The incidence of bile duct injuries has increased as a consequence of the increasing number of cholecystectomies. However, the results of biliodigestive derivation currently used for bile duct reconstruction are unsatisfactory. We report here the case of a patient with iatrogenic Bismuth II bile duct injury and propose a new technique that permits more anatomical and physiological reconstruction of extensive bile duct injuries using transverse retubularization of a pedicled jejunal segment interposed between the bile duct and duodenum.
Many cases of choledocholiths formed around sutures and clips used during cholecystectomy have been reported. We describe a case of gallstone formation around a nylon suture after non-biliary surgery. To the best of our knowledge, this is the first report of such a case.
A 75-year-old Japanese man, who had undergone distal gastrectomy for gastric cancer and reconstruction with the Billroth II method 8 years earlier, presented with gastric discomfort. Abdominal ultrasonography was conducted and we diagnosed cholecysto-choledocholithiasis with dilatation of the intrahepatic bile duct. He underwent cholecystectomy and cholangioduodenostomy for choledocholith removal. Gallstones, which had formed around a nylon suture used during the previous gastrectomy, were found in the bile duct. Sutures of the same material had also been placed on the duodenum. Chemical analysis revealed that the stones were composed of calcium bilirubinate. The patient was discharged on postoperative day 19, and choledocholithiasis has not recurred thus far.
The findings from this case suggest that standard, non-resorbable sutures used in gastrectomy may be associated with the formation of bile duct stones; therefore, absorbable suture material may be required to avert gallstone formation even in the case of gastrectomy.
Choledocholithiasis; Absorbable suture; Gastrectomy
Mirizzi syndrome is a rare cause of intermittent obstructive jaundice, where an impacted stone in the cystic duct or Hartmann’s pouch mechanically obstructs the common bile duct (CBD). We report a rare case of double cholecysto-biliary and cholecysto-enteric fistulae, in a 75-year-old female patient, presenting with a right upper quadrant abdominal pain and intermittent obstructive jaundice. Endoscopic retrograde cholangiopancreatography suggested Mirizzi syndrome. Operative findings included erosions of the lateral wall of the CBD and the second portion of the duodenum due to impacted gallstones. The defects were reconstructed primarily and a Kehr tube was inserted. The patient had an uneventful postoperative course and was discharged on the 14th postoperative day.
Mirizzi syndrome; Obstructive jaundice; Gallstone; Cholecysto-enteric fistula; Endoscopic retrograde cholangiopancreatography
A technique of orthotopic liver transplantation using a segmental graft from living donors was
developed in the dog. Male mongrel dogs weighing 25–30 kg were used as donors and 10–15 kg as
recipients. The donor operation consists of harvesting the left lobe of the liver (left medial and left
lateral segments) with the left branches of the portal vein, hepatic artery and bile duct, and the left
hepatic vein. The grafts are perfused in situ through the left portal branch to prevent warm ischemia.
The recipient operation consists of two phases: 1total hepatectomy with preservation of the inferior
vena cava using total vascular exclusion of the liver and veno-venous bypass, 2implantation of the graft
in the orthotopic position with anastomosis of the left hepatic vein to the inferior vena cava and portal,
arterial and biliary reconstruction. Preliminary experiments consisted of four autologous left lobe
transplants and nine non survival allogenic left lobe transplants. Ten survival experiments were
conducted. There were no intraoperative deaths in the donors and none required transfusions. One
donor died of sepsis, but all the other donor dogs survived without complication. Among the 10 grafts
harvested, one was not used because of insufficient bile duct and artery. Two recipients died
intraoperatively of air embolus and cardiac arrest at the time of reperfusion. Three dogs survived, two
for 24 hours and one for 48 hours. They were awake and alert a few hours after surgery, but eventually
died of pulmonary edema in 2 cases and of an unknown reason in the other. Four dogs died 2–12 hours
postoperatively as a result of hemorrhage for the graft's transected surface. An outflow block after
reperfusion was deemed to be the cause of hemorrhage in these cases. On histologic examination of the
grafts, there were no signs of ischemic necrosis or preservation damage.
