Ileal loop interposition: an alternative biliary bypass technique

Felipe JF Coimbra, AlessandrolDiniz, Heber SC Ribeiro, WilsonlCosta Jr., Eduardo NP Lima and AndrélMontagnini

São Paulo, Brasil

Ileal loop interposition: an alternative biliary bypass technique

Felipe JF Coimbra, AlessandrolDiniz, Heber SC Ribeiro, WilsonlCosta Jr., Eduardo NP Lima and AndrélMontagnini

São Paulo, Brasil

BACKGROUND:Obstructive jaundice is a common condition in advanced digestive cancer. Palliative procedures can improve quality of life and allow patients to attempt a systemic treatment. Bilioenteric anastomosis is still the procedure of choice for patients in many centers. When a surgical bypass is not possible, biliary drainage can be done by placing endoscopic or transparietal stents, which are less durable methods even when an expandable stent is employed.

METHODS:A 47-year-old male with an excellent clinical status and a previous cholecystectomy and an exploratory laparotomy for advanced gastric cancer was referred with obstructive jaundice. A preoperative CT scan showed a dilated bile duct and a small mass at the distal hepatic hilum. No other signs of metastasis were found. A surgical bilioenteric anastomosis was indicated. At surgery, a distal choledochal obstruction and a mesenteric retraction by a lymph node mass prevented the jejunum to ascend for a bilioenteric anastomosis. Surgically, an alternative bilioenteric bypass was performed by means of an ileal loop interposition between the bile duct and the jejunum.

RESULT:The recovery of the patient was uneventful and his bilirubin levels normalized after one week. The patient was then referred for systemic chemotherapy.

CONCLUSIONS:This alternative biliary bypass can be safely and easily performed, and may be a good alternative for patients already referred for surgery because of a better life expectancy and when the jejunum is not an alternative.

(Hepatobiliary Pancreat Dis Int 2010; 9: 654-657)

biliary bypass; ileal loop interposition; biliary cancer

Introduction

Obstructive jaundice is a common condition in patients with advanced digestive cancer. Palliative procedures can improve quality of life and allow patients to attempt systemic treatment. The best palliative procedure is still controversial, since there is no randomized trial comparing expandable stents and surgery, especially for patients with longer life expectancy. Bilioenteric anastomosis, usually a Roux-en-Y hepaticojejunostomy, is the procedure of choice for patients with good performance status in many centers, and offers late outcomes superior to other methods. When a surgical bypass is not the first choice, biliary drainage can be done by placing endoscopic or transparietal stents, which are less durable methods, presenting more late complications. When a hepaticojejunostomy is not feasible because a jejunum mesenteric retraction or any other situation, transparietal endoscopic stents or surgical stents are the only options. The authors describe an alternative surgical technique that creates a surgical bypass between the hepatic duct and the jejunum with an ileal loop interposition.

Case report

A 47-year-old male with an exceptional clinical status who had undergone a cholecystectomy and exploratory laparotomy for advanced gastric cancer a year before was diagnosed as having obstructive jaundice. A preoperative CT scan disclosed a dilated bile duct and a small mass (lymph nodes) at the hepatic hilum. No other signs of metastasis were observed. A surgicalbilioenteric anastomosis was indicated because of the patient's excellent clinical status and the absence of other metastatic sites, suggesting a longer life expectancy. At surgery, the abdominal cavity was carefully evaluated and a lymph node involvement, obstructing the distal choledochal duct and infiltration of the retroperitoneum, with important mesenteric retraction, was found. This condition prevented the jejunum to be ascended to the hepatic hilum for a bilioenteric anastomosis. The only available bowel for a bilioenteric bypass was the terminal ileum, which could cause major malabsorption and undernourishment. This complex situation and the aim of the best quality of life for a patient with an outstanding clinical status enabled us to attempt an internal bypass using an ileal loop interposition between the bile duct and the jejunum.

Fig. 1. The distal ileum vasculature is evaluated by transillumination and the ileum loop, approximately 40 cm from the ileocolic valvule' which can easily reach the hepatic hilum, is mobilized upward.

The distal ileum vasculature was evaluated by transillumination and the ileum loop, and approximately 40 cm from the ileocolic valve that can easily reach the hepatic hilum was mobilized upward (Fig. 1). Subsequently, a 20-cm segment of the distal ileum was isolated on a narrow pedicle and brought over the transverse colon. Care was taken to clean up, with saline solution, all mucus from the ileum segment. The proximal end was closed with a two-layer continuous suture and the common hepatic duct was anastomosed side-to-side to the ileum conduit with a one-layer absorbable suture to its anti-mesenteric border. The distal end of the conduit was then sutured to the jejunum, 20 cm below the Treitz angle. Ileal continuity was then restored with a side-to-side anastomosis (Fig. 2A). No external or internal stent placement was necessary and a drain was temporarily placed near the bilio-enteric anastomosis.

Fig. 2. A: A 20-cm segment of the distal ileum is isolated on a narrow pedicle and brought over the transverse colon. The proximal end is closed with a two-layer continuous suture and the common hepatic duct is anastomosed side-to-side to the ileum conduit with a one-layer absorbable suture to its anti-mesenteric border. The distal end of the conduit is then sutured to the jejunum, 20 cm below the Treitz angle. Ileal continuity is restored with a side-to-side anastomosis. B: Nuclear medicine study (DISIDA) after two post operative weeks shows an easy contrast release from the biliary tree to the bowel.

The recovery of the patient was uneventful, with bowel movements on the second post-operative day and eating started on the third. There was no biliary or lymphatic leakage, and the drain was removed on the fifth day. Diet was progressed until excellent acceptance and the patient was discharged on the 6th day after surgery. Serum bilirubin levels were normal one week later and a nuclear medicine study (DISIDA) two weeks after surgery showed easy contrast release to the bowel (Fig. 2B). The patient was then referred for systemic chemotherapy without any clinical or laboratory signs of obstructive jaundice; he needed no hospital stay during his lifetime due to this issue and was asymptomatic after 9 months of palliative treatment.

