Management of Injury to the Common Bile Duct in a Patient with Roux-en-Y Gastric Bypass

Introduction. Most surgeons prefer Roux-en-Y hepaticojejunostomy (RYHJ) for biliary reconstruction following a common bile duct (CBD) injury. However, in patients with a Roux-en-Y gastric bypass (RYGB) a RYHJ may be technically challenging and can interfere with bowel physiology induced by RYGB. The use of a hepaticoduodenostomy (HD) resolves both these issues.Presentation of Case. We present a case of CBD injury during laparoscopic cholecystectomy one year after laparoscopic RYGB for morbid obesity. Due to adhesions and previous surgery with RYGB, we did not want to interfere with the RYGB physiology by anastomosing the CBD to the jejunum or ileum. Succeeding a full Kocher’s maneuver we performed biliary reconstruction by a tension-free end-to-side HD. The postoperative recovery was uneventful and the patient was discharged after eight days. At four-month follow-up, the patient had stable weight and normal laboratory test results. MRCP demonstrated normal intra- and extrahepatic bile ducts with status after HD.Discussion. We propose that HD should be considered in treatment of CBD injury in post-RYGB patients as it may reduce the risk of interfering with the post-RYGB physiology.

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Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass

Surgical Endoscopy ◽

10.1007/s00464-020-08201-3 ◽

2021 ◽

Author(s):

Ignacio Fuente ◽

Axel Beskow ◽

Fernando Wright ◽

Pedro Uad ◽

Martín de Santibañes ◽

...

Keyword(s):

Gastric Bypass ◽

Bile Duct ◽

Common Bile Duct ◽

Common Bile Duct Exploration

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Common bile duct dilatation after cholecystectomy: a one-year prospective study

Journal of the Korean Surgical Society ◽

10.4174/jkss.2012.83.2.97 ◽

2012 ◽

Vol 83 (2) ◽

pp. 97 ◽

Cited By ~ 21

Author(s):

Seon Mee Park ◽

Woo Seok Kim ◽

Il-Hun Bae ◽

Ji Hoon Kim ◽

Dong Hee Ryu ◽

...

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Prospective Study ◽

Bile Duct Dilatation ◽

Duct Dilatation ◽

Common Bile Duct Dilatation ◽

One Year

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Transcystic Removal of Common Bile Duct Stones in Surgically Altered Anatomy (Roux-en-Y Gastric Bypass)

Journal of Digestive Endoscopy ◽

10.1055/s-0041-1739970 ◽

2021 ◽

Vol 12 (03) ◽

pp. 172-174

Author(s):

Surakshith K. Thyloor ◽

Vikas Singla ◽

Pradeep Chowbey

Keyword(s):

Gastric Bypass ◽

Bile Duct ◽

Common Bile Duct ◽

Common Bile Duct Stones ◽

Bile Duct Stones ◽

Technical Success ◽

Endoscopic Retrograde ◽

Technical Success Rate ◽

Surgically Altered Anatomy ◽

Retrieval Device

AbstractEndoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy can be technically challenging. Various techniques have been described; however, the technical success rate depends on the type of reconstruction, length of the afferent limb, access to the papilla, availability of accessories, and adequate expertise. We describe successful transcystic removal of common bile duct stones in a patient with Roux-en-Y gastric bypass using cholangioscope and SpyGlass retrieval device at the time of cholecystectomy.

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Management of Common Bile Duct Injury during Partial Gastrectomy

The American Surgeon ◽

10.1177/000313480907500815 ◽

2009 ◽

Vol 75 (8) ◽

pp. 719-721 ◽

Cited By ~ 2

Author(s):