This study demonstrates the technical feasibility of living hepatic allograft donation. It shows that it is
possible, in the dog, to safely harvest non ischemic segmental grafts with adequate pedicles without
altering the vascularization and the biliary drainage of the remaining liver. We propose that this
technique is applicable to human anatomy.
Operations on the common bile duct may lead to potentially serious complications such as biliary peritonitis. T-tube insertion is performed to reduce the risk of this occurring postoperatively. Biliary leakage at the point of insertion into the common bile duct, or along the fistula, can sometimes occur after T-tube removal and this has been reported extensively in the literature. We report a case where the site at which the T-tube fistula leaked proved to be the point of contact between the fistula and the anterior abdominal wall, a previously unreported complication.
A 36-year-old sub-Saharan African woman presented with gallstone-induced pancreatitis and, once her symptoms settled, laparoscopic cholecystectomy was performed, common bile duct stones were removed and a T-tube was inserted. Three weeks later, T-tube removal led to biliary peritonitis due to the disconnection of the T-tube fistula which was recannulated laparoscopically using a Latex drain.
This case highlights a previously unreported mechanism for bile leak following T-tube removal caused by detachment of a fistula tract at its contact point with the anterior abdominal wall. Hepatobiliary surgeons should be aware of this mechanism of biliary leakage and the use of laparoscopy to recannulate the fistula.
Injuries of the biliary tree, which mainly occur as a complication of laparoscopic cholecystectomy, are a potentially life threatening cause of high morbidity and mortality. The reported frequency of biliary injuries after laparoscopic cholecystectomy is from 0.5–0.8%. Such injuries may sometimes become too complicated for surgical repair. Presented here is the case of a patient with a major bile duct injury for whom bile duct continuity was achieved using a T-tube.
A 53-year-old man, who developed bile duct injury following a laparoscopic cholecystectomy performed in another center for cholelithiasis, was referred to our clinic. A Roux-en-Y hepaticojejunostomy was performed in the early postoperative period. However, ensuing anastomotic leakage prompted undoing of the hepaticojejunostomy followed by placement of a T-tube by which bile duct continuity was achieved.
For injuries with tissue loss requiring external drainage, T-tube bridging offers a feasible option in that it provides bile duct continuity with biliary flow into the duodenum, as well as achieving external drainage, thus alleviating the need for further definitive surgery.
iatrogenic bile duct injury; T-tube bridging; external and internal biliary drainage
T-tube usage is common following common bile duct exploration for calculi and other complex biliary surgeries to ensure proper biliary diversion and healing. A 25-year-old woman was referred from a surgical unit with a history of open cholecystectomy and common bile duct exploration for cholelithiasis and choledocholithiasis with T-tube placement in the common bile duct for postoperative biliary diversion. While retrieving the T-tube, it got fractured and the fragment remained in the bile duct. We report a rare case of retained T-tube fragment after T-tube removal that was retrieved endoscopically.
Objectives: This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years.
Methods: This is a prospective observational study conducted over a period of 10 years (January 2001-december 2010). A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct (CBD) stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy (both open & laproscopic) during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome.
Results: Out of 1500 patients 83(5.53%) required biliary bypass surgical procedures. The CBD stones were observed as the most common indication (25.3%), followed by CBD injuries after open(10.84%) or laproscopic-cholecystectomy (14.46%), carcinoma head of pancreas (12.05%) and CBD obstruction(14.46%) either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy (26.51%) was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy (i.e. 25.3% and 12.05% respectively). Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay.
Conclusion: Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases.
CBD stones; Biliary injuries; Pancreatico-biliary malignancies; Cholecystectomy; Biliary bypass surgery
Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair (right to left hepatic duct anastomosis over the T-tube), with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepatico-jejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical mal-repair. We propose an algorithm for the treatment of early and late biliary injuries.
Biliary tract injury; Surgical complication; Biliary surgery; Laparoscopic cholecystectomy
Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.
