Assessment of the Hepaticojejunostomy Results
HJ procedure was performed in 12 LLDs who had postoperative (n=11) or
intraoperative (n=1) biliary complications. (i) Intraoperative biliary
complication consisted of iatrogenic segment IV bile duct injury. In
this patient, HJ anastomosis was performed to the bile duct draining
segment 4 and the main bile duct was left intact (Fig.4). (ii) Isolated
major segmental duct obstruction was present in 4 LLDs and there was no
problem in the main bile duct. In these LLDs, these isolated bile ducts
were probably unnoticed in the first operation and ligated accidentally.
HJ anastomosis was performed in these patients as described above. (iii)
Two patients had obstruction in the main bile duct that could not be
resolved by percutaneous interventional procedures and the treatment
required HJ. In the above-mentioned 7 LLDs, single orifice HJ was
performed. (iv) In 3 patients, large ischemic defective area was found
on the ductal stump area which was caused by an obstruction in the main
biliary tract. Side-to-side HJ was performed and ductal continuity was
achieved in these 3 cases (Fig.5). (v) Two patients had both major
biliary tract and isolated segmental major biliary tract obstruction.
These patients underwent double orifice HJ (Fig.6). In other words,
there were 14 HJ ostium in 12 cases. One of these 12 cases was
unfortunate. Isolated major segmental duct obstruction was noticed after
HJ was performed to the main biliary tract in the re-operation. Another
HJ was performed to this bile duct on the same Roux limb in the second
reoperation.
Ten LLDs underwent PTBD catheter assisted HJ and the distal tip of the
catheters were advanced through the anastomosis into the Roux limb. In
one patient who received an emergency laparotomy in the postoperative
early period and did not have a PTBD catheter, a trans-anastomotic
catheter was inserted and distal tip of the catheter was advanced into
the intrahepatic bile ducts (Fig.7). In the remaining one patient with
HJ, it was found that there was an iatrogenic injury to the segment 4
bile duct during parenchymal transection. Therefore, end-to-side HJ was
performed between Roux limb and bile duct that drained segment IV and a
trans-anastomotic catheter was used to protect the anastomosis in this
patient. The details of the of the patients underwent HJ are given in
Graphic-2.
Twelve LLDs with biliary complications underwent HJ at a median of 50
days (min-max: 0-97 days) after the LDH. HJ was performed in 10 LLDs
with right lobe LDH and 2 LLDs with left lobe LDH. None of the LLDs
underwent segment II-III resection required HJ anastomosis. There was no
statistically significant difference between LLDs, who have biliary
complications, with (n=12) and without (n=155) HJ procedure in terms of
sex (p=0.805), age (p=0.714), graft type (right vs left; p=0.820), BMI
(p=0.330), bile duct anatomy (p=0.066) and bile leaks (p=0.137). LLDs
with a biliary complication following LDH were followed-up for a median
of 1141 days (min-max: 21-4201 days). Following HJ, 11 LLDs did not have
any complication all along the median 978 days (min-max: 139-3578 days)
of follow-up. For a patient who suffered from HJ anastomosis stricture
on long-term follow-up, an internal biliary drainage catheter was
inserted and then the catheter was withdrawn following three sessions of
balloon dilation.