Article Info

AuthorAffiliations: Department of General Surgery, Division of Hepatopancreatobiliary Surgery (Pekmezci S, Saribeyoglu K and Aytac E), and Department of Medical Education (Serdar B), Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey

Contributors: PS and SK proposed the study. SK and AE performed research and wrote the first draft. PS, SK and AE collected and analyzed the data. SB drew the figures. All authors contributed to the design and interpretation of the study and to further drafts. SK is the guarantor.

ABSTRACT: A standard hepaticojejunostomy technique might be difficult to perform, especially when the bile duct is small and located deep in the liver hilum. Herein we present a new procedure, the Hand-Fan technique, that was used to enhance the exposure and ease the performance of these challenging anastomoses. Thirty-one patients who had had hepaticojejunostomy with this technique for bile duct injury and other benign biliary pathologies from July 2004 to June 2011 were included into the study. Median postoperative hospital stay was 7 days (6-25 days) and median follow-up time was 33 months (2-84 months). Liver function tests revealed that the blood bilirubin levels of the patients were normalized after hepaticojejunostomy. Follow-up showed that there were no signs of clinical recurrence or impaired bile flow. The Hand-Fan technique considerably facilitates challenging hepaticojejunostomies. Surgeon's comfort is exceptional and the clinical results are satisfactory.

Hepaticojejunostomy (HJ) is the procedure of choice to reconstruct bile duct continuity for several indications. Although various techniques have been described for the HJ procedure, leaks and strictures after HJ are still dilemmas for the surgeons. Performing an impeccable HJ anastomosis might be difficult especially when the diameter of the remnant bile duct is narrow (<5 mm), the level of HJ injury is high or the latter is within the liver parenchyma.^[1] Even though the HJ technique is more or less standard for bilio-enteric reconstruction, there are several variations that were reported in the literature including the left bile duct technique or a procedure without mucosa-to-mucosa alignment.^[2-4] The good opposition of the edges of the bile duct mucosa and bowel mucosa/submucosa, fine sutures by absorbable materials and an adequate Roux jejunal limb are key steps for a standard HJ.

The patients with benign pathologies who had had Roux-en-Y HJ with this technique, from July 2004 to June 2011, were included in this study. Malignant cases were excluded since the outcome is closely related to the malignant disorder itself, rather than the success of the reconstruction. All the patients were managed and operated by our surgical team. The medical fitness of the patients was suitable for major laparotomy. All the procedures in this study were followed in accordance with the ethical standards of the institutional review committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.

Ultrasound, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous cholangiography were the diagnostic imaging procedures. Since all of the patients were referred from other centers, there was no uniform preoperative diagnostic follow-up and the decision for the above diagnostic procedures was made individually. There were no strict criteria about the timing of the procedure. The timing for the reconstruction was decided individually. Intraabdominal collections were drained percutaneously and the general condition of the patients was improved by conservative therapy until definitive reconstructive operation. As an overall principle, we aimed to reconstruct as soon as the general status of the patient allowed a major operation, and bile leak was under control, if existent. Moreover, if there was a mechanical jaundice which was related to bile duct injury, the bilirubin level was targeted to be <5 mg/dL preoperatively and either percutaneous or endoscopic drainage was carried out for this purpose.

A reverse L-shape (upper midline+right transverse) incision was preferred for the patients who had no history of anterior laparotomy. If there was any previous operation scar, anterior laparotomy was used to access the abdomen. A total adhesiolysis was carried out as an initial step, in order to have a better exploration and security for the planned HJ anastomosis. Then, each tubular component of the hepatoduodenal ligament including the hepatic artery, portal vein and bile duct was exposed. Since vascular injuries or anatomic variants were not uncommon in such cases, maximum effort was given to elucidate the degree of the injuries and anatomical data. The orifice of the bile duct was prepared and freed from the surrounding structures. The bile duct was dissected as long as a non-ischemic and non-scarred bile duct orifice was exposed. An intraoperative cholangiography was performed to evidence that this opening corresponded to the appropriate one since it might be just a dilated single lobe hepatic duct that may appear misleadingly like a common bile duct, in some complicated cases.

