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1. Treatment of failed Roux-en-Y
hepaticojejunostomy after
post-cholecystectomy bile ducts
injuries
Amine Benkabbou, MD,a Denis Castaing, MD,a,b,c Chady Salloum, MD,a Ren Adam, MD, PhD,a,c,d
e
Daniel Azoulay, MD, PhD,a,c and Eric Vibert, MD, PhD,a,b,c Villejuif, France
Background. Roux-en-Y hepaticojejunostomy (RYHJ) is the most well-accepted treatment for most post-
cholecystectomy bile duct injuries (BDI). RYHJ failure is a complex situation that requires expert
planning and the possibility of using a combination of operative, radiologic, and endoscopic techniques.
The aim of this study was to report our experience with a multidisciplinary approach to failed RYHJ
after post-cholecystectomy BDI.
Methods. Between January 1996 and March 2008, 44 consecutive patients were managed for RYHJ
failure in our department. They presented with recurrent cholangitis in 40 patients (91%) and/or
jaundice in 9 (20%). First-line treatment consisted of primary revisionary surgery in 26 cases (59%;
repeat RYHJ in 22 and hepatectomy in 4) and a percutaneous approach in 18 cases (41%; biliary
interventions in 16 and portal vein embolization in 2).
Results. Postoperative mortality was nil. Postoperative morbidity was 11% after repeat RYHJ without
hepatectomy, 80% (bile leaks) after hepatectomy, and 10% (mild cholangitis and hemobilia) after a
percutaneous approach. Delayed revisionary surgery with the intent to wait for bile duct dilation failed
in all 5 patients. With a mean follow-up of 49 ± 40 months, second- or third-line treatment was
attempted in 7 patients (16%). One patient (2%) died because of suicide. Overall clinical success
defined by the absence of incapacitating biliary symptoms after treatment was achieved in 39 patients
(89%).
Conclusion. An immediate, multidisciplinary approach including repeat biliary surgery and/or a
percutaneous approach in a tertiary hepatobiliary center is required to obtain good, long-term results
when treating the failure of RYHJ post-cholecystectomy BDI. (Surgery 2013;153:95-102.)
From the AH-HP,a H^pital Paul Brousse, Centre Hpato-Biliaire, Inserm,b Unite 785, the Universit
o e e
Paris-Sud,c and Inserm,d Unite 776, Villejuif, France
ROUX-EN-Y HEPATICOJEJUNOSTOMY (RYHJ) is the stan- of this complex situation requires careful and ex-
dard treatment for most post cholecystectomy bile pert management and the possibility of having a
duct injuries (BDI) with long-term clinical success combination of operative, radiologic, and endo-
rates reaching 90%.1 Some patients who undergo scopic techniques. Few reports have specifically
RYHJ for BDI will experience incapacitating biliary analyzed the results of failed biliary repairs for
symptoms, such as jaundice or recurrent cholangi- post-cholecystectomy BDI.2-6 The aim of our study
tis.2 However, in addition to anastomotic stricture, was to evaluate the short- and long-term results of
several other, isolated or associated pathogenic fac- a multidisciplinary approach regarding failed
tors for RYHJ failure include intrahepatic calculi, RYHJ after post-cholecystectomy BDI.
intrahepatic stricture, and improper technical
construction of the Roux-en-Y limb. Management PATIENTS AND METHODS
Between January 1996 and March 2008, 44
Accepted for publication June 14, 2012. consecutive patients were treated in our depart-
Reprint requests: Eric Vibert, MD, PhD, 12 avenue Paul Vaillant ment (Centre Hpato-Biliaire, Paul Brousse Hos-
e
Couturier, 94804 Villejuif Cedex, France. E-mail: eric.vibert@ pital, Assistance Publique des Hopitaux de Paris,
pbr.aphp.fr. Villejuif, France) for the failure of RYHJ per-
0039-6060/$ - see front matter formed because of post-cholecystectomy BDI.
