The current study presented a modified technique of hepatojejunostomy for patients with perihilar tumors, which could reduce the incidence of postoperative anastomotic leak and stenosis. Initially, the investigators closed the gap between the left and right branches of the portal vein, and the cut surface of the liver, in order to enhance the integrity and firmness of the posterior wall of the anastomosis. Then, the posterior wall of the jejunum was sutured to the wall of the adjoining portal vein branches, the connective tissue, and the liver tissue below the lower edge of the bile duct, in order to strengthen the anastomosis, since the wall of smaller bile ducts is often weak. The benefit of this step is that the main branches of the portal vein can be fully skeletalized during the process of resection. Previous studies have also reported the use of the portal vein wall and connective tissue below the bile duct as a part of the posterior wall of the anastomosis, but the gap between the portal vein branches and liver section was not closed before anastomosis [10, 11, 13, 15, 16].
For the present technique, proper reshaping of the biliary stumps was emphasized. After the resection, the distance between the biliary stumps was different, and it was impossible to reshape this into one opening. This may be the reason why the modification of biliary stumps was not mentioned in most of the previously reported hepatojejunostomy techniques. The biliary stumps, which were close to each other, especially the bile ducts used for the posterior wall of the anastomosis, were sutured together using absorbable sutures. With this step, the posterior wall of the bile ducts was aligned in a straight line as much as possible, and the difficulty in performing the anastomosis was reduced.
In the present study, silicon or latex tubes were used as the external biliary stents. The material of the drains/stents depends on the surgeon’s preference. Ha et al. only placed silicone stent tubes in thinner bile ducts (< 2 mm), while some surgeons do not use any biliary stent[1, 17]. Dilek et al. placed the longer part of the stent in the jejunum as unbound[16]. In Bednarsch’s procedure, the distal end of the drainage was positioned in the intrahepatic bile duct, the other end was led through the jejunal wall, reconstruction was performed in a Roux-en-Y manner, and this was fixed at the level of the skin after passing the abdominal wall[17]. Chen Xiaoping did not place stents in the bile duct, but made a small incision at the anterior jejunal wall, which was approximately 10 cm away from the anastomosis, and inserted a drainage tube with a diameter of 5–7 mm into the jejunal cavity close to the anastomosis[10]. The postoperative bile secretion was monitored, and the pressure in the jejunal lumen was reduced through the drainage. The disadvantage of an external drainage is that this causes bile loss, which in turn, can cause water and electrolyte imbalance, and the drainage tubes fixed to the abdominal wall are cumbersome to manage for patients. Internal drainage overcomes the disadvantages of external drainage, but the biliary drainage across the anastomosis cannot be confirmed during the postoperative period.
In the selection of biliary stents and drainage method, the advantages and disadvantages of the above methods were considered. The small and thin bile ducts were supported by thin silicone tubes with a length of 8–10 cm, and the extrahepatic part of the stents was placed in the jejunum cavity. For larger and thicker bile ducts, a silicone or latex tube was placed in the bile duct, according to its diameter. Then, a side hole was made at the extrahepatic part of the tube near the anastomosis, the distal end of the tube was drawn out through the jejunum wall at 10 cm from the anastomosis, and finally, this was fixed to the abdominal wall. In this manner, the bile secretion can be observed after the operation, and the accumulation of fluid in the intestinal lumen near the anastomosis can be reduced. These would be helpful for the healing of the anastomosis, and reducing the bile loss, when compared to that of total external drainage.
