[Long-term results of reconstruction of benign stenoses of the bile ducts].

UNLABELLED: Over 27 year period (1.01.1974-31.12.2001) a 168 patients (pts) were operated on for benign bile duct strictures of types I to IV according to Bismuth's classification. Reconstruction of fresh lesions and lesions and strictures of sectorial or segmental ducts were not taken into account. The later are to be the subject of separate publication. There were 107(63.7%) women and 61(36.3%) men of average age of 46 years (ranging from 14 to 76 years). The average time from injury to our reconstruction was 8.2 years. In 162 pts (96.4%) an operative injury was the cause of the stricture, in 150 (89.3%) during cholecystectomy, in 8 (4.76%) during distal gastrectomy for duodenal ulcer and in 4 (2.38%) during surgery of the central hydatid cyst of the liver. In 112 (66.66%) pts 1 to 6 previous attempts of reconstructions had been performed elsewhere. According to the Bismuth, s classification there were 27 (16.07%) strictures of type I, 46 (27.38%) of type II, 66 (39.28%) of type III and 29 (17.26%) of type IV. The most frequent preoperative complications were intrahepatic lithiasis (34%), fibrosis or cirrhosis of the liver in 9.5%, liver abscesses in 6%, bilioduodenal fistula in 4.16%, biliary peritonitis in 4.16% and incisional hernia in 8.9% of pts. Suture mucosa-to-mucosa hepaticojejunostomy with 75 cm long Roux-en-Y jejunal limb described by Blumgart was performed in 161 (95.8%), choledochoduodenostomy in 3 (1.8%) and strictureplasty in 2 (1.2%) while in 2 pts the reconstruction was not technically possible. Three pts died during the first 6 months, 2 in whom the reconstruction was not possible and 1 with chronic endemic nephropathy. Eight of the rest 165 pts were lost from follow up being from Bosnia and Croatia due to well known war events. Six out of the 157 pts died in the mean time, 2 due to variceal bleeding (they had cirrhosis and portal hypertension at the time of reconstruction) an 4 due to unrelated causes (2 due to pancreatic carcinoma, 1 due to myocardial infarction and 1 due to stroke). Out of 151 alive fully followed pts, good result (pts symptom-free as after standard cholecystectomy) was achieved in 121 (80.13%), satisfactory (mild occasional symptoms but not cholangitis) in 27 (17.88%) and unsatisfactory result in 3 pts (2%), 2 of which were successfully reoperated (1 passed into group with good and 1 into group with satisfactory results).

CONCLUSION: With properly performed suture mucosa-to-mucosa hepaticojejunostomy with 75 cm long Roux-en-jejunal limb good or satisfactory results can be achieved in almost all patients with benign bile duct stricture, provided it was not performed too late before the patient develop a secundary bilary cirrhosis and portal hypertension.