Ó 2013 Mosby, Inc. All rights reserved. Our group of patients comprised 13 males (30%)
http://dx.doi.org/10.1016/j.surg.2012.06.028 and 31 females (70%) with a mean (± SD) age of
SURGERY 95

2. 96 Benkabbou et al Surgery
January 2013
Table I. Serum biochemistry findings at referral
Normal range Median Min Max
PT (%) 70 94 68 100
Bilirubin (mmol/L) 17 13 5 134
AP (UI/L) 120 183 123 1,128
GGT (UI/L) 50 210 52 2,074
AST (UI/L) 35 48 15 491
ALT (UI/L) 43 62 9 776
Creatinine (mmol/L) 18–106 64 47 140
Protein (g/L) 60–80 71 48 80
Albumin (g/L) 38 41 29 50
Leukocytes (N./mL) 4,800–10,800 6,150 3,240 14,800
Hemoglobin (g/dL) 12–16 12.9 8 15.8
Platelets (N.103/mL) 150–400 256 85 658
ALT, Alanine aminotransferase; AP, alkaline phosphatase; AST, aspartate aminotransferase; GGT, gamma glutamyl transferase; PT, prothrombin time.
51 ± 14 years (range, 17–78). All BDI were abnormalities were present (Table I). Leukocytosis
sustained during cholecystectomy performed and thrombocytopenia were present in 3 patients
for cholecystolithiasis. The approach for the cho- (7%) and 1 patient (2%), respectively.
lecystectomy was laparoscopic in 35 patients (80%) Vascular and liver parenchymal assessments
and open in 9 patients (20%). The level of BDI was (Table II) were performed using routine abdominal
assessed according to Bismuth’s classification (7): ultrasonography and computed tomography of the
Type 1 in 2 patients (5%), type 2 in 18 (41%), type liver with intravenous contrast. These imaging mo-
3 in 12 (27%), type 4 in 5 (11%), and type 5 in 7 dalities revealed liver atrophy in 7 patients (16%),
(16%). The time elapsing between BDI and initial and evidence of injury to the main (2 patients
repair (RYHJ) was a median of 6 days (range, 0– [4%]) or right branch (6 patients [14%]) of the he-
703). The initial repair was performed very early patic artery injury in 8 patients (18%). Liver atrophy
(48 hours) in 9 patients (20%), early (45 days) and vascular injury were both present in 2 patients.
in 22 (50%), and delayed (45 days) in 13 (30%). Biliary assessments were performed using per-
The BDI was incurred and the failed RYHJ was cutaneous cholangiography in 34 patients (77%)
performed in the same hospital in 34 patients and/or magnetic resonance cholangiography in 23
(72%). Before referral to our department, an (52%). These procedures revealed intrahepatic
initial revisionary operation for the failed RYHJ calculi in 18 patients (41%) and bile duct dilation
was performed in 10 patients (23%), and involved in 11 (25%). The level of obstruction was suspected
a hepaticojejunostomy repair in 3 patients, Roux- to be hilar or suprahilar in 39 patients (89%).
en-Y limb repair in 2 patients, and percutaneous Treatment strategy was defined at a multidisci-
dilatation of a stricture in 5 patients. These 10 plinary staff meeting including surgeons, radiolo-
patients were referred to our department because gists, and hepatogastroenterologists during a
of persistent biliary symptoms despite this revision- case-by-case analysis in our tertiary center that offers
ary operation. different multidisciplinary approaches to hepato-
The patients were admitted to our department biliary disorders (operative, endoscopy and inter-
for recurrent cholangitis in 40 patients (91%) ventional radiology). The treatment strategy
and/or jaundice in 9 (20%). Recurrent cholangitis comprised 2 types of treatments: Revisionary sur-
was defined as fever 388C or episodic right upper gery, including a revision of hepaticojejunostomy
quadrant pain with no identifiable source outside and/or hepatectomy, or a percutaneous approach,
the hepatobiliary system occurring a minimum of 3 including biliary maneuvers and/or portal vein
times in the preceding year. Continuous or inter- embolization. These treatments were performed
mittent biliary symptoms had developed within a alone or in combination and subsequently defined
median period 4 months (range, 0–204) since the the different lines of treatment in the same patient.
pre-referral procedure. An external biliary drain Revisionary surgery was considered in patients
was present in 7 patients (16%), and no patient in good general condition without uncontrolled
had an active bile leak. biliary sepsis and was designed to perform an end-
Cholestasis had been present in all patients. No to-side, wide, healthy, mucosa–mucosa hepaticoje-
major coagulation and renal function junostomy without tension and with a 70-cm long

3. Surgery Benkabbou et al 97
Volume 153, Number 1
Table II. Radiologic findings at referral bile duct. A hepatotomy between segments 5 and 4
Findings n through of the bed of the gallbladder was used to
access the secondary right biliary confluence.
