Common Bile Duct Stricture Repair with Serosal Onlay Technic Rafael M. Sanchez, MD, FACS, Englewood, New Jersey George 0. Halsted, MD, D-S, FACS, FACA, Englewood, New Jersey Rohitkumar R. Trivedi, MDDS, MD, Englewood, New Jersey
Benign strictures of the biliary tract are the result of surgical trauma. In a survey conduct,ed at the Lahey Clinic of 987 patients with benign strictures of the extrahepatic bile ducts, 97 per cent of the strictures followed surgery, and in only 3 per cent could no surgical procedure be implicated [I]. The most common areas of stricture involve the common hepatic duct and the right and left hepatic ducts. The very fact that multiple technics for operative management of biliary strictures have been reported indicates that a completely satisfactory method is not yet available. A case of repeated episodes of obstructive jaundice and cholangitis secondary to anastomotic stricture between a choledochal cyst and the duodenum associated with an extremely narrowed proximal common hepatic duct is described. The surgical repair of the common duct was done using onlay of a loop of jejunal serosa. Case Report SC, a forty-two year old white female, underwent cholecystectomy on October 25,197l for chronic right upper quadrant pain and nonvisualization of the gallbladder on double dose oral cholecystography. Postoperatively the patient developed jaundice. Percutaneous transhepatic cholangiography revealed obstruction of the distal common duct with proximal dilatation compatible with choledochal cyst. The patient was operated on on November II,1971 and was found to have a choledochal cyst in the lower common duct measuring approximately 10 cm in diameter. The common duct was extremely narrowed, and it was impossible to pass the smallest dilator through it into the duodenum. Anastomosis between the choledochal cyst and duodenum was established in two layers using chromic catgut and silk. Her postoperative course was uneventful From the Department of Surgery, Englewocd Hospital, Englewocd. New Jersey. Reprint requests should be addressed to Rafael M. Sanchez, MD, 185 Grand Avenue, Englewocd, New Jersey 07631.
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and all liver chemistries returned to within normal limits. Between 1971 and 1976 the patient was admitted five times with repeated attacks of obstructive cholangitis which were treated with antibiotics. Because she had developed a skin reaction after previous percutaneous cholangiography, it was not redone. The patient was last admitted on February 20,1976 with obstructive jaundice. Anastomosis between the choledochal cyst and duodenum could not be visualized using endoscopic retrograde cholangiography, and she underwent surgery on March 2,1976. The pathologic findings are diagrammed in Figure 1A. Strictured anastomosis associated with an extremely narrowed proximal common hepatic duct was noticed. Also of interest was the markedly diminished size of the cyst just distal to the union of the hepatic ducts. The choledochal cyst measured approximately 1 to 2 cm. It was believed that any procedure requiring an end-to-side or end-to-end anastomosis between the common hepatic duct and either duodenum or jejunum or a Roux-en-Y anastomosis would be extremely difficult because of marked narrowing of the common hepatic duct. Because there was a definite possibility of recurrent stricture, a serosal onlay repair of the common hepatic duct was done. (Figures 1B and C.).This was accomplished by making an incision on the anterior wall of the common hepatic and common bile ducts across their entire lengths and extending through the anastomosis for a small distance on the duodenum. A loop of jejunum was laid over it as a roof patch. A two layer approximation using chromic catgut and interrupted silk sutures was achieved between the split open duct and duodenum posteriorly and serosa of jejunum anteriorly. The patient had an uneventful postoperative course and has remained free of symptoms and signs to date. Comments
Stricture of bile duct presents a major surgical problem and is usually a result of various surgical procedures done on or near the biliary tree. Many technics have been reported for surgical repair of biliary stricture, often a very formidable and stren-
The American Journal of Surgery
Common Bile Duct Stricture Repair
F&we 7. A, strictwad anasfomosk between cholecbchal cyst and duodenum. B, incision on ante&u wall of blk duct extending through anasfomosis and for a small distance on duodenum. C, serosal patching on the sp//t open duct as a roof.
uous procedure for both the surgeon and the patient and associated with very high failure rates. Biliary intestinal anastomosis using a Roux-en-Y limb of jejunum stands out as the most satisfactory procedure from the presently available methods, with an eventual success rate of 78 per cent [2]. Considerable postoperative morbidity and mortality and a very high recurrent stricture rate are acknowledged fears of surgeons undertaking such procedures. If more than three operative procedures were required for repair of the biliary stricture, a satisfactory outcome is unlikely [2]. Reconstructive attempts with metal and plastic prostheses as well as a series of autogenous tissues including vein and artery have not met with satisfactory results [3-51. Ever since Thal and Kobold successfully repaired experimental wounds of duodenum [6] their serosal onlay patch technic has been improved and utilized for management of a wide variety of surgical problems [ 7-101. Immediate adequate regeneration of mucosa on the serosal surface of the patch utilized for roofing the defect [6] is an important factor in enlarging the lumen and minimizing fibrosis, thereby preventing scarring and subsequent stricture. Condon et al [2] successfully repaired experimental stricture of the common duct by applying a patch of jejunal serosa to the reopened common duct. Histologic examination of the serosal patch demonstrated regeneration of biliary epithelium over the serosa.
