Long-term evaluation of biliary reconstruction after partial resection of segments IV and V in iatrogenic injuries |
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Authors: | Miguel Ángel Mercado MD Carlos Chan MD Héctor Orozco MD José M Villalta MD Alexandra Barajas-Olivas MD Javier Eraña MD Ismael Domínguez MD |
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Institution: | (1) Department of Surgery, Instituto Nacional de Ciencias M_edicas y Nutrición ‘Salvador Zubirán’, Vasco de Quiroga No. 15, 14000 Tlalpan, México, D.F. |
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Abstract: | Roux-en-Y hepatojejunostomy is the procedure of choice for biliary reconstruction after complex iatrogenic injury that is
usually associated with vascular injuries and concomitant ischemia of the ducts. To avoid the ischemic component, our group
routinely performs a high repair to assure an anastomosis in noninflamed, nonscarred, and nonischemic ducts. If the duct bifurcation
is preserved, the Hepp-Couinaud approach for reconstruction is an excellent choice. Partial liver resection of segments IV
and V allows adequate exposure of the bile duct at its bifurcation with an anterior approach of the ducts (therefore not jeopardizing
the circulation), allowing a high quality anastomosis. Long-term results of bile duct reconstruction using this approach are
described. Two hundred eighty-five bile duct reconstructions were done between 1989 and 2004 in a tertiary care university
hospital. The first partial-segment IV resection was done in 1994; 94 cases have been reconstructed since then using this
approach. All of them had a complex injury (Strasberg E1-E5), and although in many cases the bifurcation was preserved (E1-E3),
a high bilioenteric anastomosis was done to facilitate the reconstruction. In 70 cases, the bifurcation was identified, and
in the 24 in which the confluence was not preserved, the right and left ducts were found except in one case. In three patients,
the right duct was found unsuitable for anastomosis, and a liver resection was done. In the remaining 21, an anastomosis was
done using a stent (transhepatic, transanastomotic) through the right duct. According to Lillemoe’s criteria, 86 cases had
good results (91%). In four of the eight remaining patients, there was the need to operate again due to the presence of an
obstruction and/or cholangitis. In the rest, radiological instrumentation was done. Four of these cases have developed secondary
biliary cirrhosis, two of which have died while waiting for a liver transplant, four and six years after reconstruction. Partial
segments IV and V resection allows adequate exposure of the confluence and the isolated left or right hepatic ducts. Anterior
exposure of the ducts allows an anastomosis in well-preserved, nonischemic, nonscarred, or noninflamed ducts. Parenchyma removal
also allows the free placement of the jejunal limb, without external compression and tension, obtaining a high quality anastomosis
with excellent long-term results.
Presented at the Fifth Biennial Meeting of the American Hepato-Pancreato-Biliary Association, Fort Lauderdale, Florida, April
14–17, 2005. |
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Keywords: | Bile duct injury hepatojejunostomy |
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