Nonoperative management (NOM) of hemodynamically stable patients with blunt hepatic injuries is considered the current standard of care. However, it is associated with several in-hospital complications. In selected cases laparoscopy could be proposed as diagnostic and therapeutic means.
A 28 years-old male was admitted in the Emergency Unit following a motor vehicle crash. CT-scan showed an isolated stade II hepatic injury at the level of the segment IV. Firstly a NOM was decided. Laparoscopic exploration was then performed at day 4 due to a biliary peritonitis. Intraoperative trans-cystic duct cholangiography showed a biliary leaks of left hepatic biliary tract, involving sectioral pedicle to segment III. Cholecystectomy, trans-cystic biliary drainage, application of surgical tissue sealing patch and abdominal drainage were performed. Postoperative outcome was uneventful, with fast patient recovery.
Laparoscopy has gained a role as diagnostic and therapeutic means in treatment of complications following NOM of blunt liver trauma. This approach seems feasible and safety, with satisfactory postoperative outcome.
We report a case of necrosis of a reconstructed gastric tube in a 77-year-old male patient who had undergone esophagectomy. At the time of admission, the patient had active gastric ulcers, but these were resolved by treatment with a proton pump inhibitor. Subtotal esophagectomy with gastric tube reconstruction was performed. Visually, the reconstructed gastric tube appeared to be well perfused with blood. Using indocyanine green (ICG) fluorescence imaging the gastroepiploic vessels were well enhanced and no enhancement was visable 3 to 4 cm from the tip of the gastric tube. Four days after esophagectomy, gastric tube necrosis was confirmed, necessitating a second operation. The necrosis of the gastric tube matched the area that had been shown to lack blood perfusion by ICG angiography imaging. It seems that ICG angiography is useful for the evaluation of perfusion in a reconstructed gastric tube.
Ischemia; Necrosis; ICG angiography; Esophageal cancer; Gastric tube; Esophagectomy
The biliary excretion of a new derivative of cephalosporin, cephacetrile (CIBA 36 278 Ba), was studied (i) in the isolated perfused rabbit liver, (ii) in humans with a duodenal tube, and (iii) in patients after cholecystectomy with a Kehr's drain in the common bile duct. The biliary excretion of the antibiotic was very low in the perfused liver, and no antibiotic activity was found in liver tissue at the end of the experiment. This observation, together with the finding of a rapid decline of the antibiotic concentration in the circulating blood serum, favors the assumption that a metabolic transformation of CIBA 36 278 Ba in liver tissue takes place. In humans, the antibiotic concentration was found to be low both in the duodenal juice and in the bile obtained by external drainage. The biliary concentrations found in these subjects seem to be inferior to those required for the inhibition of the common bacteria of biliary infections. In renal failure, however, the biliary excretion of CIBA 36 278 Ba increased considerably.
Benign biliary postoperative stenoses and biliary leaks and fistulas usually occur due to injury after laparoscopic cholecystectomy, gastric or hepatic resection, bilio-enteric anastomoses and after liver transplantation. In most of the cases a new surgical intervention is not possible and the percutaneous trans-hepatic approach is of paramount importance in the diagnosis and treatment of the problem. This review aims to highlight the spectrum of percutaneous cholangiographic findings and methods of treatment of postoperative benign biliary stenoses and biliary leaks and fistulas. In the case of stenosis, dilation of the narrow tract is the usually the first approach, whereas in the case of leaks and fistulas bile diversion with drainage is usually attempted in order to seal the fistulous tract. However, a great variety of combination of materials and techniques may be used on a “case-by case” approach
A selection of cases of benign biliary postoperative stenoses and biliary leaks and fistulas that were managed percutaneously are presented and the most common lines of approach are discussed.
The imaging spectrum of percutaneous treatment of benign biliary postoperative stenoses and biliary leaks and fistulas is presented in order to aid interpretation and management with image guided procedures.
• Treatment of benign biliary stenosis is performed with cholangioplasty and stents.
• The main goal of fistula treatment is to divert the bile away from the site of bile wall defect.
