clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Intrahepatic Biliodigestive Anastomosis

Without Indwelling Stent

William R. Jarnagin

Introduction

The technique for reestablishing continuity of the extrahepatic bile ducts to the intestinal tract is described. Multiple biliary lumen may be encountered even with minor dissection into the hepatic parenchyma. All lumens should either be anastomosed or ligated with permanent sutures.

Indications and Contraindications

provide adequate drainage of all ducts often leads to serious postoperative complications, such as persistent bile leak or subhepatic abscess, biliary fistulation, lobar atrophy, cholangitis or hepatic abscess.

The jejunal limb is temporarily anchored with a stay suture at some distance from the bile duct to allow precise placement of the sutures.

Working from left to right, full-thickness sutures are placed from the jejunal limb (inside to out) to the back wall of the bile duct (outside to in) (B).

The sutures are not tied but are sequentially clamped with the needles removed. Again, it is important to keep the sutures in order.

The jejunal loop is then slid upward along the posterior row of sutures until the back wall of the bowel and the bile ducts are apposed.

The posterior sutures are then tied and the sutures are cut.

The anterior layer is then completed by securing the sutures, tying from left to right (A).

The completed anastomosis is shown (B).

Ducts that are not connected by a septum are brought into apposition by placing two or three interrupted sutures. The complex of exposed ducts can be treated

as a single ductal orifice, and the anastomosis is created to a single jejunal opening. The anastomosis is carried out using the general technique described in “Procedures”,“General (End to Side)”.

Multiple Simultaneous Anastomoses to Separated Ducts

If the surgeon determines that the ductal orifices are too widely separated to create a single anastomosis, multiple simultaneous anastomoses will be required, using the same general approach as described in “Procedures”,“General (End to Side)”. Working from left to right, the anterior row of sutures is placed on all exposed bile ducts (inside to out). The sutures are sequentially clamped and the needles are retained, keeping the sutures in order so that they can be easily retrieved (A).

The jejunal loop is then slid upward along the posterior row of sutures until the back wall of the bowel and the bile ducts are apposed, making sure that the jejunal openings are properly aligned to the respective ductal orifices. The posterior sutures are then tied and the sutures are cut (B).

The previously placed sutures on the anterior wall of the bile duct are now used to complete the anastomosis, as in “Procedures”,“General (End to Side)”, making certain that the ductal sutures are correctly placed to the corresponding jejunal opening (C).

Side-to-Side Intrahepatic Anastomosis

Side to side intrahepatic biliary-enteric anastomoses are generally undertaken for palliative biliary drainage in patients with unresectable cancer, most commonly hilar cholangiocarcinoma or gallbladder cancer; they are much less frequently used in cases of benign strictures/bile duct injuries. The most common approaches are to use the segment 3 duct or the right anterior sectoral duct. Techniques have been described for exposing the segment 5 duct at the base of the gallbladder fossa, although this is difficult and rarely used. The anastomotic technique used is identical to that described in “Procedures”,“General (End to Side)” above. There are several general points worth emphasizing regarding these approaches:

■In patients with advanced cancer, the right and left ductal systems are often isolated. Decompression of the right or left side alone will result in normalization of the serum bilirubin if at least 30% of the functional hepatic parenchyma is adequately drained.

■A bypass created to a lobe with ipsilateral portal vein occlusion or gross atrophy is doomed to failure and should be avoided.

■If the right and left ductal systems are isolated, the contralateral side will not be adequately drained. In patients with advanced malignancy, this is acceptable, provided that the contralateral biliary tree has not been contaminated (i.e., prior instrumentation). If this is the case, interventional radiologists may be able to place an internal wall stent from left to right (or right to left), allowing decompression of the contralateral system through the bypass; if not, the patient will require

a permanent external biliary drain.

■For benign strictures, unlike palliative bypass for malignancy, intrahepatic bypass approaches require continuity at the hilus so that complete biliary decompression is achieved.

Tricks of the Senior Surgeon

■When multiple ducts are encountered, it is particularly important to find the open caudate ducts. If these are left without anastomoses to the intestinal tract, a chronic fistula may occur.

■If a small open duct is encountered that is too small for anastomosis, ligation with a non absorbable suture is the most expedient solution.

The Ligamentum Teres Approach and Other Approaches to the Intrahepatic Ducts for Palliative Bypass

Michael D’Angelica

Introduction

When the hilus of the liver is not accessible for decompression of obstructive jaundice, use of intrahepatic ducts for surgical bypass is a safe and effective technique as originally described by Bismuth and Corlette in 1975 and later by Blumgart and Kelly in 1984. The general principle is to identify intrahepatic healthy bile duct mucosa proximal to a point of biliary obstruction and to create a mucosa-to-mucosa anastomosis to a long Roux-en-y loop of jejunum. Anastomosis should provide biliary drainage and relief of symptoms such as jaundice and pruritis.

Indications and Contraindications

Investigation/Preparation