HJ was performed by the Roux-en-Y technique. The upper limb was pulled up through the mesocolon and jejuno-jejunostomy was created 40 cm distal to the HJ and 20 distal to the Treitz ligament. In the presence of a small caliber bile duct, an 8-Fr pediatric feeding tube was occasionally used as a trans-anastomotic stent and it was placed either by a transjejunal or transhepatic approach.

The following were steps of the HJ technique. At first, a hole was created on the jejunum. An anastomosis was started to be performed by the posterior row of sutures and an absorbable monofilament suture, such as 4/0 or 5/0 polydioxanone (PDS II, Ethicon, NJ, USA) or poliglecaprone 25 (Monocryl, Ethicon, NJ, USA). 4/0 diameter was chosen for relatively thicker bile duct walls (especially after long-lasting cholangitis), whereas finer 5/0 sutures were used for thinner, small bile ducts. The initial posterior row was made by taking a stitch from the jejunum (direction in-out) and then the bile duct (direction out-in) (Fig. 1). The jejunal stitches were near full-thickness (the needle was inserted just above the free edge of the mucosa-submucosal layer, passed tangentially and exited on serosal surface). This type of suturing provided easy inversion along with complete opposition. The sutures were left unknotted and held by small straight clamps, which were held in order, by passing their handles through a long right angle forceps. All the sutures were placed in this manner with a suture distance of 1.5-2 mm.

The next step was suturing of the anterior row. Initially, a rectangle gauze (about 30×5 cm) was secured to the upper edge of the incision either by sutures or towel clamps. Then, the needle passed by the gauze (direction up-down) then by the anterior edge of the bile duct wall (direction out-in) and the suture left unknotted and secured by a small straight clamp (Fig.2A). Similar sutures were placed to the entire anterior row. It had a "Hand-Fan" like look after the completion of this part of the anastomosis.

The third step was knotting the posterior row sutures. The sutures were knotted one-by-one, the suture line was checked for its integrity and then the sutures were cut (Fig. 2B). At this step, a feeding tube, which was occasionally used as a trans-anastomotic stent, was secured at the anastomotic line by using two uncut sutures.

Subsequent to the completion of the posterior row, surgeon focused again to the anterior row. The clamp that grasped the suture was opened but the suture was not freed from the gauze. The needle that had been already passed from the bile duct at step 2, stitched at this point the anterior edge of the jejunal wall (Fig.3A). Again, the stitch was passed tangentially by "in-out" direction, and the needle was inserted just above the free edge of the mucosa (submucosal layer), just like the posterior edge sutures. The sutures were not knotted and grasped again by the clamp. Similar technique was used for the entire sutures.

The postoperative management included routine medical therapy (fluid resuscitation, analgesia, antibiotics as needed etc). The patients were allowed to have liquid diet on postoperative day 4. The drain was taken out as early as possible if there were no signs of bleeding or bile leak. Control cholangiography was performed by the stent, if existent, one month after the operation; the stent was taken out if there was no problem on the anastomosis. The patients were followed up clinically and by biochemical tests and ultrasound.

There were 31 (20 females, 64.5%) patients. Their median age was 51 years (range 27-72 years). The indications were presented in the Table. The majority of the patients with prior laparoscopic cholecystectomies had type II and III injuries according to Bismuth-Strasberg classification. None of the patients who had a laparoscopic cholecystectomy history was operated on by our surgical team. Four patients (12.9%) who had HJ stenosis were referred from other hospitals and limited information was obtained about the initial reconstruction. Three patients (9.7%) with benign biliary stenosis had neither additional disease nor previous surgery. They underwent prior ERCP and laparoscopic cholecystectomies that were reported to be uneventful clearance of choledocholithiasis, and the removal of the gallbladder. No etiological factor was found in one patient (3.2%) who had benign biliary stenosis. Only one patient (3.2%) with hydatid disease had prior cystotomy to a cyst located in the segments 2 and 3, and a postoperative ERCP intervention. A trans-anastomotic stenting by a feeding tube was used in 21 (67.7%) patients. Median postoperative hospital stay was 7 days (6-25 days) and median follow-up time was 33 months (2-84 months).

