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494
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Fig. 7 Parenchyma
transection (a) and control
of left hepatic duct (b).
(Reprinted from Atlas of
Upper Gastrointestinal and
Hepato-Pancreato-Biliary
Surgery, 2nd ed., Ebata T,
Nagino M, Right
Hepatectomy (Resection of
Segments 5, 6, 7, 8, and 1)
with Bile Duct Resection.
637–647, Copyright
(2016), with permission
from Springer) [14]
J. D. de MeiraJúnior and I. D. Rosado
a
b
The left liver is mobilized through the division of the falciform, the left coronary
and the left triangular ligaments, and the lesser omentum. Next, the middle and left
hepatic veins are exposed, and the caudate lobe is mobilized with ligation and division of the short hepatic veins. Next, the distal end of the Arantius ligament is
ligated and divided. Parenchymal transection is then performed according to the
surgeon’s preference. The left hepatic vein is then encircled and stapled or sutured
after the division between clamps. After completion of the liver transection, the
surgical specimen is connected only by the hilar plate containing the right hepatic
duct [15].
The right hepatic duct is identied behind the middle hepatic vein, and the posterior wall is carefully detached from the right anterior branch of the proper hepatic
artery. Then, the right ducts are divided, and the specimen is removed (Fig.8). If
additional resection is feasible, the intrahepatic bile duct margins are sent for frozen
section examination [15].
ab
Perihilar Cholangiocarcinoma
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Fig. 8 Division of right anterior (a) and posterior (b) hepatic ducts in left hepatectomy. (Reprinted
from Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, 2nd ed., Cherqui D,
Bismuth, Shimizu H, Miyazaki M, Left-sided Hepatectomy (Left Hemihepatectomy or Left
Trisectionectomy) Extending to the Caudate Lobe with Bile Duct Resection for Perihilar
Cholangiocarcinoma. 649–661, Copyright (2016), with permission from Springer) [15]
495
7 Biliary Reconstruction
Biliary reconstruction is performed in a Roux-en-Y fashion. First, a 40cm-long
jejunal limb is lifted in a retro colic route. Next, bile duct orices are grouped as
much as possible to reduce the number of anastomoses required (Fig.9). Finally, the
hepaticojejunal anastomosis is performed with 5-0 absorbable interrupted sutures
with a water-tight, mucosa-to-mucosa approximation [16].
The anterior layer of the suture is placed on the bile duct to facilitate lumen exposure. The posterior wall is then anastomosed. In small ducts, biliary stents can be
placed through the anastomosis, exteriorized through the intestinal wall in a Witzel
fashion, and exteriorized through the abdominal wall. The anterior layer is then
anastomosed with the previously placed sutures.
Due to the high risk of bile leak (up to 47%) [17], a sizeable abdominal drain is
placed close to the hepaticojejunal anastomosis.
The reported perioperative morbidity is up to 80%, with close to 60% of severe
complications. Clinically relevant post-hepatectomy liver failure may occur in up to
22.5% of patients. Perioperative mortality related to hepatectomy due to h-CCA
ranges from 4% to 14%, and the 5-year survival from 17% to 43%. Recurrence may
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J. D. de MeiraJúnior and I. D. Rosado
a
Fig. 9 Technique of biliary reconstruction: reducing the number of anastomosis (a) and placing
the sutures in the anterior layer rst to improve the view of the ductal lumen (b). (Reprinted from
Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, 2nd ed., Cherqui D,
Bismuth, Shimizu H, Miyazaki M, Left-sided Hepatectomy (Left Hemihepatectomy or Left
Trisectionectomy) Extending to the Caudate Lobe with Bile Duct Resection for Perihilar
Cholangiocarcinoma. 649–661, Copyright (2016), with permission from Springer) [15]
b
occur in 60% of patients even after R0 resections; the main risk factors for recurrence are lymph node metastasis and microscopic venous invasion. However, even
in patients without these risk factors, recurrence may reach 30% in 5years and 50%
in 10years [17].
