Reconstructive interventions on bile ducts in patients with benign obstructive jaundice

Aim. To evaluate immediate and long-term results of surgical reconstruction of the biliary system in various types of benign obstructive jaundice.

Materials and methods. The study enrolled 110 patients with choledocholithiasis, iatrogenic biliary strictures, common bile duct strictures, as well as strictures of biliodigestive and biliobiliary anastomoses. Patients were divided into 3 groups. Group 1 included 43 patients with multiple choledocholithiasis and bile duct dilatation >15 mm. Group 2 enrolled 35 patients with multiple choledocholithiasis and hepaticolithiasis who were intraoperatively diagnosed with stricture, injury, or pressure ulcers of the common bile duct wall. Group 3 included 32 patients with cicatricial and iatrogenic biliary strictures. The immediate and long-term results of surgical treatment were compared.

Results. In group 1, the survival rate comprised 89.4%, the average duration of surgery amounted to 137 minutes, complications involved wound infection, bile leakage, bile peritonitis. In group 2, the survival rate accounted for 91.4%, the average duration of surgery comprised 192 minutes; strictures of biliodigestive anastomosis were detected in the remote period, and reconstructive surgeries were performed. Group 3 revealed the survival rate of 100%, the average duration of surgery of 215 minutes, and no complications in the long term.

Conclusion. The diameter of the common bile duct, its wall changes, size of gallstones, signs of cholangitis, patency of the bile papilla, and localization of biliary stricture determine the surgical tactics, when performing biliary reconstruction in patients with non-cancerous obstructive jaundice. In case minimally invasive surgery is found impossible under conditions of multiple choledocholithiasis, common bile duct diameter >15 mm, and preservation of its wall, choledocholithotomy with Kerr drainage is considered to be optimal. In case of damage to the CBD wall and patency of the bile papilla, preference shall be given to hepaticoenterostomy. Bile duct reconstruction with stent drainage is indicated for treatment of cicatricial and iatrogenic biliary strictures.

1. Liu J.J., Sun Y.M., Xu Y., Mei H.W., Guo W., Li Z.L. Pathophysiological consequences and treatment strategy of obstructive jaundice. World J. Gastrointest. Surg. 2023; 15 (7): 1262–1276. https://doi.org/10.4240/wjgs.v15.i7.1262

2. Hanif H., Khan S.A., Muneer S., Adil S.O. Diagnostic accuracy of ultrasound in evaluation of obstructive jaundice with MRCP as gold standard. Pak. J. Med. Sci. 2020; 36 (4): 652–656. https://doi.org/10.12669/pjms.36.4.1665

3. Darvin V.V., Vetshev P.S., Onishchenko S.V., Lysak M.M., Vardanyan T.S., Kostrubin A.L. Obstructive jaundice: epidemiology, diagnosis and choice of optimal method of biliary decompression. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2023; 28 (4): 16–23. https://doi.org/10.16931/1995-5464.2023-4-16-23 (In Russian)

4. Lee W., Kwon J. Ten-year experience on common bile duct exploration without T-tube insertion. Korean J. Hepatobiliary Pancreat. Surg. 2013; 17 (2): 70–74. https://doi.org/10.14701/kjhbps.2013.17.2.70

5. Hussain Talpur K.A., Mahmood Malik A., Iqbal Memon A., Naeem Qureshi J., Khan Sangrasi A., Laghari A.A. Biliary bypass surgery – Analysis of indications & outcome of different procedures. Pak. J. Med. Sci. 2013; 29 (3): 799–802. PMCID: PMC3809296

6. Tocchi A., Mazzoni G., Liotta G., Costa G., Lepre L., Miccini M., De Masi E., Lamazza M.A., Fiori E. Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting. Arch. Surg. 2000; 135 (2): 153–157. https://doi.org/10.1001/archsurg.135.2.153

7. Shalayiadang P., Yasen A., Abulizi A., Ahan A., Jiang T., Ran B., Zhang R., Guo Q., Wen H., Shao Y., Aji T. Long-term postoperative outcomes of Roux-en-Y cholangiojejunostomy in patients with benign biliary stricture. BMC Surgery. 2022; 22 (1): 231. https://doi.org/10.1186/s12893-022-01622-y

8. Mehanicheskaja zheltuha neopuholevogo geneza [National clinical guidelines “Non-tumor obstructive jaundice”, 2023]. Russian Society of Surgeons. http://общество-хирургов.рф/stranicapravlenija/klinicheskie-rekomendaci/urgentnajaabdominalnaja-hirurgija/mehanicheskaja-zheltuhaneopuholevogo-geneza-2023.html (In Russian)

9. Joliat G.R., Kobayashi K., Hasegawa K., Thomson J.E., Padbury R., Scott M., Brustia R., Scatton O., Tran Cao H.S., Vauthey J.N., Dincler S., Clavien P.A., Wigmore S.J., Demartines N., Melloul E. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J. Surg. 2023; 47 (1): 11–34. https://doi.org/10.1007/s00268-022-06732-5.

