Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1100_Библиотеки_им_академика_М_И_Перельмана.pdf
22 Hepatic Abscess
235
d–f). The aspirate grew Escherichia coli
Fr locking loop catheter was placed (
catheter drainage, an abscessogram was performed, which demonstrated no significant residual
weeks of active
Fig. 22.3 A 67-year-old female presented with a large symptomatic simple appearing cyst (14.4 × 11.8 × 15.9 cm) in the dome of the liver (a) and underwent laparoscopic cyst wall
fenestration and cyst wall fulguration. She was discharged home the next day but presented to the emergency department on postoperative day 7 with worsening right shoulder and flank
pain with a leukocytosis of 12.8 K/uL. A CT of the abdomen and pelvis was obtained, which demonstrated a low attenuating fluid collection with a thin rim of peripheral enhancement
adjacent to the site of prior laparoscopic cyst fenestration with a small focus of air (b). The fluid collection was accessed via an intercostal approach underneath the 11th rib posteriorly
utilizing US guidance through the rib interspaces with aspiration of serosanguinous fluid (c). A limited noncontrast CT performed after placement of the needle under US guidance
confirmed appropriate positioning of the needle and due to the concern for an infected collection, a 10
and the patient was treated with appropriate oral antibiotics. After 2
collection or communication to the biliary system and the catheter was uneventfully removed (g)
236 M. A. Woods et al.
drainage or is frankly purulent, a catheter can be
placed in the same setting utilizing the Seldinger
technique. Catheter drainage may also be performed utilizing the trocar technique and a multiside hole, locking catheter of various sizes can be
placed. Abscess drainage catheter monitoring and
care is of critical importance to ensure adequate
drainage. Abscess catheters are usually flushed
up to three times daily with sterile normal saline
to prevent clogging. The output from the catheter
should be recorded on a daily or per shift basis,
and the presence of high outputs is suggestive of
a fistula to the cavity. Clinical parameters such
as drain output, hemodynamic status, leukocyte
count, and culture results should be followed on
a daily basis in the early postprocedure period to
evaluate the patient’s clinical progress. Catheters
can be placed to either suction or gravity drainage. Passive drainage may minimize catheter occlusion secondary to aspirated debris within the
abscess cavity; however, active drainage (suction) may result in more rapid evacuation of the
abscess with opposition of the abscess cavity
wall. Patients who do not respond clinically to
percutaneous drainage catheter placement should
be further evaluated with cross-sectional imaging,
preferably CT, to assess the adequacy of catheter
placement and/or the development of new potential sites of infection. In the event of catheter
malfunction or inadequate drainage of the collection, the drainage catheter can be exchanged
over a wire for larger bore catheters; however,
in some cases of significant loculation or debris,
more than one catheter may be required for adequate percutaneous management. Another option to aid in the success of percutaneous abscess
drainage is the administration of thrombolytic
agents through the abscess drainage catheter. If
follow-up imaging demonstrates a persistent abscess cavity despite optimal drain placement and
sizing, tissue-type plasminogen activator (tPA)
can be instilled into the cavity to promote further
drainage. Common practice is to dilute 4–6
tP
A in 25
infuse through the catheter and allow it to dwell
for 30
is replaced to passive or active drainage, and the
outputs from the catheter are monitored closely.
mL of
min–1 h. Afterward, the drainage catheter
sterile 0.9
% normal saline
mg of
and
This technique can be performed from once per
day up to three times per day as long as it is effective. Thrombolytic therapy in abscess cavities can
be effective due to the presence of a fibrin matrix
within the cavity which when administered can
result in breakdown of loculations and reduction
of the viscosity of the fluid within the collection.
Thrombolytic therapy has proved to be a safe and
effective therapy even in the postoperative period
with minimal to no risk of bleeding [45]. Drainage is usually continued until the patient demonstrates clinical improvement and drainage output
is less than 10–20
time required for successful percutaneous catheter drainage is highly variable and dependent on
multiple patient and infection site factors. A fluoroscopic abscessogram can be performed prior
to catheter removal to assess the residual size of
the cavity and the presence of fistulization to the
bowel or biliary system if indicated.
