External metallic circle in hepaticojejunostomy
© Göçmen et al; licensee BioMed Central Ltd. 2004
Received: 15 April 2004
Accepted: 06 October 2004
Published: 06 October 2004
Biliary-enteric anastomosis especially Roux-en Y hepaticojejunostomy is frequently used for biliary diversion in benign biliary strictures. In this study, we present the results of hepaticojejunostomy with external metallic circle.
Hepaticojejunostomy with external metallic circle were performed in eight male Sprague-Dawley rats. At the end of the third month, anastomoses were analysed for patency and stability of external circles.
Relaparotomy revealed that all the anastomoses were patent and circles were in original places.
To provide the patency of narrow hepaticojejunostomy anastomoses, external metallic circle can be a good alternative to use of internal stents in suitable cases.
Although the risk of late bile duct cancer complicating biliary-enteric anastomosis has been well documented [1, 2], biliary-enteric anastomosis especially, Roux-en Y hepaticojejunostomy is frequently used for high biliary injuries and for biliary diversion in benign biliary strictures . Among the surgical techniques hepaticojejunostomy yields the most favaroble results .
External metallic circle had been used for the end to end choledochocholedocostomy in rats by Tez et al . The patency of anastomosis was higher than conventional primary anastomosis with this device.
The aim of this study was to examine applicability of external metallic circle in hepaticojejunostomy.
Eight male Sprague-Dawley rats (Laboratory of Experimental Animals, Hacettepe University Faculty of Medicine, Ankara, Turkey) weighing 250 to 300 g were used. The animals housed under environmentally controlled conditions at 21 ± 2°C and 30% to 70% relative humidity with a 12-hour dark and 12-hour light cycle. Free access to water and standard laboratory food was provided. Before the operations, the rats were fasted overnight and were only allowed free access to water. Guiding Principles in the Care and Use of Laboratory Animals was strictly adhered to at all times together with the recommendations from the Declaration of Helsinki.
All anastomoses were completed with five or six sutures. Mean operation time was 30 minutes.
One rat died in the postoperative fourth day. In necropsy, there was anastomotic disruption on the anterior surface of anastomosis and external circle was on the original place.
At the end of third month, relaparotomy was performed on the remaining seven rats. There were no anastomotic dehiscense or biliary leakage. In all animals, there was a good connective tissue mass between the bile duct and jejunum. Dissection of the anastomosis region revealed that all the anastomosis were patent and all the circles were staying in original places.
For the past 10 to 15 years, hepaticojejunostomy has been the method of choice for the treatment of benign biliary stricrures [6, 7]. In this study, our aim was to examine the applicability of external circle in hepaticojejunostomy, not comparing the hepaticojejunostomy with or without external metallic circle. Since the first description of injured bile duct repair, many stenting techniques have been used . In clinical practice, there is arguement about the use of internal stents in hepaticojejunostomy. Some authors recommend internal stents when unhealty (ie, ischemic, scarred) and small bile ducts (<4 mm) are found . Braasch , Saypol  and Cameron  have reported high long-term results. when biliary-enteric anastomosis was complimented with internal stent; 80%, 80% and 88% success rates respectively. On the other hand, some authors suggest that biliaryenteric anastomosis can be performed without anastomotic stents. Aust , Bismuth  and Innes  have reported 84%, 86%, 95% success rates respectively when biliary-enteric anastomosis was performed without using any stents and they suggest that a stent may promote fibrosis of the anastomosis due to constant irritation of ductal mucosa. Thus, transanastomotic stents appear to have little impact on outcome and probably should not be used routinely. However, stents still may be useful in selected cases in which poor outcome is considered preoperatively or intraoperatively.
In a previous study of us , we showed that end to end biliary anastomosis with an external metallic circle had the advantage of shorter operating time and lower bile leakage rate compared to primary microsurgical anastomosis. And alkaline phosphatase levels were also found to be significantly lower for end to end biliary anastomosis with external metallic circle. This results directed us to search the applicability of external metallic circle in narrow hepaticojejunostomy anastomoses. Therefore, we designed a study to perform end to side hepaticojejunostomy with external metallic circle. During the relaparotomy performed at the end of third month, we found all the anastomosis were patent but we were not able to find circles in original places except in one rat. Later on, in this study, we modified our technique and added 2–3 supporting sutures between the circle and jejunal serosa. Relaparotomy revelad all the anastomosis were patent and circles were still in place.
