Surgical Intervention for Post-Cholecystectomy Biliary Strictures in a Somalian Patient: From ERCP Failure to Hepaticojejunostomy

A 71-year-old male patient from Somalia was referred to PACE Hospitals, Hyderabad for advanced treatment for benign biliary stricture - type II. The Surgical Gastroenterology expert team performed ROUX - EN-Y Hepaticojejunostomy procedure.

Medical History & Diagnosis

An elderly male patient aged 71 years has approached Surgical Gastroenterology Department of PACE Hospitals, Hyderabad for advanced treatment of biliary strictures. The patient previously underwent lap cholecystectomy for cholelithiasis (Gallstones) and acute cholecystitis (Inflammation and infection of the gallbladder). Post surgery, the patient developed jaundice for which he underwent a magnetic resonance cholangiopancreatography (MRCP) scan. The scan revealed type 2 Benign Biliary Strictures (BBS). 

A type 2 benign biliary stricture (BBS) is a narrowing of the bile duct that occurs in the upper common hepatic duct, within 2 centimeters of the hepatic bifurcation. This type 2 Benign Biliary Strictures can be caused by a liver transplant or a cholecystectomy. In this case, the patient had acute cholecystectomy (Removal of Gallbladder) for cholelithiasis.

To clear the blockages in the bile duct, the doctors tried to perform Endoscopic retrograde cholangiopancreatography (ERCP) stenting, but it was unsuccessful. Upon failure of ERCP procedure, the doctors tried to perform Percutaneous transhepatic biliary drainage (PTBD). This procedure too was unsuccessful.

Upon consecutive failures of surgical treatment approaches, he was referred to PACE Hospitals, Hyderabad, for advanced treatment and medical management.

Medical Decision Making (MDM)

Considering the previous failure of treatment approaches and complexity of the medical condition, he was admitted to Surgical Gastroenterology Department of PACE Hospitals, Hyderabad for further treatment of benign biliary stricture. Upon detailed examination, Surgical Gastroenterologist, Bariatric and Metabolic Surgeon, GI and HPB Oncologist, Liver Transplant Surgeon, Dr. Phani Krishna Ravula along with Dr. Suresh Kumar S, have affirmed to perform ROUX-EN-Y hepaticojejunostomy.

Treatment Plan

A Roux-en-Y hepaticojejunostomy (RYHJ) is a surgical procedure that treats blockages, injuries, or narrowing in the biliary system. The biliary system includes the gallbladder, liver, and bile ducts. During the procedure, a surgeon creates a new path for bile to flow to the small intestine and connects the hepatic duct, which is the end of the bile duct from the liver to the jejunum, which is the middle part of the small intestine.

Surgical Findings

The patient with the above medical history and diagnosis was prepared for performing hepaticojejunostomy. He got explained in detail about the surgical procedure and sent for Pre anaesthetic checkup (PAC) after obtaining patient’s consent. The Roux-En-Y procedure was performed successfully without any complications.

Intraoperative findings

There were adhesions of omentum and duodenum found attached to the gallbladder, adhesiolysis was done to separate them. Two clips from previous surgical approaches were observed on bile duct below the confluence and were removed gently. Bile duct confluence was identified and left hepatic duct was found anteriorly opened with pus discharge. An IFT Catheter was placed through previously tried PTBD site and brought through confluence. 

Post-surgical care

The patient underwent a Roux-En-Y Hepaticojejunostomy successfully, without any medical complications. He was shifted to General observation room from Intensive care post-surgery. During his hospitalization, he was managed further with IV fluids, antibiotics, antacids, motility agents, and other supporting medications. 

Counseling and follow-up

Prior to his discharge, he was properly counseled about his medical condition, medication instructions and precautions to be taken. He was advised to get review done after five days in Outpatient Department (OPD) with Dr. Phani Krishna Ravula. However, he was informed to seek Emergency care at PACE Hospitals, Hyderabad, anytime in case of any adverse symptoms like fever, abdominal pain, or vomiting. 

Discharge notes

Antibiotics, Proton pump inhibitors, Opioid analgesics, and steroids for pain management were prescribed to the patient as discharge medications. The patient was discharged in a hemodynamically stable condition.