Calculi 18 (41%) Visual magnifying aids were used routinely to
Bile duct dilation 18 (41%)
optimize biliary dissection, the recognition of
Bilateral 11
healthy mucosa, and the anastomoses. These anas-
Left liver 4
Right liver 1 tomoses were performed using 5/0 or 6/0 inter-
Right sector 2 rupted, nonabsorbable, monofilament sutures with
Vascular injury 8 (18%) the knots tied on the external surface of the
Right branch of hepatic artery 6 anastomosis. An ultrasonic dissector and bipolar
Hepatic artery 2 coagulation forceps were used routinely during any
Parenchymal liver atrophy 7 (16%) hepatectomy.
Right liver 5 Percutaneous approaches. All percutaneous
Left lateral lobe 1 procedures were carried out in the operating
Segment 4 1 room under full aseptic conditions as applicable
Level of biliary obstruction
to any operative procedure.7 The operating suite
Infrahilar 5 (11%)
was equipped with a Doppler Ultrasound (Aloka
Hilar 25 (57%)
Suprahilar 14 (32%) SSD 680, Aloka, Tokyo, Japan) and a light ampli-
fier (Diasonics 3800; Diasonics, Milpitas, CA).
These procedures were performed under either
local anesthesia, neuroleptic analgesia with pre-
retrocolic Roux-en-Y limb. In patients with a lon- medication, or general anesthesia with intubation
gitudinal stricture extending into the intrahepatic if the duration of the procedure was expected to
bile ducts, associated with liver atrophy, a hepatec- be of a greater duration. Biliary maneuvers con-
tomy was performed with or without RYHJ revi- sisted of 3 successive stages: Establishing adequate
sion. A percutaneous approach was considered in transhepatic and/or transjejunal8 access to the
patients with a (1) marked worsening in their biliary tract if not present, performing the re-
general condition or hepatic function, or severe quired intervention, and obtaining a contrast
sepsis, all of which contraindicated an operative study to demonstrate if the procedure was success-
procedure, (2) a local contraindication at the level ful. When necessary, endoscopic control of the
of the bile duct owing to a cavernous transforma- procedure was ensured using a pediatric broncho-
tion of a thrombosed portal vein or after numer- scope (diameter, 4 mm). Strictures were treated
ous previous biliary interventions, or (3) an by balloon dilatation and calculi by extraction
isolated short intra-hepatic biliary stricture.7 Portal and/or lithotripsy (Lithotron EL27, Walz Elektro-
vein embolization was performed in patients with nik GMBH, Germany). Portal vein embolization
an isolated longitudinal intrahepatic biliary stric- was performed via a transhepatic approach.
ture in attempt to induce parenchymal atrophy Follow-up data were obtained by means of
in the distribution of the diseased bile ducts. review of hospital and outpatient records. All
Techniques of revisionary surgery. An end-to- patients were seen 1 month after hospital dis-
side, wide, healthy, mucosa–mucosa hepaticojeju- charge and underwent computed tomography
nostomy without tension and with a 70-cm long and a complete biochemical assessment. Thereaf-
retrocolic Roux-en-Y limb was the goal in each ter, they were followed with liver ultrasonography
patient. Operative exploration consisted of 3 stages: every 4 months during the first year and every 6
Verification of the erroneous construction of the months for 2 years, and the yearly thereafter.