We think that external metallic circles are also applicable to end to side hepaticojejunostomy anastomosis, should the extra sutures were placed between the circle and jejunal serosa neighbouring the anastomotic line following the completion of anastomosis. To provide the patency of narrow hepaticojejunostomy anastomoses, external metallic circle can be an alternative to use of internal stents in suitable cases.
Authors thank to Selim Celebioglu from Department of Plastic and Reconstructive Surgery, Social Insurances Foundation Hospital, Ankara for his assistance during the research.
- Strong RW: Late bile duct cancer complicating bilary-enteric anastomosis for benign disease. Am J Surg. 1999, 177: 472-4. 10.1016/S0002-9610(99)00087-2.View ArticlePubMedGoogle Scholar
- Tocchi A, Mazzoni G, Liotta G, Lepre L, Cassini D, Miccini M: Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: a follow-up study of more than 1,000 patients. Ann Surg. 2001, 2: 210-4. 10.1097/00000658-200108000-00011.View ArticleGoogle Scholar
- Blumgart HL: Hilar and intrahepatic biliary enteric anastomosis. Surg Clin North Am. 1994, 74: 845-63.PubMedGoogle Scholar
- Mercado MA, Orozco H, Lopez Martinez LM: Survival and quality of life after bile duct reconstruction. HPB Surg. 2000, 2: 321-324.Google Scholar
- Tez M, Keskek M, Özkan Ö, Karamursel S: External metallic circle in microsurgical anastomosis of common bile duct. Am J Surg. 2001, 182: 130-3. 10.1016/S0002-9610(01)00680-8.View ArticlePubMedGoogle Scholar
- Pitt HA, Kaufmann SL, Coleman J, White RI, Cameron JL: Benign postoperative biliary strictures. Operate or dilate?. Ann Surg. 1989, 210: 417-25.View ArticlePubMedPubMed CentralGoogle Scholar
- Lillemoe KD, Pitt HA, Cameron JL: Current management of benign biliary strictures. Adv Surg. 1992, 25: 119-74.PubMedGoogle Scholar
- Braasch JW, Gordon M, Rossi RL: Intubation techniques in biliary tract surgery. Surg Clin North Am. 1980, 60: 297-312.PubMedGoogle Scholar
- Mercado MA, Chan C, Orozco H, Cano-Gutierrez G, Chaparro JM, Galindo E, Vilatoba M, Samaniego-Arvizu G: To stent or not to stent bilioenteric anastomosis after iatrogenic injury: a dilemma not answered?. Arch Surg. 2002, 137: 60-3. 10.1001/archsurg.137.1.60.View ArticlePubMedGoogle Scholar
- Braasch JW, Bolton JS, Rossi RL: A technique of biliary tract reconstruction with complete follow-up in 44 consecutive cases. Ann Surg. 1981, 194: 635-8.View ArticlePubMedPubMed CentralGoogle Scholar
- Cameron JL, Gayler BW, Zuidema GD: The use of Silastic transhepatic stents in benign and malignant biliary strictures. Ann Surg. 1978, 188: 552-61.View ArticlePubMedPubMed CentralGoogle Scholar
- Saypol GM, Kurian G: A technique of repair of stricture of the bile duct. Surg Gynecol Obstet. 1969, 128: 1071-76.PubMedGoogle Scholar
- Aust JB, Root HD, Urdaneta L, Varco RL: Biliary stricture. Surgery. 1967, 62: 601-8.PubMedGoogle Scholar
- Bismuth H, Franco D, Corlte MB, Hepp J: Long term results of Roux-en-Y hepaticojejunostomy. Surg Gynecol Obstet. 1978, 146: 161-7.PubMedGoogle Scholar
- Innes JT, Ferrara JJ, Carey LC: Biliary reconstruction without transanastomotic stent. Am Surg. 1988, 54: 27-30.PubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/4/14/prepub
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