Classification and Treatment of Roux-en-Y Hepaticojejunostomy (RYHJ) Strictures
RYHJ strictures should be classified based on the mechanism of formation and endoscopic evaluation, with treatment options ranging from endoscopic balloon dilatation to surgical revision depending on stricture type and severity.
Classification of RYHJ Strictures
RYHJ strictures can be classified based on several characteristics that guide treatment decisions:
Based on Mechanism and Endoscopic Appearance:
- Membranous strictures: Thin tissue layers that respond well to endoscopic balloon dilatation
- Cicatricial strictures: Characterized by intense fibrosis with unpredictable response to endoscopic balloon dilation
- Granular strictures: Result from secondary intention healing or tissue necrosis, requiring early endoscopic approach 1
Based on Anatomical Location:
- Anastomotic strictures: Occur at the site of the hepaticojejunostomy
- Non-anastomotic strictures: Occur in the intrahepatic biliary radicals or hilum, often more difficult to treat 1
Diagnostic Approach
- Laboratory evaluation: Liver function tests (elevation >1.5 times normal should prompt investigation) 1
- Imaging studies:
- Ultrasound with Doppler of the liver vasculature as first-line imaging
- MRI/MRCP to evaluate stricture location and severity
- Percutaneous transhepatic cholangiogram (PTC) for direct visualization and potential intervention 1
Treatment Algorithm
1. First-Line Treatment: Endoscopic/Percutaneous Approach
Double-balloon endoscope-assisted ERCP (DB-ERCP) for patients with surgically altered anatomy:
- Success rate approximately 76.9% with balloon dilation as first-line treatment
- Predictors of successful stricture resolution include:
- Post-operative time to intervention >12 months
- Scar-like appearance around the anastomosis 2
Percutaneous transhepatic approach:
- Preferred when endoscopic access is difficult or impossible
- Allows for balloon dilation and/or stent placement
- Biodegradable stents may be considered for refractory cases 3
2. Management Based on Stricture Type
- Membranous strictures: Endoscopic hydrostatic balloon dilatation
- Cicatricial strictures: May require multiple balloon dilations or stent placement
- Granular strictures: Early endoscopic approach recommended 1
3. For Refractory Strictures
Plastic stent placement for strictures not responding to balloon dilation:
- Success rate approximately 52.6%
- Lower recurrence rate (10%) compared to balloon dilation alone (34.4%) 2
Surgical revision when endoscopic/percutaneous approaches fail:
- Repeat RYHJ with careful attention to technique
- Surgical principles include:
- Good exposure for internal drainage of intrahepatic biliary tract
- Mucosa-to-mucosa anastomosis
- Prevention of reoperation risk 4
Treatment Outcomes and Complications
- Overall clinical success rate of approximately 89% with a multidisciplinary approach 5
- Complications:
Important Considerations
- Timing of intervention: Early intervention is crucial for better outcomes
- Specialized centers: Treatment should be performed at centers with expertise in hepatobiliary surgery and interventional procedures
- Multidisciplinary approach: Combining surgical, radiologic, and endoscopic techniques yields the best results 5
Pitfalls to Avoid
- Delayed intervention: Waiting for bile duct dilation before revisionary surgery has been shown to fail in most cases 5
- Inadequate follow-up: Regular monitoring is essential to detect and treat recurrent strictures early
- Inappropriate technique selection: Treatment should be tailored to the specific type of stricture
- Single-modality approach: Combining techniques often yields better results than relying on a single approach
A multidisciplinary approach in a specialized hepatobiliary center is essential for optimal management of RYHJ strictures, with treatment selection based on stricture classification, patient factors, and available expertise.