Treatment experience of subsequent complications after Roux-en-Y biliojejunostomy

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

Background

Despite the enormous surgical advancements in the last century, access to the biliary system is lost when a Roux-en-Y (RY) biliary drainage procedure is performed. Attempts have been made to overcome this inconvenient sequel using variations in the RY anastomosis, small bowel grafts and vascular grafts. These have been predominantly unsuccessful. An isolated vascularized gastric tube (IVGT) graft has been reported in the literature, which was successfully used for adult patients with common bile duct injuries. We have adopted the technique of using an IVGT graft for bile duct reconstruction in the paediatric patients at our institution. We reviewed our experience at our institution between January 2015 and October 2019. This was a retrospective review of all paediatric patients undergoing an IVGT graft procedure for biliary tract anatomical obstruction in the past 5 years. We looked at the indications for surgery, the demographic profile of the patients and outcomes following surgery and outlined the surgical technique used.

Results

IVGT bile duct reconstruction was performed on eight patients. Patients ranged from 2 months to 7 years, and there was an equal number of males and females. The diagnosis was made on clinical suspicion and confirmed with ultrasound (U/S) and magnetic resonance cholangiopancreatography (MRCP). There was an 87.5% resolution of biliary obstruction, and two patients who had bile leaks postoperatively were managed conservatively. Unfortunately, one patient died in the early postoperative period from sepsis due to pneumonia. Follow-up was for a minimum of 6 months and up to 5 years.

Conclusion

IVGT biliary enteric drainage is a safe, reproducible procedure that allows access to the biliary tree if required in the future. Thus, this procedure serves as an alternative, especially in limited-resource areas where interventional radiology is not available for future interventions.

Clinical efficacy of laparoscopic modified loop cholecystojejunostomy for the treatment of malignant obstructive jaundice

Objective

This study was performed to summarize our experience and investigate the safety and efficacy of laparoscopic modified loop cholecystojejunostomy for the treatment of malignant obstructive jaundice.

Methods

Thirteen patients with malignant obstructive jaundice who underwent laparoscopic modified loop cholecystojejunostomy from March 2015 to March 2016 were retrospectively reviewed. The patients’ characteristics, operation time, postoperative intestinal recovery time, length of hospital stay, postoperative bilirubin level, and complications were analyzed.

Results

The patients were followed up as outpatients for 2 years. Nine patients with pancreatic head carcinoma, one patient with periampullary carcinoma, and three patients with distal bile duct carcinoma successfully underwent laparoscopic modified loop cholecystojejunostomy. The mean operation time was 176 ± 45 minutes, and the mean length of hospital stay was 9.5 ± 2.8 days. The serum total bilirubin concentration and gamma-glutamyl transferase concentration significantly decreased on postoperative day 7. The median follow-up time was 7 months. No patients developed bile leakage or required a reoperation.

Conclusions

Laparoscopic modified loop cholecystojejunostomy is not only safe and minimally invasive, but it is also feasible for patients with malignant obstructive jaundice.

Gallstone in jejunal limb with jejunocolonic fistula 10 years after Roux-en-Y choledochojejunostomy

Roux-en-Y choledochojejunostomy is a common biliary reconstruction procedure. The collection of gallstones in the jejunal limb is a rare complication. Here we present a case of a 61-year-old Chinese female who received Roux-en-Y choledochojejunostomy 10 years ago. Diagnosis of recurrent bile duct stones accompanying infection was made before operation. She also had an abdominal mass which was possibly an intussuscepted colon or a huge fecolith. At laparotomy, an oval stone (5 cm in diameter) and 3 smaller multifaceted stones (2 cm in diameter) were found in the jejunal limb. A fistula between this jejunum and colon was also found. Although the typical manifestations of diarrhea were present, the diagnosis of a biliary colonic fistula was missed before operation. Partial colectomy was performed with the fistulous opening repaired. A T-tube was left in the jejunal limb and the mesocolon aperture was enlarged and revised. Her postoperative convalescence was uneventful. We report this case hoping to sharpen our diagnostic acumen.