Surgery and Interventional Radiology for Benign Bile Duct Strictures

(1991) Combined surgical and interventional radiological approach for complex benign biliary tract obstruction. British Journal of Surgery; 78: 559-563. In patients with complicated high benign biliary strictures surgical technique alone cannot exclude the possibility of recurrent problems, and hepatic atrophy/ hypertrophy, portal hypertension and intrahepatic stones may all complicate surgical management. A multidisciplinary approach to these complex cases, which minimizes the need for repeated surgical interventions, has been pursued. Roux-en-Y hepaticojejunostomy was performed and an extended limb of the jeju-num brought to the abdominal wall to allow access for later radiological intervention. Over a 30-month period 58 biliary-enteric anastomoses for benign disease were performed. Seventeen of these 58 patients were managed using the combined approach. Ten of these 17 patients had complex postcholecystectomy strictures and seven had strictures resulting from inflammatory disease, hepatic resection or congenital problems. A new classification of results of management of bile duct strictures is proposed. Seven patients were classified as 'excellent', six 'good', two 'fair' and two 'poor'. Results were obtained at a mean follow-up of 16 months and it seems likely that in some patients major surgical reinterventions were avoided. PAPER DISCUSSION KEY WORDS" Bile duct stricture, interventional radiology, access loop Standard surgical techniques of biliary reconstruction offer a high probability of cure for the majority of patients with benign extrahepatic biliary strictures1-4. The technical difficulties encountered with high or recurrent strictures are simplified by using a left hepatic duct approach as first described by Hepp and Couinand. However, when a Roux-en-Y jejunal loop is used for the biliary-enteric anastomo-sis, endoscopic access to the intrahepatic biliary tree is frequently lost. Access is essential in patients with complex recurrent intrahepatic strictures or stones where further problems are anticipated6. In the paper under review, Schweizer et al. have used percutaneous radiological techniques in selected patients with complex biliary problems as part of a combined approach with surgery using a Roux-en-Y hepaticojejunostomy and creation of an access loop for long-term dilatation. This dual approach is particularly suitable in patients who have had multiple previous operative attempts at repair or portal hypertension, segmental or lobar atrophy and hypertrophy, biliary infection and the presence of intrahepatic strictures and/or calculi which increase the difficulty and risk of surgery .T he authors leave a percutaneous silicone tube within the afferent jejunal 10015 for post-operative