Long-term postoperative outcomes of Roux-en-Y cholangiojejunostomy in patients with benign biliary stricture

Roux-en-Y cholangiojejunostomy, as a standard surgical procedure, is widely applied for the treatment of biliary stricture in clinical entity [1‐3]. However, serious short- and long-term complications in some patients after surgery may still occur, especially postoperative biliary stricture or intrahepatic calculosis, which often need to be further treated via second or even multiple surgery, thus, causing great trauma and economic burden to the patients [4‐6]. Therefore, it is of great clinical significance to select optimal treatment procedures to reduce occurrence of such potential complications.

Some significant factors must be considered in the evaluation process of long-term outcomes after Roux-en-Y cholangiojejunostomy. Most importantly, it is crucial to unify evaluation measures of long-term outcomes in specific clinical scenario, which should include the following aspects: (i) clinical manifestations and physical signs of the patients; (ii) assessing methods of patients' liver functions; (iii) representative imaging. In addition, follow-up time period was another imperative element that should be taken into consideration when analyzing long-term prognosis of patients who underwent cholangiojejunostomy [7‐10]. It has been shown by Tochhi et al. that approximately 40% of recurrent biliary strictures were diagnosed 5 years after the initial surgery [11]. Therefore, comprehensive and accurate evaluation of long-term outcomes of Roux-en-Y cholangiojejunostomy may need at least 5-year or longer follow-up period. Numerous clinical studies have demonstrated that a number of key factors, including patients' preoperative physical condition, different anatomotic methods, lesion sites and postoperative complications, may have potential effects on patients' prognosis and overall study after Roux-en-Y cholangiojejunostomy [12‐14]. Herein, this study was aimed to provide reference for the improvement of such patients' prognosis through analyzing possible risk factors of Roux-en-Y cholangiojejunostomy in 61 patients who underwent this surgical procedure for the second time.

Cholangiojejunostomy is the most widely used surgical procedure for biliary stricture caused by various abnormalities. However, postoperative complications of this surgery are gradually highlighted with its extensive clinical application, especially complications of reflux cholangitis, anastomotic stoma stricture and intrahepatic lithiasis [5, 16, 17]. Severe grasp of surgical indications during the first operation, reasonable operative time, different anastomotic techniques and lack of full understanding of anastomotic techniques may result in postoperative anastomotic stoma stricture and intrahepatic lithiasis, which need further surgery for radical treatment. When second cholangiojejunostomy is performed for the patients, especially for those with traumatic biliary stricture, tissues around the portal hepatis are severely adhered and the anatomic level is unclear. Therefore, there may occur more complications after second cholangiojejunostomy [18, 19]. Chapman et al. have showed that failure rate of second cholangiojejunostomy in patients with biliary injuries was approximately 50.0%, and postoperative complications may also occur in patients with non-traumatic biliary stricture [10]. In this present study, a total of 61 patients underwent revisional Roux-en-Y cholangiojejunostomy for the second time due to biliary stricture, among which 21 still needed hepatectomy during the second surgery. In addition, Clavien-Dindo III and higher complications occurred in ten patients, whose incidence rate was 16.4% (10/61). During follow-up, three patients died and anastomotic stoma stricture was found in four patients, indicating that incidence rate of postoperative complications after second cholangiojejunostomy was relatively high. Therefore, preventing or properly treating postoperative complications of anastomotic stoma stricture and intrahepatic calculus after cholangiojejunostomy may improve surgical treatment efficiency. Through analyzing clinical data of 61 patients undergoing cholangiojejunostomy for the second time, this study demonstrated that first preoperative bilirubin level, short-term complication after first surgery and abnormalities during the second surgery were independent risk factors affecting patients' overall survival, suggesting that first surgery was the key to second or multiple cholangiojejunostomy that surgeons should take seriously in clinical work.