Success rates for image-guided needle aspira-
tion of simple pyogenic liver abscesses less than
cm in size approach 100 % with minimal com-
5
plications
rates have varied significantly in the literature
from 66 to 100
patient factors. Higher failure rates have been
associated with the presence of advanced malignancy, particularly necrotic infected tumors, and
the presence of fistulization to an obstructed biliary system [39, 43]. Aggressive management of
biliary obstruction/injury in the setting of postoperative abscess formation is of critical importance
to ensure resolution. The risk of complications is
minimal with complications such as pneumothorax, empyema, intraperitoneal hemorrhage, and
mild pain being the most frequently reported.
[38, 41, 42]. Catheter drainage success
mL/day [46
% likely secondary
]. The length of
to abscess and
Five Key Points on How to Avoid Complications
1. Assure well-perfused liver remnant following
hepatectomy
2. Assure liver remnant has adequate biliary
drainage following hepatectomy
3. Assure biliary-intestinal anastomoses are well
perfused
22 Hepatic Abscess
237
4. Assure biliary-intestinal anastomoses are
widely patent at the time of surgery
5.
Limit biliary stents as much as possible
Five Separate Key Points on Diagnosing and/or Managing the Complication
1. Obtain contrasted CT or MRI for unexplained
postoperative fever
Utilize interventional radiologic
2.
drainage
whenever it is technically feasible
Utilize broad-spectrum antibiotics
3.
once diag-
nosed
Utilize surgical
4.
approach only for refractory
cases
Multidisciplinary team input is critical
5.
References
1. Van Buren G, Bloomston M, Hughes SJ, Winter J,
Behrman SW, Zyromski NJ, et al. A randomized
prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal
drainage. Ann Surg. 2014;259(4):605–12.
2.
Garwood RA, Sawyer RG, Thompson L, Adams RB.
Infectious
Surg. 2004;70:787–92.
3.
Farid SG, Aldouri A, Morris-Stif
Toogood GJ, Lodge JP, et
postoperative
outcome after hepatic resection for colorectal liver
metastasis. Ann Surg. 2010;251:91–100.
4. Ito H, Chandrakanth A, Gonen M, D’Angelica M,
Dematteo RP, Kemeny NE, et al. Effect of postoperative morbidity on long-term survival after hepatic
resection for metastatic colorectal cancer. Ann Surg.
2008;247:994–1002.
5. Kaibori M, Ishizaki M, Matsui K, Kwon A. Postop
erative infectious and non-infectious complications
after hepatectomy for hepatocellular carcinoma.
Hepatogastroenterology. 2011;58:1747–56.
6.
Kusano T, Sasaki A, Kai S, Endo Y, Iwaki K, Shibata
K, et al. Predictors and prognostic signicance of
operative complications in patients with hepatocellular carcinoma who underwent hepatic resection. Eur J
Surg Oncol. 2009;35(11):1179–85.
7. Neal CP, Mann CD, Garcea G, Briggs CD, Dennison
AR, Berry DP. Preoperative systemic inammation
and infectious complications after resection of colorectal liver metastases. Arch Surg. 2011;146(4):471–8.
complications after hepatic resection. Am
f G, Khan AZ,
al. Correlation between
infective complications and long-term
-
8. Njoku VC, Howard TJ, Shen C, Zyromski
Schmidt CM, Pitt HA, et al. Pyogenic liver abscess
following pancreaticoduodenectomy: risk factors,
treatment,
Surg. 2014;18(5):922–8.
9. Okabayashi T, Nishimori I,
T, Yatabe T, Maeda H, et al. Risk factors and predictors for surgical site infection after hepatic resection.
J Hosp Infect. 2009;73(1):47–53.
Sadamori H, Yagi
10.
R, Satoh D, et
after liver resection for hepatocellular carcinoma. Br
J Surg. 2013;100(1):122–9.
Virani S, Michaelson
11.
Warshaw AL, Henderson WG, et
and mortality after liver resection:
patient safety in surgery study. J Am Coll Surg.
2007;204(6):1284–92.
12. Zimmitti G, Roses R, Andreou A, Shindoh J, Curley
SA, Aloia TA, et al. Greater complexity of liver surgery is not associated with an increased incidence of
liver-related complications except for bile leak: an
experience with 2,628 consecutive resections. J Gastrointest Surg. 2013;17:57–65.
