Successful Roux-en-Y Hepaticojejunostomy for Post-Cholecystectomy Biliary Stricture

Chief Complaints

A 71-year-old male patient with a body mass index (BMI) of 21 presented to the Surgical Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of jaundice following a previous laparoscopic cholecystectomy. He was referred for further evaluation and advanced management of a benign biliary stricture.

The patient had a history of laparoscopic cholecystectomy performed for cholelithiasis with acute cholecystitis. Following surgery, he developed obstructive jaundice and was diagnosed with a Bismuth Type II benign biliary stricture. Previous attempts at endoscopic retrograde cholangiopancreatography (ERCP) stenting and percutaneous transhepatic biliary drainage (PTBD) were unsuccessful, following which he was referred to PACE Hospitals for definitive surgical management.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. Clinical evaluation was consistent with obstructive jaundice secondary to benign biliary stricture. The abdominal examination did not reveal any acute abnormalities, and the remainder of the systemic examination was normal.

Upon admission to PACE Hospitals, the Surgical Gastroenterology team conducted a detailed clinical assessment, including a review of the patient's symptoms, previous surgical history, and physical examination. Following the development of jaundice after laparoscopic cholecystectomy, Magnetic Resonance Cholangiopancreatography (MRCP) was performed, which demonstrated a Bismuth Type II benign biliary stricture involving the upper common hepatic duct.

Routine preoperative investigations, including complete blood count, liver and renal function tests, serum electrolytes, coagulation profile, viral screening, blood grouping, and pre-anaesthetic evaluation, were performed to assess the patient's overall condition and fitness for surgery.

Based on the clinical, radiological, and previous procedural findings, the patient was advised to undergo Benign Biliary Stricture Treatment in Hyderabad, India, under the expert care of the Surgical Gastroenterology Department.

After a detailed consultation with Dr. Suresh Kumar S (Consultant Surgical Gastroenterologist), a comprehensive clinical evaluation was performed to determine the most appropriate treatment strategy for the patient's post-cholecystectomy benign biliary stricture.

Considering the patient's history of laparoscopic cholecystectomy followed by obstructive jaundice, MRCP findings confirming a Bismuth Type II benign biliary stricture, and the previous unsuccessful attempts at ERCP-guided biliary stenting and Percutaneous Transhepatic Biliary Drainage (PTBD), definitive surgical reconstruction was considered the most appropriate treatment option. Routine preoperative investigations and pre-anaesthetic evaluation confirmed that the patient was fit to undergo surgery.

Based on the clinical assessment, imaging findings, and failure of minimally invasive biliary interventions, it was determined that Roux-en-Y Hepaticojejunostomy was the most appropriate surgical procedure. 

The patient and family members were counselled regarding the diagnosis, the planned surgical procedure, expected benefits, possible risks, postoperative recovery, wound care, and the importance of regular follow-up for long-term outcome assessment.

Following the treatment decision, the patient was scheduled to undergo Roux-en-Y Hepaticojejunostomy in Hyderabad at PACE Hospitals, under the expert care of the Surgical Gastroenterology Department.

The procedure involved the following steps:

• Patient Preparation and Anaesthesia: After obtaining informed consent and completing the pre-anaesthetic evaluation, the patient was taken to the operating room. Under general anaesthesia, standard aseptic precautions were followed throughout the procedure.

• Abdominal Exploration and Adhesiolysis: The abdominal cavity was explored, revealing adhesions between the omentum, duodenum, and the previous gallbladder bed. Careful adhesiolysis was performed to expose the extrahepatic biliary system safely.

• Identification of the Biliary Stricture: The previous surgical clips over the bile duct below the biliary confluence were identified and carefully removed. The biliary confluence was exposed, and the left hepatic duct was identified with purulent bile discharge. An indwelling catheter placed through the previous PTBD tract was identified and guided through the biliary confluence.

• Roux-en-Y Hepaticojejunostomy: A Roux-en-Y jejunal limb was prepared, and a tension-free hepaticojejunostomy was created to establish a new pathway for bile drainage from the hepatic duct into the jejunum, bypassing the benign biliary stricture.

• Completion of the Procedure: Haemostasis was confirmed, the operative field was inspected, and the procedure was completed successfully without any intraoperative complications.
  

The postoperative period was uneventful. The patient was initially monitored in the intensive care unit before being shifted to the general ward after achieving clinical stability. During hospitalization, he received supportive treatment for infection prevention, gastric protection, hydration, pain control, promotion of bowel motility, and overall postoperative recovery. 

Upon discharge, the patient was prescribed medications for infection prevention, gastric protection, pain relief, control of postoperative inflammation, and overall postoperative recovery.

The patient was advised to continue a normal diet as tolerated, maintain adequate hydration, take the prescribed medications as directed, and follow proper wound care instructions. He was also advised to avoid strenuous physical activities until reviewed by the treating doctor.

The patient was advised to report to the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, severe abdominal pain, persistent vomiting, yellowing of the eyes or skin (jaundice), wound discharge, bleeding, or any other concerning symptoms.

The patient was advised to return for a follow-up consultation with the Surgical Gastroenterologist in Hyderabad at PACE Hospitals after 5 days.

This case highlights the successful management of post-cholecystectomy benign biliary stricture (Bismuth Type II) through Roux-en-Y Hepaticojejunostomy after unsuccessful endoscopic and percutaneous biliary interventions. The patient had an uneventful postoperative recovery and was discharged in a hemodynamically stable condition with appropriate postoperative advice and scheduled follow-up.