Page 83 - World Journal of Laparoscopic Surgery

CASE REPORT
Laparoscopic Revision of Benign Hepaticojejunostomy

Stricture Following Previous Open Pancreaticoduodenectomy

1
Ravi Kiran Thota , Srikanth Gadiyaram 2

AbstrAct
Post-pancreaticoduodenectomy (PD) benign hepaticojejunostomy stricture (PDHJS) is an infrequent long-term complication. The therapeutic
options in these patients are endoscopic or percutaneous balloon dilatation and surgical revision of the anastomosis. We herein describe
the preoperative diagnosis and operative steps of laparoscopic revision hepaticojejunostomy (LRHJ) in an elderly male presenting with a
hepaticojejunostomy stricture (HJS) 12 years post-open PD who had a failed percutaneous intervention.
Keywords: Benign hepaticojejunostomy stricture, Laparoscopic revision hepaticojejunostomy, Pancreaticoduodenectomy, Post-
pancreaticoduodenectomy hepaticojejunostomy stricture.
World Journal of Laparoscopic Surgery (2022): 10.5005/jp-journals-10033-1511

IntroductIon 1,2 Department of Surgical Gastroenterology and MIS, Sahasra Hospitals,
Post-pancreaticoduodenectomy benign hepaticojejunostomy Bengaluru, Karnataka, India
1
stricture is reported in 2.6% of patients. We herein report a case of Corresponding Author: Srikanth Gadiyaram, Department of Surgical
HJS masquerading as hilar cholangiocarcinoma who underwent Gastroenterology and MIS, Sahasra Hospitals, Bengaluru, Karnataka,
LRHJ. India, Phone: +91 809880109971, e-mail: srikanthgastro@gmail.com
How to cite this article: Thota RK, Gadiyaram S. Laparoscopic Revision
cAse descrIptIon of Benign Hepaticojejunostomy Stricture Following Previous Open
Pancreaticoduodenectomy. World J Lap Surg 2022;15(2):179–181.
A 70-year-old male patient who had undergone a Whipple PD for Source of support: Nil
ampullary carcinoma and adjuvant chemotherapy 12 years before Conflict of interest: None
presented now with low-grade cholangitis and was evaluated
at another hospital. The diagnosis of hilar cholangiocarcinoma
with left duct extension was made based on imaging, namely, • Step IV: Jejunostomy, choledochotomy, and choledochoscopy:
multi-detector computed tomography (MDCT) (Fig. 1A), magnetic A jejunostomy (Fig. 3B) was made below HJS and across HJS into
resonance cholangiopancreatography (MRCP) (Fig. 1B), and positron the normal CHD. The PTBD catheter was flushed and cleared
emission tomography with computed tomography (PET-CT) (Fig. of sludge and stones. Choledochoscopy (Fig. 3C) revealed no
1C). A left hepatectomy/caudate resection had been advised residual calculi and normal intra hepatic biliary mucosa.
there, and he was subsequently reviewed by us. After the review • Step V: Revision HJ: The vertically aligned hepaticojejunostomy
of LFT (total Bilirubin 0.36 mg/dL and ALP, GGT 89, 87 U/L, Serum was closed horizontally with V-lock 3–0 suture in a continuous
albumin 3.34 gm/dL) and imaging, a possibility of benign HJS with manner (Fig. 3D). Check PTBD-gram showed no leak from suture
hepatolithiasis was considered. The percutaneous transhepatic line.
cholangiogram (PTC) (Fig. 1D) showed filling defects at hilar bile • Step VI: Peritoneal lavage and subhepatic drains was placed.
duct, left hepatic duct, and a non-dilatable tight biliary stricture Sheath at 10-mm port sites were closed and skin with staples.
with only a streak of contrast entering the jejunum. Percutaneous
transhepatic biliary drainage (PTBD) was left as an interno-external He made an uneventful recovery; subhepatic drain was removed
drain. Two weeks later, he underwent an LRHJ under general on postoperative day (POD3) and he was discharged on POD6.
anesthesia (GA) in a supine/leg split position. The operative steps Furthermore, PTBD-gram done after 3 weeks showed free flow
were as follows: of contrast across HJ with no evidence of leak, and it was removed.
At 12-months follow-up, he remains asymptomatic with normal LFT
• Step I: Port-placement: Illustrated in Figure 2. and no biliary dilatation on ultrasonography (USG).
• Step II: Adhesiolysis: Adhesions were lysed from anterior
abdominal wall and subhepatic regions. Hepatic flexure was
taken down and further adhesiolysis was done with harmonic dIscussIon
shears to define the HJS. Post-pancreaticoduodenectomy benign hepaticojejunostomy
• Step III: Exposure of common hepatic duct (CHD): HJS site was stricture is due to a recurrence of cancer, benign HJ stricture or a
looped with umbilical tape (Fig. 3A). Traction on umbilical second primary malignancy. A hilar cholangiocarcinoma following
tape helped further dissection, exposure of CHD up to biliary PD is most often seen in patients who had a distal common bile
1
confluence. duct (CBD) cholangiocarcinoma to start with. Imaging modalities

© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.