Fibrin Sealing for Intrahepatic Hepaticojejunostomy — A New Technical Modification
Resection of the hepatic bifurcation for Klatskin tumors necessarily requires intrahepatic anastomosis. Although these tumors grow slowly, the average resectability rate is only about 20 %. This situation may well be due to major technical problems concerning resection and reconstruction.
Although various methods have been described, reconstruction of the bile flow is still a major problem. Mucosa-to-mucosa anastomosis with resorbable monofilament material, mucosal flap technique supported by positioning sutures to the liver capsule, and omentum flap technique with long-term intraluminal stenting and a combined extracorporeal and inner drainage have been tried. Moreover, “unnecessary” liver resections of the right, left, or quadrate lobe performed only for technical reasons are used for a better exposure of the hepatic ducts during the anastomosing procedure. Nevertheless, all these techniques are still problematic if the resection margin has to be positioned up against the secondary and tertiary hepatic convergences. This situation is reflected by a high complication rate, especially late complications such as infection and stenosis. The stenosis rate is still about 20 %.
In our search for a better solution, we tried fibrin sealing for hepaticojejunostomy. In a case of type III tumor (Bismuth), we had to resect up to the tertiary convergences. Transhepatic intraluminal balloon catheters were used for approximation of a Roux-en-Y loop intrahepatically. The catheters also functioned as short-term stenting with inner and extracorporeal bile drainage. Fibrin sealing was used to perform a close anastomosis as well as to fix the bowel loop within the liver.
The postoperative outcome was totally unproblematic. As early as 2 1/2 weeks after the operation, the balloon catheters could be removed and the patient was discharged. One year follow-up of the patient showed a well-functioning anastomosis by bile X-ray, Tc-99, HIDA scan and liver function tests.
We therefore recommend fibrin sealing for this indication as a further step to improve liver surgery.
KeywordsCatheter Adenocarcinoma Bismuth Cholangitis
Andersson A, Bergdahl L, van der Linden W (1977) Malignant tumors of the extrahepatic bile ducts. Surgery 81: 198–203PubMedGoogle Scholar
Bismuth H, Corlette MB (1975) Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet 140: 170–178PubMedGoogle Scholar
Block GE, Rosemurgy AS (1986) A technique for hepaticojejunostomy with transhepatic stent. Surg Gynecol Obstet 162: 485–487PubMedGoogle Scholar
Blumgart LH, Kelley CJ (1984) Hepaticojejunostomy in benign and malignant high bile duct stricture: approaches to the left hepatic ducts. Br J Surg 71: 257–261PubMedCrossRefGoogle Scholar
Blumgart LH, Thompson JN (1987) The management of the malignant strictures of the bile duct. Curr Prob Surg 37: 88–93Google Scholar
Bolton JS, Braasch JW, Rossi RL (1980) Management of benign biliary stricture. Surg Clin North Am 60: 313–332PubMedGoogle Scholar
Cameron JL, Gayler BW, Zuidema GD (1978) The use of silastic transhepatic stents in benign and malignant biliary strictures. Ann Surg 188: 552–561PubMedCrossRefGoogle Scholar
Evandon A, Fredlund P, Hoevels J, Ihse I, Bengmark S (1980) Evaluation of aggressive surgery in carcinoma of the extrahepatic bile ducts. Ann Surg 191: 23–27CrossRefGoogle Scholar
Fortner JG, Kalium BO, Kim DK (1976) Surgical management of the main hepatic ducts. Ann Surg 184: 68–74PubMedCrossRefGoogle Scholar
Goetze O (1951) Die transhepatische Dauerdrainage bei der hohen Gallengangsstenose. Arch Klin Chir 270: 97–102PubMedCrossRefGoogle Scholar
Iwasaki Y, Okto M, Todoroky T (1977) Treatment of carcinoma of the biliary system. Surg Gynecol Obstet 144: 219–225PubMedGoogle Scholar
Klatskin G (1965) Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. Am J Med 38: 241–256PubMedCrossRefGoogle Scholar
Lai ECS, Tompkins RK, Roslyn JJ, Mann LL (1987) Proximal bile duct cancer; quality of survival. Ann Surg 205: 111–118PubMedCrossRefGoogle Scholar
Launois B, Campion JP, Brissot P, Gosselin M (1979) Carcinoma of the hepatic hilus. Ann Surg 190: 151–157PubMedCrossRefGoogle Scholar
Longmire WP, McArthur MS, Bastounis EA (1973) Carcinoma of the extrahepatic biliary tract. Ann Surg 178: 333–337PubMedCrossRefGoogle Scholar
Pellegrini CA, Thomas MJ, Way LW (1984) Recurrent biliary stricture. Am J Surg 147: 175–180PubMedCrossRefGoogle Scholar
Pitt HA, Toshimitsus M, Parapatis SK, Tompkins RK, Longmire WP (1982) Factors influencing outcome in patients with postOperation biliary strictures. Am J Surg 144: 14–21PubMedCrossRefGoogle Scholar
Ragins H, Diamond A, Meng CH (1973) Intrahepatic cholangiojejunostomy in the management of malignant biliary obstruction. Surg Gynecol Obstst 136: 27–31Google Scholar
Skoog V, Thoren L (1982) Carcinoma of the junctions of the main hepatic ducts. Acta Chir Scan 148: 411–415Google Scholar
Smith R (1964) Hepaticojejunostomy with transhepatic intubation. Br J Surg 51: 186–189PubMedCrossRefGoogle Scholar
Terblanche J, Worthley CS, Spence RAJ, Krige JEJ (1990) High or low hepaticojejunostomy for bile duct strictures. Surgery 108: 828–834PubMedGoogle Scholar
Tompkins RK, Saunders KD, Roslyn JJ (1990) Changing patterns in diagnosis and management of bile duct cancer. Arm Surg 211: 614–621Google Scholar
Warren KW, Jefferson MF (1973) Prevention and repair of strictures of the extra-hepatic bile ducts. Surg Clin North Am 53: 1169–1190PubMedGoogle Scholar
Wexler MJ, Smith R (1975) Jejunal mucosal graft: a sutureless technique for repair of high bile duct strictures. Am J Surg 129: 204–206PubMedCrossRefGoogle Scholar
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