13.
Benzoni E, Molaro R, Cedolini C, Favero A, Cojutti
A, Lorenzin
analysis of causes and risk factors linked to postoperative complications. Hepatogastroenterology.
2007;54:186–9.
14. Bentrem DJ, Yeh JJ, Brennan MF, Kiran R, Pastores
SM, Halpern NA, et al. Predictors of intensive care
unit admission and related outcome for patients
after pancreaticoduodenectomy. J Gastrointest Surg.
2005;9(9):1307–12.
15. Chok KS, Ng KK, Poon RT, Lo CM, Fan ST. Impact
of postoperative complications on long-term outcome of curative resection for hepatocellular carcinoma. Br J Surg. 2009;96:81–7.
16.
Laurent C, Sa Cunha A, Couderc P
J. Inuence of postoperative morbidity on long-term
survival following liver resection for colorectal
metastases. Br J Surg. 2003;90:1131–6.
17.
Ross A, Mohammed S, Van Buren G, Silberfein EJ,
Artinyan A, Hodges SE, et al. An assessment of the
necessity
tomy. Surgery. 2013;154(3):504–11.
18. Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, BenPorat L, Little S, et al. Improvement in perioperative
outcome after hepatic resection. Analysis of 1803
consecutive cases over the past decade. Ann Surg.
2002;236:397–407.
19. Kooby DA, Stockman J, Ben-Porat L, Gonen M, Jarnagin WR, DeMatteo RP, et al. Inuence of transfusion on perioperative and long-term outcome in
patients following hepatic resection for colorectal
metastases. Ann Surg. 2003;237:860–70.
20. de Boer MT, Molenaar IQ, Porte RJ. Impact of blood
loss on outcome after liver resection. Dig Surg.
2007;24:259–64.
21. Nagino M, Kamiya J, Arai T, Nishio H, Ebata T,
Nimura Y. One hundred consecutive hepatobiliary
and long-term outcome. J Gastrointest
Yamashita K, Sugimoto
T, Shinoura S, Umeda Y, Yoshida
al. Risk factors for major morbidity
JS, Hutter M, Lancaster RT,
D, et
al. Liver resection
of transfusion during pancreaticoduodenec-
al. Morbidity
results of the
, Rullier E, Saric
NJ,
for HCC:
238 M. A. Woods et al.
resections for biliary hilar malignancy: preoperative
blood donation, blood loss, transfusion, and outcome. Surgery. 2005;137:148–55.
22.
Bhattacharjya S, Puleston J,
JS. Outcome of early endoscopic biliary drainage in
the management of bile leaks after hepatic resection.
Gastrointest Endosc. 2003;57:526–30.
23.
Lee CC, Chau GY
Loong CC, et
leakage after
cinoma. Hepatogastroenterology. 2005;52:1168–71.
24. Yamashita Y, Hamatsu T, Rikimaru T, Tanaka S, Shirabe K, Shimada M, et
resection.
25.
De Meijer VE, Kalish BT, Puder M, Ijzermans
Systematic review and meta-analysis of steatosis as
a risk factor in major hepatic resection. Br J Surg.
2010;97(9):1331–9.
26. Browning JD, Szczepaniak LS, Dobbins R, Nurember
of hepatic steatosis in an urban population in the
United States: impact of ethnicity. Hepatology.
2004;40:1387–95.
27.
Mortelé KJ, Segatto E, Ros P
radiologic-pathologic correlation. Radiographics.
2004;24(4):937–55.
28.
Young ST, Paulson EK, McCann RL, Baker ME.
Appearance
postoperative CT scans: similarity to postoperative
abscess. AJR Am J Roentgenol. 1993;160(2):275–7.
29.
Go HL, Baarslag HJ, V
Legemate DA. A comparative study to validate the
use of ultrasonography and computed tomography in
patients with post-operative intra-abdominal sepsis.
Eur J Radiol. 2005;54(3):383–7.
30.
Melamed JW, Paulson EK,
graphic appearance of oxidized cellulose (Surgicel):
pitfall in the diagnosis of postoperative abscess. J
Ultrasound Med. 1995;14(1):27–30.