• Drain collection and tract embolisation are the other options for bile leak percutaneous treatment.
Biliary tract disease; Postoperative biliary injury; Benign biliary strictures; Bile leaks and fistula; Biliary drainage
Complete reports of biliary and vascular injuries after laparoscopic cholecystectomy are rare.
Fifteen patients with complex laparoscopic cholecystectomy injuries underwent corrective operations. The injuries consisted of 14 bile duct injuries and one large laceration of a cirrhotic liver. Five of the bile duct injuries were accompanied by inadvertent occlusion of the right hepatic artery, and one was further complicated by portal vein occlusion. One hepatic artery occlusion and one portal vein occlusion were successfully reconstructed. Two patients with arterial occlusion required right hepatic lobectomy. Corrective biliary operations consisted of common hepaticojejunostomy (seven cases), right and left hepaticojejunostomies (one case), right anterior and left hepaticojejunostomies (two cases), right hepaticojejunostomy (one case), right posterior hepaticojejunostomy (one case), and left hepaticojejunostomy after right lobectomy (two cases).
Except for a patient with a severe laceration of a cirrhotic liver who died as a result of hepatic failure, the remaining 14 patients are alive and well with normal hepatic function tests at six and 37 months after corrective operations.
A knowledge of anatomy is critical to the prevention of injuries to the hepatobiliary tree and related structures during laparoscopic cholecystectomy. J. Am. Coll. Surg., 1994, 179: 321–325.
Biliary complications continue to be an important determinant of the recipient's survival rate after orthotopic liver transplantation (OLT). The objective of this study was to evaluate the incidence of early biliary complications in OLT in the presence or absence of a T‐tube.
This retrospective study, based on inpatient data, focused on the relationship between T‐tube placement and early biliary complications of 84 patients after OLT, from November 2002 to June 2005. Patients were divided into two groups based on whether or not a T‐tube was used following bile duct reconstruction: T‐tube group (group I, n = 33); non‐T‐tube group (group II, n = 51).
45.2% of OLT recipients had a malignant neoplasm. There were no significant differences in the demographic characteristics or operation data between the two groups. Overall, early biliary tract complications developed in 19.0% (16/84) of patients. The rate of early biliary complications was 30.3% (10/33) and 11.8% (6/51) in groups I II, respectively (p = 0.035). Biliary complications which were directly caused by T‐tube placement occurred in 12.1% (4/33) of patients in group I. Overall, the percentage of malignant neoplasms, chronic viral cirrhosis, fulminant liver failure and other primary disease recipients with early biliary complications were 6.2%, 37.5%, 43.8% and 12.5%, respectively.
This study suggests that the use of a T‐tube in Chinese patients undergoing OLT causes a higher incidence of early biliary complications. Most of the early biliary complications occurred in chronic viral cirrhosis and fulminant liver failure recipients.
Combined iatrogenic vascular and biliary injury during cholecystectomy resulting in ischemic hepatic necrosis is a very rare cause of acute liver failure. We describe a patient who developed fulminant liver failure as a result of severe cholestasis and liver gangrene secondary to iatrogenic combine injury or the hepatic pedicle (i.e. hepatic artery, portal vein and bile duct) during laparoscopic cholecystectomy.
A 40-years-old woman underwent laparoscopic cholecystectomy for acute cholecystitis. During laparoscopy, a severe bleeding at the liver hilum motivated the conversion to open surgery. Many sutures were placed across the parenchyma for bleeding control. After 48 hours, she rapidly deteriorated with encephalopathy, coagulopathy, persistent hypotension and progressive organ dysfunction including acute renal failure requiring hemodialysis and mechanical ventilation. An angiography documented an occlusion of right hepatic artery and right portal vein. In the clinical of acute liver failure secondary to liver gangrene, severe coagulopathy and progressive secondary multi-organ failure, the patient was included in the waiting list for liver transplantation. Two days later, the patient was successfully transplanted with initial adequate liver graft function. However, she developed bilateral pneumonia and severe gastrointestinal bleeding and finally died 24 days after transplantation due to bilateral necrotizing pneumonia.
