Juniper Publishers- Open Access Journal of Case Studies
Heineke-Mikulicz Strictureplasty: Alternative Treatment Approach for Hepaticojejunostomy Strictures
Authored by Mohamad Rakka
Abstract
A 63-year-old man underwent an uneventful pancreaticoduodenectomy (whipple procedure) for an adenocarcinoma of the head of the pancreas. He presented 7 months later with progressive jaundice. Blood chemistry tests revealed high bilirubin level and elevated Gamma-glutamyl transferase (GGT), alkaline phosphatase. Ultrasound examination of abdomen showed dilated intrahepatic bile ducts. The magnetic resonance cholangiopancreatography (MRCP) detected a stricture at the hepaticojejunostomy (HJ) anastomosis with a stone in the common hepatic duct just above the biliary-enteric anastomosis with dilated intrahepatic bile ducts. Thus, surgery was suggested and to proceed with Heineke-Mikulicz strictureplasty.
Keywords: Pancreaticoduodenectomy; Hepaticojejunostomy; Stricture; Whipple; Heineke-Mikulicz
Introduction
Pancreaticoduodenectomy (PD) is a major surgical abdominal operation performed to treat several periampullary benign and malignant diseases and it carries high risk for postoperative complications.
One of the complications associated with PD is hepaticojejunostomy (HJ) stricture. Concerning PD for both benign and malignant diseases the median time to stricture formation is 13 months and it can manifest 1 month and up to 9 years after PD [1]. Its incidence varies widely across the literature and it ranges from 4% to 10% [2]. House et al. [3] reported an incidence of 2.6% and it was similar in benign and malignant disease [1]. However, Kim and colleagues reported a higher rate (24%) [3].
Multiple risk factors predispose to the HJ stricture formation after PD and they include: preoperative and postoperative percutaneous biliary drainage, ischemia resulting from iatrogenic causes or patient comorbidities, multiple repair of recurrent stricture, HJ leak secondary to infectious/inflammatory processes, recurrent malignant disease, small or fragile bile duct wall, and gastric or enteric reflux into biliary tree [1,2,4,5].
Most commonly HJ stricture manifests as recurrent cholangitis and/or obstructive jaundice [6]. These clinical presentations should be evaluated and treated as early as possible to prevent the progression to secondary biliary cirrhosis.
Case Presentation
A 63-year-old man underwent an uneventful pancreaticoduodenectomy (whipple procedure) for an adenocarcinoma of the head of the pancreas. He presented 7 months later with progressive jaundice. Blood chemistry tests revealed high bilirubin level (Total: 3, Direct: 2) and elevated GGT, alkaline phosphatase. Ultrasound examination of abdomen showed dilated intrahepatic bile ducts.
The magnetic resonance cholangiopancreatography (MRCP) detected a stricture at the HJ anastomosis with a stone in the common hepatic duct just above the biliary-enteric anastomosis with dilated intrahepatic bile ducts as seen in Figure 1.
A percutaneous Transhepatic Cholangiography (PTC) confirmed the presence of stricture and the impacted stone at the biliary-enteric anastomosis as seen in Figure 2.
A guide was inserted and successfully crossed the anastomosis into the jejunum. Unfortunately, the balloon dilatation of the stricture was unsuccessful. Attempted endoscopic intervention (Rendez-vous technique) failed to demonstrate the biliary-enteric anastomosis due to the limited length of the available endoscope (Figure 3).
Thus, surgery was suggested, and we decided to proceed with Heineke-Mikulicz strictureplasty. Exploration revealed dense and fibrotic adhesions. A meticulous adhesiolysis was done. A stone was palpated in the common hepatic duct that was approximately 2cm in length as seen in Figure 4.
A longitudinal incision of 3cm was made in the anastomotic line (Figure 5 & 6) and the stone was successfully extracted. The biliary duct was then irrigated using sterile water and good biliary drainage was achieved. The incision was closed in a transverse fashion using an absorbable 4-0 polyglactin interrupted simple sutures as seen in Figure 7(A&B)
The post operation course was uneventful, the patient was discharged on the fifth post-operative day in a good condition.
The patient was followed up clinically, biochemically and radiologically for a total of 12 months. He was completely asymptomatic with a normal serum bilirubin, liver enzymes and nondilated biliary tree.
Discussion
Diagnosis of HJ stricture is based on clinical, laboratory and radiological findings. Biliary obstruction should be confirmed by abdominal ultrasonography, multidetector computed tomography, and/or magnetic resonance cholangiography. Furthermore, direct visualization of the stricture is also one of the diagnostic clues. This can be accomplished by ERCP or percutaneous transhepatic cholangiography (PTC) which also can play a therapeutic role [6].
In addition, ERCP and PTC allow biliary biopsy using cytobrushing or clam shell in order to rule out recurrent malignant disease as a cause of HJ stricture [7]. Nonsurgical methods and surgical revision of the HJ are both considered in the management of the HJ stricture.
The interventional techniques including both percutaneous (PTC) and endoscopic routes (ERCP) are commonly used in the management of HJ stricture through balloon dilatation and insertion of one or more stents.
Although high success rate of endoscopic management of biliary stricture is reported by many studies [8], the endoscopic cannulation of the HJ after PD remain a challenge secondary to the anatomy changes [9]. Concerning the percutaneous techniques, House et al. [1] reported that 90% of all patients were treated successfully using the percutaneous biliary approach.
Although minimally invasive treatment is best option for HJ stricture after PD, it has the disadvantage of restenosis on longterm follow-up [10]. Thus, surgical redo of HJ should be considered especially when interventional methods failed in several attempts. In addition, several interventional attempts result in fibrosis at the anastomosis which makes surgery more difficult [11]. Therefore, early surgical revision is recommended [6].
Recently, Heineke-Mikulicz strictureplasty was included in the management of HJ stricture. Its concept based on longitudinal incision with transverse closure of the stricture was introduced in the 1970s as a therapy for tubercular strictures in the GI tract and in the 1980s for Crohn’s strictures [12,13], and later on in urethroplasty and pyloric stenosis repair [14,15].
This technique is beneficial as it provides a simple, time effective method that makes it a good alternative for redo HJ. It has although some limitations. Long thin strictures are for example not candidate for such procedure. Moreover, in order to perform this surgical concept, appropriate length of the remnant common hepatic duct of =/ >1cm as well as sufficient diameter of the newly formed anastomosis of >1cm are needed [16].
Heineke-Mikulicz strictureplasty has a disadvantage is that when applied on fibrotic tissue due to chronic inflammation associated with cholangitis it may predispose to restenosis or biliary leakage; yet this disadvantage is also proved in redo HJ [16].
Our case was presented for jaundice after 7 months of PD and was diagnosed with HJ stricture along with stone formation. A percutaneous transhepatic intervention was carried out but was unsuccessful due to the presence of the stone near the anastomosis. Endoscopic access also failed due to technical difficulty (short endoscope). Then, surgery was suggested. After reviewing the literature and the available surgical options, Heineke-Mikulicz strictureplasty was decided. Clinical follow up, along with laboratory testing and imaging for 12 months were uneventful.
In conclusion, Heineke-Mikulicz strictureplasty is one of the promising procedures that can be easily done in case of HJ stricture after PD, with good postoperative prognosis. It is useful as an alternative for redo HJ and refractory cases to interventional techniques. Our case is the second in the literature after a similar one that was released in Turkey in July 2012. This makes additional studies required to achieve a definitive conclusion.
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