10. Heidenhain C., Rosch R., Neumann U.P. Hepatobiliäre Anastomosentechniken [Hepatobiliary anastomosis techniques]. Chirurg. 2011; 82 (1): 7–13. https://doi.org/10.1007/s00104-010-1902-x (In German)

11. Shah M.M., Martin B.M., Stetler J.L., Patel A.D., Davis S.S., Lin E., Sarmiento J.M. Biliary reconstruction options for bile duct stricture in patients with prior Roux-en-Y reconstruction. Surg. Obes. Relat. Dis. 2017; 13 (9): 1629–1634. https://doi.org/10.1016/j.soard.2017.05.023

12. Manekk R.S., Gharde P., Gattani R., Lamture Y. Surgical complications and its grading: a literature review. Cureus. 2022; 14 (5): e24963. https://doi.org/10.7759/cureus.24963

13. Llàcer-Millán E., Pavel M.C., Memba R., Coronado D., González S., Achalandabaso M., Estalella L., Julià-Verdaguer E., Padilla-Zegarra E., Collins C., Jorba R. Comparison between Comprehensive Complication Index (CCI®) and ClavienDindo classification for laparoscopic single-stage treatment of choledocholithiasis with concomitant cholelithiasis. Langenbecks Arch. Surg. 2023; 408 (1): 100. https://doi.org/10.1007/s00423-023-02840-5

14. Bagnenko S.F., Korolkov A.Yu., Popov D.N., Shatalov S.A., Logvin L.A. Obstructive jaundice: routing, diagnostics, treatment tactics. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2023; 28 (4): 24–31. https://doi.org/10.16931//1995-5464.2023-4-24-31 (In Russian)

15. Goessmann H., Lang S.A., Fichtner-Feigl S., Scherer M.N., Schlitt H.J., Stroszczynski C., Schreyer A.G., Schnitzbauer A.A. Biliodigestive Anastomosen: Indikationen, Komplikationen und interdisziplinäres Management [Biliodigestive anastomosis: indications, complications and interdisciplinary management]. Chirurg. 2012; 83 (12): 1097–1108. https://doi.org/10.1007/s00104-012-2365-z (In German)

16. Egawa H., Inomata Y., Uemoto S., Asonuma K., Kiuchi T., Fujita S., Hayashi M., Matamoros M.A., Itou K., Tanaka K. Biliary anastomotic complications in 400 living related liver transplantations. World J. Surg. 2001; 25 (10): 1300–1307. https://doi.org/10.1007/s00268-001-0114-4

17. Monakhov A.R., Dzhanbekov T.A., Mesheryakov S.V., Semash K.O., Khizroev K.M., Voskanov M.A. Stent drainage of the bile ducts during biliary reconstruction in transplantation of the left lateral sector of the liver. Russian Journal of Transplantology and Artificial Organs. 2020; 22 (S): 74. (In Russian)

18. Soltani E., Mehrabi Bahar A., Dehghanian P., Afzal Aghaei M., Mozaffari S. Prevention of biliary leakage after removal of T-tube in immunocompromised patients. Indian J. Surg. 2015; 77 (Suppl 2): 645–649. https://doi.org/10.1007/s12262-013-0958-5

19. Aidemirov A.N., Shakhnazaryan N.G., Vafin A.Z., Shakhnazaryan A.M. Сurrent approach to mechanical jaundice management. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2015; 20 (4): 62–67. https://doi.org/10.16931/1995-5464.2015462-67 (In Russian)

20. Rukovodstvo po khirurgii zhelchnyh putej [Guideline on biliary tract surgery]. 2nd ed. Ed. by E.I. Galperin, P.S. Vetshev. Moscow: Vidar-M, 2009. 568 р. (In Russian)