Biliary strictures complicating pancreaticoduodenectomy

Background. Biliary-enteric anastomotic strictures may complicate pancreaticoduodenectomy. Anastomotic ischaemia and reflux of gastric and enteric contents with secondary bacterobilia and cholangitis may contribute. Methods. Four patients (3 females, 1 male) with a mean age of 50 yr (range 26-73 yr) presented 1-12 yr following pancreaticoduodenectomy with features suggestive of biliary-enteric anastomotic stricture formation. These included recurrent cholangitis, obstructive jaundice, and liver abscess. Diagnosis was confirmed by percutaneous or endoscopic cholangiography. Endoscopic and radiological management were unsuccessful, and revision surgery in the form of a Roux-en-Y hepaticojejunostomy was required. Results. Three patients remain asymptomatic 10-30 mo postoperatively. Jaundice recurred at 15 mo in one patient owing to re-stricture formation and the development of secondary biliary cirrhosis; a liver trans plantation is being considered. Conclusion. Early diagnosis and prompt management of biliary-enteric stricture is essential if secondary biliary cirrhosis is to be avoided. Definitive therapy is best accomplished with a Roux-en-Y hepaticojejunostomy that places the gastric and biliary anastomoses onto separate jejunal limbs.