Discussion

Patients with advanced digestive cancers often develop obstructive jaundice, which requires multidisciplinary palliative procedures. Options available so far are surgical bilioenteric anastomosis with jejunum or T-tube biliary positioning, and stent placement, either by endoscopic or transparietal approaches.

Even though there is a controversy over the better procedure,[1]in many centers, Roux-en-Y hepaticojejunostomy is still the standard method for patients with good performance status with no evident sites of distant metastases on radiological pre-operative exams, providing a longer life expectancy,[2]requiring fewer supplementary procedures, and presenting fewer late complications.[1,3-6]Also a longer hospital-free survival rate is reported.[6]

Once cancer patients are under a surgical procedure, hepatic duodenostomy is less suitable because of the possibility of tumoral duodenal obstruction. Thegallbladder is also an alternative for a bilioenteric bypass when the hepatic duct cannot be reached and there is a distal obstruction.

When a biliary diversion is not feasible on account of hepatic hilum involvement or mesenteric retraction by carcinoma, the available alternatives are at present endoscopic or transparietal stent placement, either plastic or expandable metallic stents. The inconveniences are that they are less durable methods needing additional procedures. Expandable metallic stents have a longer patency than plastic ones, but still present a high rate of obstruction in a longer period, reaching 40% and 60% after 6 and 12 months, respectively, with a mean patency of less than 5 months.[7-9]

Thus, surgery is still a valuable instrument for palliation of patients in excellent clinical conditions (life expectancy exceeding 6 months) presenting obstructive jaundice, with slow growth tumors, concomitant gastroenteroanastomosis requirement, unresectability found at laparotomy, and when self-expandable stents, endoscopists or interventional radiologists are not available or are not a technical option.[1,3-5]However, there are no prospective randomized trials comparing surgery with expansible stents.

When surgical bypass is the first choice, this new technique allows a biliary switch even when the jejunum is not an alternative. There are a variety of situations suitable for this technique, such as short mesenterium in obese patients, inflammatory diseases, and specialty in cancer.[10,11]

Ileal loop interposition is a recognized method employed for urinary tract reconstruction, replacing the ureter, both in benign and malignant diseases, when its distal part cannot reach the bladder or when it is completely excised.[12]In the digestive tract, particularly in the biliary tract, the use of enteric interposition is rarely reported. In patients with choledochal cysts and biliary atresia, some attempts have been made using a jejunal loop or even an ileocolic conduit interposed between the hepatic duct and the duodenum to perform a theoretically more physiologic reconstruction.[13,14]An ileal loop interposition between the hepatic duct and jejunum, however, has never been reported.

Consentino et al[13]evaluated 21 patients who had undergone resection of choledochal duct cysts during 12.5 years using a short jejunum segment with an intussusception valve (1.5 to 2 cm) interposed between the common hepatic duct and the duodenum. They concluded that the valved jejunal interposition hepaticoduodenostomy is the procedure of choice for biliary reconstruction after choledochal cyst excision because normal physiologic conditions are simulated, with bile draining into the duodenum and biliary reflux minimized with the addition of an intussusception valve.

Endo et al[14]also analyzed the role of an ileocolic (IC) conduit devised as an anti-reflux procedure in a comparative study with Roux-en-Y (RY) reconstruction in infants with biliary atresia. Bile excretion was obtained in all infants in both groups and 87.0% of infants in the IC group and 62.5% in the RY group became unjaundiced. Cholangitis occurred in 60.9% of the IC group, compared with 83.3% in the RY group.

The potential advantages of this technique are resolution of the actual clinical condition in only one procedure and hospitalization during his/her lifetime, interfering directly in the quality of life, less requirement of a specialized interventional or endoscopic team, and probably lower costs due to a shorter hospital stay during the treatment. On the other hand, the possible complications directly related to the procedure including biliary or enteric leakage, abdominal sepsis or wall disruption, or even such clinical complications, as pneumonia and thromboembolism must be taken into account.

We consider that cancer patients with good status may benefit from this alternative technique of biliary drainage with palliative intention in these complex and particular circumstances, since there is a relatively longer life expectancy and the jejunum cannot reach the hepatic hilum or even in benign conditions. It is an easy and safe procedure with only one extra entero-entero anastomosis, 30 additional minutes of surgery, fewer interventions in the lifetime, without use of external or internal stents, and an excellent quality of life. The cost of a surgical procedure may be compensated by less need for interventions and a shorter hospital stay. We encourage other surgeons to try this simple and effective method in this exceptional subset of patients when operative findings prevent the use of the conventional technique.

Funding:None.

Ethical approval:Not needed.

Contributors:CFJF wrote the first draft of this commentary. All authors contributed to the intellectual context and approved the final version. CFJF is the guarantor.

Competing interest:No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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November 17, 2009

Accepted after revision May 7, 2010

Author Affiliations: Abdominal Surgery Department (Coimbra FJF, Diniz AL, Ribeiro HSC, Costa Jr. WL and Montagnini AL), and Nuclear Medicine Imaging Department (Lima ENP), Hospital do Câncer A. C. Camargo, Rua Professor Antônio Prudente 211, Liberdade, São Paulo, SP 01509-010, Brazil

Felipe JF Coimbra, MD, Rua José Getúlio, 579, cj. 42, Aclimação, São Paulo, SP 01509-001, Brazil (Tel: 55-11-3277- 7720; Fax: 55-11-3277-7720; Email: coimbra.felipe@uol.com.br)

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