Leakage of Hepaticojejunal Anastomosis: Reoperation

Abstract

Background: Leakage of a hepaticojejunal anastomosis is a rare event with potential major morbidity. Surgeons must be aware of the technical armamentarium and pitfalls in revisional surgery for hepaticojejunal anastomosis leakage.

Methods: Review of the available literature and discussion of technical details based on experience and expert opinion.

Results: Early bile leaks as well as failed interventional therapy are indications for reoperation. Almost all reports only mention rates of leakage as a secondary endpoint but do not report details of treatment and outcome. Few authors have compared outcome after reoperation versus interventional approaches in observational studies, with the latter resulting in lower morbidity. The complex and individual situation of the complication makes evidence-based argumentation difficult; this is why personal expert opinions have to be taken into account in this review. The technical aspects and pitfalls of revisional surgery are outlined but represent anecdotal evidence as comparative studies are lacking.

Conclusion: Bile leak after bilioenteric anastomosis is a rare condition that requires differentiated workup and therapy. Early leaks usually result from technical problems and are amenable to repair by reoperation. Reoperation technique can only be discussed on a low evidence level.

Keywords: Bile leak; Hepaticojejunostomy; Liver resection; Pancreatectomy; Postoperative complications.

Fig. 1

Control of a repaired bilioenteric anastomosis. The inserted internal-external drain (Neuhaus drain) is used to control the patency and impermeability of the anastomosis. There is no extravasation of contrast media.

Fig. 2

Gütgemann modification at the common hepatic duct.

Fig. 3

a-e Steps of the hilar biliary anastomosis by Hepp-Couinaud: Longitudinal extension of the left biliary duct, prepositioning of the sutures of the anterior aspect of the anastomosis with 5-0 or 6-0 double-armed C1 monofilament suture, prepositioning of the posterior aspect of the anastomosis with 5-0 or 6-0 single-armed C1 monofilament sutures, completion of the posterior wall, completion of the anterior wall, completed anastomosis.

Fig. 4

Hepp-Couinaud technique of hilar hepaticojejunostomy. After resection of the common bile duct up to the level of the bifurcation, hepaticojejunostomy is established by interrupted monofilament (PDS 6-0) sutures joining the left and right hepatic duct in a common anastomosis site. a All sutures are placed before knotting to ensure appropriate vision and an internal-external drain (Neuhaus drain) is placed over the anastomosis to drain the jejunal limb and stent the anastomosis. b Finished anastomosis.

Fig. 5

Technical tips for performing a repair after insufficiency of a biliary anastomosis: parachute technique on distance (a), preoperative focus control, use of vital tissue, resection of non-vital tissue, proximalisation of the anastomosis (a), transenteric or transhepatic drainage of smaller biliary ducts (intraluminal stent (a)), completion with thin monofilament single sutures in a tension-free method (b).

Fig. 6

Important steps in the surgical repair of a biliary duct laceration or insufficient anastomosis: preoperative control of the septic focus, use of vital tissue and removal of lacerated or ischemic tissue. a Biliary leak and secondary stenosis. b Identification of the leak (internal stenting by green plastic endostent). c Situs after resection of the ischemic area. d New anastomosis after resection of the ischemic biliary duct.