31.
Chan JH, Tsui EY
ML, et
liver:
necrotic tumor. Abdom Imaging. 2001;26(2):161–5.
32.
Burke C, Alexander
role of hepatocyte-specic contrast agents in hepa-
tobiliary magnetic resonance imaging. Semin Ultrasound CT MR. 2013;43(1):44–53.
33.
Oto A, Remer EM,
MR characteristics of oxidized cellulose (Surgicel).
AJR Am J Roentgenol. 1999;172(6):1481–4.
34.
Andersson R, Saarela A,
Intra-abdominal abscess formation after major liver
resection. Acta Chir Scand. 1990;156:707–10.
35.
Nagino M, Kamiya J, Uesaka K, Sano T,
H, Hayakawa N, et
Ann Surg. 2001;233:45–50.
g P, Horton JD, Cohen JC, et
al. Diffusion-weighted MR imaging of the
distinguishing hepatic abscess from cystic or
, Lui WY, Tsay SH, King KL,
al. Risk factors associated with bile
hepatic resection for hepatocellular car-
of oxidized cellulose (Surgicel) on
, Luk SH, Fung AS, Yuen MK, Szeto
Grant L, Goh V, Grifn N. The
O’Malley CM, Tkach JA, Gill IS.
al. Complications of hepatec-
Davidson BR, Dooley
al. Bile leakage after hepatic
NM.
al. Prevalence
. The infected liver:
ermeulen H, Laméris JS,
Kliewer MA. Sono-
Tranberg KG, Bengmark S.
Yamamoto
tomy for hilar cholangiocarcinoma.
2001;25:1277–83.
36.
Pace RF, Blenkharn JL, Edwards WJ, Orlof
Blumgart LH, Benjamin IS. Intra-abdominal sepsis
after hepatic resection. Ann Surg. 1989;209:302–6.
37.
Shigeta H, Nagino M, Kamiya J, Uesaka K, Sano
amamoto H et
T, Y
tomy: an analysis of a single center, 10-year experience with 407 patients. Langenbecks Arch Surg.
2002;387:117–24.
38. Ferraioli G, Garlaschelli A, Zanaboni D, Gulizia R,
Brunetti E, Tinozzi FP, et
cal treatment of pyogenic liver abscesses: observation over a 21-year period in 148 patients. Dig Liver
Dis. 2008;40(8):690–6.
39. Mezhir JJ, Fong Y
LA, Covey AM, et
genic liver abscess: surgery is now second-line treatment. J Am Coll Surg. 2010;210(6):975–83.
40.
Hope WW, Vrochides
Smith WW, Iannitti DA. Optimal treatment of hepatic
abscess. Am Surg. 2008;74(2):178–82.
41.
Giorgio A, de Stefano G, Di Sarno
Ferraioli G. Percutaneous needle aspiration of
multiple pyogenic abscesses of the liver: 13-year
single-center experience. AJR Am J Roentgenol.
2006;187(6):1585–90.
42.
Zerem E, Hadzic
taneous catheter drainage versus needle aspiration in
the management of pyogenic liver abscess. AJR Am
J Roentgenol. 2007;189(3):W138–42.
43
Liu CH, Gervais DA, Hahn PF, Arellano
RN, Mueller PR. Percutaneous hepatic abscess
drainage: do multiple abscesses or multiloculated
abscesses preclude drainage or affect outcome? J
Vasc Interv Radiol. 2009;20(8):1059–65.
44.
Patel IJ, Davidson JC, Nikolic B, Salazar
Schwartzberg MS, Walker TG, et
guidelines for periprocedural
lation status and hemostasis risk in percutaneous
image-guided interventions. J Vasc Interv Radiol.
2012;23(6):727–36.
45.
Beland MD, Gervais DA, Levis DA,
lano RS, Mueller PR. Complex abdominal and pelvic
abscesses: efcacy of adjunctive tissue-type plasminogen activator for drainage. Radiology. 2008;
247(2):567–73.
46.