Although the tumor location frequently dictates the side of the hepatectomy, in
some Bismuth II or Bismuth IV cases, the surgeon can choose the side of the resection, and there is an ongoing debate about which side is better. In a recent multicentric study [17], right hepatectomy was associated with a higher mortality when
compared to left hepatectomy. In addition to higher morbidity and post- hepatectomy
liver failure rate. This same study advocated against the “no touch technique” proposed by some groups who performed portal vein resection as a standard of the
procedure, as it was correlated with worse morbidity, liver failure, and mortality
rates. Portal vein resection should be performed only when the vessel cannot be
freed from the tumor during hepatoduodenal ligament dissection. Most authors do
not recommend arterial resection.
Surgery for h-CCA is performed mainly with the open approach, as laparoscopy
lacks the direct palpation of the hilar structures and adds technical difculty to the
lymphadenectomy and hepaticojejunostomy. The robotic approach was associated
with higher morbidity and expenditure and is not currently supported.
Adjuvant therapy with chemotherapy or chemo-radiation is still controversial.
The only evidence-based recommendation is a 6-month course of capecitabine.
Adjuvant radiation therapy may be considered for patients with residual disease
(positive margin) or those at high risk of recurrence (positive nodes). However,
there needs to be better quality evidence to support this strategy [18].
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497
References
1. Kirstein MM, Vogel A. Epidemiology and risk factors of cholangiocarcinoma. Visc Med.
2016;32:395–400.
2. Nakeeb A, Pitt HÁ, Sohn TA, etal. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar,
and distal tumors. Ann Surg. 1996;224:463–73.
3. DeOliveira ML, Cunningham SC, Cameron JL, et al. Cholangiocarcinoma: thirty-one-year
experience with 564 patients at a single institution. Ann Surg. 2007;245:755–62.
4. Jarnagin W, Winston C.Hilar cholangiocarcinoma: diagnosis and staging. HPB. 2005;7:244–51.
5. Lauterio A, De Carlis R, Centonze L, etal. Current surgical management of peri-hilar and
intra-hepatic cholangiocarcinoma. Cancers. 2021;13(15):3657. https://doi.org/10.3390/
cancers13153657.
6. Soares KC, D’Angelica MI, Jarnagin WR.Extrahepatic biliary tumors. In: Jarnagin WR, editor. Blumgart’s surgery of the liver, biliary tract and pancreas. 7th ed. Philadelphia: Elsevier;
2017. p.724–41.
7. Lidsky ME, Jarnagin WR. Surgical management of hilar cholangiocarcinoma at memorial sloan kettering cancer center. Ann Gastroenterol Surg. 2018;2(4):304–12. https://doi.
org/10.1002/ags3.12181.
8. Nagino M.Perihilar cholangiocarcinoma: a surgeon’s perspective. ILIVER. 2022;1(1):12–24.
https://doi.org/10.1016/j.iliver.2022.03.004.
9. Wiggers JK, Groot Koerkamp B, Cieslak KP, etal. Postoperative mortality after liver resection
for perihilar cholangiocarcinoma: development of a risk score and importance of biliary drainage of the future liver remnant. J Am Coll Surg. 2016;223:321–31.
10. Shindoh J, Truty MJ, Aloia TA, etal. Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal
liver metastases and small future liver remnant. J Am Coll Surg. 2013;216(2):201–9.
11. Cherqui D, Bismuth H.Resection hilar cholangiocarcinoma with en bloc hepatectomy. In:
Khatri VP, editor. Atlas of advanced operative surgery. 1st ed. Philadelphia: Elsevier; 2013.
p.324–37.
12. Gilbert RWD, Lenet T, Cleary SP, et al. Does caudate resection improve outcomes of
patients undergoing curative resection for perihilar cholangiocarcinoma? A systematic
review and meta-analysis. Ann Surg Oncol. 2022;29(11):6759–71. https://doi.org/10.1245/
s10434- 022- 11990- 7.
