Duodenal Anastomosis Preferred for Biliary Reconstruction

Laurie Barclay, MD

July 24, 2013

Duodenal appears to be preferred over jejunal anastomosis for biliary reconstruction, as it is safe and simple, with low rates of leak, stricture, cholangitis, and bile gastritis, according to a retrospective cohort study published online July 24 in JAMA Surgery. To date, this is the largest series comparing biliary reconstruction via either end-to-side Roux-en-Y jejunal anastomosis or direct duodenal anastomosis with at least 2-year follow-up.

"Numerous studies have reported satisfactory outcomes with Roux-en-Y jejunostomies but very little is known about the long-term results of duodenal anastomoses for biliary reconstruction," write J. Bart Rose, MD, MAS, from Virginia Mason Medical Center, Seattle, Washington, and colleagues.

"There have been long-standing biases against using the duodenum for biliary reconstruction."

The researchers conducted a record review and telephone survey that included patients who had undergone nonpalliative biliary reconstruction for all indications in the hepatopancreatobiliary surgery division of a high-volume tertiary care facility. Anastomosis-related complications were the main study outcomes; overall complications, endoscopic or radiologic interventions, readmissions, and death were secondary outcomes.

Between February 1, 2000, and November 23, 2011, 96 patients underwent biliary reconstructions for bile duct injury, cholangiocarcinoma, choledochal cysts, or benign strictures. There were 59 duodenal reconstructions and 37 Roux-en-Y jejunal reconstructions. The groups had similar demographics, operative indications, postoperative length of stay, and mortality.

Compared with the jejunal cohort, the duodenal cohort had fewer anastomosis-related complications of leaks, cholangitis, or strictures (7 patients [12%] vs 13 [35%]; P = .009). Cholangitis occurred in none of the duodenal group but in 5 patients (14%) in the jejunal group, all with concurrent obstruction. Stricture rate was 3% vs 24%, respectively.

Five of 9 patients with stricture in the jejunal cohort had to be managed with percutaneous transhepatic access compared with only 1 of 2 patients in the duodenal cohort.

Study Limitations and Clinical Implications

"Duodenal anastomosis is a safe, simple, and often preferable method for biliary reconstruction," the study authors write. "This anastomosis can successfully be performed to all levels of the biliary tree with low rates of leak, stricture, cholangitis, and bile gastritis. When anastomotic complications do occur, there is less need for transhepatic intervention because of easier endoscopic access."

Limitations of the study include its retrospective design, lack of postoperative follow-up in some patients, and the relatively low number of jejunal procedures, suggesting potential selection bias.

In an invited commentary, Timothy R. Donahue, MD, from the Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, notes that the jejunum was used when conditions were less than ideal. Because many strictures in the jejunal group occurred after 2 years, he suggests annual monitoring of serum alkaline phosphatase to help avoid the development of cholangitis.

"Rose et al should be commended for using 'the organ less traveled' for a complex problem," Dr. Donahue writes. "Although the outcomes obtained with the jejunum and duodenum would best be directly compared in a randomized trial, the authors' results and experience suggest that one should consider using the duodenum, because 'it's right there.' "

The study authors and Dr. Donahue have disclosed no relevant financial relationships.

JAMA Surg. Published online July 24, 2013.

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