Stepwise Percutaneous Approach to Treat Severe Benign Hepaticojejunostomy Stenosis

Hepaticojejunostomy surgery was first introduced in 1949.[1] It is often performed to relieve an extrahepatic biliary obstruction or to restore biliary-enteric continuity as part of operations such as total pancreatectomy, Whipple's procedure, and liver transplantation.[1] [2] Hepaticojejunostomy anastomotic stenosis is one of the main complications that can result in reduced survival and quality of life.[3] The incidence of hepaticojejunostomy stenosis ranges from 9 to 15% in nontransplant settings, and up to 30% in liver transplant recipients.[4] [5] Biliary-enteric anastomotic stenosis is a late complication and is usually diagnosed 12 to 18 months after the surgery.[6] [7] In recent decades, acute postsurgical complications and mortality rates have declined, and the survival rates have increased; therefore, more cases present with late hepaticojejunostomy stenosis.[8] [9]

Severe hepaticojejunostomy stenosis is more often reported after Roux-en-Y and choledochojejunostomy than duct-to-duct anastomosis.[10] Strictures that present in the early postoperative period mostly result from technical factors including small duct size, inappropriate suture material, excess tension at the anastomotic site, infection, and excessive cautery use.[11] Late biliary stenoses are often caused by vascular insufficiency, poor healing, and fibrosis.[12] These complications are associated with additional interventions, repeat hospitalizations, and an overall decline in the quality of life.[5] Surgical revision can be exceedingly difficult, technically challenging, and is associated with increased morbidity and mortality.[2] The treatment options have gradually shifted from surgical revision to primarily minimally invasive management.[13]

Intraluminal endoscopy is considered the first step to treating postsurgical hepaticojejunostomy strictures, though, in some instances, the anastomosis may not be amenable to endoscopic access. In such cases with failed endoscopy, percutaneous treatments including percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD), balloon dilatation, and stent placement can help restore patency for the majority of cases.[8] [14] More recently, the introduction of percutaneous cholangioscope-assisted procedures has widened the range of procedures offered by interventional radiology to patients with failed conventional percutaneous approaches.[15] [16] [17]

Financial Disclosures

None declared.

Publication History

Article published online:
17 November 2022

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