Jennifer A. Dixon ◽

Katherine A. Morgan ◽

David B. Adams

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Negative Impact ◽

Gastrointestinal Surgery ◽

Partial Gastrectomy ◽

Bile Leakage ◽

Stricture Formation ◽

Ulcer Disease ◽

Presenting Symptoms ◽

Cbd Injury

Injury to the common bile duct (CBD) during upper gastrointestinal surgery for peptic ulcer disease is a serious complication with an underestimated prevalence in light of the few cases reported in the surgical literature. Three cases of CBD injury were referred to a multidisciplinary specialized gastrointestinal unit for management over a 4-year period. Anomalous anatomy, adhesions, and potential duodenal shortening secondary to contracture all predispose the biliary ducts to intraoperative injury. The axial nature of the blood supply to the extrahepatic ducts and the tendency of bile itself to cause rapid collagen turnover and fibrosis, combined with the inflammation and subsequent fibrosis to the surrounding tissues caused by bile leakage, give the bile ducts a high propensity for stricture formation. Frequently presenting symptoms of CBD injury immediately after surgery include jaundice, elevated bilirubin values, elevated t-tube drainage, and symptoms of sepsis. The most common complaints noted in patients who present in a delayed manner are symptoms of cholangitis. Even when injuries are rapidly identified and corrected, the potential for lasting negative impact on quality of life is great in many cases. When CBD injury occurs, the pancreatic duodenal union can be concomitantly disrupted.

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The Value of Cholangiography through Jackson-Pratt Drains in the Management of Postoperative Biliary Injuries

The American Surgeon ◽

10.1177/000313481408000126 ◽

2014 ◽

Vol 80 (1) ◽

pp. 66-71 ◽

Cited By ~ 1

Author(s):

Francisco Igor B. Macedo ◽

Victor J. Casillas ◽

James S. Davis ◽

Joe U. Levi ◽

Danny Sleeman

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Hepatic Duct ◽

Magnetic Resonance Cholangiopancreatography ◽

Common Hepatic Duct ◽

Biliary Reconstruction ◽

Biliary Injury ◽

Endoscopic Retrograde ◽

Distal Common Bile Duct ◽

Potential Benefits

Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.

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Results of surgical treatment of extrahepatic bile duct injuries

Perm Medical Journal ◽

10.17816/pmj37163-72 ◽

2020 ◽

Vol 37 (1) ◽

pp. 63-72

Author(s):

L. P. Kotelnikova ◽

I. G. Burnyshev ◽

O. V. Bazhenova ◽

D. V. Trushnikov

Keyword(s):

Laparoscopic Cholecystectomy ◽

Surgical Treatment ◽

Bile Duct ◽

Bile Ducts ◽

Bile Leakage ◽

Biliary Reconstruction ◽

Long Term Outcomes ◽

Endoscopic Retrograde ◽

Extrahepatic Bile Ducts

Aim. To evaluate the short-and long-term outcomes after surgical repair of iatrogenic lesions of extrahepatic bile ducts depending on the timing of diagnosis in conditions of specialized clinic. Materials and methods. Our study involved a retrospective analysis of 159 patients who were treated for iatrogenic lesions of extrahepatic bile ducts during 1987-2017. These patients were divided into two groups depending on the timing of surgical treatments: early biliary reconstruction ( 5 days after bile duct transection) and late biliary reconstruction ( 5 days post-transection). These groups were compared on the basis of postoperative morbidity and long-term outcomes. Results. Following laparoscopic cholecystectomy, 2 patients received endoscopic retrograde stents due to bile leakage from the cystic ducts, and 14 patients underwent hepaticocholedochostomy using Ker drainage. The incidence of bile leakage was observed in 14. 3 % of cases during the early post-operative period, strictures appeared in 28.6 % of cases. Hepaticojejunostomy was performed in 91 cases: in 62 with stents and in 29 without stents. Bile leakage was observed in 17.6 % of cases, and strictures in 19.8 % of cases. Our statistical analyses revealed no significant differences between the two groups (i.e., early and late timing of surgical treatment) in the rates of bile leakage and strictures. The extent of surgeons experience in bile surgery significantly correlated with positive outcomes. Conclusions. Endoscopic retrograde stent proved to be an effective and fast solution in cases of bile leakage from cystic ducts following laparoscopic cholecystectomy. Although it is preferable to perform reconstructive surgeries within the first five days after bile duct injury, our results indicated that in the presence of external bile fistula without peritonitis and severe cholangitis, reconstructive surgery can be performed in specialized surgical departments later than 5 days with satisfactory results.

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