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.