Leakage of Hepaticojejunal Anastomosis: Reoperation

Abstract

Background: Leakage of a hepaticojejunal anastomosis is a rare event with potential major morbidity. Surgeons must be aware of the technical armamentarium and pitfalls in revisional surgery for hepaticojejunal anastomosis leakage. Methods: Review of the available literature and discussion of technical details based on experience and expert opinion. Results: Early bile leaks as well as failed interventional therapy are indications for reoperation. Almost all reports only mention rates of leakage as a secondary endpoint but do not report details of treatment and outcome. Few authors have compared outcome after reoperation versus interventional approaches in observational studies, with the latter resulting in lower morbidity. The complex and individual situation of the complication makes evidence-based argumentation difficult; this is why personal expert opinions have to be taken into account in this review. The technical aspects and pitfalls of revisional surgery are outlined but represent anecdotal evidence as comparative studies are lacking. Conclusion: Bile leak after bilioenteric anastomosis is a rare condition that requires differentiated workup and therapy. Early leaks usually result from technical problems and are amenable to repair by reoperation. Reoperation technique can only be discussed on a low evidence level.

Afferent limb syndrome, biliocutaneous fistula, bilioenterocutaneous fistula, dehiscence of the hepaticojejunostomy: Can we treat all of this endoscopically?

“… 2 Although acute leaks around hepaticojejunal anastomoses are not uncommon, chronic anastomotic dehiscence is very rare but can lead to abscess formation and subsequent fistulization. 3 In patients who are deemed poor surgical candidates, can these conditions be treated endoscopically? (Institutional review board approval was obtained for this study.)…”

Gd-EOB-DTP-enhanced MRC in the preoperative percutaneous management of intra and extrahepatic biliary leakages: does it matter?

“…The latter is usually performed with anastomoses between a normal bile duct segment proximal to the site of disease and a Roux-en-Y loop of the jejunum (44), without cystic duct remnant, although a very small remnant may be left in place. Biliary leaks after hepaticojejunal anastomosis are rare events, but with potential greater morbidity (44), occurring in 0.4% to 8% of the patients, depending on the type of procedure (7) with a median onset around day 4 (ranging between 2-13 days) after the index operation (45). De Castro et al, showed that biliary leaks occurred in 24 of 1,033 patients (2.3%) after hepaticojejunostomy with an incidence varying from 11% after proximal bile duct resection to 1% after a palliative bypass procedure for malignant disease (7).…”

“…After pancreatoduodenectomy, biliary leakage may also be derived from an insufficient pancreatojejunostomy, especially when a single jejunal loop is used for bilioenteric and pancreatoenteric anastomosis and the distance between the pancreatic and the biliary anastomosis is short. Therefore, the localization of the bile leak is mandatory before considering reoperation or a percutaneous drainage (44).…”

Management of Complications after Major Gastrointestinal Surgery

“…The surgical treatment of leakages of hepaticojejunal anastomosis -a rare event -is addressed by Wellner and Keck [4]. In addition, the authors provide impressive pictures of the operation technique for repairing a hepato-intestinal anastomosis in the case of early leaks.…”