Bilioenteric anastomotic stricture in patients with benign and malignant tumors: prevalence,risk factors and treatment

BACKGROUND: Stricture formation at the bilioenteric anastomosis is a rare but important postoperative complication. However, information on this complication is lacking in the literature. In the present study, we aimed to assess its prevalence and predictive factors, and report our experience in managing bilioenteric anastomotic strictures over a ten-year period. METHODS: A total of 420 patients who had undergone bilioenteric anastomosis due to benign or malignant tumors between February 2001 and December 2011 were retrospectively reviewed. Univariate and multivariate modalities were used to identify predictive factors for anastomotic stricture occurrence. Furthermore, the treatment of anastomotic stricture was analyzed. RESULTS: Twenty-one patients (5.0%) were diagnosed with bilioenteric anastomotic stricture. There were 12 males and 9 females with a mean age of 61.6 years. The median time after operation to anastomotic stricture was 13.6 months (range, 1 month to 5 years). Multivariate analysis identified that surgeon volume (<30 cases) (odds ratio:-1.860; P=0.044) was associated with the anastomotic stricture while bile duct size (>6 mm) (odds ratio: 2.871; P=0.0002) had a negative association. Balloon dilation was performed in 18 patients, biliary stenting in 6 patients, and reoperation in 4 patients. Five patients died of tumor recurrence, and one of heart disease. CONCLUSIONS: Bilioenteric anastomotic stricture is an uncommon complication that can be treated primarily by interventional procedures. Bilioenteric anastomosis may be performed by a surgeon in his earlier training period under the guidance of an experienced surgeon. Bile duct size >6 mm may play a protective role.

Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration

BACKGROUND Bilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown. AIM To explore the feasibility and effectiveness of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China. METHODS This is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated. RESULTS Forty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60 (93.8%) cases and successful diagnosis in 59 (92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation, and no post-ERCP pancreatitis occurred. CONCLUSION Based on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.

Dilation of a severe bilioenteric or pancreatoenteric anastomotic stricture using a Soehendra Stent Retriever

Bilioenteric or pancreatoenteric anastomotic stric-tures often occur after surgery for a pancreaticobiliary disorder. Therapeutic endoscopic retrograde cholan-giopancreatography using balloon enteroscopy has been shown to be feasible and effective in patients with such strictures. However, when a benign anas-tomotic stricture is severe, a dilation catheter cannot pass through the stricture despite successful insertion of the guidewire. We report on the usefulness of the Soehendra Stent Retriever over a guidewire for dilating a severe bilioenteric or pancreatoenteric anastomotic stricture under short double-balloon enteroscopy, in two patients with surgically altered anatomies.

Does bilioenteric anastomosis impair results of liver resection in primary intrahepatic lithiasis?

AIM:To evaluate the long-term results of liver resection for the treatment of primary intrahepatic lithiasis.Prognostic factors,especially the impact of bilioenteric anastomosis on recurrence of symptoms were assessed.METHODS:Forty one patients with intrahepatic stones and parenchyma fibrosis/atrophy and/or biliary stenosis were submitted to liver resection.Resection was associated with a Roux-en-Y hepaticojejunostomy in all patients with bilateral stones and in those with unilateral disease and dilation of the extrahepatic biliary duct(>2 cm).Late results and risk factors for recurrence of symptoms or stones were evaluated.RESULTS:There was no operative mortality.After a mean follow-up of 50.3 mo,good late results were observed in 82.9% of patients;all patients submitted to liver resection alone and 58.8% of those submitted to liver resection and hepaticojejunostomy were free of symptoms(P=0.0006).Patients with unilateral and bilateral disease showed good late results in 94.1% and 28.6%,respectively(P<0.001).CONCLUSION:Recurrence of symptoms in patients with hepaticojejunostomy showed that this may not be the ideal solution.Further studies are needed to establish the best treatment for patients with bilateral stones or unilateral disease and a dilated extrahepatic duct.

