Fibrin Sealing for Intrahepatic Hepaticojejunostomy — A New Technical Modification

Abstract

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.