The appropriate selection of sutures for constructing the anastomosis is very crucial. In the present study, 4 − 0 prolene was used for the anastomosis, and the biliary stents were fixed to the jejunal wall using 4 − 0 vicryl. Vicryl sutures, which becomes completely absorbed within 60–90 days, are often used for bile duct reconstruction, since these can decrease the incidence of early postoperative bile duct strictures and stone formation[18, 19]. However, vicryl sutures are not smooth enough to slide through tissue, and are not preferred for continuous sutures, especially when the surgical field is difficult to expose. Prolene, which is very smooth, can easily pass through tissues. A number of surgeons use Prolene for the continuous suture of anastomosis, because the tension of the suture can be easily adjusted[20, 21]. Regrettably, Prolene is not absorbable, and this may increase the risk of anastomotic stones[18]. In the present study, merely a small part of the bile duct wall and jejunum were sutured together with Prolene. Hence, even if the suture is permanently left at the anastomosis, the impact of Prolene on the anastomosis would be relatively small. Polydioxanone (PDS) is an absorbable, monofilament and smooth suture, which is also a commonly used suture for hepatojejunostomy in clinical practice[16, 17]. However, no statistically significant difference in complication rates between the use of PDS and prolene for biliary reconstruction was reported[22]. Absorbable sutures were used for bile duct modification and stent fixation. After 2–3 months, these sutures were completely absorbed, and the internal stents would slip into the intestinal lumen, and be excreted out. Regarding the suturing technique, some surgeons prefer interrupted sutures, while other surgeons prefer continuous sutures. In a large survey in Germany, both techniques were equally preferred by surgeons for hepaticojejunostomy, and no significant difference in postoperative complications was found[23].
The incidence of postoperative complications is an important factor in evaluating the success of a surgical technique. No serious complications, especially bile leakage and anastomotic stenosis, occurred in the study patients. Traditional cholangiojejunostomy is not only complicated to perform, but also time-consuming, and prone to anastomotic stenosis, biliary fistula and reflux cholangitis after the operation[20]. Furthermore, the in-hospital mortality rates for conventional methods for HCCA is higher, when compared to other diseases that require liver resection[24].
Bile leakage is one of the most dreaded complications of hepatojejunostomy. This occurs mainly due to anastomotic dehiscence or a missed bile duct. Anastomotic leakage is caused by infection, ischemia, edema, faulty anastomotic techniques, and anastomotic tension[23, 25, 26]. In some conventional surgery for HCCAs, multiple thin biliary ducts (< 1–2 mm) are ligated, since the number of end-to-side cholangioenterostomy is technically restricted. The ligated bile ducts can dilate in the long term, and compress the portal vein within the Glissonian sheath, leading to portal hypertension and persistent cholestasis, and increasing the risk of cholangitis, bile leakage and septic events after the operation[1]. Therefore, all dilated intrahepatic ducts must be opened. Dilek considered that it might be advantageous if the missed bile duct remains within the anastomotic area using the portoenterostomy technique[16].
Another major complication after biliary reconstruction is anastomotic stricture. Anastomotic strictures are prone to occur when the anastomosis is very small, there is tension at the anastomotic site, and ischemia occurs due to aggressive dissection, fibrosis, and/or adhesions[25]. One of the ways to prevent strictures is to perform portoenterostomy for patients with complex hilar bile duct strictures[11]. Some surgeons also perform portoenterostomy as a rescue procedure after major biliary complications following traditional cholangioenterostomy[17]. Kasai portoenterostomy can be used for patients with HCCA, since this is associated with a low incidence of postoperative bile duct stenosis. No anastomotic stenosis was detected in the present study up to six months of follow up after the operation.
The modified hepatojejunostomy also provides an opportunity for resection in HCCA patients with high preoperative jaundice. For example, in some patients with HCCA type 3a and 3b, right hepatectomy/ trisectionectomy or left hepatectomy may not be possible due to various reasons such as high preoperative bilirubin or poor compliance and can't wait for biliary drainage before surgery. In such cases, local excision can be performed with reconstruction using modified technique. Hence, except for two patients, none of the patients in this study underwent preoperative biliary drainage in this study.
The present study had some limitations. First, the present study was a single-center retrospective study with a small sample size. This is because only selected patients with various special conditions were included in this study. Second, there was a lack of long-term follow-up data due to various reasons, and the impact of the described technique on overall survival was not determined.