Roux-en-Y limb, exposure of the anastomotic area Postoperative morbidity was assessed according to
with collection of a sample of bile, and assessment the Clavien-Dindo classification.9 Clinical outcome
of biliary anatomy and/or abnormalities (calculi, was determined according to the Terblanche classi-
stricture) using intraoperative cholangiography. fication10: grade I, no biliary symptoms; grade II,
When feasible in patients with intra-hepatic bile transitory symptoms and no current symptoms;
duct dilation, a preoperative transhepatic cholan- grade III, biliary symptoms requiring medical
giography followed by transhepatic biliary drainage therapy; and grade IV, recurrent biliary symptoms
was performed. Intraoperatively, this drainage was requiring correction or related to death. Ter-
very useful in localizing the bile duct after removal blanche class IV constituted a poor result. Ter-
of the RYHJ and dissecting the hilar plate to expose blanche I, II, and III constituted a clinical success
the primary biliary confluence and notably the left with excellent, good, and fair results, respectively.

4. 98 Benkabbou et al Surgery
January 2013
RESULTS thus optimize revision. None of these patients
The mean (± SD) follow-up period was 49 ± 40 developed bile duct dilation after a mean of
months (range, 2–153). One patient (2%) died as waiting time of 20 ± 17 months. During this period,
a result of suicide 44 months after the initial 4 patients developed recurrent cholangitis. Liver
hepatectomy. In 7 patients (16%), $2 treatments abscess and pylephlebitis of the right portal branch
were required, with a mean follow-up of 33 ± 36 occurred in 1 patient with a previous injury of the
months (range, 2–85). At the time of last follow- right branch of the hepatic artery.
up, clinical success had been achieved in 39 Revisionary surgery without hepatectomy (n = 26 pro-
patients (89%): 34 patients (77%) were asymptom- cedures in 25 patients): Revisionary surgery without
atic (Terblanche I–II), and 5 patients (11%) had hepatectomy was performed as first-line treatment
experienced an improvement in their symptoms in 22 patients, as second-line treatment in 3
(Terblanche III). The overall result was poor patients (after a percutaneous approach), and as
(Terblanche IV) in 5 patients (11%). An overview third-line treatment in 1 patient (after revisionary
of the results is shown in Fig 1. First-line treatment surgery followed by a second-line percutaneous
(Fig 2) consisted of primary revision surgery (first- approach). Morbidity occurred after 3 of 26 pro-
line revisionary surgery) in 26 patients (59%) and cedures (11%): Abdominal hematoma managed
a percutaneous approach (first-line percutaneous with transfusion in 1 patient (Clavien-Dindo II),
approach) in 18 patients (41%). cholangitis managed with antibiotics in 1 (Clavien-
First-line revisionary surgery (n = 26 [59%]; Dindo II), and acute pancreatitis that required
Table III). The Roux-en-Y limb was found to be exploratory laparotomy for suspected biliary peri-
short (70 cm) in 12 patients (44%) and was re- tonitis in 1 (Clavien-Dindo IIIb).
modeled to a length of 70 cm. Revisionary surgery Revisionary surgery with hepatectomy (n = 5 proce-
included repeat hepaticojejunostomy in 23 patients dures in 4 patients): Hepatectomy was performed
(89%), which involved more than a single duct in as first-line treatment in 4 patients and as second-
13 (54%; (range, 1–5). In 3 patients (11%), revi- line treatment in one who underwent operation
sionary surgery was suboptimal because an anasto- twice. Bile leaks occurred after 4 procedures
mosis of the isolated right sector duct (1 case) or (80%). Morbidity occurred as Clavien-Dindo II
segment 4 duct (2 cases) was impossible. Drains after 3 procedures and Clavien-Dindo IIIb after
were placed through the hepaticojejunostomy in 4 1 first-line procedure complicated by a bilio-
patients (17%). An access limb of jejunum was pleural fistula managed with prolonged drainage
placed under the abdominal wall to enable subse- that progressed to a chronic external fistula re-
quent percutaneous access in 3 patients (13%). quiring repeat hepatectomy.