A purulent intraabdominal collection had been diagnosed in one patient (3.2%) on postoperative day7; it was drained percutaneously (grade IIIa according to Clavien's classification^[5]). Wound infection was observed in two (6.5%) patients (grade I according to Clavien's classification). One patient (3.2%) underwent mesh repair for an incisional hernia one year after HJ, but obstructive jaundice occurred in the same patient one year after mesh repair (grade IIIb according to Clavien's classification). The jejunal segment, which had been prepared for the bilio-digestive anastomosis, was affected by the adhesions in this case and the HJ anastomosis was revised and a Roux-en-Y HJ was reconstructed with the same technique. The liver function tests and the blood bilirubin levels of the patients were normal after HJ in all patients. There were no signs of clinical recurrence or impaired bile flow during follow-up.

We named this procedure as the "Hand-Fan" technique because the surgical field after passing the sutures of the anterior wall looked like a Hand-Fan (Fig. 4). In this series, we faced no complication directly related with this technique and moreover, surgeon felt comfortable in the whole procedure, even in highly challenging bilio-digestive reconstructions.

HJ is still a demanding procedure, complications after biliary reconstructions include fistula (10%-15%) and stenosis (5%-7%).^[2] The morbidity and mortality rates increase with small diameter bile ducts, high-level injuries, revision reconstructions and accompanying infections.^[3] Technical aspects of this specific surgery, which requires a tension-free, non-ischemic anastomosis, play an important role in the success of the treatment; appropriate exposure of the bile duct, precise suturing and a watertight anastomosis are crucial.

In these circumstances, we applied above-mentioned maneuvers to our HJ anastomosis technique. This approach has the advantage to ease the suturing of challenging bile ducts that are deep in the hepatic hilum, open the orifice in multi-directions by retracting the anterior wall of the bile duct, and prevent the anastomosis to be puckered. Small size bile ducts are more or less rotated with classic HJ techniques where the suture holding graspers were collected at one side of the surgical field. Passing the sutures from the gauze, which is placed on the superior wound edge, keeps the lumen of the bile duct wide open and sutures separated. We believe that this approach increases surgeon's comfort during HJ.

The results of our series are acceptable and comparable with the published data in the literature.^[2-7] Schmidt et al^[7] reported 19% of biliary morbidity and they emphasized that the presence of peritonitis or concomitant vascular injuries and higher injuries above the bifurcation were associated with poor outcome. Another important point of the technique is the layers of the anastomosis. Even though full-thickness sutures were usually advocated for both sides, a recently study reported successful long-term results of their bilio-enteric reconstruction without mucosa-to-mucosa alignment, in small caliber bile ducts.^[4] In our technique, we used near full-thickness bites and we believe that it is the finest way to oppose the bile ducts and jejunum since the bile duct is clearly thinner than the enteral wall. Moreover, the exploration of all tubular structures of the hepatic hilum is crucial.^[2] In most cases, the dissection of the liver plate is mandatory to reach this goal. In two patients who had prior HJ reconstruction, we confronted incomplete anastomoses that were draining only the left lobe. As for the trans-anastomotic stents, we used it occasionally in particularly small and problematic bile ducts.

It is impossible to decide the superiority of a technique to another within the limits of a single study. We presented our HJ technique to provide a new suggestion to hepatobiliary surgeons. It is quite simple to understand and perform, and no new sophisticated devices are needed. HJ with the "Hand-Fan" technique is a safe and feasible approach to maintain the continuity between the bile ducts and intestine. The potential clinical use is both for the reconstruction of bile duct strictures and any small bile duct orifices deep in the liver. Further studies with large patient numbers are needed to evaluate the effectiveness of the technique.

1 Laukkarinen J, Sand J, Leppiniemi J, Kellomäki M, Nordback I. A novel technique for hepaticojejunostomy for nondilated bile ducts: a purse-string anastomosis with an intra-anastomotic biodegradable biliary stent. Am J Surg 2010;200: 124-130. PMID: 20074696

3 Shimizu H, Kimura F, Yoshidome H, Ohtsuka M, Kato A, Yoshitomi H, et al. Intrahepatic cholangiojejunostomy (Longmire procedure) for recurrent bilioenteric anastomotic stricture with hepatolithiasis. Hepatogastroenterology 2012; 59:1023-1025. PMID: 22580652