The role of portoenterostomy in the treatment of patients with multiple bile duct trauma: Case series and review of the literature

BACKGROUND: Hepaticojejunostomy is a challenging and complex procedure to be administered with the confidence, in conditions which contain a large number of bile duct damaged by benign pathologies or major bile duct trauma.
METHODS: Here, our clinical series of portoenterostomy (PE), in which we applied in patients who had aggressive hilar dissection for hilar benign biliary pathologies and major bile duct traumas during laparoscopic cholecystectomies were discussed in the light of the literature. The PE procedure was performed in the presence of three or more bile ducts that could not be merged. The classic Roux-en-Y style hepaticojejunostomy was performed to prevent postoperative ascending cholangitis. The ropeway system was used when sewing. 6-8 stitches were laid on the back or anterior wall and the sutures were tied on the outside. Thin-long silicone stents placed in the small diameter (2 mm) bile ducts coinciding with the anastomosis line were extended into the jejunum.
RESULTS: This study included six patients who underwent PE between 2015–2019. Five of the cases were male and one was female and the mean age was 70.33 years. Hepaticojejunostomy was performed in two of the four cases with biliary trauma, but the endoscopic and surgical revision was performed due to developing strictures and bile flow was corrected with stents. In these two cases coming from the external center, PE was applied to multiple bile ducts resulting from aggressive hilar dissection. In two patients who developed major biliary tract trauma (Strasberg-Bismuth-E4) at our hospital underwent PE in the same session. In the other two cases, PE was performed due to a large number of bile ducts caused by benign pathology-related complications (Mirizzi syndrome, Type 4). The mean follow-up period for six patients was 20.1 months (range 11 to 37 months).
CONCLUSION: Portoenterostomy can be performed as a salvage procedure in cases where multiple biliary tracts occur and hepaticojejunostomy is inadequate. PE can be safely used in selected cases that had benign pathologies, major bile duct trauma, in the presence of intense fibrosis, inflammation, very thin bile ducts and more fragile tissues in the liver hilum. PE should be performed in centers with surgeons experienced in hepatobiliary surgery. However, to better understand the efficacy of PE, large multicentric clinical series and patient follow-up are required.

Çoklu safra yolu travmasý olan hastalarýn tedavisinde portoenterostominin yeri: Olgu serisi ve literatürün gözden geçirilmesi

AMAÇ: Benign patolojiler veya majör safra yolu yaralanmasý sonucu ortayan çýkan çoklu safra yolunun yaralandýðý olgularda hepatikojejunostominin güvenle yapýlmasý zor ve kompleks bir iþlemdir.
GEREÇ VE YÖNTEM: Burada, benign hiler patolojiler nedeniyle yapýlan agressif diseksiyonlar sonucunda ve laparoskopik kolesistektomiler sýrasýnda majör safra yolu yaralanmasý geliþen olgularda uyguladýðýmýz portoenterostomi (PE) olgularýmýzý literatür verileri ýþýðýnda tartýþmayý amaçladýk. Travmatize olmuþ ve birleþtirilemeyen üç veya daha fazla safra kanalý varlýðýnda PE tekniðini uyguladýk. Asendan kolanjit riskini azaltmak amacýyla klasik Roux-N-Y tipi hepatikojejunostomi tekniðini uyguladýk. Anastomozun arka ve ön duvarýný yaparken, ropeway (teleferik sistemi) tekniðiyle, tek-tek (separe) 6–8 dikiþ kullanarak ve düðümü dýþarýda baðlayarak iþlem tamamlandý. Ýnce safra kanallarý (>2 mm) içerisine ince-uzun silikon stentler konularak jejunuma uzatýldý.
BULGULAR: 2015–2019 yýllarý arasýnda altý hastamýzda PE uygulandý. Hastalarýn beþi erkek, biri kadýn olup yaþ ortalamasý 70.33 idi. Safra yolu travmasý geliþen dört olgumuzdan ikisinde hepatikojejunostomi yapýldýðý, ancak geliþen striktürler sonucu endoskopik ve cerrahi revizyon yapýldýðý ve stentlerle safra akýmýnýn düzeltilmeye çalýþýldýðý saptandý. Bu iki olgumuzda agressif hiler diseksiyon sonucu ortaya çýkan multiple safra kanallarýna PE uygulandý. Diðer iki olguda ise majör yaralanma sonucu ortaya çýkan çok sayýda safra kanalý (Strasberg-Bismuth-E4) nedeniyle PE yapýlmýþtýr. Mirizzi sendromu (Tip 4) nedeniyle yapýlan agressif hiler diseksiyonlar sonucunda ortaya çýkan çoklu safra kanallarý için iki olguda da PE yapýlmýþtýr. Hastalarýmýzýn ortalama izlem süresi 20.1 aydýr (11–37 ay).
TARTIÞMA: Portoenterostomi iþlemi çok sayýda safra yolunun ortaya çýktýðý ve hepatikojejunostominin yetersiz kalacaðý durumlarda, kurtarýcý bir iþlem olarak uygulanabilir. PE iþlemi özellikle benign hiler patolojilerde, majör safra yolu travmalarý, yoðun fibrozis ve enflamasyonun olduðu durumlarda, frajil doku ve ince kanallarýn olduðu durumlarda uygulanabilir. PE iþlemi hepatobiliyer cerrahi konusunda deneyimli cerrahlarýn olduðu merkezlerde uygulanmalýdýr. Bununla beraber, PE etkinliðini saptayabilmek için çok merkezli, daha geniþ ve daha uzun süreli takibi yapýlan çalýþmalara ihtiyaç vardýr.