13. Lenet T, Gilbert RWD, Smoot R, etal. Does intraoperative frozen section and revision of
margins lead to improved survival in patients undergoing resection of perihilar cholangiocarcinoma? A systematic review and meta-analysis. Ann Surg Oncol. 2022;29:7592–602. https://
doi.org/10.1245/s10434- 022- 12041- x.
14. Ebata T, Nagino M.Right hepatectomy (resection of segments 5, 6, 7, 8, and 1) with bile duct
resection. In: Clavien PA, Sarr M, Fong Y, Miyazaki M, editors. Atlas of upper gastrointestinal
and hepato-pancreato-biliary surgery. 2nd ed. Berlin: Springer; 2016. p.637–47. https://doi.
org/10.1007/978- 3- 662- 46546- 2_71.
15. Shimizu H, Miyazaki M. Left-sided hepatectomy (left hemihepatectomy or left trisectionectomy) extending to the caudate lobe with bile duct resection for perihilar cholangiocarcinoma. In: Clavien PA, Sarr M, Fong Y, Miyazaki M, editors. Atlas of upper gastrointestinal
and hepato-pancreato-biliary surgery. 2nd ed. Berlin: Springer; 2016. p.649–61. https://doi.
org/10.1007/978- 3- 662- 46546- 2_72.
16. Miyazaki M, Shimizu H.Intrahepatic bilioenteric anastomosis. In: Clavien PA, Sarr M, Fong
Y, Miyazaki M, editors. Atlas of upper gastrointestinal and hepato-pancreato-biliary surgery.
2nd ed. Berlin: Springer; 2016. p.663–7. https://doi.org/10.1007/978- 3- 662- 46546- 2_73.
17. Mueller M, Breuer E, Mizuno T, etal. Perihilar cholangiocarcinoma– novel benchmark values
for surgical and oncological outcomes from 24 expert centers. Ann Surg. 2021;274(5):780–8.
https://doi.org/10.1097/SLA.0000000000005103.
18. Shroff RT, Kennedy EB, Bachini M, etal. Adjuvant therapy for resected biliary tract cancer:
ASCO clinical practice guideline. J Clin Oncol. 2019;37(12):1015–27.
Biliary Bypass
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MiguelAngelMercado andGabrielaDelAngelMillán
1 Introduction
Biliary bypass surgery consists in creating a new route for biliary ow in patients
who have a disrupted bile ow due to malignant and benign diseases causing
obstruction or disruption of the biliary tract.
When a biliary drainage is needed is usually preferred less invasive routes such a
endoscopically or percutaneous approach, but in some cases a surgical approach
provides a long-term resolution with better quality of life for these patients.
2 Surgical Indications
The need of a biliary bypass surgery can be due to many causes. The most common
cause of extrahepatic biliary obstruction is due to choledocholithiasis, biliary structures, sclerosing cholangitis, periampullary tumors, pancreatic tumors and congenital choledochal cysts. Also, biliary tract disruption due to iatrogenic injuries during
cholecystectomy is also a common indication for biliary bypass surgery [1].
Even though these are the most common causes for obstructive jaundice, most of
them now a days can be treated with endoscopic or percutaneous interventional techniques, leaving surgery as a resource in case of failure of less invasive tools, or as the
rst choice in patients with a complete disruption of the biliary tract, choledochal
cysts, and respectable tumors of extrahepatic bile duct or pancreatic head and ampulla.
M. A. Mercado (*) · G. D. A. Millán
Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán,
Ciudad de México, México
e-mail: miguel.mercadod@incmnsz.mx
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_41
499© The Author(s), under exclusive license to Springer Nature
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M. A. Mercado and G. D. A. Millán
3 Preoperative Assessment
3.1 Dene theAnatomy
Is mandatory when planning a biliary bypass to have a complete knowledge of the
anatomy and cause of the obstruction or disruption of the biliary tract.
Ideal preoperative image to delineate the biliary anatomy is a magnetic cholangio magnetic resonance, other options that can help dening the anatomy before the
surgery are cholangiography percutaneously or endoscopically, and CT scan to
dene properly the causes of obstructive jaundice [2].