Hepatectomy was performed in 4 patients (15%) in- Percutaneous approach (n = 120 procedures in 21 pa-
cluding 2 right hepatectomies, 1 left hepatectomy, tients): A percutaneous approach was adopted as
and 1 left lateral sectionectomy). first-line treatment in 18 patients and as addi-
First-line percutaneous approach (n = 18 [41%]; tional treatment in 3 (after initial revisionary
Table IV). Access to the biliary tract was established surgery). In 1 patient, additional treatment con-
by catheterization of the jejunal limb (the ‘‘cul-de- sisted of a combination of biliary maneuvers and
sac’’) in 9 patients (54%), transhepatic catheteriza- right sectoral portal vein embolization. There was
tion in 4 patients (23%), or combined techniques no mortality. No morbidity was observed after
in 4 (23%). The procedures were performed un- portal vein embolization. Hemobilia that did not
der biliary endoscopic control in 12 patients require a blood transfusion (Clavien-Dindo I)
(27%). Balloon dilatation of a stricture, extraction and/or cholangitis managed with IV antibiotics
of calculi and/or biliary cast, and lithotripsy were (Clavien-Dindo I) occurred after 10% of the
performed in 12 (70%), 8 (47%), and 4 patients biliary interventions.
(23%), respectively. In 2 patients with calculi, su- Long-term results. Revisionary surgery without
tures exposed in the bile duct lumen were re- hepatectomy (n = 22 patients): Satisfactory primary
moved percutaneously under endoscopic control results were achieved in 18 patients (82%): 17
via access of the jejunal limb. Transhepatic portal patients (94%) became asymptomatic (Terblanche
vein embolization was performed in 2 patients I–II) and 1 patient (6%) improved, although with
(right posterior sectoral portal branch and right some symptoms (Terblanche III). In 4 patients
portal branch). (9%), the symptoms did not improve (Terblanche
Short-term results. In 5 patients (20%), first-line IV). One of these patients experienced generally
revisionary surgery was delayed at referral in at- fair results (Terblanche III) after an additional
tempt to wait for bile duct dilation to develop and percutaneous approach.

5. Surgery Benkabbou et al 99
Volume 153, Number 1
Fig 1. Overview of the results as a function of the Terblanche classification of 44 patients, achieved with 1, 2 or 3 step(s).
HJ, Hepaticojejunostomy; PVE, portal vein embolization; T, Terblanche classification10; TI, no biliary symptoms; TII,
transitory biliary symptoms, no current symptoms; TIII, biliary symptoms requiring medical therapy; TIV, recurrent bil-
iary symptoms requiring correction or related to death.
and 4 (29%) had improvement in their symptoms
(Terblanche III). In 2 patients (6%), the symptoms
were not primarily improved (Terblanche IV), but
both became asymptomatic (Terblanche I–II) after
further revisionary surgery.
Portal vein embolization (n = 2 patients): Poor
results were obtained in these 2 patients. One
patient who underwent portal vein embolization
alone had overall good results (Terblanche II)
after additional revisionary surgery, whereas the
second with initial combined portal vein emboli-
zation and biliary interventions was listed for liver
transplantation because of development of second-
ary biliary cirrhosis.
Fig 2. Overall results of the revisionary approach. Full
line: Overall results including additional revision. Dotted DISCUSSION
line: Results after first-line revision. This study shows that with an experienced
multidisciplinary approach (according to the strat-
Revision surgery with hepatectomy (n = 4 patients): egy summarized in Fig 3), patients with a failed
Good primary results were achieved in 3/4 patients RYHJ after post-cholecystectomy BDI can achieve
who were asymptomatic (Terblanche I–II), but the good long-term clinical success in 89%. These re-
symptoms did not improve in the other patient. sults required more than the first-line revision in
This patient (Terblanche IV) underwent addi- 16% of patients. Although we showed that waiting
tional repeat hepatectomy for a bile leak from an for bile duct dilation before revisionary surgery was
excluded segment 4 with histologic evidence of not successful; moreover, we were unable to iden-
secondary biliary cirrhosis, but this procedure tify any prognostic predictive factor at referral in
failed. She died from suicide. our small and heterogeneous population.