In this current study, first preoperative bilirubin level was one of the factors that may influence long-term surgical efficiency after cholangiojejunostomy. So far, there has been no consensus on whether drainage should be performed for patients with obstructive jaundice before cholangiojejunostomy. However, drainage should be performed before operation in the following situations: (i) Serum total bilirubin (TBIL) level is more than 250 µmol/L. (ii) Indocynine Green Rate 15 (ICGR15) is lower than 15.0%. (iii) Liver function was relatively poor. (iv) Patients are presented with clinical manifestation of cholangitis. (v) Patients are more than 70 years old. (vi) Patients are accompanied with basic diseases [20‐24]. In our study, first preoperative total bilirubin level was more than 200 µmol/L in nine patients and there were varying degrees of short- and long-term postoperative complications in these patients, indicating that it was crucial to treat jaundice through biliary drainage when patient's preoperative bilirubin level was high. Additionally, short-term complications after the first cholangiojejunostomy were another influencing factor of patients' overall survival state. There occurred biliary fistula in six patients and intestinal obstruction in one patient. From the survival curve, it may be found that biliary fistula had significant postoperative effects on patients' survival and lasted for relatively longer time.

Abnormal findings during the second surgery were also of great significance after choledochojejunostomy. Among the patients, anastomotic stoma stricture was found in 42 patients with the highest incidence (68.9%). Compared with the patients with non-traumatic biliary stricture, patients with traumatic biliary stricture were more likely to have anastomotic stoma stricture. However, shorting of biliary output loop occurred in more patients with non-traumatic biliary stricture than patients with traumatic biliary stricture. In patients with traumatic biliary stricture, right posterior lobe biliary duct was end to side anastomosed with the jejunum in one patient, but the right anterior biliary duct and left hepatic duct were not anastomosed. In patients with non-traumatic biliary stricture, lower right posterior lobe biliary duct was not anastomosed in one patient during the first surgery, and cholangiojejunostomy was performed for the second time in another patient due to leaving some stones in the biliary duct of right posterior lobe during the first surgery. According to the survival analysis, it may be concluded that problems related to residual lesions occurred in the early stage after cholangiojejunostomy.

Anastomotic stoma stricture and shortening of biliary output loop occurred relatively later in patients. Most patients with traumatic biliary stricture had anastomotic stoma stricture before shortening of biliary output loop. Thus, second cholangiojejunostomy was performed for these patients. It was inevitable that there may appear biliary stricture after latrogenic biliary duct injuries, which often occurred two years after biliary repair. However, despite its rarity, there were still biliary related complications ten years after biliary repair. Stilling et al. have showed that the time of anastomotic stoma stricture after iatrogenic biliary duct injury repair ranged from 2 to 141 months [25]. Relatively, the average follow-up time for non-stricture patients was 102 months. Compared with patients with non-traumatic biliary stricture, cholangitis occurred earlier in patients with traumatic biliary stricture, and anastomotic stoma stricture occurred in more patients. However, biliary output loop related complications were more common in patients with non-traumatic stricture. For instance, shortening of biliary output loop was found in eight patients, calculous obstruction of biliary output loop in one patient, adhesive ileus of biliary output loop in one patient and internal hernia of biliary output loop in one patient. Relatively, shortening of biliary output loop and adhesive ileus of biliary output loop respectively occurred in three and two patients with traumatic biliary stricture. Collectively, combined with the above results, it was suggested that optimal biliary output loop used for cholangiojejunostomy was 40 ~ 60 cm. Too long biliary output loop used for drainage may be twisted, folded and obstructed due to adhesion, thus resulting in poor biliary drainage and increasing the chance of cholestasis and intestinal bacterial reproduction. In comparison, too short biliary output loop used for drainage may cause reflux easily [26, 27]. During follow-up, it was found that there was disuse atrophy of jejunum due to too short biliary output loop in some patients, whose length was less than 30 cm and even 20 cm, thus causing further narrow of the intestinal cavity.

Due to the retrospective characteristics of this study, there may exist some bias. Moreover, due to the small sample size, prospective studies are expected to be performed to further summarize the potential risk factors of cholangiojejunostomy in the patients complicated with biliary stricture. Despite the above limitations, this current study may provide valuable references for medical staff to realize and pay more attention to the possible postoperative complications of cholangiojejunostomy in their clinical work.

In summary, postoperative complications are common clinical phenomenon in patients with benign biliary stricture after cholangiojejunostomy. Therefore, in order to minimize incidence of postoperative complications, it is necessary for surgeons to fully evaluate optimal operative time and procedures through preoperative imaging and combining with patients' overall health state. Moreover, standardized operation procedures may improve long-term surgical efficiency and patients' overall survival.