3.2 Surgical Preparation
Patients undergoing a biliary bypass should be in the best general condition. This
refers to control sepsis, cholangitis, or intraabdominal collections. Hydroelectricity
disorders and anemia should be managed before an elective surgery. When necessary endoscopic or percutaneous drainage should be performed earlier the surgical
approach.
Also, the time of the repair will be chosen in order to avoid the inammatory
phase in cases where a previous surgery or iatrogenic injuries had occurred.
Surgery is planned when the patient is stable, without sepsis and preferable without hyperbilirubinemia [3].
4 Operative Technique
There are different techniques for creating a biliary bypass, the most common so far
are bilio-enteric anastomosis as an hepaticojejunostomy in Roux en Y, and choledochoduodenostomy. Other types of Biliary bypass surgeries are hepatoportoenterostotomy and choledochojejunostomy. Nowadays these techniques are also widely
performed trough minimally invasive approaches.
4.1 Hepaticojejunostomy
Access to the biliary tract is achieved by a subxiphoid midline incision, Kocher incision or subcostal with a left extension if necessary. Once in the abdomen adhesions
are sectioned if present.
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Fig. 1 Bile duct
exploration and extension
into the left duct to widen
the conuence
501
Hilar dissection most be performed carefully to avoid injury of arterial branches,
once the biliary tract or remanent of biliary duct is found the hilar plate is sectioned
and the rest of the hilum is retracted caudally. If bile leak is identied, this bile dilators are inserted to identify the main ducts. If conuence is preserved, the dilator is
placed in the left duct and the anterior aspect of the common bile duct is sectioned
in direction to the left duct. Small arterial bleeding from arteries of the bile duct is
controlled with single stiches of 5-0 absorbable monolament suture (Fig.1).
The purpose of this extension is to widen the conuence and perform a highquality anastomosis.
The success of a biliary bypass depends on several factors, the free-tension anastomosis, wide and having a full contact between mucosa and biliary epithelium are
those considered to be most relevant. Having non-scared, non-inamed and nonischemic tissues are also important keys for obtaining a high-quality anastomosis.
In some cases, in order to have these characteristics in the biliary duct is necessary to expose the conuence. This is achieved through the removal of the hilar plate
and liver parenchyma partially removing segments IV and V.This allows to expose
the ducts and to perform a mucosa-epithelium anastomosis with adequate placement of the jejunal limb [2].
Once the conuence is exposed and it has an adequate diameter the anastomosis
is performed. Our preferred technique is to place separate everted stiches with an
absorbable monolament suture. In patients with a dilated common bile duct and
healthy tissue a running suture can also be performed (Fig.2).
Sometimes because of an iatrogenic injury, ducts can be found separated, if distance between right and left hepatic duct is less than 1cm a neoconuence can be
created by placing everted stiches approaching medial and lateral margins of the
right and left ducts.
Once the biliary-enteric anastomosis is completed, the enteric anastomosis is
made creating a Roux en Y manually or with stapler.
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Fig. 2 Biliary-enteric
anastomoses is performed
with separated stiches with
an absorbable suture
M. A. Mercado and G. D. A. Millán
4.2 Choledochoduodenostomy
This type of anastomosis is feasible when the dilated common bile duct relies in
close proximity with the duodenum, this type of biliary bypass has the advantage to
be a quick and easy procedure with little modication to the normal anatomy, it is
an option for elderly patients with benign causes of obstructive jaundice.
First step is to remove the gallbladder if still in place. Peritoneum of the hepatoduodenal ligament is incised to expose the anterior aspect of the common bile duct.
Mobilization of the duodenum is then achieved with a Kocher maneuver to free the
duodenum from posterior attachment and allowing a free-tension anastomosis. A
longitudinal incision is made in the dilated common bile duct approximate of 2cm
long, this incision should be long enough to avoid future stenosis; a longitude incision is performed on the duodenum to match the one made in the biliary tract.
