The acute complications of these procedures are related to the magnitude of the upper-abdominal operation to accomplish them (outlined in the section on liver resection) as well as bile leaks.
Bile leaks can occur not only from the anastomosis itself, but also from unappreciated ducts in the liver. This latter problem occurs almost exclusively in the setting of an acute repair of a bile duct injury when an injured segmental duct joins the injured bile duct at or below the bifurcation and is simply missed when the biliary-enteric anastomosis is performed. Most anastomotic bile leaks can be handled with the judicious use of percutaneous drainage and/or transhepatic stents. Leaks from missed ducts usually require reoperation.
Later complications of these operations revolve around progression of the disease that precipitated the need for the original operation (e.g., pancreatic cancer), complications associated with any upper abdominal operation (e.g., wound pains, hernias, adhesive bowel obstructions), and stricture of the biliary enteric anastomosis. Stricture of these anastomoses generally leads to episodes of cholangitis, and even frank obstructive jaundice. In repetitive and neglected cases this can progress to cirrhosis and portal hypertension; a development that greatly complicates subsequent therapeutic maneuvers. Although early problems with the anastomosis can presage later failure, recurrence of a benign stricture may take 10 yr to develop (6). So these patients must be followed with periodic checks of their liver function tests (particularly alkaline phosphatase) for years. Whether prolonged perioperative stenting of biliary-enteric anastomoses decreases the chance of later stricture formation is a minor surgical controversy. Although there is no definitive data, most surgeons no longer stent their anastomoses beyond the first few weeks postoperatively if they have achieved a good mucosa-to-mucosa anastomosis in relatively normal, nonsclerotic duct. Many do, however, fashion the roux limb for easy percutaneous access to the biliary tree in case that becomes necessary (Fig. 5). An early advantage of having percutaneous tubes across the biliary-enteric anastomosis is the ease of radiographic study it if things are not going well or if a leak needs to be managed.
Radiological studies of patients with biliary-enteric anastomoses will frequently show air in the biliary tree. This is often seen even after an ERCP and sphincterotomy. It is not
Bile duct anastomosis
Bile duct anastomosis
Ligament of Treitz
Fig. 5. Roux limb tip to abdominal wall after biliary-enteric anastomosis to facilitate future access to the bile ducts.
necessarily a pathologic finding. However, obstruction of the GI tract in these patients can cause abnormalities of liver function. Occasionally, a bowel obstruction will lead directly to cholangitis by virtue of the concomitant obstruction of the biliary tract. Therefore, it is prudent to consider antibiotic coverage in these patients if they do develop even a partial bowel obstruction. Episodes of cholangitis in the absence of bowel obstruction should precipitate a search for strictures in the biliary tree or at the anastomosis, or at jejunojejunostomy of the Roux limb. Unless the bypass is a spincteroplasty or a choledochoduodenostomy it may be difficult to reach the duct or the duct-enteric anastomosis with an endoscope. Usually, a percutaneous transhepatic cholangiogram of some sort must be done. Often these studies can be combined with balloon dilation of any strictures that are found; a maneuver that can either be temporizing or result in a more durable solution.
The hospital charges for these sorts of procedures vary widely; depending on the underlying condition of the patient that has precipitated the need for a biliary bypass and the magnitude of the operation required to accomplish it. Professional charges for these operations (excluding pancreatectomy and hepatectomy) run in the range of $3000 to $6000.
1. The biliary tree may be anastomosed to the proximal intestine to deal with all sorts of biliary obstructions, and the most common construction is with a Roux-Y jejunal limb.
2. Bile leak is the main early complication and can be from the anatomosis or a missed duct.
3. Stricture of these reconstructions is one of the main late complications and is often heralded by cholangitis.
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