A Promising Method for Repairing Low-Level Biliary Strictures After Cholecystectomy

The purpose of this study is to introduce and evaluate a new technique of repairing bile ducts by the tubular gastric wall with a vascularized pedicle. Both the end-to-end bile duct repair and Roux-en-Y hepatoenterostomy have limitations in the treatment of benign bile duct strictures after cholecystectomy. There are no other good choices to manage these cases, especially the bile duct transection injuries or partly missing common bile duct or hepatic duct. Eleven patients with partly missing common bile ducts in the Chinese People''s Liberation Army General Hospital between January 2007 and December 2012 were retrospectively analyzed. The study comprised 8 females and 3 males, whose age ranged from 29 to 56 years. All patients underwent successful bile duct repair. The time of operations ranged from 210 minutes to 240 minutes. The maximal blood loss was less than 220 ml. There was no perioperative mortality and no case of gastric fistula. Postoperative complications occurred in 3 patients, including wound infection, bile leakage, and erosive gastritis. All complications were cured by conservative treatment. The mean follow-up time was 42 months. One patient was classified as Terblanche''s grade II and 10 patients were classified as Terblanche''s grade I. The observations indicate that this technique is a feasible and effective choice to manage low level biliary stricture after cholecystectomy, especially suitable to repair bile duct transection injuries or partly missing common bile duct or hepatic duct.Key words: Tubular gastric wall with a vascularized pedicle, Biliary injury, Benign biliary strictureIt is a great challenge for surgeons to manage benign biliary strictures (BBSs) after cholecystectomy. BBS patients often survive for a long time, so surgeons pursue a long-term treatment for BBSs and minimize the effect on the patients'' quality of life as they are able. Traditionally, surgery has been used as a means to treat BBSs, and the common procedure includes end-to-end bile duct repair and biliary-enteric anastomosis. However, current studies suggest that the former has a limited role in the treatment of benign bile duct strictures due to its narrow indications and poor long-term outcome.^1,2 The latter emphasizes the anatomy and treatment of proximal bile ducts. This approach misses the important “sphincter of Oddi” function of an antireflux device, and therefore, cannot avoid the incidence of reflux cholangitis, which increases not only the pain but also the risk of cholangiocarcinoma in long-term follow-up patients. Moreover, a biliary-enteric anastomosis alters the normal bile flow, changing the physiologic conditions of the gastrointestine and leading to the disorder of gastrointestinal hormone release. Hence, it increases the incidence of postoperative duodenal ulcer and inhibits fat metabolism and absorption due to the lack of bile between the duodenum and jejunum.^3–5New technologies should be developed to overcome the above disadvantage of current surgery, and the method of biliary reconstruction should be improved. The ideal surgical procedure for BBSs should be technically simple and should preserve both the physiologic passage of bile and the function of sphincter of Oddi.⁶ This article introduced a new method using the tubular gastric wall with a vascularized pedicle to repair iatrogenic biliary strictures based on this idea.