Corner sutures can be placed to facilitate the construction of the anastomosis, this
could be performed with separate stiches or running suture with an absorbable
monolament suture [4].
An abdominal drain can be placed to identify any complication as biliary leak.
Although this is not mandatory and should be individualized.
4.3 Hepatoportoenterostomy
When conuence or hepatic ducts lie deep intrahepatic posterior to the resection of
the base of segments IV and or V base a hepatoportoenterostomy can be performed.
The anastomosis is performed with separated stiches direct into the liver
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parenchyma and or the hilar plate to the jejunal limb, this allows the bile to ow
direct into the jejunum. [5].
Hepatoportoenterostomy is a last resource for patients with no extrahepatic bile
duct, it represents a temporal pathway for a biliary bypass although most cases
progress to stenosis [2] (Figs.3 and 4).
Fig. 3 When separated
ducts are found with a high
intrahepatic location,
resection of base of
segments IV and V is
performed. The hilar plate
between both ducts is used
to perform the anastomoses
Fig. 4 The anastomosis is
performed with separated
stiches directly to the hilar
plate and liver parenchyma
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M. A. Mercado and G. D. A. Millán
5 Outcomes
The reported incidence of postoperative complication following a biliary bypass
range between 3% and 43%. Most common complications after a biliary-enteric
anastomosis are anastomotic leak and late biliary stricture. Anastomotic leak has
been reported in 2–24% depending on the surgical indication. Biliary bypass due to
a bile duct injury has been associated to higher rates of anastomotic leak [6].
Choledochoduodenoastomosis has been associated to specic complications
such as sump syndrome and gastritis caused by biliary reux. Sump syndrome is
caused by the accumulation of debris in the distal common bile duct after a side-toside anastomosis potentially causing obstruction and cholangitis; it has been
reported in 0–8% in most series. Biliary reux gastritis has been reported to occur
in 4% to 33% of cases. Long term results are more favorable after hepaticojejunostomy, although short term results can be comparable. The choice of the type of biliary bypass depends on the diagnosis, age, previous surgeries, between other factors.
References
1. Hussain Talpur KA, Mahmood Malik A, Iqbal Memon A, Naeem Qureshi J, Khan Sangrasi
A, Laghari AA.Biliary bypass surgery—analysis of indications & outcome of different proce-
dures. Pak J Med Sci. 2013;29(3):799–802.
2. Mercado MA, Chan C, Orozco H, Villalta JM, Barajas-Olivas A, Eraña J, Domínguez
I. Long-term evaluation of biliary reconstruction after partial resection of segments IV and
V in iatrogenic injuries. J Gastrointest Surg. 2006;10(1):77–82. https://doi.org/10.1016/j.
gassur.2005.07.003.
3. Dominguez-Rosado I, Sanford DE, Liu J, Hawkins WG, Mercado MA. Timing of surgical
repair after bile duct injury impacts postoperative complications but not anastomotic patency.
Ann Surg. 2016;264(3):544–53. https://doi.org/10.1097/SLA.0000000000001868.
4. Dhote A, Micelli Lupinacci R, Peschaud F. Side-to-side choledochoduodenostomy for
common bile duct stones. J Visc Surg. 2022;159(1):59–64. https://doi.org/10.1016/j.jvisc-
surg.2021.04.007. Epub 2021 Nov 23
5. de Carvalho NMN, Torres SM, Cavalcante JCB, Ximenes ACM, Junior JAL, da Silveira
Moreira SO.Hepatoportoenterostomy surgery technique. J Pediatr Surg. 2019;54(8):1715–8.
https://doi.org/10.1016/j.jpedsurg.2018.10.041. Epub 2018 Oct 13.
6. Kadaba RS, Bowers KA, Khorsandi S, Hutchins RR, Abraham AT, Sarker SJ, Bhattacharya
S, Kocher HM. Complications of biliary-enteric anastomoses. Ann R Coll Surg Engl.
2017;99(3):210–5. https://doi.org/10.1308/rcsann.2016.0293. Epub 2016 Sep 23.
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