Volume 135, February 1978
Summary
To our knowledge this is the first reported patient in whom the technic of serosal onlay for biliary stricture was applied successfully. The approach proved easy and satisfactory, and we plan to continue its use in similar cases. References 1.
Thal AP, et al: Patch grafting of the gastrointestinal and urinary
tracts. Minn Med 49: 45, 1966 2. Condon RE, Callen P, Beltz WR, et al: Serosal onlay repair of common duct stricture. Am J Surg 127: 13, 1974. 3. Thomas JP, Metropot HJ, Myers RT: Teflon patch graft for reconstructionof the extrahepatic bile ducts. Ann Surg 160: 967, 1964. 4. Waller MD, Kenneth W, Mildred F, Jefferson MD: Prevention and repair of stricture of the extrahepatic bile ducts. Surg C/in North Am 53: 1169, 1973. 5. Warren KW, Mountain, JC, Mkiell Al: Management of strictures of the biliary tract. Surg C/in North Am 51: 711, 1971. 6. Hatahker T, Thai AP: Use of onlay gastric patch in m of experimental perforation of distal esophagus. Surgery 56: 556.1966. 7. Kirby CK, Fits WT Jr: Reconstruction of bile ducts with isolated segment of jejunum; experimental study. Arch Surg 61: 462, 1950. 8. Kobold EE, Thal AP: A simple method for the management of experimental wounds of duodenum. Surd Gynecol Obstet 116: 340, 1963. 9. Sherman RT. Jackson TM, Nielson CA, Wilson H: Reconstruction of the common bile duct with an acrylate-amkfe prosthesis. Ann Surg 158: 420, 1963. 10. Thal AP, Hatafuker T, Kurtzman R: New operation for distal esophageal stricture. Arch Surg 90: 464, 1965.
259
Benign strictures of the biliary tract are the result of surgical trauma. In a survey conduct,ed at the Lahey Clinic of 987 patients with benign strictures of the extrahepatic bile ducts, 97 per cent of the strictures followed surgery, and in only 3 per cent could no surgical procedure be implicated [I]. The most common areas of stricture involve the common hepatic duct and the right and left hepatic ducts. The very fact that multiple technics for operative management of biliary strictures have been reported indicates that a completely satisfactory method is not yet available. A case of repeated episodes of obstructive jaundice and cholangitis secondary to anastomotic stricture between a choledochal cyst and the duodenum associated with an extremely narrowed proximal common hepatic duct is described. The surgical repair of the common duct was done using onlay of a loop of jejunal serosa. Case Report SC, a forty-two year old white female, underwent cholecystectomy on October 25,197l for chronic right upper quadrant pain and nonvisualization of the gallbladder on double dose oral cholecystography. Postoperatively the patient developed jaundice. Percutaneous transhepatic cholangiography revealed obstruction of the distal common duct with proximal dilatation compatible with choledochal cyst. The patient was operated on on November II,1971 and was found to have a choledochal cyst in the lower common duct measuring approximately 10 cm in diameter. The common duct was extremely narrowed, and it was impossible to pass the smallest dilator through it into the duodenum. Anastomosis between the choledochal cyst and duodenum was established in two layers using chromic catgut and silk. Her postoperative course was uneventful From the Department of Surgery, Englewocd Hospital, Englewocd. New Jersey. Reprint requests should be addressed to Rafael M. Sanchez, MD, 185 Grand Avenue, Englewocd, New Jersey 07631.
