The Role of Portoenterostomy with Aggressive Hilar Dissection in Biliary Tract Tumors: Report of Case Series and Review of the Literature

Abstract

Hepaticojejunostomy is a challenging and complex procedure to be done with confidence in conditions that contain a large number of segmental bile ducts. Portoenterostomy can be defined as the joining of multiple bile ducts into a single cavity using segmenter bile duct ends, stents, and surrounding connective tissues. During surgery, in cases with advanced stage biliary tract tumors that cannot be performed hepatectomy, after aggressive dissections to provide a negative surgical margin, a large number of segmental bile ducts can be revealed and needs to ensure the continuity of bile flow. Here, our clinical series of portoenterostomy (PE) in which we applied in patients who had aggressive hilar dissection and resection for hilar cholangiocarcinomas and biliary tract tumors were discussed. The study included 15 patients who underwent PE for biliary tract tumors and hilar cholangiocarcinomas between 2015 and 2019. Six of the patients had a tumor-negative surgical margin, with a mean follow-up of 14.4 months (range 2 to 28 months). Nine of the patients had a tumorpositive surgical margin, with a mean follow-up of 7.7 months (range 2 to 17 months). Portoenterostomy instead of hepaticojejunostomy in small and multiple biliary radicles and bile duct cancers has been successfully performed in 15 patients of bile duct cancer and Klatskin tumor. In the presence of active inflammation, fibrosis, major bile duct trauma, and thin bile duct radicles, this method, which is described in detail, provides an excellent salvage surgical procedure with less morbidity.

Modified technique of Hepatojejunostomy for biliary tract reconstruction after resection of tumors affecting the perihilar region: a case series

“…Then, the posterior wall of the jejunum was sutured to the wall of the adjoining portal vein branches, the connective tissue, and the liver tissue below the lower edge of the bile duct to strengthen the anastomosis, since the wall of smaller bile ducts is often weak. Previous studies have also reported the use of the portal vein wall and connective tissue below the bile duct as a part of the posterior wall of the anastomosis, but the gap between the portal vein branches and liver section was not closed before anastomosis [ 10 , 11 , 13 , 15 , 16 ]. Subsequently, the biliary stumps, which were close to each other, especially the bile ducts used for the posterior wall of the anastomosis, were sutured together using absorbable sutures.…”

“…Most surgeons place silicone stent tubes in bile ducts, while some surgeons do not use any biliary stent [ 1 , 16 , 17 ]. Some surgeons place the distal end of the stents completely into the intestinal lumen, but others drain the bile out of the body.…”

“…Regrettably, prolene is not absorbable, and this may increase the risk of anastomotic stones [ 18 ]. Alternatively, polydioxanone (PDS) can be used for hepatojejunostomy in clinical practice [ 16 , 17 , 22 ]. The advantages and disadvantages of both absorbable and non-absorbable sutures were both taken into account in the present study.…”

Risk factors of delayed recovery from general anesthesia in patients undergoing radical biliary surgery

“…In the perioperative factors of DR from anesthesia, the main factors are the dosage of anesthetic drugs, the patient's body temperature and duration of surgery, and the amount of intraoperative fluid infusion [39] . Patients who are lighter or have liver and kidney function abnormalities who are not carefully evaluated before surgery, may be given overdosed anesthetic drugs, which may lead to high drug concentration in the body and DR [40] . If the operation time is very long and the evaluation of the end of the operation is biased, the anesthesia duration will be too long accordingly, [41] which is also an important factor for occurrence of DR from anesthesia.…”

“…In the perioperative factors of DR from anesthesia, the main factors are the dosage of anesthetic drugs, the patient's body temperature and duration of surgery, and the amount of intraoperative fluid infusion. [39] Patients who are lighter or have liver and kidney function abnormalities who are not carefully evaluated before surgery, may be given overdosed anesthetic drugs, which may lead to high drug concentration in the body and DR. [40] If the operation time is very long and the evaluation of the end of the operation is biased, the anesthesia duration will be too long accordingly, [41] which is also an important factor for occurrence of DR from anesthesia. It must be noted that patients with lower body temperature who enter the recovery room after surgery are more likely to develop DR. [42] Drops in body temperature may decrease the activity of enzymes related to drug metabolism, which may cause drugs to accumulate in the body and patients experience DR. [43] Several limitations in this present study must be considered.…”