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Laparoscopic Choledochoduodenostomy for the Management of Post Gastric Bypass Biliary Stricture

Contributors: Jessica Cioffi

Laparoscopic hepatoduodenostomy is an excellent option for post-gastric-bypass patients with benign biliary tract disease as an indication for biliary bypass. It involves minimal dissection, but does require complex intracorporial suturing.

DOI: http://dx.doi.org/10.17797/5aizaeub3p

Editor Recruited By: Jeffrey B. Matthews, MD

Laparoscopic access to the abdomen is achieved and the porta hepatis is idenitified. A patulous bile duct is identified and the duodenum is mobilized to provide excellent exposure for an anastomosis. The bile duct is incised to create a ductotomy and opposite this, a longitudinal duodenotomy is created. 4-0 PDS sutures are used to create a running anastomosis. The posterior row is fashioned and the percutaneous transhepatic cholangiogram catheter is delivered into the duodenum through the anastomosis. The anterior row of the anastomosis is then completed completing the procedure.
Indications include development of a biliary stricture following gastric bypass or retained primary common bile duct stones following gastric bypass.
Contraindications include cholangiocarcinoma, and an individuals patient¢s inability to tolerate general anesthesia.
The patient is placed supine with both arms tucked. The surgeon is on the patient¢s right side with the assistant on the patient¢s left side. Five trocars are placed with a 12mm port placed infraumbilically (camera), a second 12mm port placed on the right side of the abdomen at the level of the umbilicus (working port) and 5mm ports placed with one subcostal in the anterior axillary line in the right upper quadrant (Surgeon's left hand) and two spaced across the left upper quadrant (first assistant and liver retractor).
Preoperative workup includes cross-sectional imaging to evaluate for a source of biliary stricture and rule out malignancy. A percutaneous transhepatic cholangiogram demonstrates the biliary stricture and brushings may be used to rule out malignancy. Laboratory tests may include a complete blood count and complete metabolic panel.
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Advantages to this technique include less blood loss, decreased post-operative pain and lower rates of wound infection and hernia development. Disadvantages may include a significant learning curve for laparoscopic suturing as well as potentially longer operating times.
Intra-operative complications may include bleeding or misidentification of structures within the porta hepatis. Early post-operative complications may include biliary leak or enteric leak from the anastomosis, while late complications may include a recurrent biliary stricture.
Intra-operative complications may include bleeding or misidentification of structures within the porta hepatis. Early post-operative complications may include biliary leak or enteric leak from the anastomosis, while late complications may include a recurrent biliary stricture.
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El Nakeeb A, Askr W, et al. Long term outcomes of choledochoduodenostomy for common bile duct stones in the era of laparoscopy and endoscopy. Hepatogastroenterology. 2015; 62(137): 6-10. Khajanchee YS, Cassera MA, et al. Outcomes following laparoscopic choledochoduodenostomy in the management of benign biliary obstruction. J Gastroint Surg. 2012; 16(4):801-5. Cai H, Sun D, et al. Primary closure following laparoscopic common bile duct exploration combined with intraoperative cholangiography and choledochoscopy. World J Surg. 2012; 36(1):164-70. Toumi Z, Aljarabah M, et al. Role of the laparoscopic approach to biliary bypass for benign and malignant biliary diseases: a systematic review. Surg Endosc. 2011; 25(11):2105-16. Khalid K, Shafi M, et al. Choledochoduodenostomy: reappraisal in the laparoscopic era. ANZ J Surg. 2008; 78(6):495-500.

Review Laparoscopic Choledochoduodenostomy for the Management of Post Gastric Bypass Biliary Stricture.

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