Application of a new-type sutureless anastomosis stent to the primary reconstruction of the bilioenteric continuity after acute bile duct injury in dogs

Objective： To evaluate the effect of a new-type sutureless magnetic bilioenteric anastomosis stent that was used to reconstruct the bilioenteric continuity （primarily under the circumstances of severe inflammation after acute bile duct injury in dogs ）. Methods： Establishing an animal model of acute bile duct injury with severe inflammation and bile peritonitis in dogs. The newtype sutureless magnetic bilioenteric anastomosis stent was used to reconstruct the bilioenteric continuity primarily. Results： The experiment group anastomosis healed well with a mild local inflammation reaction, and the collagen lined up in order without the occurrence of observable bile leakage and infection. Conclusion： It was safe and feasible to use the new-type anastomosis stent to reconstruct the bilioenteric continuity primarily under the circumstances of severe inflammation after acute bile duct injury in dogs.

Pneumobilia,chronic diarrhea,vitamin K malabsorption:A pathognomonic triad for cholecystocolonic fistulas

Cholecystocolonic fistula (CF) is an uncommon type of internal biliary-enteric fistulas, which comprise rare complications of cholelithiasis and acute cholecystitis, with a prevalence of about 2% of all biliary tree diseases. We report a case of a spontaneous CF in a 75-year-old diabetic male admitted to hospital for the investigation of chronic watery diarrhea and weight loss. Massive pneumobilia demonstrated on abdominal ultrasound and computerized tomography, along with chronic, bile acid-induced diarrhea and a prolonged prothrombin time due to vitamin K malabsorption, led to the clinical suspicion of the fistula. Despite further investigation with barium enema and magnetic resonance cholangio-pancreatography, diagnosis of the fistulous tract between the gallbladder and the hepatic flexure of the colon could not be established preoperatively. Open cholecystectomy with fistula resection and exploration of the common bile duct was the preferred treatment of choice, resulting in an excellent postoperative clinical course. The incidence of biliary-enteric fistulas is expected to increase due to the parallel increase of iatrogenic interventions to the biliary tree with the use of endoscopic retrograde cholangio-pancreatography and the increased rate of cholecystectomies performed. Taking into account that advanced imaging techniques fail to demonstrate the fistulas tract in half of the cases, and that CFs usually present with non-specific symptoms, our report could assist physicians to keep a high index of clinical suspicion for an early and valid diagnosis of a CF.

A New Surgical Technique of Biliary Drainage

Introduction: Roux-en-Y Hepatico-jejunostomy is the standard technique of biliary reconstruction after excision of choledochal cyst. Here the author describes a new surgical technique of biliary reconstruction using native gall bladder as biliary conduit. New Surgical Technique: The choledochal cyst is excised as standard technique but gall bladder with its neck is kept in situ. The gall bladder neck is anastomosed with the common hepatic duct stump and gall bladder fundus is anastomosed with the antero-inferior wall of the first part of distal duodenum. Materials & Methods: Eleven patients with choledochal cyst have been operated with the new technique from July 2011 to December 2012 in the city of Dhaka, Bangladesh. Feeding was started from 3rd post-operative day and drain was removed by 7th day unless complicated and they were released from the hospital between 10-15 days. Results: The ages of eleven patients were from 3 months to 11 years. There were 7 females and 4 males. Lump was felt in 3 patients and jaundice was present in 4 patients. Recurrent abdominal pain was present in all patients. They were diagnosed by ultrasonography and MRCP was done in 6 patients only. Prothrombin time was elevated by 10% & 15% in 2 patients. Average operation time was 2 hours and 10 minutes. A 9-year girl died suddenly and unexpectedly on the 5th post-operative day from severe convulsion of unknown origin. One child suffered from prolonged bile leakage and re-explored to repair anastomotic leak. Another patient had a collection near the anastomosis which resolved spontaneously. Discussion: Benefits of the new surgical technique are total absence of Roux-en-Y related intestinal complications. Possible disadvantages are discussed. It is anatomical and physiological. Small incision and less operation time are other benefits which need to be mentioned. Possible disadvantages are discussed.