Overview
Definition:
Hepaticojejunostomy redo for anastomotic stricture refers to a repeat surgical procedure to reconstruct or revise a connection between the hepatic duct and the jejunum, performed to address a narrowing (stricture) that obstructs bile flow
This is commonly performed as a Roux-en-Y hepaticojejunostomy, creating a new anastomosis to bypass the narrowed segment or to re-establish a patent bile ductal system.
Epidemiology:
Anastomotic strictures after hepaticojejunostomy occur in approximately 5-15% of patients, with variations depending on surgical technique, patient factors, and intraoperative events
Recurrence of stricture after redo surgery can range from 10-30%
Risk factors include prolonged operative time, extensive dissection, aggressive manipulation of the bile ducts, and early postoperative complications like infection.
Clinical Significance:
Bile duct strictures are a significant cause of morbidity after biliary surgery
They lead to cholestasis, recurrent cholangitis, liver dysfunction, and potentially biliary cirrhosis if left untreated
Redo hepaticojejunostomy is crucial for restoring bile flow, preventing further liver damage, and improving the quality of life for affected patients
Understanding the management of these complex cases is vital for surgical residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
Jaundice, often progressive
Right upper quadrant abdominal pain, typically colicky or dull
Fever, chills, and rigors, suggestive of cholangitis
Pruritus, secondary to hyperbilirubinemia
Nausea and vomiting
Unexplained weight loss
Fatigue and malaise.
Signs:
Icteric sclera and skin
Palpable, tender liver
Possible distended abdomen with ascites in advanced cases
Signs of sepsis, including fever, tachycardia, and hypotension
Clay-colored stools and dark urine due to altered bilirubin excretion.
Diagnostic Criteria:
Diagnosis is typically made based on a combination of clinical suspicion, laboratory findings, and advanced imaging
Elevated serum alkaline phosphatase and GGT levels are hallmark indicators
Cholangiographic evidence of a focal or diffuse narrowing within the hepaticojejunostomy anastomosis, with upstream dilatation of bile ducts, is diagnostic.
Diagnostic Approach
History Taking:
Detailed history of prior biliary surgery, including the type of procedure, any immediate postoperative complications, and previous interventions for bile leaks or strictures
Inquire about symptoms of cholangitis (fever, pain, jaundice), pruritus, and changes in bowel habits
Assess for risk factors like inflammatory bowel disease or sclerosing cholangitis.
Physical Examination:
Comprehensive abdominal examination focusing on tenderness, hepatomegaly, and signs of infection
Careful assessment of skin and scleral icterus
Evaluate for signs of chronic liver disease, such as stigmata of portal hypertension.
Investigations:
Laboratory Tests: Complete blood count (CBC) to assess for leukocytosis indicative of infection
Liver function tests (LFTs) including bilirubin (total and direct), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), and aspartate aminotransferase (AST)
Coagulation profile (PT/INR) to assess synthetic function
Imaging: Ultrasound of the abdomen to assess bile duct dilatation and identify gallstones or masses
CT scan or MRI with MRCP (Magnetic Resonance Cholangiopancreatography) to delineate the stricture, assess its length and severity, and identify any associated pathology such as stones or tumors
ERCP (Endoscopic Retrograde Cholangiopancreatography) for direct visualization and potential therapeutic intervention (though often limited in redo cases due to prior surgery and risk of further injury)
Percutaneous transhepatic cholangiography (PTC) if ERCP is not feasible or successful, often used for access for drainage.
Differential Diagnosis:
Malignancy of the biliary tree or surrounding structures
Benign biliary strictures due to inflammation (e.g., primary sclerosing cholangitis)
Gallstone disease in the common hepatic duct or intrahepatic ducts
Biliary leaks leading to fibrosis
Portal biliopathy from portal hypertension
Anastomotic leak with granulation tissue formation.
