Hepaticocholecystoenterostomy as an alternative to hepaticojejunostomy for biliary bypass

Abstract

Introduction: Hepaticojejunostomy is the standard biliary bypass technique for periampullary cancer when trial dissection reveals unresectable disease or endoscopic stent placement is not possible. This anastomosis can be technically demanding and potentially difficult. The simpler technique of hepaticocholecystoenterostomy (HCE) has only previously been reported in very limited numbers and without outcome data. Methods: All patients undergoing HCE for the management of periampullary cancer were identified from a prospectively maintained computerised database of a single surgeon and were reviewed retrospectively. The HCE technique achieves a biliary bypass by two anastomoses, using the gallbladder as a conduit. It involves an anastomosis of the infundibulum of the gallbladder to the common hepatic duct followed by a second anastomosis of the gallbladder fundus to the proximal small bowel. Results: From 1996 to 2010, 30 patients with pancreatic adenocarcinoma required a biliary bypass after a failed trial of Whipple procedure (80%) or failed endoscopic stenting (20%). There were 19 men and 11 women with a mean age of 64.5 years. The mean operative time for HCE alone was 92 minutes. The mean length of hospital stay was nine days. There was a single grade 2 complication (readmission with gastric emptying delay) and a single grade 3 complication (bile leak requiring reoperation). Thirty-day mortality was zero and the mean survival was 12 months (with one patient still alive at the time of writing). There were no readmissions with recurrent biliary obstruction or cholangitis. One patient had developed an incisional hernia by the 24-month follow-up appointment. Conclusions: HCE in periampullary cancer is safe and effective in selected patients. It involves two simple anastomoses with good access rather than one more demanding anastomosis. Morbidity, patency and overall survival are comparable with contemporary published series of hepaticojejunostomy.