High or low hepaticojejunostomy for bile duct strictures?

The 19 patients who underwent 22 postoperative repairs of bile duct stricture in our institution between 1973 and 1984 were evaluated to assess whether the recognition of the tenuous blood supply of the supraduodenal bile duct in 1979 had improved the results thereafter. Thirteen of these 22 operations followed a previous biliary tract repair; in 10 of the operations a low anastomosis had been performed without taking blood supply into account. Follow-up was complete and ranged from 5 to 15 years. There were no operative deaths and minimal morbidity. There were three deaths at a later time. Five of the 11 patients treated by surgery to 1979 had a clinically unsatisfactory result: recurrent strictures developed in all five patients. All but one of the eight patients receiving a high hepaticojejunostomy from 1980 had a clinically satisfactory result with no recurrent strictures. The one exception was the patient who had a second repair with separate high right and left hepatic duct anastomoses and who has ongoing symptoms from preexisting secondary sclerosing cholangitis. The results in the five high repairs performed for low strictures were particularly striking: All five were asymptomatic. This study lends support to the hypothesis of an ischemic basis for biliary strictures and to the recommendation that strictures be repaired with a high hepaticojejunostomy.