What is the ideal surgical approach for benign biliary (bile duct) strictures?

Ideal Surgical Approach for Benign Biliary Strictures

Roux-en-Y hepaticojejunostomy with mucosa-to-mucosa anastomosis is the gold standard surgical approach for benign biliary strictures, providing superior long-term outcomes compared to other techniques. 1, 2

Preoperative Assessment and Planning

• Evaluate stricture location, extent, and tissue quality through imaging (MRCP, ERCP, or PTC)
• Assess for associated vascular injuries which may worsen outcomes 2
• Consider timing since injury, as early repair (48-72h) or delayed repair (after 6-8 weeks) are preferred over intermediate repair 2
• Referral to a tertiary center with HPB expertise is essential for optimal outcomes 2

Technical Considerations for Optimal Hepaticojejunostomy

Exposure and Bile Duct Preparation

1. Fully expose the proximal bile duct using appropriate approaches:

   • Anterior approach through hepatic portal
   • Superior approach above hepatic portal
   • Approach through fissure of umbilical vein
   • Posterior approach through hepatic portal 2

2. Prepare anastomotic bile duct tissue:

   • Remove all ischemic and scarred tissue
   • Identify healthy bile duct with normal mucosa
   • For high strictures, follow the principle of "bile duct is three rather than two" to avoid missing the right posterior hepatic duct 2
   • For multiple separate openings, consider preoperative PTCD to facilitate intraoperative identification 2

Anastomotic Technique

1. Create a tension-free bilioenteric anastomosis with:

   • Good mucosal apposition
   • Well-vascularized ducts 2
   • Single-layer stitching with 5-0 or 6-0 fine suture material
   • Uniform margins and appropriate density 2

2. Construct a wide anastomosis to prevent stricture formation:

   • For type II1 strictures with connected left and right hepatic ducts: extend incision from left hepatic duct to right hepatic duct
   • For type II1 strictures with disconnected ducts: suture medial margins of left and right ducts to form a single stoma 2

3. Avoid excessive tissue manipulation to preserve blood supply to bile ducts 3

Stenting Considerations

• Transanastomotic stents are generally not necessary for Roux-en-Y hepaticojejunostomy 1, 3
• Short-term drainage (≤3 months) may be considered in cases with:
  • Unsatisfactory anastomosis
  • Significant inflammation of bile duct wall
  • Intrahepatic bile duct stones 2

Outcomes and Follow-up

• Surgical repair with Roux-en-Y hepaticojejunostomy has superior outcomes (88% success) compared to balloon dilatation (55% success) 4
• Long-term follow-up shows excellent or good outcomes in approximately 77-81% of surgically treated patients 5
• Anastomotic stricture rates vary between 4.1% and 20%, with most studies reporting 10-20% 2
• Risk factors for poor outcomes include:
  • Associated vascular injury
  • High level of bile duct injury
  • Sepsis or peritonitis
  • Postoperative bile leakage 2

Common Pitfalls to Avoid

1. Inadequate exposure of proximal bile ducts leading to missed ducts, especially the right posterior hepatic duct
2. Attempting repair during the inflammatory phase (48-72h to 6-8 weeks after injury)
3. Repair by surgeons without HPB expertise
4. Creating anastomosis under tension or with poor mucosal apposition
5. Excessive dissection compromising bile duct blood supply
6. End-to-end anastomosis, which has higher failure rates than hepaticojejunostomy 2

For high-level injuries with multiple separate bile duct openings, consider preoperative PTCD to facilitate identification of all ducts during surgery, preventing missed branches and subsequent cholangitis 2.