258
and all liver chemistries returned to within normal limits. Between 1971 and 1976 the patient was admitted five times with repeated attacks of obstructive cholangitis which were treated with antibiotics. Because she had developed a skin reaction after previous percutaneous cholangiography, it was not redone. The patient was last admitted on February 20,1976 with obstructive jaundice. Anastomosis between the choledochal cyst and duodenum could not be visualized using endoscopic retrograde cholangiography, and she underwent surgery on March 2,1976. The pathologic findings are diagrammed in Figure 1A. Strictured anastomosis associated with an extremely narrowed proximal common hepatic duct was noticed. Also of interest was the markedly diminished size of the cyst just distal to the union of the hepatic ducts. The choledochal cyst measured approximately 1 to 2 cm. It was believed that any procedure requiring an end-to-side or end-to-end anastomosis between the common hepatic duct and either duodenum or jejunum or a Roux-en-Y anastomosis would be extremely difficult because of marked narrowing of the common hepatic duct. Because there was a definite possibility of recurrent stricture, a serosal onlay repair of the common hepatic duct was done. (Figures 1B and C.).This was accomplished by making an incision on the anterior wall of the common hepatic and common bile ducts across their entire lengths and extending through the anastomosis for a small distance on the duodenum. A loop of jejunum was laid over it as a roof patch. A two layer approximation using chromic catgut and interrupted silk sutures was achieved between the split open duct and duodenum posteriorly and serosa of jejunum anteriorly. The patient had an uneventful postoperative course and has remained free of symptoms and signs to date. Comments
Stricture of bile duct presents a major surgical problem and is usually a result of various surgical procedures done on or near the biliary tree. Many technics have been reported for surgical repair of biliary stricture, often a very formidable and stren-
The American Journal of Surgery
Common Bile Duct Stricture Repair
F&we 7. A, strictwad anasfomosk between cholecbchal cyst and duodenum. B, incision on ante&u wall of blk duct extending through anasfomosis and for a small distance on duodenum. C, serosal patching on the sp//t open duct as a roof.
uous procedure for both the surgeon and the patient and associated with very high failure rates. Biliary intestinal anastomosis using a Roux-en-Y limb of jejunum stands out as the most satisfactory procedure from the presently available methods, with an eventual success rate of 78 per cent [2]. Considerable postoperative morbidity and mortality and a very high recurrent stricture rate are acknowledged fears of surgeons undertaking such procedures. If more than three operative procedures were required for repair of the biliary stricture, a satisfactory outcome is unlikely [2]. Reconstructive attempts with metal and plastic prostheses as well as a series of autogenous tissues including vein and artery have not met with satisfactory results [3-51. Ever since Thal and Kobold successfully repaired experimental wounds of duodenum [6] their serosal onlay patch technic has been improved and utilized for management of a wide variety of surgical problems [ 7-101. Immediate adequate regeneration of mucosa on the serosal surface of the patch utilized for roofing the defect [6] is an important factor in enlarging the lumen and minimizing fibrosis, thereby preventing scarring and subsequent stricture. Condon et al [2] successfully repaired experimental stricture of the common duct by applying a patch of jejunal serosa to the reopened common duct. Histologic examination of the serosal patch demonstrated regeneration of biliary epithelium over the serosa.
Volume 135, February 1978
Summary
To our knowledge this is the first reported patient in whom the technic of serosal onlay for biliary stricture was applied successfully. The approach proved easy and satisfactory, and we plan to continue its use in similar cases. References 1.
Thal AP, et al: Patch grafting of the gastrointestinal and urinary
tracts. Minn Med 49: 45, 1966 2. Condon RE, Callen P, Beltz WR, et al: Serosal onlay repair of common duct stricture. Am J Surg 127: 13, 1974. 3. Thomas JP, Metropot HJ, Myers RT: Teflon patch graft for reconstructionof the extrahepatic bile ducts. Ann Surg 160: 967, 1964. 4. Waller MD, Kenneth W, Mildred F, Jefferson MD: Prevention and repair of stricture of the extrahepatic bile ducts. Surg C/in North Am 53: 1169, 1973. 5. Warren KW, Mountain, JC, Mkiell Al: Management of strictures of the biliary tract. Surg C/in North Am 51: 711, 1971. 6. Hatahker T, Thai AP: Use of onlay gastric patch in m of experimental perforation of distal esophagus. Surgery 56: 556.1966. 7. Kirby CK, Fits WT Jr: Reconstruction of bile ducts with isolated segment of jejunum; experimental study. Arch Surg 61: 462, 1950. 8. Kobold EE, Thal AP: A simple method for the management of experimental wounds of duodenum. Surd Gynecol Obstet 116: 340, 1963. 9. Sherman RT. Jackson TM, Nielson CA, Wilson H: Reconstruction of the common bile duct with an acrylate-amkfe prosthesis. Ann Surg 158: 420, 1963. 10. Thal AP, Hatafuker T, Kurtzman R: New operation for distal esophageal stricture. Arch Surg 90: 464, 1965.
259