Biliary interventions (n = 16 patients): Good pri- Concordant data suggest that both repair of
mary results were achieved in 14 patients (87%): BDI repair by an expert hepatobiliary surgeon11
10 (71%) were asymptomatic (Terblanche I–II) and a multidisciplinary approach involving

6. 100 Benkabbou et al Surgery
January 2013
Table III. Revisionary surgery procedures (n = 31) Table IV. Percutaneous approach procedures
First line Additional (n = 21)
(n = 26) (n = 5*) First line Additional
(n = 18) (n = 3)
Hepaticojejunostomy revision 23 (88%) 4 (80%)
Number of ducts/anastomosis Portal vein embolization 2 (11%) 1
1 13 2 Right branch 1 —
2 5 1 Right posterior sector branch 1 1
3 6 — Biliary maneuvers 17 (94%) 3 (100%)
4 1 1 Catheterization approach
5 1 — Transhepatic 9 1
Endobiliary extraction 18 (69%) 2 (40%) Transjejunal 4 —
Calculi and/or biliary cast 15 2 Combined 4 2
Clips 2 — Endoscopic control 12 (67%) 2
Alimentary 1 1 Procedures
R-en-Y revision with 12 (46%) 0 Stricture dilatation 12 (70%) 3
Hepatectomy 4 (15%) 1 (20%) Calculi and/or biliary cast 8 (47%) 1
Right liver 2 — extraction
Left liver 2 — Lithotripsy 4 (23%) 1
Left lateral lobe 1 — Suture extraction 2 (12%) —
Segment 4 (excluded bile leak) — 1 Median number of procedures 5 (2–23) 10 (2–24)
*Second-line in 4 patients and third-line in 1 patient. (range)
gastroenterologists, radiologists, and surgeons12
favorably affects outcomes. RYHJ has been success- although at the time of initial biliary repair only
fully used in such cases since the 1970s13 and is cur- 38% of them had an injury or stricture at that level.
rently the standard treatment, with success rates Hence, a precise assessment of bile duct anatomy
of up to 91% and very long-term (10 years) and the level of the stricture are critical to the
stricture-free survival.14,15 Nevertheless, $10% of success of any revisionary strategy.4,16 In this set-
these patients will suffer from a failure of the ting, percutaneous cholangiography can be consid-
RYHJ.2 ered as the ‘‘gold standard’’ because it provides
This failure involves isolated or associated critical information on the biliary anatomy and
pathogenic factors responsible for recurrent epi- ductal communication. Magnetic resonance chol-
sodes of cholangitis in 90% of patients and/or angiography has been claimed to be as reliable as
jaundice in 20%.16 These symptoms of biliary ob- the percutaneous approach in defining biliary
struction may occur without anastomotic stricture tree anatomy20 and may be the procedure of
and are possibly caused by the passage of calculi choice in selected patients.
or by enterobiliary reflux induced by inappropri- The second major problem encountered in the
ate construction of the Roux-en-Y limb.2 Between management of RYHJ failure is an absence of intra-
80% and 90% of patients with failure of the biliary hepatic bile duct dilation that complicates the
repair develop symptoms within 5–7 years.3,17 This biliary repair. This situation was observed in 59%
delay can vary from a few days to several years18 (a of our patients. It should be noted that revisionary
maximum of 17 years in our series), which empha- surgery was delayed in 5 patients specifically to wait
sizes the need for prolonged follow-up. By con- for bile duct dilation, but this strategy failed in all 5
trast, some patients who are clinically ‘‘normal’’ patients and was associated with severe morbidity
after repair can continue to experience mild during the waiting period. We, therefore, consider
increases in serum bilirubin and/or gamma glu- that when surgical revision criteria are fulfilled, an
tamyl transferase activity during long-term fol- elective procedure assisted by the routine use of
low-up.19 optical magnification should be scheduled without
The management of RYHJ failure is hampered waiting for bile duct dilation.
by the fact that biliary strictures are found at a From a technical point of view, if the biliary
higher level than before the first attempt at BDI confluence is intact, a wide stoma of healthy duct
repair. Indeed, with each failed attempt, the level can be achieved by extending the opening in the
of the scarred biliary stricture recedes higher into bile duct to the extrahepatic portion of the left
the hepatic hilum. In our experience, 89% of hepatic duct.21 If the biliary confluence is obliter-
referred patients had hilar or suprahilar strictures, ated, and the left and right hepatic ducts are

7. Surgery Benkabbou et al 101
Volume 153, Number 1
Fig 3. Initial treatment algorithm in failed RYHJ after post-cholecystectomy BDI.
isolated, hilar plate dissection is necessary up to analysis and an immediate multidisciplinary ap-
the level at which a healthy duct can be found. proach in tertiary hepatobiliary centers.
When the results of revision of the hepaticojeju-
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