The occurrence of acute liver failure due to portal triad injury during laparoscopic cholecystectomy is a catastrophic complication. Probably, the indication of liver transplantation as a life-saving strategy in patients with late diagnosis, acute liver failure, severe coagulopathy and progressive secondary multi-organ failure could be considered but only minimizing immunosuppressive regimen to avoid postoperative infections.
A case of esophageal ulcer caused by nasobiliary tube is described. This tool is not routinely considered to be a cause of major complications in the literature and to our knowledge, this is the first report of this kind of complication in nasobiliary tube placement. A 72-year-old patient presented with Charcot's triad and was demonstrated to have cholangitis with multiple biliary stones in the common bile duct. Biliary drainage was achieved through endoscopic retrograde cholangiography, endoscopic sphincterotomy, biliary tree drainage and nasobiliary tube with double pigtail. The patient presented odynophagia, dysphagia and retrosternal pain 12 h after the procedure and upper endoscopy revealed a long esophageal ulcer, which was treated conservatively. This report provides corroboration of evidence that nasobiliary tube placement has potential complications related to pressure sores. In our opinion this is a possibility to consider in informed consent forms.
Nasobiliary tube; Complication; Esophagus
In several clinical situations, including resection of malignant or benign biliary lesions, reconstruction of the biliary system using the Roux-en-Y jejunum limb has been adopted as the standard procedure. The basic technique and the procedural knowledge essential for most gastroenterological surgeons are described in this article, along with a video supplement. Low complication rates involving anastomotic insufficiency or stricture can be achieved by using proper surgical techniques, even following small bile duct reconstruction. Using the ropeway method to stabilize the bile duct and jejunal limb allows precise mucosa-to-mucosa anastomosis with interrupted sutures of the posterior row of the anastomosis. Placement of a transanastomotic stent tube is the second step. The final step involves suturing the anterior row of the anastomosis. In contrast to the lower extrahepatic bile duct, the wall of the hilar or intrahepatic bile duct can be recognized within the fibrous connective tissue in the Glissonean pedicle. The portal side of the duct should be selected for the posterior wall during anastomosis owing to its thickness. Meticulous inspection to avoid overlooking small bile ducts could decrease the chance of postoperative intractable bile leakage. In reconstruction of small or fragile branches, a transanastomotic stent tube could work as an anchor for the anastomosis.
Electronic supplementary material
The online version of this article (doi:10.1007/s00534-011-0475-5) contains supplementary material, which is available to authorized users.
Biliary reconstruction; Bilioenteric anastomosis; Choledochojejunostomy; Hepaticojejunostomy; Hepatobiliary resection
Radiographic assessment of the biliary tract is often essential in patients who have undergone liver transplantation. T- or straight-tube cholangiography, percutaneous transhepatic cholangiography, and endoscopic retrograde cholangiography all may be used. A total of 264 cholangiograms in 79 adult liver transplant patients (96 transplants) was reviewed. Normal radiographic features of biliary reconstructive procedures, including choledochocholedochostomy and choledochojejunostomy, are demonstrated. Complications diagnosed by cholangiography included obstruction, bile leaks, and tube problems, seen in eight, 24, and 12 transplants respectively. Stretching and incomplete filling of intrahepatic biliary ducts were frequently noted and may be associated with rejection and other conditions. Transhepatic biliary drainage, balloon catheter dilatation of strictures, replacement of dislodged T-tubes, and restoring patency of obstructed T-tubes using interventional radiologic techniques were important in avoiding complications and additional surgery in selected patients.
A 29 year old morbidly obese patient suffered injury to his common bile duct during cholecystectomy.
Subsequent access to the biliary tree was obtained by using a long heavy gauge needle after
first opacifying the system with contrast injection through a nasobiliary tube. It is now twenty six
months after initial percutaneous biliary drainage placement and eighteen months after removal
of all biliary access. The patient is asymptomatic and has normal liver function tests. This
technique can be useful in morbidly obese patients who are at increased risk from surgical repair
of biliary duct injuries.
