Laparoscopic Roux-en-Y hepaticojejunostomy reconstruction after iatrogenic bile duct injury: case series report.

INTRODUCTION: Bile duct injury (BDI) is a devastating complication after a cholecystectomy. Laparoscopic management has become a mainstay approach because of the advantages offered to patients; nevertheless, outcomes after repair are influenced by the center, the surgeon's experience, and the type of reconstruction. MATERIALS AND METHODS: Patients with common BDI managed at a referral center from January 2013 to June 2018 with a novel modified and simplified laparoscopic technique for a hepatic duct jejunostomy with a Roux-en-Y reconstruction were retrospectively reviewed. RESULTS: Twenty patients had a BDI (20/5430-0.3%), 8 (40%) had intraoperative diagnosis, and 12 (60%) patients with diagnosis before 72 h. Type E Strasberg classification, the predominant BDI was Strasberg E1 (65%), the average surgery time was 146.5 min (115-178 min), the average intraoperative bleeding was 15-50 cc. The overall complication rate was 10 % (2/20), 1 (5%) patient required, there were no mortalities, and the mean hospital stay was 5 days. One (5%) patient presented bile leak (Type SE4), and 1 (5%) patient required intensive care unit admission after reintervention. Long-term follow-up showed no bile duct stricture, cholangitis, or recurrent choledocholithiasis up to 5 years after the procedure and with a minimum of 1 year minimum follow-up. CONCLUSIONS: This simplified laparoscopic approach to bile duct reconstruction with Roux-en-Y anastomoses appears to be an effective and safe alternative to reconstructive open bile duct surgery, offering to patients the benefits of laparoscopic surgery with a low complication rate.

ANTECEDENTES: La lesión del conducto biliar es una complicación devastadora tras una colecistectomía. El tratamiento laparoscópico se ha convertido en un enfoque principal debido a las ventajas ofrecidas a los pacientes; sin embargo, los resultados después de la reparación están influenciados por el centro, la experiencia del cirujano y el tipo de reconstrucción. MÉTODO: Se revisaron retrospectivamente los pacientes con lesión del conducto biliar tratados con reconstrucción biliar en un centro de referencia, desde enero de 2013 hasta junio de 2018, por vía laparoscópica con una técnica modificada y simplificada con hepatoyeyunostomía en Y de Roux. RESULTADOS: Veinte pacientes de 5,430 tenían lesión del conducto biliar (0,3%), 8 (40%) tuvieron diagnóstico intraoperatorio y 12 (60%) diagnóstico antes de las 72 horas. Todos con una clasificación de Strasberg tipo E, con predominio de E1 (65%). El tiempo quirúrgico promedio fue de 146,5 (rango 115-178) minutos y el sangrado intraoperatorio promedio fue de 15-50 cm3. La tasa general de complicaciones fue del 10% (2/20); 1 (5%) paciente requirió reintervención. No hubo mortalidad y la estancia hospitalaria media fue de 5 días. Un paciente (5%) presentó fuga biliar (tipo SE4) y 1 (5%) paciente requirió ingreso en la unidad de cuidados intensivos después de la reintervención. El seguimiento fue de hasta 5 años tras el procedimiento, con un mínimo de 1 año, y no se han documentado estenosis del conducto biliar, colangitis ni coledocolitiasis recurrente. CONCLUSIÓN: Este enfoque laparoscópico simplificado para la reconstrucción del conducto biliar con anastomosis en Y de Roux parece ser una opción efectiva y segura a la cirugía reconstructiva del conducto biliar abierta, ofreciendo a los pacientes los beneficios de la cirugía laparoscópica y con una baja tasa de complicaciones.

Endoscopic management of biliary complications after liver transplantation: An evidence-based review.

Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.