Jaundice, Obstructive Clinical Trial
Official title:
Endoscopic Access Loop With Bilio-enteric Anastomosis: A Prospective Randomized Comparison Between Gastric and Subcutaneous Accesses
Roux-en-Y hepaticojejunostomy is the standard procedure used by most hepatobiliary surgeons
for biliary reconstruction following iatrogenic bile duct injury, benign and malignant CBD
strictures, choledochal cysts and biliary tract tumors management. The incidence of
anastomotic stricture following hepaticojejunostomy in experienced centers ranges between
5%-22%. Hepaticojejunostomy stricture is a serious complication of biliary surgery, if
untreated, can lead to repeated cholangitis, intrahepatic stones formation, biliary
cirrhosis, hepatic failure and eventually death.
Revision of hepaticojejunostomy is a complex procedure, the surgical procedure being made
difficult by the sequelae of long-standing unrelieved biliary obstruction like portal
hypertension due to secondary biliary cirrhosis, atrophy of liver lobes and presence of
cholangiolytic liver abscess.
Endoscopic management is not only the least invasive but also very effective via either
balloon dilatation or stenting of the stricture. In patients with "Roux-en-Y"
hepaticojejunostomy, the endoscopic access to the anastomosis is hampered by the distance
traveled by the jejunal loop until reaching the angle of the enteral anastomosis.
Many modifications of hepaticojejunostomy to provide permanent endoscopic access have been
described in the literature including duodenal, gastric and subcutaneous access loops.
Gastric access loop was first described by Sitaram et al. Ten patients had undergone gastric
access loop. Access loop was entered easily with the gastroscope in five patients in whom it
was attempted. In a series with 16 cases, Hamad MA and El-Amin H assessed different
construction of gastric access loop in the form of bilioenterogastrostomy the overall success
rate of endoscopic access to the HJ through the three types of BEG was 87.5%, while it was
100% for BEG type III, which is a construction similar to the previous series (BEG) type.
Subcutaneous loop access was described by Chen et al. and by Huston et al. In Hutson's series
of 7 patients, recurrent strictures were treated with repeated balloon dilations. The stone
extractions were all successful. In most series, the subcutaneous loop was used for
management os HJ stricture and intrahepatic stones by radiologic intervention. Recently the
subcutaneous loop can be used as an endoscopic biliary access.
This study is a prospective randomized controlled study; which will include all patients who
will undergo Roux-en-Y hepaticojejunostomy reconstruction during the period from 9-2017 to
12-2019.
* Methodology:
Patients will be randomized into three groups according to the surgical procedure performed
as follows:
- Group A: Patients undergoing modified hepaticojejunostomy with gastric access loop
- Group B: Patients undergoing modified hepaticojejunostomy with subcutaneous access loop
- Group C: Patients undergoing standard hepaticojejunostomy with no endoscopic access loop
- Pre-operative preparation:
For all patients, full medical history, clinical examination, laboratory investigations in
the form of complete blood count (CBC), prothrombin time and concentration (PTT), liver
function tests (LFT) and kidney function tests (KFT) will be performed.
Imaging studies will also be carried out in the form of abdominal ultrasonography (US),
computerized tomography scan (CT) of the abdomen and magnetic resonance cholangiography (MRC)
if indicated.
ERCP will be performed, whenever applicable, whether for diagnosis or therapeutic trial.
* Surgical Technique:
For gastric access loop:
- Surgical technique: under general intubation anesthesia, a generous right subcostal
incision is performed and could be extended on demand upward to the xiphoid process
and/or to the left subcostal area. Thorough dissection and adhesiolysis is performed to
reach the CBD and prepare the unaffected proximal part for anastomosis. The Roux jejunal
loop is prepared and passed retrocolic to reach the porta hepatis.
- Then, the hepaticojejunostomy is done via end to side anastomosis using interrupted
sutures of polyglactin of 3-0 or 4-0 size. The anastomosis is done 10-15 cm away from
the free distal end of the Roux jejunum loop to allow anastomosis without tension to the
stomach. A biliary stent may be optionally placed according to operative circumstances
and is brought out through the anterior abdominal wall.
- The end of the Roux jejunal loop taken up for hepaticojejunostomy is not closed but is
anastomosed to the anterior wall of the gastric antrum near the pyloric orifice.
- All the enterogastrostomies and enteroenterostomies were in the form of single-layer
continuous sutures of polyglactin of 3-0 size. An intraperitoneal drain was left in the
hepatorenal pouch before closing the incision.
For subcutaneous access loop:
In the subcutaneous access loop, the same steps are done for performing roux-en-Y
hepaticojejunostomy.
The closed free end of roux loop is passed through the anterior abdominal wall in the right
subcostal area and then fixed to the wall in a subcutaneous position using 3/0 polyglactin
sutures. The limb between the hepaticojejunal anastomosis and the subcutaneous fixation
should be short and straight.
Four Ligaclips are used to mark the jejunal loop by clipping the sutures holding the access
loop in place.
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