Rajak CL, Gupta S, Jain S, Chawla Y, Gulati M, Suri
S. Percutaneous treatment of liver abscesses: needle
aspiration versus catheter drainage. AJR Am J Roentgenol. 1998;170(4):1035–9.
al. Bacteremia after
al. Percutaneous and surgi
, Jacks LM, Getrajdman GI, Brody
al. Current management of pyo-
DV, Newcomb WL, Mayo-
A. Sonographically guided percu-
World J Surg.
f M,
hepatec-
A, Liorre G,
RS, Uppot
GM,
al. Consensus
management of coagu-
Hahn PF, Arel-
-
Hepaticojejunostomy Anastomotic Strictures
François Cauchy and Jacques Belghiti
23
Introduction
For patients requiring bilioenteric anastomosis,
Roux-en-Y hepaticojejunostomy (HJ) remains
the procedure of choice in the vast majority of
the cases. Several complications may occur following the creation of HJ. These include anastomotic strictures, stone formation, reflux of gastrointestinal content into the biliary tree, obstruction of the Roux-en-Y anastomosis [1], and both
de novo [2] and recurrent malignant disease [3].
HJ anastomotic stricture, which is defined as the
narrowing of the anastomosis leading to biliary
obstruction and retention, accounts for more than
50 % of these complications. Indeed, state-ofthe-art hepaticojejunostomy requires precise creation of a (1) tension-free, (2) widely patent (3)
mucosa-to-mucosa anastomoses using (4) wellvascularized bile ducts that (5) drain all parts of
the liver. The lack of one or several of these conditions dramatically jeopardizes the quality of the
anastomosis and puts the patient at risk of stricture development. HJ anastomotic strictures may
cause recurrent cholangitis with life-threatening
risks and, after several years, may also evolve
toward biliary cirrhosis, hepatic failure, or even
death. However, both diagnosis and treatment
J. Belghiti () · F. Cauchy
Department of HPB Surgery and Liver Transplantation,
Beaujon Hospital, Clichy, France
e-mail: Jacques.belghiti@bjn.aphp.fr
F. Cauchy
e-mail: fafatoubib@gmail.com
of HJ stricture may be difficult. While surgical
repair was the treatment of choice several years
ago, there has been growing interest in more conservative approaches with the development of
balloon dilatation and stricture stenting. Hence,
modern management of these strictures is often
multimodal, requiring repeated therapeutic sessions and combined approaches.
Diagnosis
Clinical and Biological Presentation
HJ stricture progressively leads to retention of
contaminated bile. In this setting, any mild elevation of g-GT (gamma-glutamyl transferase)
and trasnsaminase level and also transitory fever
should highlight the possibility of a nascent anastomotic stricture. Once the stricture occurs, presenting symptoms are dominated by cholangitis
in 80 % of the cases, with isolated jaundice occurring in only 15 % of the cases [1]. However,
these symptoms are not specific and may be related to other causes of HJ malfunction, including
intrahepatic stone formation without HJ stenosis,
stenosis of the Roux-en-Y anastomosis, or the socalled sump syndrome, which is defined as the
reflux of gastrointestinal content into the biliary
tree because of inadequate length of the Roux-enY loop [4]. Likewise, in patients operated on for
malignant disease, surgeons should also systematically rule out the possibility of loco-regional
disease recurrence [3]. Finally, in transplanted
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_23,
© Springer Science+Business Media New York 2015
239
240 F. Cauchy and J. Belghiti
Fig. 23.1 Hepaticojejunostomy stenosis following early
repair of a bile duct injury during laparoscopic cholecystectomy in a 27-year-old women. This patient was suc-
patients, impairment of liver functional tests or
symptoms such as jaundice or cholangitis may
account for non-anastomotic biliary strictures,
graft rejection, viral infections, arterial complications, and recurrent primary disease. In this setting, diagnosis of HJ strictures should therefore
be retained only after complete workup ruling
out other complications has been performed.
