Hepatikojejunostomi Anastomoz Tekniğinin Safra Fistülü Gelişiminde Etkisi Var Mı?

GİRİŞ ve AMAÇ: Bilioenterik anastomozların erken ya da geç dönem komplikasyonları mücadelesi zor başka sorunları beraberinde getirebilmektedir. Yara yeri enfeksiyonundan başlayıp karaciğer yetmezliğine kadar uzanan bu komplikasyon yelpazesinde görülen safra fistülünün oluşumunda anastomoz tekniğinin etkisini değerlendirmeyi amaçladık. YÖNTEM ve GEREÇLER: 2013-2019 yılları arasında periampuller bölge kitleleri, mide tümörü, safra yolu yaralanması nedenleri ile hepatikojejunostomi anastomozu uygulanan hastalar tercih edilen anastomoz yöntemine göre gruplandırıldı. 5 mm den küçük ve 5-7 mm arasında ana safra kanalı çapına sahip morbid obez hastalarda tek tek sütürasyon tekniği, diğer hastalarda ise kontiü anastomoz tekniği tercih edildi. Kontinü teknik kullanılan hastalarda anastomozda safra sızıntısı olan alana tek tek sütürasyonlar eklenip kombine yöntem grubuna alındı. Hastaların postoperatif kaçak oranları karşılaştırıldı. BULGULAR: 130 hastaya hepatikojejunostomi anastomozu uygulandı. Hastaların yaş ortalaması 62 olup 54’ü erkek, 76’sı kadınlardan oluşmaktaydı. Uygulanan anastomoz tekniğine göre hastalar kontinü, tek tek sütürasyon ve kombine yöntem grupları isimleriyle 3 gruba ayrıldı. 130 hastanın 5’inde safra kaçağı görüldü. Bu hastaların 4’ünde kontinü 1’inde ise tek tek sütürasyon yöntemi uygulandı. 1 hastanın safra kaçağı kontrol altına alınamayıp tekrar ameliyat ihtiyacı oldu. TARTIŞMA ve SONUÇ: Çalışmamızın değerlendirilmesinde 7 mm den büyük ana safra yoluna sahip hastalarda kontinü hepatikojejunostomi anastomozunun avantajları olup, erken dönem komplikasyonları arasında belirgin fark görülmedi.

Does Hepaticojejunostomy Anastomosis Technique Have an Effect on Bile Fistula Development?

INTRODUCTION: Early or late complications of bilioenteric anastomoses may bring other problems that are difficult to tackle. We aimed to evaluate the effect of anastomosis technique on the formation of bile fistula seen in this spectrum of complications starting from wound infection to liver failure. METHODS: Patients who underwent hepaticojejunostomy anastomosis due to periampullary region masses, stomach tumor, biliary tract injury between 2013-2019 were grouped according to the preferred anastomosis method.The interrupted suturing technique was preferred in the main bile duct less than 5mm and morbidly obese patients with a diameter of 5 to 7 mm, whereas in other patients, the continuous anastomosis technique was preferred. In patients using continuous technique, basic sutures were added to the area with bile leakage in anastomosis and included in the combined method group. Postoperative leak rates of patients were compared. RESULTS: 130 patients underwent hepaticojejunostomy anastomosis. The mean age of the patients was 62, of which 54 were men and 76 were women. According to the anastomosis technique applied, the patients were divided into 3 groups with the names of continuous, interrupted suturing and combined method groups. Bile leakage was observed in 5 of 130 patients. In 4 of these patients, continuous suturing method was used in 1. One patient's bile leak could not be brought under control and he needed surgery again. DISCUSSION AND CONCLUSION: In the evaluation of our study, there are advantages of continuous hepaticojejunostomy anastomosis in patients with a main bile duct larger than 7 mm, and there was no significant difference between early complications..

