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Volume: 22 Issue: 4 April 2024


Hepaticoduodenostomy for Recurrent Biliary Anastomotic Stricture after Liver Transplant

Biliary strictures after liver transplant are amenable to endoscopic dilatation or percutaneous dilatation and stenting in most cases. In rare cases, for recurrence or tight stricture, surgery is required, and hepaticoje-junostomy is the favored procedure. We report a case of posttransplant stricture in a duct-to-duct anastomosis that could not be accessed due to prior gastric bypass. Despite multiple percutaneous transhepatic cholangiography dilatations, the stricture recurred, and the patient was taken up for bilioenteric bypass. During surgery, dense adhesions in the infracolic compartment with chronically twisted jejunal loops, due to prior mini gastric bypass, were encountered, which prevented the creation of a jejunal Roux limb. Hepaticoduodenostomy was performed with no recurrence of stricture at 12 months. Hepaticoduodenostomy is a viable option for surgical management of recurrent biliary strictures, especially in a setting of prior bariatric/diversion procedures.

Key words : Duct-to-duct anastomosis, Percutaneous transhepatic cholangiography, Surgical management of recurrent biliary strictures


Anastomotic stricture can develop in 5% to 15% of duct-to-duct biliary anastomoses after orthotopic whole liver transplant.1,2 These strictures present as segmental narrowing at the anastomosis due to fibrotic healing around a biliary anastomosis, and most of these are a single and short segment. Most such strictures present in the first year, with early strictures often seen secondary to technical issues such as size mismatch, poor stump vascularity, or redundancy, whereas late strictures are mostly as a result of underlying arterial stenosis, rejection, cytomegalovirus infection, or disease recurrence such as primary sclerosing cholangitis.1-3

Most anastomotic strictures are amenable to endoscopic retrograde cholangiopancreatography (ERCP), whereas percutaneous transhepatic cholan-giography (PTC) is rarely required for strictures that are inaccessible to endoscopy or for strictured hepaticojejunostomy.4

Prior bariatric bypass surgery, encountered in many patients with metabolic-associated fatty liver disease who undergo liver transplant, presents a special situation for which the ampulla is inaccessible for ERCP. In this situation, the percutaneous approach is the first choice with surgery when the stricture is persistent or recurrent.

We report a case of recurrent anastomotic biliary stricture in a young woman with a deceased donor liver transplant with prior omega loop mini gastric bypass that required surgical management after failed multiple attempts at percutaneous dilatations and stenting.

Case Report

A 40-year-old female patient with metabolic-associated fatty liver disease, which had led to liver cirrhosis complicated by ascites, and with hepatorenal syndrome and encephalopathy (Model for End-Stage Liver Disease sodium score of 34) underwent deceased donor liver transplant. The graft was a whole liver from a standard criteria heart-beating brain dead donor without anatomical variations. The recipient had a history of prior laparoscopic omega loop mini gastric bypass 2 decades before the liver transplant.

During surgery, dense adhesions were encoun-tered between the left lobe of liver and stomach, and the omentum and transverse colon were adherent to the anterior abdominal wall. The adhesions in the infracolic compartment were not disturbed, because the hepatic hilum was accessible after adhesiolysis and the recipient hepatectomy could be performed without need for bypass. Bicaval implantation was performed with a cold ischemia time of appro-ximately 7 hours, with standard portal and arterial reconstruction and with duct-to-duct biliary anastomosis.

Our recipient’s postoperative course was notable for renal dysfunction that required postoperative continuous renal replacement therapy for 48 hours, and she was discharged from the hospital after 2 weeks. She was diagnosed with anastomotic bile duct stricture 3 months after transplant on magnetic resonance cholangiopancreatography. The ERCP was unsuccessful due to prior gastric bypass, which prevented access to the ampulla through the afferent limb of gastrojejunostomy, due to long omega limb as well as inability to safely traverse to the distal gastric pouch endoscopically (Figure 1A).

The PTC via left duct puncture with external percutaneous transhepatic biliary drainage (PTBD) was performed and followed 1 week later by balloon dilatation to 8 Fr and conversion to interno-external PTBD. After 12 weeks, the PTBD was successfully dilated to 12 Fr along with capping of external tube. However, follow-up imaging after 12 weeks showed recurrence of stricture and redundancy of duct with low likelihood of success with further dilatations/stentings. The imaging results and clinical course for our patient were discussed in multidisciplinary hepato-pancreato-biliary meeting, and bilioenteric bypass was recommended (Figure 1B).