Morphological Evaluation
Even though ultrasound (US) examination and
computed tomography (CT) have no place in
the direct visualization of anastomotic strictures,
they should be routinely performed in the management of these patients. Indeed, both US and
CT scan may be of value in the evaluation of
nonspecific indirect signs of strictures and may
allow for the assessment of differential diagnoses
and stricture-related complications. Historically,
diagnosis was achieved using percutaneous transhepatic cholangiography (PTC) (Fig. 23.1a),
which may also allow for direct visualization of
the strictures using cholangioscopy [5]. However, since this invasive procedure is associated
with both risk of vascular injury in approximately 2 % of the cases [6] and septic complications, it should now be restricted to therapeutic
purposes or rare situations of inconclusive magnetic resonance (MR) cholangiography. Indeed,
cessfully managed using repeated sessions of percutaneous dilatation. a Percutaneous cholangiography. b Magnetic cholangiography
MR cholangiography has become the standard
morphological examination in the assessment of
HJ stenosis and allows direct visualization of the
strictures with a sensitivity reaching more than
90 % (Fig. 23.1b) [1]. Other anecdotal diagnostic
modalities include endoscopic retrograde cholangiography, which has been reported to be feasible
in 58–93 % of HJ patients [7–9], or percutaneous
transjejunal endoscopy, which may be facilitated
in patients with prior subcutaneous fixation of
the Roux-en-Y loop [10, 11], but has been also
successfully reported using US-guided puncture
of non-fixed loops in experienced hands [12, 13].
Incidence and Risk Factors According to the Clinical Context
Since creation of HJ may be required in various
surgical situations, both incidence and risk factors of HJ strictures widely vary according to the
clinical context (Table 23.1).
Iatrogenic Bile Duct Injury
Since the description of the Hepp and Couinaud
biliary-enteric anastomosis using the extrahepatic left hepatic duct [14], HJ has remained the
standard procedure in the surgical management
of most postcholecystectomy bile duct injuries.
Table 23.1 Incidence and risk factors of hepaticojejunostomy strictures according to the clinical situation
Indication for HJ Incidence of
strictures (%)
Bile duct injury 5–22 Sepsis during repair
Liver transplantation (LT)
Deceased donor 2–21 Primary sclerosing cholangitis
Living donor 6–22 Graft related factors:
Pancreatic head resection 2.6 –
Choledochal cyst excision
Children 0–6 Type Iva cysts
Adults 5–24 Short duration of symptoms
Risk factors
Absence of bile duct dilatation
Postoperative biliary leakage
Steatosis, Prolonged cold ischemia time, donor age > 50 years
Technical factors:
Biliary anatomical variation, small ducts, no microsurgical repair
Postoperative complications:
Biliary leakage, arterial thrombosis, CMV infection
Large-sized cysts
10 years
Age >
24123 Hepaticojejunostomy Anastomotic Strictures
In this setting, HJ anastomotic strictures nevertheless occur in 5–22 % [15–19] of the patients.
The absence of bile duct dilatation has long been
incriminated as the most prominent risk factor
for the development of HJ stricture following
bile duct injury repair [16], leading some authors
to either postpone the intervention until bile duct
dilatation was obtained or to routinely use transanastomotic stents on non-dilated bile ducts [20].
However, several studies have highlighted that
early repair achieved similar results as delayed
biliary reconstruction provided that the procedure was performed by a specialist hepatobiliary
surgeon [21]. This clearly emphasizes the need
for early diagnosis and referral to a specialized
HPB unit. Other risk factors for the development
of HJ stricture include the presence of biliary
peritonitis at repair [22] and postoperative complications following the repair, especially biliary
leakage [16], which both intuitively increase the
risk of postoperative inflammatory stenosis. Finally, the impact of an associated right hepatic
arterial injury in the occurrence of anastomotic
stricture is still a matter of ongoing debate [15,
21, 22], with several arguments suggesting a role
of arterial injury in favoring ischemia and retraction of the bile ducts and others supporting a
rapid revascularization through the anastomosis.
In our experience, routine CT scan with vascular
reconstruction is always performed to preoperatively assess the arterial vascularization. Similarly, we believe that both operative evaluation of
the biliary vascularization and confection of high
anastomoses may help to prevent postoperative
strictures. Finally, we consider that the existence
of an associated vascular injury should probably
lead to considering early repair with the utmost
caution.