PDF

___

1.Pitt HA, Kaufman SL, Coleman J, White RI, Cameron JL. Benign postoperative biliary strictures. Operate or dilate? Ann Surg. 1989 Oct;210(4):417-25; discussion 426-7.
2.Nealon WH, Urrutia F. Long-term follow-up after bilioenteric anastomosis for benign bile duct stricture. Ann Surg. 1996 Jun;223(6):639-45; discussion 645-8.
3.Duconseil P, Turrini O, Ewald J, Berdah SV, Moutardier V, Delpero JR. Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeon’s enemies. World J Surg. 2014;38:2946–51.
4.Wellner U.F., Keck T Leakage of Hepaticojejunal Anastomosis: Reoperation Visc Med. 2017 Jun; 33(3): 197–201. Published online 2017 May 26. doi: 10.1159/000471909
5.Hong-Tao Mou, Na Li, Yun Liu, Qiu-Shi Feng, Jia Xu. Use of choledochoscopy to treat anastomotic stricture after cholangiojejunostomy through a preset subcutaneous intestinal loop: a study of 30 cases J Int Med Res. 2019 Aug; 47(8): 3719–3726. Published online 2019 Jul 5. doi: 10.1177/0300060519851399
6.Brunner M, Stockheim J, Krautz C, Raptis D, Kersting S, Weber GF, et al. Continuous or interrupted suture technique for hepaticojejunostomy? A national survey. BMC Surg. 2018 Oct 11;18(1):84. doi: 10.1186/s12893-018-0418-z. PMID: 30309351
7.J. D. Bowie What is the upper limit of normal for the common bile duct on ultrasound: how much do you want it to be? Am J Gastroenterol 2000 Apr;95(4):897-900. doi: 10.1111/j.1572-0241.2000.01925.x.
8.Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome, European Society for Organ Transplantation. 2011;24(4) 379–392 https://doi.org/10.1111/j.1432-2277.2010.01202.x 9.Chok KS, Ng KK, Poon RT, Lo CM, Fan ST. Impact of postoperative complications on long-term outcome of curative resection for hepatocellular carcinoma. Br J Surg. 2009;96:81–7.
10.Antolovik D, Koch M, Galindo L, Wolff S, Müzik E, Kienle P, et al. Hepaticojejunostomy- Hepaticojejunostomy-analysis of risk factors for postoperative bile leaks and surgical complications J Gastrointest Surg. 2007 May;11(5):555-61. doi:10.1007/s11605-007-0166-3.
11. de Castro SM, Kuhlmann KF, Busch OR, van Delden OM, Laméris JS, van Gulik TM, et al. Incidence and management of biliary leakage after hepaticojejunostomy J Gastrointest Surg 2005 Nov;9(8):1163-71; discussion 1171-3. doi: 10.1016/j.gassur.2005.08.010. 12. Andrianello S, Marchegiani G, Malleo G, Pollini T, Bonamini D, Salvia R, et al. Biliary fistula after pancreaticoduodenectomy: data from 1618 consecutive pancreaticoduodenectomies HPB (Oxford) 2017 Mar;19(3):264-269. doi: 10.1016/j.hpb.2016.11.011. Epub 2017 Jan 11.
13.Kasahara M, Egawa H, Takada Y, Oike F, Sakamoto S, Kiuchi T, et al. Biliary reconstruction in right lobe living-donor liver transplantation: comparison of different techniques in 321 recipients. Ann Surg. 2006;243(4):559–66.
14.Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Harada N, Ijichi H, et al. Biliary strictures in living donor liver transplantation: incidence, management, and technical evolution. Liver Transpl. 2006;12(6):979–86.
15.Eric C.H. Lai, Chung Ngai Tang Robot-assisted laparoscopic hepaticojejunostomy for advanced malignant biliary obstruction Asian Journal of Surgery Volume 38, Issue 4, October 2015, Pages 210-213 https://doi.org/10.1016/j.asjsur.2015.01.010
16. Andrianello S, Marchegiani G, Malleo G, Pollini T, Bonamini D, Salvia R, et al. A New Era of Bile Duct Repair: Robotic-Assisted Versus Laparoscopic Hepaticojejunostomy J Gastrointest Surg. 2019; (23):451-9. https://doi.org/10.1007/s11605-018-4018-0
17. Klaiber U, Probst P, Knebel P, Contin P, Diener MK, Büchler MW, et al. Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy. Br J Surg. 2015;102:331–340.
18. Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011;149:680–688. 19.
19.Si-Ming Zheng, Hong Li, Gen-Cong Li, Dan-Song Yu, Dong-Jian Ying, Bin Zhang, Cai-De Lu, Xin-Hua Zhou Risk factors, treatment and impact on outcomes of bile leakage after hemihepatectomy ANZ J Surg 2017 Jul;87(7-8):E26-E31. doi: 10.1111/ans.13073. Epub 2015 Apr 16. DOI: 10.1111/ans.13073
20.Cuneyt Kayaalp, Cemalettin Aydin, Aydemir Olmez, Sevil Isik and Sezai Yilmaz. Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery Clinics (Sao Paulo). 2011 Mar; 66(3): 421–424. doi: 10.1590/S1807-59322011000300010
21. Wang C, Peng W, Yang J, Li Y, Yang J, Hu X, et al. Application of near-infrared fluorescent cholangiography using indocyanine green in laparoscopic cholecystectomy J Int Med Res. 2020 Dec; 48(12): 0300060520979224. Published online 2020 Dec 18. doi: 10.1177/0300060520979224
22. Asano T, Natsume S, Senda Y, Sano T, Matsuo K, Kodera Y, et al. Incidence and risk factors for anastomotic stenosis of continuous hepaticojejunostomy after pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 2016 Oct;23(10):628-635. doi: 10.1002/jhbp.385. Epub 2016 Aug 29.
23. House MG, Cameron JL, Schulick RD, Campbell KA, Sauter PK, Coleman J, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy Ann Surg 2006 May;243(5):571-6; discussion 576-8. doi: 10.1097/01.sla.0000216285.07069.fc.
24.Ulrich F Wellner, Tobias Keck Leakage of Hepaticojejunal Anastomosis: Reoperation. Visc Med 2017;33:1–5 doi: 10.1159/000471909 Visc Med 2017;33:1–5