Overview
Definition:
Biliary-enteric anastomosis stricture refers to the narrowing or blockage of a surgical connection between the bile duct and a segment of the intestine, typically occurring months or years after the initial procedure
This can lead to obstructive jaundice and cholangitis.
Epidemiology:
The incidence of biliary-enteric anastomosis strictures varies widely depending on the type of anastomosis (e.g., choledochojejunostomy, hepaticojejunostomy, cholecystojejunostomy) and surgical technique
Rates can range from 2-10% after common bile duct reconstruction
Risk factors include technical factors, ischemia, inflammation, and superimposed infection.
Clinical Significance:
These strictures significantly impact patient quality of life by causing recurrent pain, jaundice, pruritus, and potentially life-threatening cholangitis
Prompt diagnosis and effective management are crucial to restore bile flow, alleviate symptoms, and prevent long-term complications like liver damage and biliary cirrhosis
Understanding revision strategies is paramount for surgical residents preparing for complex reconstructive procedures.
Clinical Presentation
Symptoms:
Progressive jaundice
Pruritus
Abdominal pain, typically in the right upper quadrant
Fever and chills, suggestive of cholangitis
Nausea and vomiting
Steatorrhea, if pancreatic involvement is suspected
Weight loss in chronic cases.
Signs:
Icteric sclerae and skin
Palpable, distended gallbladder (Courvoisier's sign) in distal common bile duct obstruction
Tenderness on abdominal palpation, especially in the right upper quadrant
Fever
Signs of sepsis in severe cholangitis.
Diagnostic Criteria:
No single set of definitive criteria, but diagnosis is established based on a combination of clinical suspicion, laboratory findings (elevated bilirubin, alkaline phosphatase, GGT, possibly leukocytosis), and characteristic findings on imaging modalities
Recurrence of symptoms after a prior biliary reconstruction is a strong indicator.
Diagnostic Approach
History Taking:
Detailed history of prior biliary or abdominal surgeries
Time interval since the initial procedure
Nature of symptoms, their progression, and any preceding events
History of cholangitis or pancreatitis
Medications and allergies.
Physical Examination:
Comprehensive abdominal examination, focusing on palpation for tenderness, masses, and organomegaly
Assessment of skin and scleral icterus
Examination for signs of systemic infection or sepsis.
Investigations:
Liver function tests (LFTs): Elevated total and direct bilirubin, alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT)
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) may be elevated
Complete blood count (CBC): Leukocytosis may indicate infection
Coagulation profile: Prothrombin time (PT)/International Normalized Ratio (INR) may be prolonged due to vitamin K malabsorption
Imaging: Ultrasound: Initial modality to assess bile duct dilation and gallstones
Computed tomography (CT) scan: Provides anatomical detail, assesses ductal caliber, and identifies potential causes of obstruction
Magnetic resonance cholangiopancreatography (MRCP): Excellent non-invasive tool for visualizing biliary anatomy and strictures
Endoscopic retrograde cholangiopancreatography (ERCP): Both diagnostic and therapeutic, allowing visualization, brush cytology for malignancy, and potential intervention like stenting or balloon dilation
Percutaneous transhepatic cholangiography (PTC): Invasive but useful when ERCP is unsuccessful or contraindicated
Biopsy: For suspected malignancy.
Differential Diagnosis:
Malignancy of the bile duct (cholangiocarcinoma) or ampulla of Vater
Benign biliary strictures from other causes (e.g., primary sclerosing cholangitis, post-cholecystectomy injuries)
Gallstones in the common bile duct
Pancreatitis causing extrinsic compression
Mirizzi syndrome.
Management
Initial Management:
Stabilization of the patient, especially if cholangitis is present
Broad-spectrum intravenous antibiotics
Intravenous fluids
Correction of coagulopathy with vitamin K if indicated
Pain management.
Non Surgical Management:
Endoscopic management (ERCP): The preferred initial approach for many benign strictures
Includes balloon dilation of the stricture and placement of temporary or permanent plastic stents to maintain patency
Success rates vary, and multiple sessions may be required.
Surgical Management:
Surgical revision is indicated when endoscopic management fails, for complex or multiple strictures, or if malignancy is suspected
Options include: Resection of the strictured segment and re-anastomosis
Roux-en-Y hepaticojejunostomy or choledochojejunostomy is often the preferred reconstructive technique
Strictureplasty: Less common, but may be considered in select cases
Placement of internal or external drainage catheters.
Supportive Care:
Nutritional support: Adequate caloric and protein intake, potentially with fat-soluble vitamin supplementation
Monitoring for signs of infection or recurrence
Fluid and electrolyte balance
Patient education regarding symptoms of recurrence.
Complications
Early Complications:
Post-ERCP pancreatitis
Bleeding
Cholangitis
Anastomotic leak
Sepsis
Injury to adjacent organs.
Late Complications:
Recurrent stricture formation
Cholangitis
Biliary cirrhosis
Liver abscess formation
Nutritional deficiencies
Cholangiocarcinoma development in long-standing benign strictures.
Prevention Strategies:
Meticulous surgical technique during the initial anastomosis, avoiding excessive tension and ischemia
Careful handling of bile ducts
Judicious use of sutures
Early recognition and management of postoperative complications
Avoiding prolonged drainage in the common bile duct where possible, unless indicated.
Prognosis
Factors Affecting Prognosis:
The underlying cause of the stricture (benign vs
malignant)
The extent and number of strictures
The patient's overall health status
The success of the initial management (endoscopic or surgical)
The presence and severity of cholangitis or liver damage.
Outcomes:
For benign strictures managed successfully, prognosis is generally good with restoration of bile flow and symptom relief
However, recurrence is possible, requiring ongoing surveillance
For malignant strictures, prognosis is poorer and depends on the stage of the cancer
Surgical revision aims to improve quality of life and prevent complications, but cure is often not achievable for advanced malignancy.
Follow Up:
Regular clinical review and LFT monitoring are essential
Periodic imaging (ultrasound, MRCP) may be necessary to detect recurrence or complications
Patients should be educated on symptoms that warrant urgent medical attention
Surveillance for cholangiocarcinoma may be recommended in patients with long-standing benign strictures.
Key Points
Exam Focus:
Distinguish between benign and malignant biliary strictures
Understand indications for ERCP vs
surgery
Recognize common reconstructive techniques like Roux-en-Y hepaticojejunostomy
Recall complications of both endoscopic and surgical interventions.
Clinical Pearls:
Suspect biliary stricture in any patient with recurrent jaundice and a history of biliary surgery
Always consider cholangitis in a febrile jaundiced patient
ERCP is often the first-line treatment for benign strictures, but surgical revision offers definitive management for recalcitrant cases.
Common Mistakes:
Attributing recurrent jaundice solely to gallstones without considering anastomotic issues
Inadequate investigation of biliary dilation
Undertreating or delaying treatment of cholangitis
Aggressive dilation of benign strictures without considering malignancy
Failure to adequately resect diseased or fibrotic tissue during surgical revision.