Liver Transplantation (LT)
In deceased donor liver transplantation (LT), HJ
is more and more restricted to a limited number
of situations including large disparity in size between the recipient’s bile duct and the donor’s
bile duct, liver retransplantation, LT for primary
sclerosing cholangitis, and biliary atresia. In these
situations, the incidence of HJ strictures ranges
from 2 %, in the case of liver retransplantation
[23], to 21 % in patients with PSC [24]. In this
latter setting, it has been recently suggested that
duct-to-duct anastomosis (DDA) provided better
long-term functional results than HJ [24] without
increasing the risk of disease recurrence [25, 26],
supporting that it should be probably preferred
242 F. Cauchy and J. Belghiti
over HJ. In living donor LT, no randomized study
has yet documented the superiority of DDA over
HJ. Hence, HJ is still performed in 20–40 % of
the cases [27, 28]. In this latter setting, biliary
anastomotic strictures represent the Achilles heel
of these procedures with reported rates ranging
from 6 to 22 % [29, 30]. The occurrence of HJ
strictures may be the consequence of: (1) impaired graft quality as evidenced by increased
rates of HJ strictures with significant steatotic
grafts [31, 32] with prolonged cold ischemia time
[33] or grafts from donors aged > 50 years [30];
(2) technical factors including biliary anatomical
variations [31] requiring > 1 biliary anastomosis
[30] and small donor right or left bile ducts; [31];
and (3) postoperative complications, mainly biliary leakage [30, 34], hepatic artery thrombosis
[35], CMV infection [35], and acute cellular rejection [33]. Obviously, prevention of HJ strictures in patients undergoing LDLT may essentially be achieved by improving the selection of
the grafts with the systematic use of preoperative
donor liver biopsy but also with refinements in
surgical technique. In this latter setting, Lin et al.
have emphasized the value of routine microsurgical biliary reconstruction in decreasing the number of anastomotic strictures regardless of both
types and number of ducts [27].
Pancreatic Head Resection
Biliary complications following pancreatic head
resection are often neglected and overlooked
by those involving the pancreatic anastomosis.
Hence, only one study has to date specifically
examined the incidence of biliary strictures after
pancreaticoduodenectomy (PD) [3]. In this large
single-center study analyzing 1595 patients undergoing PD over 8 years, 42 (2.6 %) patients experienced HJ stricture and median time for stricture occurrence was 13 (median: 1-98) months.
No significant risk factor for the development of
strictures was observed with only marginal influence of preoperative biliary drainage and no
impact of either common bile duct size or postoperative biliary leakage. Interestingly, the rates
of strictures were also strictly similar in patients
operated on for benign and malignant disease. In
this latter context, less than 10 % of the patients
were found to have recurrent neoplastic disease
involving the bilioenteric anastomosis. Of these,
none were operated on for pancreatic or ampullary carcinoma supporting that development of
a biliary stricture in these patients is usually benign. However, all patients with malignant anastomotic strictures carried a diagnosis of cholangiocarcinoma. This result, which is in line with
the reported 16 % rate of tumor recurrence at the
proximal stump in patients operated on for extrahepatic cholangiocarcinoma [36], suggests that
anastomotic tumor recurrence should be systematically ruled out in this subset of patients.
Choledochal Cyst
In the long-term follow-up of patients undergoing choledochal cyst excision, the development
of postoperative HJ anastomotic stricture widely
varies according to the age of the patient at the
time of surgery. 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]. 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. In
this situation, definition of a subgroup of patients
24323 Hepaticojejunostomy Anastomotic Strictures
Fig. 23.2 Proposed management of patients with he-
paticojejunostomy strictures. In patients with isolated HJ
strictures, first-line treatment should be as much conservative as possible. Surgery should remain a second-line
at low risk of malignant transformation would
probably allow avoiding unnecessary procedures
at extremely high risk of postoperative complications.
Therapeutic Options
In patients with HJ strictures, a multimodal and
gradual management with repeated treatment
sessions and a combination of several approaches is often required (Fig. 23.2). Treatment options, which include conservative management
with endoscopic, percutaneous transhepatic, or
transjejunal balloon dilatation and surgery from
revisionary HJ to LT, depend on the clinical situation and the existence of associated complications. In this setting, the Terblanche classification
[41], which was designed for the assessment of
biliary repair following bile duct injury, stratifies the functional results of HJ into IV grades
(Table 23.2) and may be of value in the analy-
treatment after failure of well-conducted conservative
management or in rare cases of associated Roux-en-Y
malfunction
sis of the efficacy of the management of these
strictures.
