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Upfront hepaticojejunostomy in portal biliopathy: is a decompressive shunt always necessary?
Amitabh Yadav1, Samiran Nundy2
1Institute of Surgical Gastroenterology, GI and HPB Onco-Surgery, Sir Ganga Ram Hospital, New Delhi, India and.
Background & Aims:
Hepaticojejunostomy (HJ) for portal biliopathy (PB) in extrahepatic portal venous obstruction is considered to be difficult and associated with major intraoperative bleeding due to the raised pressure in periportal collaterals. Upfront HJ is deemed unsafe and advocated to be a second stage procedure after a prior decompressive splenorenal shunt to reduce the pressure in the periportal veins. However, in some cases with dominant biliary presentation or if the shunt is not possible/ineffective, upfront HJ is an alternate. The study is done to assess the feasibility, complications and effectiveness of an upfront HJ in patients with PB.
Methods:
The outcome of HJ was analyzed in two groups of patients with PB. Group A had 11 (HJ after a prior decompressive splenorenal shunt) while group B had 9 patients (upfront HJ). The end points were the feasibility of the procedure, postoperative complications and long-term stricture rate.
Results:
The upfront HJ was feasible in 8/9 patients in group B with lesser duration of surgery (325.4 ± 167.3 vs 396.3 ± 147.8 min), blood loss (750 ± 775.4 vs 803.6 ± 787.1 mL) and blood transfusion (4.1 ± 1.9 vs 4.3 ± 3.13 units). It had lesser grade III and above complications. Biliary obstruction was relieved in 8/9 patients in group B with one intrahepatic biliary stricture.
Conclusions:
In patients of PB with dominant biliary presentation and non-shuntable vein, despite limitations, upfront HJ without a prior shunt, albeit a difficult procedure, is a feasible and an effective option with acceptable complications.