Pediatric Spontaneous Bile duct perforation is a rare clinical condition with only around 150 cases reported worldwide. Early management gives excellent prognosis but the condition often presents a diagnostic dilemma. Hepato-biliary Technetium-99m-iminodiacetic acid scintiscan is the diagnostic investigation of choice but its availability in third world countries is limited. We present two cases of spontaneous biliary peritonitis in children, which were diagnosed without scintiscanning. The first case was a one-and -a half-year-old child, who was diagnosed with biliary peritonitis without pneumoperitoneum by a combination of Ultrasound (USG), Contrast enhanced computed tomography (CECT), and Magnetic Resonance Imaging (MRI). The child underwent USG-guided drainage and subsequent cholecystectomy with hepatico-jejunostomy. The second child also had biliary peritonitis without pneumoperitoneum, which was initially suspected on USG. CECT revealed dilated gall bladder and fluid collection in sub-hepatic space and pelvis. Abdominal paracentesis revealed presence of bile. The child responded to conservative therapy. Both are doing well on two-year follow-up. In a patient with jaundice, biliary tract abnormalities and/or free fluid, either generalized or localized to peri-cholecystic/sub-hepatic space on USG/CT/MRI, in the absence of pneumoperitoneum, suggest a diagnosis of biliary perforation even in the absence of scintiscanning.
Biliary peritonitis; conjugated hyperbilirubinemia; spontaneous biliary perforation; ultrasound
Spontaneous bile duct perforation is an unusual cause of acute abdomen. It is an extremely rare condition and rarely suspected or correctly diagnosed pre-operatively. A case of a 29year old adult female, presenting with peritonitis, 2days post partum is presented. Exploratory laparotomy showed biliary peritonitis secondary to a perforated common bile duct. She had a cholecystectomy and closure of the perforation over a T-tube. She recovered well and was discharged home. Awareness of spontaneous common bile duct perforation as a rare cause of biliary peritonitis, avoids undue delay in the diagnosis and thus improve prognosis. Cholecystectomy and drainage of bile duct using a T-tube is emphasized.
Pregnancy; Pre-eclampsia; Peritonitis; Bile duct perforation; Cholangiogram
A 43-year old woman was admitted 11 days after open cholecystectomy with a iatrogenic bile
duct injury. On admission the patient showed an uncontrolled biliary fistula through an external
drain placed at an emergency laparotomy for biliary peritonitis with fever and jaundice. PTC
showed a biliary stricture type II (Bismuth). A percutaneous drainage was performed to
decompress the biliary system. Three weeks later, percutaneous balloon dilatation of the
stricture was performed. However, bile leakage persisted. In a combined transhepatic/
endoscopic procedure, the percutaneous biliary drainage was replaced by a nasobiliary tube.
One week later, no stricture was found and the biliary leak was sealed. The patient could be
discharged without symptoms or signs of cholestasis. The multidisciplinary management of
post-operative biliary fistula is presented, comparing the role of interventional radiology,
endoscopy and surgery.
We propose a method of reconstruction after pancreaticoduodenectomy consisting of a double Roux en Y
on the same jejunal loop without interruption of the mesentery and a third anatomical Roux en Y to
reconstitute the alimentary tract.
The construction of the double Roux en Y draining pancreas and bile ducts separately, requires a linear
Stapler 3-4 centimeters from the biliary anastomosis. In this way, by employing the same loop without
mesenteric interruption, two functional excluded loops will be ’obtained. The rationale of the suggested
model is based on the separation of biliary and pancreatic secretions. This makes it possible to avoid a
stagnant cul-de-sac coinciding with the pancreaticojejunal anastomosis and to obtain in the case of
leakage, a pure biliary and/or pancreatic fistula as far as is possible.
99mTc HIDA scans demonstrated the efficiency, of the biliopancreatic limbs of the reconstruction,
showing normal emptying time for the gastric remnant and the absence of radionuclide stagnation or any
alkaline enterogastric reflux.