Management
Initial Management:
Aggressive management of sepsis if present, including broad-spectrum antibiotics
Correction of coagulopathy with Vitamin K and fresh frozen plasma if indicated
Nutritional support and fluid resuscitation
Biliary drainage may be required to decompress the biliary tree and manage cholestasis
This can be achieved via percutaneous transhepatic drainage (PTD) or, if feasible, endoscopic stenting.
Surgical Management:
Surgical redo hepaticojejunostomy is the definitive treatment for symptomatic anastomotic strictures
The approach is tailored to the individual case and the nature of the stricture
Options include: Re-anastomosis of the hepatic duct to a new jejunal loop
Use of a biliary conduit to bypass the strictured segment, often requiring a longer segment of jejunum
Intraoperative cholangiography to confirm patency and identify residual strictures or stones
Techniques may involve creating a very long Roux limb to reach healthy hepatic ductal tissue, or employing techniques like the long loop Roux-en-Y or hepaticoduodenostomy if appropriate
Placement of internal stents during surgery may be considered to maintain patency postoperatively
Careful dissection is paramount to avoid further injury to the delicate hilar structures.
Supportive Care:
Intensive postoperative monitoring for bile leaks, hemorrhage, cholangitis, and anastomotic dehiscence
Pain management
Mobilization and early feeding
Close monitoring of liver function tests and bile drainage output
Management of electrolyte imbalances and fluid status.
Complications
Early Complications:
Bile leak from the new anastomosis
Hemorrhage
Cholangitis
Sepsis
Pancreatitis (if pancreatic duct is involved or injured)
Wound infection
Anastomotic dehiscence.
Late Complications:
Recurrence of anastomotic stricture
Cholangitis
Biliary cirrhosis
Hepatic failure
Adhesions and bowel obstruction
Cholangiocarcinoma (long-term risk, especially in benign stricture patients).
Prevention Strategies:
Meticulous surgical technique with careful handling of bile ducts
Adequate biliary drainage during surgery
Judicious use of electrocautery
Appropriate use of prophylactic antibiotics
Avoiding excessive tension on the anastomosis
Careful selection of materials for sutures
Ensuring adequate blood supply to the anastomotic site
Postoperative cholangiography to assess patency and identify issues early.
Prognosis
Factors Affecting Prognosis:
Extent and cause of the stricture
Presence of cholangitis or sepsis at the time of surgery
The surgeon's experience and technical proficiency
Patient's overall health status and comorbidities
Development of recurrent strictures
Presence of underlying liver disease.
Outcomes:
Successful redo hepaticojejunostomy can significantly improve symptoms and prevent further liver damage
Long-term success rates vary, with recurrence being a significant concern
Patients may require long-term follow-up and occasional endoscopic or interventional radiology procedures to manage residual or recurrent strictures.
Follow Up:
Regular clinical assessment and LFT monitoring for at least 1-2 years post-surgery
Imaging (ultrasound, MRCP) at regular intervals to assess for recurrent strictures or dilatation of bile ducts
Prompt investigation of any recurrent symptoms of cholangitis or jaundice.
Key Points
Exam Focus:
Redo hepaticojejunostomy is a complex procedure indicated for symptomatic anastomotic strictures causing cholestasis or cholangitis
The Roux-en-Y configuration is standard
Imaging modalities like MRCP and PTC are crucial for diagnosis and planning
Early and late complications are common and require vigilant management.
Clinical Pearls:
Always suspect a stricture in a patient with prior biliary surgery presenting with recurrent jaundice or cholangitis
Thorough preoperative workup is essential
Consider the length and location of the stricture when planning the redo
A longer Roux limb is often necessary to find healthy, pliable ductal tissue
Intraoperative cholangiography is mandatory to assess the reconstruction.
Common Mistakes:
Inadequate length of the jejunal limb for the anastomosis
Failure to identify all strictured segments or associated stones
Aggressive dissection leading to further injury
Insufficient management of sepsis preoperatively
Not considering malignancy as a cause of stricture
Over-reliance on ERCP in patients with complex anatomy post-redo surgery.