so far has been attempted only in surgical failures or in complicated cases. In view of our midterm results it may well become the initial treatment in many patients.

Hepaticodochojejunostomy with afferent limb: CT anatomy

Hepaticodochojejunostomy with an afferent limb constructed to provide a permanent access route for retrograde biliary dilation has been described. The computed tomographic (CT) scans of 12 patients who had undergone this procedure were reviewed. The appearance of the afferent limb from its position within the subcutaneous tissues to its anastomosis with the biliary tree is described and illustrated. Recognition of the limb as a surgical pathway is important because familiarity with its anatomy will avoid errors in CT interpretation and aid in successful transjejunal catheterization of the bile ducts.

Benign postoperative biliary strictures. Operate or dilate?

At The Johns Hopkins Hospital from 1979 through 1987, 42 patients had 45 procedures for benign postoperative biliary strictures. Three patients were managed with both surgery and balloon dilatation. Twenty-five patients underwent surgical repair with Roux-Y choledocho- or hepaticojejunostomy with postoperative transhepatic stenting for a mean of 13.8 +/- 1.3 months. Twenty patients had balloon dilatation a mean of 3.9 times and were stented transhepatically for a mean of 13.3 +/- 2.0 months. The two groups were similar with respect to multiple parameters that might have influenced outcome. Mean length of follow-up was 57 +/- 7 and 59 +/- 6 months for surgery and balloon dilatation, respectively. No patients died after any of the procedures. The same definition of a successful outcome was applied to both groups and was achieved in 88% of the surgical and in only 55% of the balloon dilatation patients (p less than 0.02). Significant hemobilia occurred more often with balloon dilatation (20% vs. 4%, p less than 0.02). The total hospital stay and cost of balloon dilatation was not significantly different from surgery. We conclude that surgical repair of benign postoperative strictures results in fewer problems that require further therapy. Nevertheless balloon dilatation is an alternative for patients who are at high risk or who are unwilling to undergo another operation.

The radiology of jaundice

Ultrasonography is the most useful technique for screening patients with suspected obstructive jaundice. Additional information may be gained with CT when US fails either because of disturbing gas-filled loops of bowel or because the patient is obese. A more specific diagnosis is usually obtained from the ERCP which can be combined with percutaneous biopsy and drainage of obstructed bile ducts. PTC and PTCD are left for those patients in whom ERCP has failed.

The role of nontransplant procedures for sclerosing cholangitis

Twenty-five of 38 patients with sclerosing cholangitis underwent operative therapy at our institution. Seven patients with primarily extrahepatic obstruction had biliary bypass procedures and maintained normal liver function for 1 to 96 months. Biliary procedures were performed in 11 patients with combined intrahepatic and extrahepatic disease. Seven patients underwent subsequent liver transplantation because of deteriorating hepatic function, and two patients died before transplantation could be performed. Although there were no significant differences in outcome of liver transplantation whether or not a biliary procedure had been performed previously, previous biliary tract procedures influenced the type of biliary reconstruction performed, and two complications occurred as direct results of prior operations. Nontransplant procedures should be restricted to those patients with primarily extrahepatic obstruction, whereas liver transplantation should be considered the initial procedure of choice for patients with diffuse sclerosing cholangitis.

Combined surgical and radiologic approach to recurrent cholangitis and intrahepatic pigment stones

A 37-yr-old white woman from Australia presented with ascending cholangitis and jaundice and was found to have multiple brown, "earthy" pigment stones in the biliary tree, including the segmental ducts. Removal of these stones was accomplished via a subcutaneously placed afferent jejunal limb of a choledochojejunostomy using balloon dilators. The jejunal conduit also served as an access for periodic removal of newly formed stones. This combined surgical and radiologic approach is an effective way of removing recurring pigment stones. The afferent jejunal limb can also be used to perfuse dissolution agents, if necessary, via catheters placed in the biliary tree.