Conservative Management
Choice of the Approach
The percutaneous approach remains the approach
of choice with reported therapeutic success rates
reaching 90–100 % [42, 43]. In this setting, a
multistep strategy is generally undertaken. The
first step usually consists in transhepatic cholangiography and external catheter drainage. A
single-puncture technique is used whenever direct insertion of a thin wire offers a suitable approach to the biliary system. Otherwise, a common double-puncture technique is performed.
Percutaneous transhepatic tracts are created to
ensure complete drainage of all excluded territories. Once the bilioenteric stricture has been
passed, insertion of one or several external cath-
244 F. Cauchy and J. Belghiti
Table 23.2 Classification of the functional results of hepaticojejunostomies. (Derived from Telbranche et al. [41])
Grade I. No biliary symptoms
Grade II. Transitory symptoms, currently no symptoms
Grade III. Clearly related symptoms requiring medical therapy
Grade IV. Recurrent stricture requiring correction or related death
eters allows drainage of the entire biliary tree
above the stricture. When present, small biliary
tract stones might be removed using irrigation
with saline solution or may be pushed forward
through the bilioenteric anastomosis [5]. On the
other hand, large stones might be removed after
percutaneous electrohydraulic lithotripsy under
cholangioscopic guidance [5, 42]. The second
step is usually performed between 3 and 7 days
later. An angioplasty balloon catheter is inserted
across the stenosis and inflated gradually. Thereafter, stenting is achieved using an internal–external biliary drainage or wall-stent placement.
Control cholangiography with catheter exchange
and complementary dilatations are performed
every 6 weeks. When no residual stenosis is observed on at least two consecutive sessions, the
catheter is removed and the patient is followed
regularly to detect any recurrent stricture.
Recently, several teams have reported their
results using endoscopic retrograde balloon dilatation. This approach, which may facilitate both
multiple stent placement [7, 9] and use of lithotripsy, however, currently only provides success
rates of 70 % cases using single-balloon enteroscope [7]. Even though endoscopy may be facilitated with the use of short-limb Roux-en-Y [44]
reconstruction or positioning of the Roux-en-Y
loop on the duodenum, it should be restricted to
experienced centers in the setting of therapeutic
evaluation. The percutaneous transjejunal approach represents a valuable alternative to the
endoscopic approach with satisfactory long-term
results but is also restricted to very few experienced centers [12, 13]. Finally, the “rendez-vous”
technique, which combines both endoscopic and
percutaneous approaches, may be useful in complex situations. However, in a setting of HJ stricture, this strategy remains clearly marginal with
only limited reported experience [45, 46].
To Stent or Not to Stent?
The rationale of using metallic wall-stent would
be to allow limiting the number of procedures
and decrease hospital stays [47]. However, despite initial promising results and high primary
technical success rates [48, 49], long-term results
of benign biliary stricture treatments by metallic
stents have been tempered by high rates of late
re-occlusion [50]. On the other hand, retrievable
covered stent seems to be a good alternative to
shorten treatment duration compared to interposition of an internal–external catheter. However,
the risk of branching bile duct occlusion limits
its use in the setting of living donor LT recipients
owing to high frequency of complex biliary anastomotic strictures.
Periprocedural Management
Preanesthetic consultation and routine blood tests
including a coagulation profile are systematically
required. Similarly, the vast majority of the patients have contaminated bile, and it is mandatory
to systematically start antibiotherapy prophylaxis
before the procedure in order to prevent the occurrence of severe septic complications during
manipulation of the bile ducts. Antibiotics are
generally continued for at least 2–5 days following the procedure. Since most of the patients will
require several therapeutic sessions, it is important to adapt the antibiotics to the microbiological findings of previous interventions. After the
procedure, occurrence of blood in the drainages
should lead to immediate elimination of vascular
complications such as active hemorrhage, hematoma, or pseudo-aneurism on CT scan. Similarly,
in patients with external drainage, tubes should
be flushed daily with 5–10 ml of saline to ensure
adequate bile outflow and bile loss should be rigorously compensated. If occlusion is suspected
in the absence of bile outflow, proper fixation of