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... main difference between this new technique and the original Roux-en-Y hepatico-porto-jejunostomy (RYHJ) is the preservation of gall bladder, which has been used as the biliary conduit. The abdomen was explored by smaller upper right transverse incision mostly dividing the rectus only. The area of dissection was only the sub hepatic region. The choledochal cyst was excised in the classical way (Figure 1). The important point in dissec- tion is the isolation and preservation of the cystic artery. In one patient, the cystic artery was accidentally injured and ligated. But no adverse effect occurred since the gall bladder is well vascularized with alternate sources from the liver bed. The cystic duct was excised en-masse with the choledochal cyst at its junction with the neck of the gall bladder (Figure 2). The gall bladder fundus and part of body is mobilized from the liver bed such that the fundal tip easily comes close to the duodenum without any tension. The biliary channels in the liver were cleared of all stones, debris or sludge. Then the gall bladder neck was brought near the remaining common hepatic duct for anastomosis. Any inequality was ad- justed by opening the gall bladder neck longitudinally. Extra Care was taken not to twist the gall bladder neck. Interrupted water tight sutures with 6/0 polyglycolic acid (Vicryl) were applied in a single layer. The site for the anastomosis of the fundal tip with duodenum was se- lected on the antero-inferior wall of distal first part of the duodenum. This site was specifically selected for possi- ble prevention of reflux and subsequent cholangitis. The size of the anastomosis was kept within 10 mm. The an- astomosis was completed in two layers with interrupted stitches of 6/0 polyglycolic acid (Vicryl). The outer sero- muscular stiches were taken little away from the margin such that the stoma invaginates a little into the duodenal lumen like a papilla to prevent possible reflux (Figure 3). The excised choledochal cyst was sent for histological ex- amination. The cystic duct stump was also examined sepa- rately in 4 patients. Any leakage was checked. The wound was closed by giving a drain in the subhepatic ...
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Citations
... Despite the enormous surgical advancements in the last century, access to the biliary system is lost when a Rouxen-Y biliary drainage (RYBD) procedure is performed. Attempts have been made to overcome this inconvenient sequel by using alternative techniques that have not been universally accepted for many reasons [1][2][3][4][5]. Although access to the biliary tree post-RYBD is possible with interventional radiology, this highly specialized service is rarely available, especially in developing countries [6,7]. ...
... Hepatico-duodenostomy is still performed in some units; however, other centres have changed to RYBD because of bile reflux and incidental malignancy [20][21][22][23]. Other alternates that have been used were the gallbladder, an ileal loop between the hepatic duct and jejunum, and an isolated vascularized jejunal tube that has also been successfully used in an animal study [1,3,4]. Interventional radiology procedures are paramount for addressing complications of RYBD [14,15,24]. ...
Background
Despite the enormous surgical advancements in the last century, access to the biliary system is lost when a Roux-en-Y (RY) biliary drainage procedure is performed. Attempts have been made to overcome this inconvenient sequel using variations in the RY anastomosis, small bowel grafts and vascular grafts. These have been predominantly unsuccessful. An isolated vascularized gastric tube (IVGT) graft has been reported in the literature, which was successfully used for adult patients with common bile duct injuries. We have adopted the technique of using an IVGT graft for bile duct reconstruction in the paediatric patients at our institution. We reviewed our experience at our institution between January 2015 and October 2019. This was a retrospective review of all paediatric patients undergoing an IVGT graft procedure for biliary tract anatomical obstruction in the past 5 years. We looked at the indications for surgery, the demographic profile of the patients and outcomes following surgery and outlined the surgical technique used.
Results
IVGT bile duct reconstruction was performed on eight patients. Patients ranged from 2 months to 7 years, and there was an equal number of males and females. The diagnosis was made on clinical suspicion and confirmed with ultrasound (U/S) and magnetic resonance cholangiopancreatography (MRCP). There was an 87.5% resolution of biliary obstruction, and two patients who had bile leaks postoperatively were managed conservatively. Unfortunately, one patient died in the early postoperative period from sepsis due to pneumonia. Follow-up was for a minimum of 6 months and up to 5 years.
Conclusion
IVGT biliary enteric drainage is a safe, reproducible procedure that allows access to the biliary tree if required in the future. Thus, this procedure serves as an alternative, especially in limited-resource areas where interventional radiology is not available for future interventions.
... 3,4 Choledocho-cholecysto-duodenostomy is a new surgical technique that preserve the gall bladder and used as the biliary conduit. 5 Hepatico-jejunostomy is latest technique. It requires complete excision of the cyst and anastomosis of hepatic duct with jejunum without Roux-en-Y limb. ...
... No late follow up mentioned but noted that anastomotic leakage, anastomotic stricture, biliary fistula, reflux, recurrent cholangitis, gall stones, carcinoma of gall bladder may developed in the late postoperative period. 5 Hepatico-jejunostomy without Roux-en-Y reconstruction is a newest technique practiced in our center. It requires shorter time. ...
... 12,13 There is a reported case of mortality in a patient of Choledocho-cholecysto-duodenostomy where the author mentioned unexplained cause of death without any abdominal signs and symptoms. 5 In a another study, one late mortality due to liver failure occurred 6 months after Roux-en-Y Hepaticojejunostomy with preoperative severe liver cirrhosis. 14 ...
