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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


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