Wide hilar hepaticojejunostomy: the optimum method of reconstruction after choledochal cyst excision

Standard reconstruction after choledochal cyst excision is by Roux-en-Y hepaticojejunostomy to the common hepatic duct. Long-term follow up studies have shown a 10% incidence of late complications, including anastomotic stricture. By extending the bilio-enteric anastomosis along the left hepatic duct, a wide hilar bilio-enteric anastomosis is created which may help to minimize late anastomotic complications. Forty-one consecutive patients (24 girls, 18 infants) with a median age of 2.3 years (range 44 days to 15.6 years) and median weight 11.5 kg (range 2.1-59 kg) underwent radical choledochal cyst excision with a wide hilar hepaticojejunostomy. Thirty-eight were followed-up both clinically and by ultrasound scan and biochemical liver function tests for a median of 2.7 years (range 0.1-12.5 years). The median width of the hilar hepaticojejunostomy was 8 mm (range 6-25 mm) in 18 infants, and 15 mm (range 10-25 mm) in 22 older children. In one patient it was not measured. Only one surgical complication occurred--a self-limiting bile leak which settled spontaneously. Median postoperative stay was 6 days (range 5-21 days). No patient has had an episode of cholangitis or adhesive small bowel obstruction to date. Postoperative biochemical liver function tests have remained normal in all but one child (with pre-existing biliary cirrhosis). After radical resection of a choledochal cyst, a wide hilar hepaticojejunostomy is a, safe, effective and durable reconstructive technique that can be performed at any age and may help to minimize the long-term risk of complications.