A New Surgical Technique of Biliary Draina ge 403
with narrow gall bladder neck where it may be com-
plicated by str icture. Even it happened it can be treated
by a redo-cholecystostomy with wider part of gall blad-
der body or Roux-en-Y choledocho-jejunostomy.
Biliary fistula: An anastomotic leakage if not closed
spontaneously o r not repaired in time it will result in a
biliary fistula. It is not a common complication. Bil-
iary fistula as a complication is found in one report of
Roux-en-Y Hepaticojejunostomy [3].
Reflux and Recurrent cholangitis: It is a common
complication in bilio-enteric/biliary duct-to-duct an-
astomosis [3,5,10,13,14,17]. When the normal anat-
omy of protruding papilla and sphincter of Oddi at
termination of CBD (Common Bile Duct) is replaced
by simple anastomosis there is possibility of reflux of
foods to cause cholangitis. A long isoperistaltic seg-
ment of jejunum (>40 cm) in Ro ux-en-Y anastomosis
or an interposition of reconstructed valve is a good
prevention for reflux. Even then there is reflux to
cause cholangitis [2,3,5,13,14,17]. But in choledo-
choduodenostomy no such mechanism works and
hence incidence of reflux is more [14]. This high in-
cidence of reflux is probably due to the fact that the
short common hepatic duct is anastomosed directly
with the superior surface of duodenum which has
been pulled up making an angulation and easy way
for reflux. Also to add that the anastomosis with duo-
denum is wide because of dilated common hepatic
duct from obstructive effect of the choledochal cyst.
In the present technique a small anastomosis with
some degree of projecting stoma into th e anterior wall
of first part of duodenum is likely to minimise the in-
cidence of reflux.
Gall stones: Gall stone is an uncommon complication
[6,13] which may occur in the present technique as
because native gall bladder is preserved. But in the
new technique, the possibility is less as the gall blad-
der has been used as a conduit where there is conti-
nous flow of bil e instea d of a normal reservoir.
Carcinoma of gall bladder: If cyst wall with the lin-
ing epithelium is retained (as in earlier days) either in
partial excision or cystoduodenostomy there is good
chance of carcinoma formation from the abnormal
cyst epithelium. But in presnt technique the cyst has
been completely removed. So chance of developing
carcinoma from cyst remnant does not arise. But, as
gall bladder is retained the possibility of developing
carcinoma from it is always there like a normal gall
bladder.
6. Conclusion
The new surgical technique is more anatomical and
physiological than standard Roux-en-Y hepatico-jeju-
nostomy. There was no significant disadvantage or com-
plication within this sh ort period of follow-up. However,
a long term follow-up of patients is needed to look for
future probable complications of stricture, recurrent
cholangitis or any other untoward complications. Even
such complications occur there is scope for a redo-sur-
gery or a Roux-en-Y Hepaticojejunostomy. The tech-
nique can be employed not only for the treatment of
choledochal cyst but also for the treatment of other
causes of Common Bile Duct replacement.
7. Acknowledgements
I would like to acknowledge my wife, Dr. Nasreen
Raushan, for her contributions in editing and proofread-
ing the paper and for her constant support.
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