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“Sideways”: Results of Repair of Biliary Injuries Using a Policy of Side-To-Side Hepatico-Jejunostomy

Winslow, Emily R. MD*; Fialkowski, Elizabeth A. MD*; Linehan, David C. MD*; Hawkins, William G. MD*; Picus, Daniel D. MD; Strasberg, Steven M. MD*

doi: 10.1097/SLA.0b013e31819a6b2e
Original Articles

Background: The Hepp-Couinaud technique describes side-to-side HJ to the main left hepatic duct but a side-to-side approach is not consistently used when repairing other ducts. Compared with end-to-side repairs, side-to-side anastomoses require less dissection, theoretically preserving blood supply to the bile ducts, and usually permit wider anastomoses.

Methods: We report the treatment results of 113 consecutive biliary injuries, with intention to perform side-to side anastomosis in all.

Results: 113 biliary injuries, 109 associated with cholecystectomy, were treated from 1992–2006. Injury types were B (7 patients, 6%); C (11 patients, 10%); E1 (8 patients, 7%); E2 (37 patients, 33%); E3 (20 patients, 18%); E4 (24 patients, 21%); E5 (6 patients, 5%). 19% of repairs were early (within 1 week after cholecystectomy), 58% were delayed (at least 6 weeks after cholecystectomy), and 22% were reoperations for recurrent strictures. In 92% of cases, side-to-side repair was accomplished. 23/113 (20%) developed postoperative complications, with one postoperative death. Mean follow-up was 4.9 years. Excellent anastomotic function was achieved in 107/112 (95%). “Poor” anastomotic results occurred in 5 patients: 2 patients with E4 injuries had postoperative anastomotic stenting >3 months, and 3 developed strictures requiring percutaneous dilation. There have been no reoperations for biliary strictures.

Conclusions: HJ using side-to-side anastomosis has theoretical advantages and is usually possible. In some high right-sided injuries it could not be achieved. 95% excellent anastomotic function without intervention attests to the benefit of the method, especially as postoperative stenting >3 months was considered to be a “poor” result.

We report a large series of patients with biliary injuries who underwent repair using a technique which emphasized the construction of widely patent anastomoses using a side-to-side technique. Postoperative strictures occurred in only 4% of patients and each was treated successfully nonoperatively. At nearly 5 year follow-up, all patients are clinically well without stents in place and with no suggestion of stricture development.

From the Section of Hepato-Pancreato-Biliary Surgery,*Department of Surgery and Section of Vascular, and †Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in Saint Louis, St. Louis, Missouri.

Presented at the 2008 Annual Meeting of American Hepato-Pancreato-Biliary Association, Fort Lauderdale, Florida.

Corresponding Author: Steven M. Strasberg, MD, Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in Saint Louis, Suite 1160, Northwest Tower, 660 South Euclid Ave, Box 8109, St. Louis, MO 63110, USA, Phone: 314-362-7147, Fax: 314-367-1943, E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.