The patient was taken up for conversion to possible Roux-en-Y hepaticojejunostomy. Significant time was spent on adhesiolysis because of dense infracolic compartment adhesions and chronic internal herniation of the small bowel behind the loop gastrojejunostomy with nonstandard orientation of afferent jejunal limb in relation to the pouch. Attempts to reduce the hernia and straighten the bowel, including intraoperative assistance of expert bariatric surgeons, were unsuccessful. Because the loops in the chronically altered position were not dilated or obstructed, we decided to perform a hepatic duodenostomy for bile duct drainage. A dilated healthy common hepatic duct was identified above the stricture, ensuring good duct vascularity, and a wide end-to-side anastomosis of 2-cm diameter was performed with prior PTC catheter used as a transanastomotic stent (removed 2 weeks later after follow up cholangiogram) (Figure 1C). The posto-perative course was uneventful, and the patient showed no radiological or biochemical evidence of recurrence of stricture at 1 year.


In the present era, most anastomotic bile duct strictures are managed by endoscopy with ERCP and stenting.1,2,4 The treatment has evolved from the dilation of strictures and serial stenting or multiple plastic stent placement to self-expandable metal stents, especially since the recent development of removable covered self-expandable metal stents.1,4-6

The rate of recurrence of posttransplant biliary strictures ranges from 10% to 20%. Late strictures, tight strictures, and nonanastomotic strictures are more likely to require surgical treatment.5,6

The PTC, which has an overall technical success rate of 40% to 85%, is considered as a second-line therapy because of its invasiveness and the potential complications of hemorrhage, bile leaks, infection, and external drain or catheter. However, PTC is the first option when the proximal duodenum is inaccessible due to scarred pylorus or prior gastrojejunostomy anastomosis with a long afferent limb. A prior bariatric procedure that involves a disconnected proximal gastric pouch anastomosed to a long afferent limb such as Roux-en-Y gastric bypass or mini gastric bypass invariably means strictures cannot be accessed for endoscopic therapy and need PTC.1,2,4

Surgical revision is mostly reserved for patients with strictures refractory to either ERCP-guided therapy or PTC-guided therapy.7 The most common operation for surgical treatment remains hepatico-jejunostomy. However, with prior abdominal surgery and adhesions preventing creation of a suitable jejunal Roux limb, hepatic duodenostomy is an acceptable alternative that has also been used for index anastomosis during liver transplant in presence of size mismatch, recipient ductal tissue condition, or unsuitability. It has a higher chance of anastomotic leak, but the advantages are accessibility to ERCP (if ampulla is accessible) and no requirement for additional intestinal anastomosis.8

Our case had both problems, inaccessible ampulla due to prior mini gastric bypass and recurrent tight stricture despite multiple PTC and inability to create a Roux limb of jejunum due to chronic internal herniation and adhesions.

Hepatic duodenostomy in this situation is a good bilioenteric anastomosis strategy due to the ease of anastomosis with a wide duct over a covered transanastomotic stent (PTC). In addition, due to the bypassed duodenum, the chances of leak and consequence in terms of diet cessation are low, and the gut physiology of prior bariatric procedures requires no alteration because the bile still drains in duodenum.8

We recommend consideration of hepatic duo-denostomy as a viable option for posttransplant stricture in prior gastric bypass and also as primary modality for bile duct reconstruction at the time of liver transplant, if duct-to-duct anastomosis is not feasible.


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Volume : 22
Issue : 4
Pages : 311 - 313
DOI : 10.6002/ect.2024.0070

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From the 1Division of Abdominal Transplantation, Department of Surgery, University of North Carolina; and the 2University of North Carolina Center for Transplant Care, University of North Carolina, Chapel Hill, North Carolina, USA
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Sorabh Kapoor, Division of Abdominal Transplantation, Department of Surgery, University of North Carolina, 4025 Burnett Womack Building, CB 7211, 160 Dental Circle, Chapel Hill, NC 27599-7050, USA